Report to the commission on medical geography

Soe. Sci. & Med. Vol.

12D, pp. 227-237.

Pergamon Press Ltd. 1978. Printed in Great Britain.

REPORT TO THE COMMISSION ON MEDICAL GEOGRAPHY by ARTHUR GEDDES D. 6s L., Ph.D., Dept. of Geography, University of Edinburgh

I.

INTRODUCTION: MALARIA, TURKS AND CHRISTIANS IN THE MEDITERRANEAN: A CASE HISTORY, 1 8 9 6 - 1899.

The contribution to discovery for healing which can be made by an essentially geographic field technique may be illustrated by a specific local experiment, hitherto unrecorded, undertaken with full awareness of its implications, regional and international, and moral. In "'the Turkish Empire" from the Adriatic to the coastlands of the Aegean and the Black Sea, early massacres of villagers and citizens by the Ottoman invaders were being xenewed in the last quarter of the nineteenth century, as the Sultans slowly lost hold. In this moral and political issue, fundamental factors in human geography, in health and disease, were hardly ever envisaged by statesmen, still less surveyed. The problem arose as to how to diagnose these factors and find a cure. One Mediterranean island offered unique possibilities for controlled survey and experiment. Its fundamental problems were those of "the Near East". It suffered from misuse of fields, forests and pastures, from decay of craftsmanship, from under-resources and over-population, from malnutrition, dirt, a lack of medical care and public sanitation and from disease, most notably malaria. And it was inhabited by depressed communities of Christians and Turks, living side by side in embittered relations. But it was unique in that - for strategic reasons - the British policeman was present and could prevent widespread bloodshed and destruction of property. This island was Cyprus. Convinced that no political remedy could bring peace and create harmony of the Near Eastern peoples to one another without renewal of their harmony to their environment, a small group in Bi~itain acquired a tract of land for survey and experiment upon peasant economy and health in Cyprus. A beginning was made to restore irrigation, commence reafforestation, encourage handicrafts and arrange for sales, and to check malaria. Malaria was not only seen to be physically debilitating and a cause of high mortality: it was understood to be a factor in the breeding of fears, suspicions, hatred. It seemed the greatest single curse, physiological and psychological, f r o m which the peoples must free themselves if they were to make good. The means of infection however, was as yet unknown. To the historic knowledge that malaria is found adjacent to shallow, stagnant waters and is borne on the evil 'night air' which gave the disease its name, there had been added the rapidly growing knowledge of micro-biotic agency in infectious disease. The question arose as to the life-cycle of malaria's unknown agent. Clearly this must be connected both with the environment, the marsh, and man. A working hypothesis, tentatively induced, was that some noxious, airborne form of life lived first in the water before taking the air. Since living things must breathe, it should be possible to 'drown' the agent, before it left the water, by some liquid with a lbw surface tension, spreading widely over the surface and able to enter microscopic breathing tubes. Small quantities of paraffin were therefore poured on the margins of stagnant water adjacent to malarious communities and the effects were watched. Naturally, in the virtual absence of medical care or cure among the people, the halting of infection bore slow fruit. The difficulties of rural reconstruction were immense upon a tract of marginal land - all that could be purchased in an overcrowded island among a landhun,gry people. In the nature of things, this marginal tract was inhabited by 'marginal men of whom many were semi-outlawed squatters from Turkish or Greek villages elsewhere. In the absence of government support for what should have proved a pilot experiment in medical geographic technique at all levels of research and applieation, capital gave out~ the experiment stopped; and the small limited company formed had ultimately to go into voluntary liquidation. The 10ss was not confined to Cyprus. The next twenty-five years saw the continuation of Turkish massacres of Greek, Slav, and Armenian populations, international wars, of course with retaliation upon Turkish peasants and townsfolk, and the continued ravages of malnutrition and malaria. No general effort was made to diagnose these tragic conditions as a pathological complex rooted in land and life, still less to resolve it. Now it will at once be seen that an anti-malarial measure was correctly applied according to a working hypothesis which, being incomplete, was nartly mistaken. The role of the mosquito as carrier or vector had vet to be discovered. Dr. Ronald Ross first worked out the cycle of infection in 1897 though his findings were at first brushed aside as absurd by his medical superiors. Ross followed up his discovery by pointing

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out the means for breaking the chain in the life-cycle of the carrier, from egg through active larva or 'wriggler, feeding below but breathing at the surface (the "drownable stage), then pupa, to winged, adult sexed mosquito. Cure and prevention were to be effected not clinically alone, by drugging the individual patient, but 'environmentally" as well, by parafinning stagnant marshes. While Ross henceforth concentrated upon malaria and mosquito-prevention as such, he was aware of broader inter-relationships of the way of life in environment, with which geography concerns itself. One gathers that, ideally, Ross linked the full range of medical techniques, from the patient to the laboratory, on to the field of labour and the home of a community. Convergence of aims and findings resulted in a li.fe-long friendship between Ross, who had been somewhat embittered by early criticism, and the experimenter in Cyprus, Patrick Geddes. In this case two separate approaches converged towards synthesis and solution, including the discovery and application of the right sanitary measure to prevent a specific disease. These two approaches may be described as the generalized, geographic, and the specialized, medical approach. A first principle of the Cyprus experiment was that while a-specific disease must be attacked and overcome by sanitary measures, prevention and cure of disease would be futile without readaptation of the community to its environment and of its members to one another. The experiment showed the need for medical collaboration, which proved lacking at that period and left the hypothesis unproven and partly mistaken, until the discovery elsewhere by a physician. And be it noted, the technique here described as geographic did not stop short at observation and interpretation: thought and action advanced together. The achievements of medicine are inseparable from its twofold discipline as a science of man and an art of healing. So this experiment, of which the lesson holds good, was conducted by human geography, infused with ecological biology and with social psychology and was then carried into corresponding action. For this active art corresponding to the science of geography, a term is required. Patrick Geddes's own term, now coming into recognition and use, was geotechnics. II.

D E F I N I T I O N S : A GEOGRAPHICAL APPROACH. At this point, a word on definitions may be pertinent in a report designed to be read not only by geographers such as the writer, who are laymen medically, but by medical men. The late emergence of scientific geography is no doubt due both to the need for specialism and to its practical successes, and also to the difficulty of conceiving of environment and human life as a whole, still more of working out the methods to evaluate the causal factors in the ever-changing complex of global humanity. Professional geographers are still few - a mere handful compared to the numbers of trained, selected and experienced workers in medical research. The day is passing when geography was regarded merely as the classification and consideration of so many separate factors of environment in a world-field covered and competently studied by pre-existing specialisms. In brief, geography m~y be defined as the study of environment and mankind in dynamic, mutual relationship, from local, through regional, to world scale. Geography is increasingly understood as a synoptic view of fundamental facts of which the causal interrelationships are sought. With each search towards assessment of cause and effect, the facts offered by dittering, usually uncoordinated specialisms are seen to be inadequate or lacking. Geography, while continuing to use all that can be gathered from correlated specialisms upwards from geology, meteorology or the ecology of vegetation and fauna, has constantly to discover elements of physico-biotic environment hitherto little noticed and virtually disregarded. Since the task is immense and the workers few, the need for collaboration is increasingly recognized. The formation of this Commission and its members' work in each of their respective countries mark a stage towards collaboration. On their part geographers can assure their medical colleagues of their awareness that medicine is at once a science and an art: a science from which they can and must learn, an art applied to human welfare for which they also care. They are aware of the recognition given by certain leading students of medicine in its wider aspects to the need for geograohical collaboration. To Henry E. Sigerist, the task of medicine is "promotion of health, prevention of illness, restoration of health" and also "rehabilitationS'. The study of "health and disease among the nations" involves "two main groups of studies". To the first, "the experience of the clinic and laboratory" by which have been established a number of diseases as recognizable entities, we must add the study of these diseases "in time and space" as their "history and geography". (Sigerist, 1951, p. 88). Sigerist has supplied the Stimulus of criticism to geographers for failing to appreciate the factor of health in their studies. H e pomts . .out . the . omission . . m. the. Principles of Human Geography" by Vidal de la Blache (1st ed. 1921 ) and similar works by Brunhes and others. In defense, it should be said that no recent work on regional geography, at least on tropical or sub-tropical lands, has failed to take account of health and disease, though hitherto we have balked at the mapping of health and disease in industrialized, temperate lands. So far as clear restatement of principles and method is concerned, Sigerist's criticism was all too well founded for the period between the appearance of Elis6e Reclus' posthumous L'Horarae et la Terre (1902) and that of

Report to the IGU 1952 Colmnission on Medical Geography

Max Sorre's Les Fondements de la Geographic humaine; 1, fondements biologiques (1942 rev. ed., 1951). And it was in oraer to carry forward the problems envisaged that Professor Sorre proposed the formation of our Commission, later supported by an independent medical approach from Dr. J. M. May. In Britain a similar approach was sketched by F. A. E. Crew in his Inaugural Lecture to the new Chair of Social Medicine, Edinburgh, 1944. From the narrower analyses of the nineteenth century, medical science is coining to conceive of disease as a "natural reaction of the individual, body, mind and spirit, to his total external world". Through the application of the physical sciences, man s natural environment is being, transformed in the absence of a "real knowledge of human and social biology . . . While clinical medicine "is the science of the sick individual, social medicine is medical science in relation to groups of human beings," applied towards prevention. Concluding, Crew turned to the assessment of the agencies that make for positive health in a community and pied fur "a new science of human ecology". III.

PROGRESS REPORT. A. lndo-Pakistan. On being nominated to the Commission in 1950, my first step was to seek out a clear case of a major region approaching continental scale in which the people lived so close to the physico-biotic environment that elemental geographic factors could readily be seen in direct action upon them. There must be a body of geographical material available in the form of maps from topographic to atlas scales, statistics, photographic documents and written knowledge and interpretation. All these desiderata are present in the sub-continent of Indo-Pakistan. Moreover its peoples and communities are perhaps the most closely rooted to their native place o f any in the world and the most rigidly classified and sub-classified, localized and enumerated, according to social group or caste. Regional environments range from desert to sub-equatorial swamp, from mountain and plateau to vast, subtly varied alluvial plains. This, and the fact that in addition to the majority of relatively static and hierarchised Hindus are found primitive nature-folk, on the one hand, and two great masses of Muslim population on the other, combine to make the sub-continent perhaps the most remarkable field for geographical synthesis in the world. Here, if anywhere, was ground for "medical geography". After a preliminary study of documents, Mr. A. T. A. Lcarmonth accepted the invitation to undertake the study. Previous to graduation and appointment in Geography Mr. Learmonth had acquired a statistical grounding and had served with responsibility in the Royal Army Medical Corps in India, 1942-1945. In spite of the admitted and obvious inaccuracy of medical statistics - little more than estimations by an illiterate watchman for most of the villages of India - , the phenomena of health and disease are on such a tremendous scale, epidemics and famines striking with such mortal impact, that paradoxically they can be more instructive than statistics of far greater accuracy where the phenomena are less striking in period and place. The balance sheet of life and death is closed at each decade by the census, accompanied by reports written with close regional knowledge of land and life. A preliminary account of his work to date will be given by Mr. Learmonth in Iris paper on "Regional differences in natality and in mortality in the sub-continent of Indo-Pakistan, 192119~0". All that can be said here is to point out the importance of a study of the subcontinent - hereafter referred to as "All-India" as a term still suitable for the lands southeast of the Indus Valley. The primary fact that the population almost everywhere dwell close to the very margin of survival or extinction by famines, by malnutrition and deficiencies, by disease or by all combined, makes it clear that medical geography must always retain sight of the fundalnental needs of a given people in relation to their environment, the sum or potential multiplicand of its resources and their present and possible capacity for their utilization. Not only so, their social psychology must be related to their health or ill-health. And while the study of psychology goes beyond the geographer's training, he can, given the magnitude and impact of recurrent mortality, map the psychological experiences undergone by regional populations during stated periods. This can allow the psychologist and psychiatrist to 'place their case studies, regionally, and relate these to the experiences and vicissitudes of the people as measured by "the ups and downs'" or variability, indexed during a period of a given net population change. An outline method has been published by the writer (1941-48). This concept has been utilized in "A Psychiatric Study of Indian Soldiers in the Arakan" by A. Hyatt Williams, M.D. (1950). In addition to the broad cleavages of religion and race there stood out a number of well defined regional types. Each came from a different sort of environment, and his place and part in it had an important bearing on how the individual soldier became the sort of person he was, and how he developed his particular psychiatric assets and liabilities. Williams felt it particularly appropriate to consider elements of life in the home region which gave the individual his military weaknesses and strengths, as these showed themselves in blended British forces. In a different military setting, namely in a strictly Pakistani or in an Indian Republican army (the latter possibly mixed in religion), given regional groups might behave differently. ss.M

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Summing up their characteristics, Williams describes the types as follows. Pathans are staunch, often fanatic Muslim peasants, from the mountainous, arid, sparsely populated North-West. Their climate is extreme and it is difficult to obtain a living from their holdings. But on the whole health is good, partly because there is a poor chance for weaklings. While Pathans varied, men from the wilder tribal territories found the orderliness of military discipline difficult. The hardships of the campaign were no problem to them. They required leaders who were strong, strict, just and fearless. They were experts at guerrilla warfare, men of their word, sensitive to loss of face from insult, illness or weakness. Wounds and death in the field were highly honoured. Muslim Baluchis were similar. Punjabi Muslims were robust in build, solid and reliable :n t~rnnpr~rn~n~ "th,~ backbone of the Indian Army". They are farmers in a rich countr~y, whi'"c~h - is"expandm"g owing,to irrigation schemes. The climate is notable for intensely hot summers and cool pleasant winters. Health is fairly good, although epidemics of malaria do occur after the monsoon. In training, the Punjabi Muslim was responsive and well-disciplined, but inclined to be slow to learn. In the field he was willing and cooperative. In successful action there was solid endeavour and high morale. Unsuccessful action depressed, but did not demoralize him. When ill with anything other than fever, he often did not realize that he was ill, but when illness was over, there was prolongation of symptoms - he simply could not realize he had recovered. He is very suggestible, relations with leaders were relatively good the successful leader was a manly person who was strict but benevolent. Types of stress most to be feared were physical illness, loss of a charm (a portion of the Koran carried on the person) and loss of face. Hindustani Muslims, similar to their Hindu neighbors in race and language, differed from them in religious custom and in their diet which tended to promote better physique and physical health. Rajputs from each Punjab, Rajputana and the upper Ganges plain and Dogras from the adjacent Himalayan foothills are Hindu peasants of Warrior Caste. They are tall, strong and essentially honest, and are strict Hindus. Many come from the zone of intermittent rainfall, recurrent droughts and famine. As a result, (I understand), a period of good nourishment without undue exertion might have to precede intensive training. They were usually fairly intelligent, amenable to discipline, "but remarkably lacking in guile". "They had to be taught the art of taking cover and keeping their heads down." Their response to imprisonment and relations with leaders were like those of the Punjabi Muslims. Stresses most severe to them were loss of face and nutritional deficiency. Similar to the Dogras were the hillmen from Garhwal and Kumaon. Jats are stolid farmers, humbler in caste and status t h a n the Rajputs but inhabiting much the same areas. Ahirs are similar to the Jats but humbler. Gujars are robust, swarthy, difficult and "the ablest cattle thieves round Delhi". Health in the villages is fairly good, but the area is not very prosperous, and the diet of the three classes is not so good as that of the Punjabi Muslims. The response to an adverse battle situation, plus poor physical health, was a marked lowering o f morale. The stress factors most to be feared were ignorant leadership and nutritional deficiency. The Sikhs are Jat Sikhs who after adopting a pacific and" tolerant religion under their first teacher or Guru, changed, under the impact of Muslim persecution and bound themselves to strict military readiness which developed from defense into offense, Sikh rulers having gained possession of the Punjab before their inclusion in the British Indian Empire. Thus the people hold land, work it and defend it and with the introduction of irrigation readily moved to the Canal Colonies. They are robust, strikingly with subcutaneous fat and are athletic. They excel at games, are ruthless, quick-witted and argumentative, proud, fearless and quarrelsome. "There are more murders in the Sikh area than in any other part of the Punjab." A point of post-war historical geography is called for here. As is known, the ruthless and organized machine-gunning of Muslim refugees traveling from the Ganges Plain to the western Punjab in 1947 was the work of Sikhs. What is known by few, however, is that not only did this occur where the railway passed through the territory of Sikh Maharajahs but that there is the strongest evidence t h a t it was these who supplied the arms, ammunition and officers to the rank and file, many of whom may actually have been under orders. It is fair to remember this in partial defense of the Sikh people's reputation, this organized Sikh attack having commenced and provoked the ghastly massacres of 1947. Williams remarks that a development of the aggressive components of the personality is much encouraged. It had ensured their survival and increase in a primarily Muslim Province, but it provoked their expulsion since the Partition. Sikhs were q~ick to learn military training but found discipline somewhat irksome. If successful they were wildly enthusiastic, ruthless and sometimes savage. If unsuccessful in action they were resourceful and cunning if well led. If badly led their morale broke suddenly. Although eating neither beef nor pork, they were well nourished, and were so adaptable in times of hardship that most of them remained without signs of deficiency disease. Significantly, the types of psychiatric stress most to be f e a r e d were idleness and weak leadership.

Report to the IGU 1952 Commission on Medical Geography

The Gurkhas, mainly from the independent Himalayan state of Nepal are sturdy mountaineers, active and lithe of movement. They call for special comment. They cultivate the steeply sloping hillsides with "dry crops" of native millets and recently brought maize and potatoes and follow their animals on the pastures but in addition probably a more important disciplinary training than is realized - they irrigate the valley bottoms and even terrace the hillsides for rice. If their rice paddies lie low in the malarial zone, they descend daily to plow, sow, water and transplant during the monsoon, men and women climbing back to their homes, often 3,000 ft. higher, every evening with light free step and laughter. This all-round way of life has trained them to adaptability and for the last century they have colonized eastward, both under native organization and on the hillside tea plantations. Added to this, they have nmltiplied by help of pay in the British Indian Army and continue to serve in that of the Indian Republic. Included in the Gurkha regiments are men from the Khasi Hills with similar environment, race and adaptation. Among the Gurkhas, weakness is regarded with scorn, sickness is regarded with callousness, and mental illness with amusement. "The Gurkha is an ideal soldier", but his ruthlessness makes him not only feared but sometimes hated by common folk in the plains. In action, whether successful or not, the Gurkha fights really well. Few taken prisoners by the Japanese seem to have joined the Indian National Army, numbers remained in Rangoon jail and retained their morale but some who had masqueraded as Burmese and lived a precarious existence in the jungle did become demoralized, displaced people. 'They demanded to admire their leaders and could not do without British officers whom they frankly loved. Breakdowns were rare. Exposure to shell-fire where hand-to-hand fighting was impossible proved the only serious stress. Mahrattas are Hindu peasants of Warrior Caste from the north-west Deccan, a zone of variable rainfall, and recurrent crisis, of drought and famine; their home region suffered most from the terrible influenza epidemic of 1918-19. Regimentation was adjusted to with minimal difficulty but (I undertsand) not without a preliminary period of good feeding. In action Mahrattas were brave and stubborn. At home their village organization has remained comparatively intact under their traditional headman or Patel. I am inclined to associate this with the fact that "they served well with any leader whom they liked and admired; his competence was not essential". The type of stress most to be feared was physical illness. Of South Indians, few are capable of bearing arms - notable exceptions being the Nayars, a matrilinear Warrior Caste of the sub-equatorial, S-W coastal plain, and certain castes of the high and healthy plateaus, in all these cases people with an adequate, or almost adequate, diet, 'South Indians are emotionally labile, uninhibited individuals with a sense of humor." In training the South Indian was quick to learn, but found di~eulty in adjusting to regimentation. Among combatants the response to successful action heightened morale, while unsuccessful action lowered morale and sometimes brought panic. There was a great deal of physical illness among South Indians. The most important stress was physical illness, followed by unit difficulties, separation from home, loneliness and lack of leave. From western Bengal the people, mainly Hindus, were of poor physique, often ill, and, despite an intelligence which appeared to be high, were apathetic and depressed. They had the reputation for guile rather than aggressiveness. From eastern Bengal the men were mainly Muslims, and, in contrast to those from western Bengal, were happy and industrious and of sturdy build, vigorous and active. Williams agrees that the difference is marked and is due to differences in health. A passivity and an inactivity in the face of disaster is seen more in west Bengal than east, but was quite marked in east Bengal in the deadly famine of 1948. Compared with the population of the province, there were few Bengalis in the army, and they were employed as follows: (a) O~cers: 1. Medical, composing nearly half of the Indian Army Medical Corps officers; 2. Technical; 8. Combatant, fewest. (b) Non-commissioned officers, mainly clerks; and (e) Pioneers and labourers, the latter probably mostly Muslims from east Bengal who worked hard for an efficient and strict leader. The educated, mainly high caste Hindu Bengalis showed a high rate of psychiatric breakdown. One cause must surely have been intense emotional stress of divided allegiance between Nationalist's aspirations, loyalty to the Allied cause and duty to the sick and wounded. The response is also associated with long enduring conditions of mind. The puckered brow of the Bengali Hindu of every caste contrasts with the knitted brows characteristic of the Muslim in Bengal as elsewhere, a fact linked to creeds deeply rooted in regional erience through millenia. "The high percentage of depressive reactions is notable. except one of these was in men from western Bengal, where the general social atmosphere was one of depression. ,The types of stress most to be/eared were physical illness and domestic catastrophes.' Williams quotes a fellow-Indian observer who stated that the Bengal/ is paralysed by poor health, and a disrupted home life owing to family bereavement. Williams' apparently unique psychiatric study of Muslim and Hindu soldiers in the last war provides an independent account of reactions in crisis which have sprung from long-enduring conditions of environment, way of life, nutrition, health and disease. It is perhaps remarkable, but not unexpected, to find that Williams observations frequently recall the terse comments of a Buddhist pilgrim from China who traversed

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Indian afoot in the sixth century A.D. for example, the comparison between the Mahrattas and the Tamils of south India. No such psychiatric study, so far as I am aware, has been attempted for the peoples of All-India before or since the Partition. Yet without it, the work of reconstruction, of agricultural improvement and industrial development of sanitary measures for the promotion of health and the diminution of disease cannot be undertaken with success. Such work depends upon the conditions of life and upon the character of men, women and children according to region, class and community. The basis for health is nutrition: there must be enough food for the eople and not too many people for the food. Coordinated, geographical survey is undamental. Given food production with development of handicrafts and industry there must come sanitation and the prevention of disease, always in its regional geographic setting. Mr. Learmonth's study will form a step towards a needed survey of medical geography of Indo-Pakistan. Upon this in turn may be laid the study of hea!th and disease, described by Crew as the natural reactions of individual and group 'in body, mind and spirit" to their "total external world", and one would add to one another and ultimately to mankind.

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PROGRESS REPORT (continued.) B. Britain. Having decided, with Mr. Learmonth, that an exploratory study of the "human ecology" of Indo-Pakistan was feasible in terms of its medical geography, the next~I step was to consider the problem of exploring the medical geography of Britain. Her4 the natural environment has been so transformed that the basis of geography in natural factors of human ecology, though still present as an irremovable foundation, has been overlayed by successive and accumulating layers of historic and contemporary change. While so much more is known than in countries where physicians, clinics and laboratories are scarce, the facts are less outstanding. Great epidemics have virtually ceased and severe endemic disease has been overcome by a combination of improved living conditions. The problem is thus exceedingly complex. There is an enormous body of material, but, as the standard of health rises and with it the aims of social medicine, there is more and more to be learned before a synthesis is approached. At first sight Scotland appeared to members of the Commission to offer a suggestive field for inquiry by virtue of its extremes of environment and m o d e of life from the crowded conurbation of Clyde-side, centered upon a built-up area of a million and a quarter people and linked to the larger regional conurbation of Clyde-Forth, to the rural farming areas of the Lowlands and, beyond, to the Outer Hebrides. On Clyde-side the crudest, early "'paleotechnic" phase of heavy industry based on mining still maintains momentum in spite of the high skill of the shipbuilders and other engineers and workers. Mining upon which serfdom was reimposed after 1600 and only abolished by law in 1799 and in virtual practice after 1840 has slowly been improved in its conditions of health; but since 1980 unemployment had too much offset improvement until 1939. Finer skills had been m/~intained and advanced to a "neotechnic" phase in Edinburgh and Aberdeen but in Dundee the poverty and male unemployment associated with over-dependence upon the jute industry had led to the worst housing and social conditions o t a n y city in the United Kingdom and Northern Ireland outside Belfast. Difficulties of inquiry proved to be greater than one had foreseen. The peasant "crofting" communities of the Hebrides were so small that, statistically, no conclusions could be drawn from the incidence of specific diseases. The high rate of temporary migration among its people, many of whom earn in Glasgow, as seamen, or over-seas makes it impossible to differentiate between the effects of life at home and abroad. Finally, the "standardizing factors" applied to health statistics are only now being brought up to date. having until recentl), been related to the age-group deaths and the age-group population of 1930-82 and the population pattern of 1911. Conditions for standardizing the statistics for England and Wales, already somewhat better will shortly be up to date. In spite of these draw-backs, the distribution of health and disease in Britain deserves a brief outline. The most outstanding frontier between conditions follows roughly the line from the Severn to the Tees. To the northwest the standardized mortality rates for all agegroups are much higher than to the southwest. So much is, broadly speaking, a matter of common knowleage among o~cers of public health. Nevertheless, the complexity of localized response has never been disentangled, nor has any serious attempt yet been made to map and publish a series of distributions of standardized mortality rate, as a whole and by age groups according to the location of population, occupation, and type of housing. Nor has any atlas, even in terms of administrative units, been published of the distribution of specific diseases. A series of draft maps was prepared by a partially trained research student in geography and they proved highly suggestive of the possibilities of mapping health and disease and relating these both to the facts normally considered by health authorities and those which form the normal basis for works on the economic geography of Britain. (One cannot as yet streak of any regional work upon the social geography of Britain as a whole.) The non-British members of the Commission were struck by the general pattern of mortality and of specific diseases. While mortality, as stated, showed a marked frontier line or zone from Severn to Tees, certain specific diseases followed the same line, others a line from Severn to the Humber and yet others a line bending north from the Severn then eastward to the Teesmouth.

Report to the IGU 1952 Conm~ission on Medical

Geography

The problem of morbidity in relation to environment in N-W Britain is urgent both in view of efficiency in production and of community life in general. Research workers in medicine feel that the Survey of Sickness carried out on behalf of the Registrar General for England and Wales does not answer the urgent question of what is causing morbidity. Scotland lacks even this survey. Througho.ut the northwest morbidity may be regarded as only one, unconscious expression of maladjustment with conditions, and the more conscious form, expressed by migration, is a major factor. Migration, abroad and to the Greater London region, was greatest during the depression of the 30's from South Wales but was also severe from Lancashire, northeastern England and Clyde-side. By contrast with England and Wales as a whole, the condition of Scotland was grave, for it led to a loss of manhood in its prime and a disbalance between the sexes at home, increasing rather than diminishing the poverty of the nation. The most significant inquiry into the effects of unemployment of men among unemployed men in Britain was that conducted during 1936-39 in Dundee, but never published. It showed the gradual loss of self-reliance and capacity, self-respect and family esteem, and social cohesion, month by month from the date of loss of employment, along with loss of physical weight and muscular strength. (Trist and Chapman, communicated. ) Yet little is known even about the relation of sickness of the insured workers to social and occupational factors and still less about sickness of the noninsured or about minor ailments, without claim or benefit among the insured. It is urgently necessary to arrive at some answers to this question of the effect of "environment" upon health and happiness in the North-West. It is urgent there since, particularly in the tracts of severe unemployment successively described as "Depressed, Special and Development" Areas, changes are taking place in the location of industry, in the composition and age of the population, and in the type of sickness, as evidenced by the gravity of Tuberculosis there. The purpose of socio-medical research would be to arrive at answers as to the present and the future condition and "to assess the effect of the individual factors such as nutrition, housing, occupation, etc., within the complex of socio-economic factors which affect morbidity." (Thomson and Stein, 1950, communicated. ) Here, geographical knowledge and techniques furnish two complementary lines of attack. The first is to apply the standard techniques of regional geography to all factors, including that of health, inefficiency or disease. The technique of cartography is basic here and is detailed in the report by Professor Sorre. Let it to suffice to remind the non-geographical reader that while maps of administrative areas showing ranges of any given incidence provide a useful starting point, greater precision of location is required before space-correlations can be plotted. While the administrative map or "cartogram" is a useful spatial administrative diagram, cartography goes beyond this preliminary stage, involving as this does a deceptive "smoothing" of reality. While maps are sometimes described as the geographer's "tools", his equipment calls for the superimposition of any two (or more) maps showing associated and possibly correlated distributions: if the map is a geographer's tool, the glass topped tracing table is his loom on which he may trace the warp and weft of environment and lifeI Professor Sorre has described techniques for showing two correlated factors, such as the density and change of population upon a single map. An example will be exhibited, showing density and change in population in Bengal, to the Commission on Population, I.G.U., 1952, and a simplification of the method is employed by Mr. Learmonth. Cartography, however, is simply an important technical method for the configuration of geographic realities. The same is true for the graph showing change in time, a necessary complement of the map. They form bases for a full statement of fact and progressive interpretation of regional wholes. The second, complementary line of research is analytic rather than regional. It involves the study of specific factors contributing to disease. In certain cases, such as the incidence of weather upon the health of patients under observation, some specialist might perform this work as well or better than an all-round geographer: in fact, however, it frequently happens that a geographer s interest in the effects of phenomena of human life and their analysis as factors in vital response leads him to acquire and apply a specialist's technique. During the year 1951-52, Mr. Gordon W. Sutherland, M.A. (Honours Geography, 1952), undertook preliminary research with the collaboration and assistance of the Department of Social Medicine of the University of Edinburgh. The Commission are the more indebted to Professor Crew and his colleagues for their guidance, owing to my absence in the United States from January, 1952. It would be premature to report upon Mr. Sutherland's work to date other than by the briefest statement. The work as undertaken includes (1) An experimental investigation into the reaction of rheumatoid arthritic patients to weather change in collaboration with Dr. J. J. R. Duthie, Rheumatic Research Unit, Northern General Hospital, Edinburgh. (2) the writing of an article on "Climate and the Distribution of Disease" in conjunction with Dr. R. Passmore, M.D., to appear in the June issue of the "Practitioner", 1952. (3) Preparations for long-term research involving knowledge of (a) the cycle of disease epidemiology and (b) the results of previous investigation into the distribution of a particular disease. This study should include the geographic factors controlling (i) the incidence of bacteria and, (ii) the distribution of vectors, (iii) those, especially the climatological,

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controlling transmission of disease (e.g. air-borne infection), and (iv) those which may induce lowered resistance of the human body to infection. In the" present state of geographical training With its basic emphasis on landforms and climate (including types of weather-sequence), attention may be drawn to the possibility of locating areas of characteristic weather-sequence which may promote health or harm it. In the course of a study upon Planning and Climate: climates of region, locality and site ', (1946) my attention was drawn by medical colleagues to the work of the Medical Officer of Health for Glasgow, then Sir Alexander MacGregor, showing how the occurence of frost with fog was followed three days later by a high death rate from respiratory complaints among infants and old folk, particularly in the poorer, lower-lying and foggier quarters of the city. In course of correspondence on the subject, it became evident that the knowledge acquired by observation of sequence and time-lag could be effectively applied to the choice of sites given by appropriate surveys of climates of locality and site such as have been undertaken by geographers in Germany and Britain. In geography, in which the study of environment is centered upon its inter-relationship with mankind, the climate of a deserted (or very thinly inhabited) region is of far less importance than the climate of a locality of which the component sites are densely populated. The requirements for sites should depend upon their use during school or shopping hours, employment hours or, for homes, through day and night. In conclusion, regional studies must, so far as possible, be linked together by maps on continental and world scale, each with its corresponding text f o r its interpretat_ion. In addition to the work of Dr. J. M. May and Professor Max Sorre, mention should be made of the current work of Professor E. Rodenwaldt, M.D., Heidelberg, who is preparing an atlas of medical geography of which the first part was to be published in 1951-52. This atlas is not to form a continuation of the Seuchenatlas, printed for purposes of war by the German government. Professor Rodenwaldt informs me that the presentation of the geomedical facts is based on a different, but uniform, method of portrayal. The work is being undertaken under the auspices of the United States Naval Department. Professor Rodenwaldt has utilized the publications of the League of Nations of the World Health Organization. He and his staff are endeavoring to compare these publications and their data not only with other statistics, sueh as those of population distribution and density but above all with any environmental factors obtainable. IV.

CONTEMPORARY AND HISTORICAL GEOGRAPHY OF POPULATION, HEALTH A N D DISEASE.

The geography of health and disease in peace and war is a field of inquiry for which the data are increasingly rich. Moreover, knowledge of contemporary conditions and their interpretation throws new light on the historic and archeological development of regional civilizations. Not only are the facts of the distribution of mankind at given periods important: the density in relation to resources and the conditions which permit, inhibit or prohibit natural increase or free expansion by correlation, unchecked by deficiency and disease profoundly affect social relations within communities and may transform the effects o f racial groups of nations to one another. There is space here only to touch upon major points related to medical geography. A general realization that the relation of the population to' its means of subsistence must be maintained if health is to ensue is of comparatively recent growth. The facts have been realized through history again and again but tended to be lost sight of when attention was paid to sanitation alone and the cure of specific diseases unrelated to general amelioration. The importance of this principle has been stressed by T. H. Davey, Professor of Tropical Hygiene, Liverpool School of Tropical Medicine, (1948, 1951 ). Poverty m its wide sense is the fundamental cause not only for mala m but 1 1 for other epidemic and endemic commu n icab.e d'seases. Hence, in .agricultural communities o f tropical and sub-tropical regions it is fundamental to raise the general standard of living of a people along with, or even before, attacking the .prevention of a particular disease, with one essential proviso. This is that where, as is often the case, a disease lowers efficiency so seriously as to prevent the economic advancement of a community or people through its own effort, medical cure and prevention may well come first. Davey remarks that it is not the function of the doctor to assess priorities for the development of primitive", or traditional, "communities". That extremely difficult task must be undertaken by help of teamwork an,d, a geographer wou!d suggest, by means of what has earlier been summed up as geotechnics . It is ' fundamentally important for the doctor to realize his role in development, and often to accept with good grace a temporarily subordinate place in the general scheme . . . The greatest benefit to the health of the community will be found along the lines of disease prevention, and in the early stages of development effort and expenditure should be concentrated in this direction. Later, conditions will arise as a result of an improved economy, in which urbanization and industrialization will require the introduction of our western medical organization," but the time for this is not yet ripe in primitive communities. This holds true even for peoples of ancient civilization which we increasingly realize has decayed owing to an excess of populaton over resources which have frequently undergone long sustained decline.

Report to the IGU 1952 Commission on Medical Geography

To put the matter as a layman may, two steps must be taken to allow mankind to ascend above the poverty line. Below this must be found a lack of health and susceptibility to epidemic or endemic disease. A check in population is not only a disaster to those concerned but a symptom of a pathological condition. It is sometimes said that a check in population is a remedy to over-population: an almost equally self-evident truth to say that death is a cure for dying. Only when statistics are considered not as mere totals of individuals, upon which nature makes arithmetical sums of multiplication, addition or subtraction, but as enumerations implying human relations in widening circles from the family and kin to the village, the neighborhood, the region and the city. The first step toward passing the poverty line must reach a bare sufficiency of needs: food and drink, clothing, firing and shelter. The second must allow of adequate quantity and kind. The diet must be adequately composed, the water clean or properly treated (as by the Chinese peasant in prosperity), there must be at least one change of clothing to allow washing without which parasites and vectors of disease will breed and gather and in mortal epidemics be passed from the bodies of the dead to infect the living with death. There must be firing to cook food, warm the body, sometimes to allow of smoke to diminish insect vectors by night and of a kind which makes it unnecessary to destroy fertility, as is done by burning dung where forests are lacking or have been destroyed. There must be shelter or the health of individuals will suffer and over-crowding bring ill health and encourage contagion. A geographical contribution to the interpretation of periodic rises and falls in the development or decay of material civilization and spiritual culture is being developed, primarily in terms of the relationship of clearance and colonization to limits increasingly discoverable by help of the cartography of contemporary and recent utilization of the land, and secondarily of the sites and development of cities. The example of India is as yet a comparatively open field for which the materials are increasingly available. In England the studies of Postan in economic history and geography from the Domesday survey to the present day are complementary; they provide a basis for estimates of livelihood in terms of the relationship of subsistence to population, its numbers and its health or disease. In Scotland the mapping of cultivation and the foundation and growth of settlements, linked to a knowledge of the manner of increase of populations to a point at which they exceed the expansion of subsistence, may throw light on the health of all classes of the people and with this of their individual and social psychology, their culture in its fullest sense. V.

HISTORICAL GEOGRAPHY OF HEALTH AND DISEASE IN WAR.

In a brilliant historical sketch entitled "Rats, Lice and History", Zinnser has outlined the importance of-health and disease in its bodily and mental effects upon peoples through history in peace and war. In a chapter entitled "On The Importance of Lice and the Unimportance of Generals" he has stressed the importance of typhus, of which lice are carriers, in deciding the issues of campaigns. The chapter might have been read with profit not only by a Tolstoy, as a philosopher of history, but by generals throughout the nineteenth century. In the Crimea, the American Civil War, the Franco-German War of 1870-71 and the Boer War of 1899-1902, battle deaths and even mortally septic wounds formed an insignificant fraction of deaths from disease. In the Russo-Japanese war really effective health measures were observed for the first time by one side, that of the victors. In the Balkan Wars, the Balkan allies, hitherto victorious, met defeat by cholera during their investment of the Chatlja Lines at the gates of Constantinople. Even in the 1914-1918 war and its aftermath, the sickness and deaths from 'trench fever" often communicated behind the lines in lice-infested barns, from influenza and from venereal disease took formidable toll of health and life. The cordon sanitaire by which the inhabitants of the devastated lands of the western Russian Empire were roped off with little assistance, hid the effects of typhus from general knowledge. In Burma the health of the troops, both European and Indian, was cared for with unprecedented success, in view of the enormous difficulties (Bruce c. 1949). The same was true in other fields of the last war (Aird, 1944). Not only the physical, but the psychological morale of the men was looked after with skilled and sympathetic, though dispassionate, care by methods which had only begun to be tried by 1918 but have been continued since. The publication of the British Medical History of the War, edited by Prof. (Brigadier) F.A.E. Crew, will increase our knowledge not only of military but of civilian medical geography, to which, as Prof. Crew remarks, it will form a contribution. But the sufferings of the cotton-clad Chinese armies, retreating into the hills before the Japanese, led to deaths which fa~ surpassed battle losses, heavy though these were. Here, too, the deaths of civilians followed, doubtless in yet greater numbers. The same may prove true in Korea. Napoleon's disastrous retreat from Moscow, preceded by his almost more disastrous advance, offers perhaps the first case in history of clearly recorded data in the medical geography ,of war. As Zinnser has noted, the observations of the surgeon general of Napoleon s Grand Army recorded the temperatures and (approximately) the incidence of sunshine, drought or-rainfall together with the health and, number of the troops. The facts of Napoleon's advance to Moscow and his retreat are outlined in the accompanying diagram which sketches the facts of actual weather experienced

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by the rank and file of the Grand Army. Much simplified for reproduction on a small scale, the general rise and fall of the temperature and precipitation experienced are indicated. At the end of May, leaving behind them the relative comfoi't of well-filled barns, the Grand Army, now some 425,000 strong, crossed the Vistula and faced in all their splendour of scarlet, blue and gold, and glittering steel - the heat and cold, the drought and rain, the lack of shelter or the filth of poverty-stricken hovels for which their equipment left them defenceless. Through June the eastward march brought them to rising temperatures by day but cold in the nights, spent shivering in bivouacs; sore throats and cases of pneumonia were common. Heavy showers and thunderstorms at the beginning and end of July soaked the men's tunics, while the Niemen and other flooded rivers had to be forded. Rain drove the men to seek shelter where they might fiind it; lice infested their uniforms and typhus broke out. Provisions were running short and the men suffered from hunger. At the beginning of August came heavy rains and floods followed by heat, and drought, with dust that filled their throats as they tramped along the rutted, unmade roads, halting to drink fouled water when they found it. Dysentery began and the Army dwindled. Meantime the two Russian armies from North and South had joined in a single force which may have numbered 40,000 men and gave battle at Smolensk before falling back. Men fell in battle but they were outnumbered by the wounded, among whom sepsis brought high mortalitv. Some 8,000 deaths resulted; yet the figure was small compared to the loss of effectives already sustained by disease. On August 7th the Russian army stood its ground once more, on the Moskva river at Borodino, and the slaughter and septic wounds ca.used some 40,000 deaths. The impression on the men was terrible; yet those left behind by the way, many of them to die, outnumbered the dead on the stricken field. On September 14th, the Grand Army entered Moscow without resistance, but fewer than 100,000 men of the 425,000 men who had set out stood to answer the roll call. Rations were short. Shelter there was, but it was none too clean and typhus broke out again, offsetting the slight increase due to the arrival of stragglers. For over a month the Army halted. The fire of Moscow broke out; shelter was scarce. Unable to advance further to seek out an enemy which destroyed food and shelter in its retreat, unable to feed his army in a half-starved land and threatened by the first falling snow, Napoleon at last decided on evacuation. On October 19th, the retreat from Moscow began. The rest is well known. Cold grew and snow fell, with a severity somewhat exceeding the 'means' established from previous years and upon which Napoleon had rashly reckoned. Bivouacing in snow that lay ever deeper through November and December, wearied by skirmishing Cossacks who fell upon them from the forests then sped away, suffering from frost-bite, and deaths from exposure, the Army dwindled. Meantime the Russians, living on their country, gathered in strength, approaching some 100,000 men or more when, at the start of January, Napoleon re-entered Germany with a remnant he no longer led, and numbering no more than 20,000 broken men. Now, it is significant that for the most part, military historians have dwelt upon the battles and the dramatically tragic retreat from which all suffered, officers and men almost alike. It is the Surgeon General who brings out the essentials of truth with his observations of changes in weather, in food and water, shelter from cleanliness to dirt from which officers were partly protected, and the deadly effects of wrong conditions upon the 'common soldier' and the campaign. Of the effect of the campaign upon 'civilians' -- men, women and children - historians for the most part are silent. REFERENCES

:

Aird, Ian (1944), "Military Surgery in Geographical Perspective: A Libyan Exercise in Surgical Strategy and Tactics." Edin. Med. ]., Vol. LI., pp. 166-188. Bruce, John (c. 1949), "Surgery in Far Eastern Theatres of War." (Reference not supplied. ) Crew, F. A. E. (1944), "Inaugural Lecture to the Chair of Social Medicine."

Edin. Univ. 1. Davey, T. H. (1948), "M.igration as a Factor in the Adjustment Of National Populations," Proc. Internat. Congress on Population and World Resources in Relation to the Family. Mimeographed pp. 65-84. (1949), "'The Effect of Population Growth on the Advancement of Undeveloped Communities." Rev. Internat. Co-op., October. (4 pp.)

Geddes, Arthur (1948), "Geography, Sociology, and Psychology: A Plea for Coordination, with an Example from India." Geog. Rev., Vol. 88, pp. 590-97. Learmonth, A. T. A. (1952), "Regional Differences in Natality and in Llortality in the Sub-Continent of IndoPakistan, (t.G.U.) Passmore, R. and Sutherland, G. W.. (1952), "Climate and the Distribution of Disease." Practitioner (forthcoming, June). Rodenwaldt, E., M.D. (current), Communication on atlas of medical geography. Sigerist, H. E., (1951), "History of Medicine." Sorre, Max, ( 2nd ed. 1951 ), "Fondements De Geographie Humaine: I Fondements Biologiques."

Report to the IGU 1952 Commission on Medical

Thomson, J. G., M.D., Ch.B., and Stein, Lili, B.Sc., of the Department of. Social Medicine, University of Edinburgh. Communication. Williams, A. Hyatt, M.D. (1950), "'A Psychiatric Study of Indian Soldiers

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in the Arakan." Brit. 1. Med, Psychology, Vol. XXIII, Parts 8 & 4, 1950, pp. 130-181. Zinnser, (c. 1935-88), "Rats, Lice and History."

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