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Approaches to medical geography: An historical perspective
Sec.Sci. Med. Vol.20,No. 4,pp.399-409,1985 Printed in Great Britain. All rights reserved
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0277.9536/85 S3.00+ 0.00 1985 Pergamon Press Ltd
APPROACHES TO MEDICAL GEOGRAPHY: AN HISTORICAL PERSPECTIVE BIMAL KANTI PAUL* Department
of Geography,
Kent State University,
Kent, OH 44242, U.S.A.
Abstract-This paper provides a brief account of the development of various approaches to medical geography through a tree diagram. It is possible to visually present six important aspects of medical geography through this diagram: various approaches to medical geography; the approximate time of their developments; the mother approaches from which they originated; their relationships with other approaches; scale; and extent of studies done in the past.
Disease ecology
INTRODUCTION Medical geography has now become a well recognized subfield of geography. From its inception in the late eighteenth century to its present state, a number of approaches have developed, which, in fact, have contributed to the development of this subfield. The aim of this paper is to introduce some of these approaches in a chronological order. Though Pyle [ 1 ] successfully performed this job in 1977, the main distinction here lies in the mode of presentation of the approaches. Pyle [ 1 ] summarized various approaches to medical geography through a cross-tabulation. He considered eight different approaches that evolved in medical geography prior to 1977. These approaches were shown horizontally against eight different geographic scales, ranging from worldwide coverage to those of no particularly specified geographical concern, which were shown vertically. This has resulted in sixty four square cells. Two different shades were used to fill some of these cells. The darker shade represented the areas where considerable work had been accomplished; the lighter shade symbolized fewer studies. The empty cells, on the other hand, were areas where very little works has been done. In this paper, the historical development of various approaches to medical geography is summarized through a tree diagram (Fig. 1). Besides showing the scale and extent of work done, the diagram also depicts the approximate time of development of various approaches; the mother approaches from which they originated; relationships with other approaches; and the two development periods of medical geography. MAJOR APPROACHES It is very difficult approaches to medical
‘Disease ecology’ or ‘geographic pathology’ is the oldest approach to medical geography. Though its origin may be traced back to the work of Hippocrates [2,3], a number of German physicians (e.g. Finke, Schnurrer, Fuchs, Muhry), whom Barrett [4] called ‘early geographical pathologists’, laid the foundation of the disease ecology approach in the late eighteenth and early nineteenth centuries [5]. Until the end of the nineteenth century, these German physicians tried to understand the pathology of diseases through the disease ecology approach. Unfortunately, little work was done on disease ecology from the late nineteenth to the middle of the twentieth century. May, who is considered the twentieth century exponent of the disease ecological approach to medical geography, almost single-handedly introduced the approach in the early 1950s through his association with the American Geographical Society [6]. He emphasized the holistic-interactive nature of disease systems and delineated the inter-relationships between living organisms, the physical and biological environments within which they interact and the role of human cultural behavior in the success of the disease system [7]. Most works of Armstrong, Audy. Dunn, Hunter, Learmonth and McGlashan fall within this approach to medical geography.
TO MEDICAL GEOGRAPHY
to objectively classify various geography because of the fact
that they are not mutually exclusive, but rather, have strong relationships with one another. Considering the multicausal and multidimensional nature of medical geography, a seven-fold classification is outlined here. Note that the number of approaches may vary from person to person since there is no basis for objectively dividing the approaches. *Bimal Kanti Paul, currently a University Fellow in Geography at the Kent State University, is Assistant Professor (on study leave) from the Department of Geography, University of Dhaka, Dhaka, Bangladesh.
Fig. 1. Development with: little works -; p-p;
399
period: early CD; modern a. Period numerous works __ Scale: large small and large
400
BIMAL KANTI PAUL
In the most general sense, disease ecology is the interaction of man with his total environment. The principal goal of disease ecology is to understand the dynamics of disease which vary according to climate, vegetation, mineral traces in water and bedrock minerals [8]. Disease is viewed by the disease ecologists as maladaptation between organism, culture and environment, requiring the coincidence in time and space of agent, pathogen and host [3,7,8]. Henschen [9] divides these into endogenous factors operating within the patient and exogenous or outside factors, such as culture. The theme of disease ecology has changed little since its inception in the eighteenth century as ‘geographic pathology’. Some conceptual differences, however, began to appear within the literature of disease ecology near the end of the 1960s. These differences can be partly attributed to the increased amount of attention some geographers were giving to the concept of disease causation through cartographic knowledge, as opposed to May’s increasing tendency to view medical geography as a question of understanding the processes of disease ecology [lo]. Disease mupping Disease mapping has been playing an important role in medical geography since the late eighteenth century. Probably the first attempt to produce a disease map was made in the United States by some physicians. In the words of Spencer [ 111, “the mapping of disease in America germinated in the virus of yellow fever and blossomed in the cholera vibrio”. A careful search of relevant documents indicates that the maps produced by Seaman and Pascalis are believed to be among the earliest examples of disease mapping [ 12,13 1. Seaman’s map, published in 1798, shows the locations of residences of persons affected by yellow fever in 1796 in New Slip, New York. Pascalis also mapped the distribution of yellow fever cases in the Old Slip area of New York. Both of them aimed, in producing these maps, at disproving the general notion prevailing at that time that yellow fever was contagious and an imported disease [ 141. The mapping of cholera in the United States started around the middle of the nineteenth century. As in the maps for yellow fever, the ‘dot’ method was used in the cholera maps to depict the localized epidemic pattern. In both cases, the scale of the map was fairly large. Apart from the ‘dot’ map, ‘progress’ maps were also used to illustrate the epidemic’s flow along the inland waterways. These were relatively small-scale maps. Both ‘dot’ and ‘progress’ maps were useful because they demonstrated a visual method of presenting the epidemic theories of the time. The first medical map in Germany was produced by Berghaus in 1847. This is also the first known map that attempts to show distribution of various diseases on a world scale [ 15, 16 3, Following Berghaus’ lead, Fuchs’ first German-language medical geography textbook included eleven maps [ 151. Muhry also included one map in his book, which appeared in 1856. In his map, Muhry related the distribution of diseases over the world to the climatic zones and marked isothermal lines, isocheims, etc. Since a considerable number of work was done on disease mapping during the late eighteenth and the
first half ofthe nineteenth century, Gilbert [ 171 termed this period the ‘golden age’ of medical geography. A waning interest in disease mapping. however, was observed during the second part of the nineteenth and the first part of the twentieth century. But the years since the Second World War have seen a considerable upsurge of interest in disease mapping [l&19]. an interest which is regarded as a ‘renaissance of medical cartography’ [20]. The World Atlas qf Disease, published by the American Geographical Society under the direction of May. represents a major landmark in the disease mapping of the twentieth century. The atlas contains both large and small-scale maps, in which diseases are shown by simple shading or symbols. A similar attempt was undertaken by Rodenwaldt and Jusatz, who produced the three-volume World Atlas qf‘ Epidemic Diseases [21]. The works of Rodenwaldt and Jusatz are monumental, in comattempts to define parison to previous environmentally-oriented diseases [22]. Howe’s [23] National Atlas of Disease in the United Kingdom is another addition to the mapping of diseases. Within the United States, Murray [24] developed comparable studies ofdisease mapping in the mid-1960s. Pyle [25] and Dever [26] also contributed in this area. Like the disease maps of the early developmental period, both small and large-scale maps have been produced in the period following World War II. But, more recently, the objectives of disease mapping have become more important than just producing maps as a means of illustration. Moreover, the period is characterized by the application of various cartographic techniques. Associatiue anulyses Although disease maps can identify certain kinds of causal links, such attempts are best strengthened by concurrent statistical or associative analyses. This led to the emergence, during the mid-to-late 1960s of a new approach to medical geography termed ‘associative’ by McGlashan [lo]. The principal aim of the associative analyses is to identify hypothesized risk factors for a given disease and to measure their statistical associations with the disease on different geographical scales, using univariate, bivariate or multivariate methods. Murray’s [24] studies ofdisease distributions within the United States and of differences among specific cultures and sub-cultures exemplify such a trend. McGlashan has successfully accomplished various types of probability mapping with statistical tests at the regional and urban levels. It is also possible, through the use of multivariate analyses, to offer multiple explanations of disease, as did Pyle [25] for chronic ailments within the Chicago area. A well designed research methodology is required for associative analyses. This is partly due to the fact that the interpretation of the results of associative studies largely depends on the geographic scale. Particular conclusions that might be reached at the international scale may not be substantiated at a microgeographic scale. Pyle [27] listed some of the errors of associative studies, which include sampling formulations, problems, control errors, improper misclassifications and spurious conclusions. The
Approaches
to medical
geography:
validity of any such associative studies basically depends on the reasonable and correct use of ‘bestfitting’ techniques.
Disease diflision Studies of disease diffusion largely utilize the formal geographical diffusion theory in the analysis of disease distribution and dynamics, and thus the approach evolved after diffusion had become an important ingredient in geographic research by early 1960. But the concept of disease diffusion is implicit in Hirsch’s (1883-1886) works of the late nineteenth century. His works represent accounts of mechanisms possibly contributing to the diffusion of disease from a pathogenetic point of view. Such an approach is particularly concerned with the influence of the physical environment. Thus Hirsch’s concept of the spread of disease has much in common with the disease ecological approach of medical geography. The particular advantage of the disease diffusion approach is that it makes it possible to simultaneously view time and space in relation to the disease being studied. Hunter’s [28] landmark 1966 study of river blindness is such an example. Other examples of disease diffusion include the works of Girt [27], Haggett [30], Kwofie [31], Patterson and Pyle [ 32,34 1. Most studies of disease diffusion have concentrated either on the development of highly abstract models of diffusion processes or on analyzing past outbreaks of communicable diseases. These studies have resulted in the understanding of many major principles of disease diffusion and processes of diffusion which might have been instrumental in predicting the spread of disease [34]. They also offer a variety of approaches and explanations to problems of disease diffusion. But they share some common ground in the sense that they test different hypotheses with a view to offering explanations beyond the generally more static descriptions resulting from disease mapping [35]. Geography of nutrition Geography of nutrition is one of the more recent approaches to medical geography to emerge. This approach finds its origin in some of the later works of May [36,37]. With the help of Donna, May [36] compiled a massive series of bench-mark surveys on the state of nutrition and of knowledge about nutrition and malnutrition over nearly all the world in the early 1970s. Following May, a few studies were done on nutrition or related aspects of health, particularly that of the Third World countries [38-421. The study of nutrition has a direct link with the ecological approach to medical geography, since many geographical factors are involved in nutrition. Among them, topography, climate and soil are very important. Climate, in most instances, affects the amount and nature of food available. Particular crops can only be grown under particular climatic and soil conditions. The direct effects of climate on health and disease are also important. For example, calorie requirements vary according to temperature conditions. Also, the need for salt is greater in tropical climates, as much is lost in the form of sweat.
an historical
perspective
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Geography of health care As noted earlier, medical geography has traditionally emphasized the spatial study of diseases and their possible etiologies, but the scope of study has recently been expanded. Since the mid-1960s geographers have paid increasing attention to such aspects as health-care planning, health-seeking behavior and health service provision. Thus, geographical concern with the provision of health-care services developed historically after the ecological approach to the study of medical geography. The development of this approach parallels, in many ways, the development of the geographical study of public services in general. This approach, however, is rooted deeply in location theory, theories of public service provision, transport geography and philosophical issues. From the onset, the goal of spatial studies of medical care has revolved around normative considerations, particularly those dealing with locational and distributional aspects of health-care facilities and health-care providers. Most of these studies evolved from the general exposition of location and central place theory. It is implicitly understood that in order to get the required service, a patient has to travel to the appropriate health facility. This usually depends on the type of specialities he requires. Thus, the system of health-care facilities can be viewed as a theoretical hierarchy of locations with equivalent degrees of attraction, and distances travelled will vary in a regular manner depending upon facility size and the range of specialities offered [43]. This concept and central place theory ultimately led to the development of spatial allocations models in health-care geography. Transportation, distance and hospital size are the main elements of the allocation models. The earliest form of this model is found in the work of Godlund [44]. Mulvihill [45], Bennett [46] and Mohan [47] recently applied the allocation models in health facility locations. Spatial studies of the use of health-care resources often produce results indicating various forms of maldistribution. In a detailed study of physician location behavior, Shannon and Dever [48] have offered several overlapping explanations. Important factors considered in such behavior include economic pull, the proximity to medical schools, the scale of facilities available, the attraction of metropolitan centers and especially of prosperous areas within them [49 I. Although there have been numerous studies of health service systems and of physician and provider distribution, most of these studies were conducted in an attempt to optimize access to health facilities. Of the two main dimensions of access (spatial and aspatial), geographers are more interested in the spatial aspect. Here again, distance plays a vital role because it is considered the principal constraint to spatial access to health-care facilities. Since a health facility is not always located in the center of its service area, there is often a spatial inequality or spatial disparity with regard to both availability and utilization of the resources. This may also happen if there exists a tremendous and unnecessary duplication in available services. This disparity, however, may be minimized to
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a greater extent by modifying the existing institutional settings and characteristics of both the delivery system and the potential users by relocating the facility. This sometimes involves regionalization of health-care, which has become a widespread goal of a number of developed countries [50]. Here, regionalization basically refers to the regional planning and coordination of health services delivery. Adequate health-care planning requires knowledge of the principles of disease distribution, dynamics and spread. As Mayer [51 ] noted, “certain types of regions will have particular public health problems associated with them that are absent or less significant elsewhere”. Moreover, there is the potential for developing predictive disease diffusion models to anticipate the movement of diseases, particularly communicable ones. This will show where there is a need for disease control strategies. Adequate health service planning further requires sophisticated epidemiological knowledge. This implies that optimal location policies are predicated on locating facilities in areas of need. The objective function of a locational problem, therefore, involves minimization of travel time or distance between areas of need and potential facilities’ locations. Too often, the distribution of population as a whole is used to estimate need. Since diseases are unequally distributed within a given population, it is preferable to use population at risk for disease to estimate need [5 1,521. Studies on health care providers have been accomplished, in general, on regional and local levels. It is, however, possible in such studies to develop highly sophisticated, process-oriented analyses of human responses to disease patterns and utilization of health-care facilities. Since health-care geography often deals with problems of access to health facilities, it can be linked to an important stream of thought in human geography, which is termed welfare geography [53]. Ethnomedicine
and medical
pluralism
The type of health systems existing in developing countries differ greatly from those of developed nations. The fundamental difference is that most nonWestern nations have dual medical systems: indigenous medicine and Western or modern medicine [54-561. According to some estimates, traditional medical practitioners-including herbalists, diviners, midwives, spiritualists and others-form the main body of primary health workers for up to 90 % of rural populations [57]. Moreover, evidence from Ghana, India, Kenya, the Philippines, Sri Lanka, Zambia and many other developing countries [54-56,581, shows that urban people also depend on and patronize traditional medical systems. It is well known that modern medical practitioners are few in number compared to the total population of the developing world. Moreover, they are unevenly distributed-concentrated primarily in the urban areas. Therefore, they are physically inaccessible to the vast majority of rural people. But widespread utilization of traditional healers and other indigenous health resources is not explained simply by inaccessibility to or shortage of modern medical practitioners. They are culturally, socially, and environmentally closer to the people and hence more
accessible. They are also more sympathetic and less expensive [59]. They use local resources (herbs, metals, etc.), local technology and local labor. Though hardly more than a dozen published works by geographers focus on the traditional medical systems ofdevelopingcountries, also called ethnomedicine and medical pluralism. this approach is slowly emerging. Recently, a number of medical geographers [5,34,55-571 made a plea for conducting research on ethnomedicine and medical pluralism. Good [57] contends that: It is long overdue for medical geographers (the “disease ecology” specialists as well as those doing health delivery systems analysis and planning) to ask why and how traditional medicine relates to our individual and collective research and teaching programs. Furthermore, Good [55,57] recently outlined the probable areas of research on traditional health-care systems. In the context of the World Health Organization’s (WHO) recent recognition of the importance of traditional medicine and the subsequent incorporation of it in WHO’s Primary Health Care Strategy [60], the above plea is a timely one. In addition to WHO, some governments of Third World countries such as Bangladesh and India, have acknowledged the contributions of traditional medicine and have already taken steps to integrate it into the national primary health care system. CONCLUSION
An attempt has been made in this paper to provide an account of the development of various approaches to medical geography. The main points emerging from the paper are summarized here. It is evident from the above that the development of medical geography occurred in two distinct time periods. The early development of the discipline began in Germany in the late eighteenth century. Numerous studies were done during its early developmental period, which extended up to the 1860s and 1870s. During this period, two important approaches to medical geography (disease ecology and disease mapping) evolved. The modern period of the discipline, however, began after the Second World War. The remaining five approaches to medical geography, as listed earlier, developed during this period. Between the early and modern development period, little interest was shown in the study of disease patterns. It is interesting to note that it was the physician, not the geographer, who contributed solely to the early development of medical geography. In contrast, the current development of the discipline is being widely contributed to by the geographer. It is further evident that associative analyses developed from disease mapping in the mid-to-late 1960s. At about the same time, disease diffusion also evolved as an approach of medical geography. But the concept of disease diffusion may also be linked to the works of Hirsch (1883-1886). Since his works have much common ground with the disease ecological approach, disease diffusion is considered as having evolved from disease ecology. Geography of nutrition also developed from disease ecology in the early 1970s. Ethnomedicine and medical pluralism, on the other hand, are emerging as an independent approach to
Approaches to medical geography: an historical perspective medical geography from the geography of health-care. The classification outlined in the present paper indicates that various approaches to medical geography are relevant to one another. Disease ecology, disease associative analyses, disease mapping, diffusion and nutrition studies are interrelated since all of these approaches either directly or indirectly aim to understand the multiplicity of geographical factors involved in disease causation. The basic tenet of disease ecology is to study relationships between natural environment and diseases, while the researchers interested in disease mapping and associative analyses try to develop various methodologies for detailed mapping of disease patterns in order to identify the causal links between diseases and other factors, Some medical geographers produce analyses of the geographical spread, or diffusion of diseases, from endemic foci to other places in time and space with a view to identifying the factors involved in the diffusion processes. Health-care geography, on the other hand, is related to ethnomedicine and medical pluralism. Thus, the suggested seven approaches do seem to represent viable clusters of approach specialization. Indeed, we find two such clusters which correspond to the two major approaches of medical geography: ecological approach and health-care approach. Based on the points summarized in this section, it is possible to visually express the historical development of medical geography through a tree diagram (Fig. 1). The diagram depicts six important aspects of medical geography: varidus approaches to medical geography; the approximate time of their developments; the mother approaches from which they originated; their relationships with other approaches; scale; and extent of studies done in the past. As can be seen from the diagram, bold and thin lines are used to indicate the extent of work done so far on various aspects of medical geography. If a period is shown by a thin line, it means few studies were done during that particular period. The bold line, in contrast, indicates the reverse situation. Geographical scales of studies are shown by three different types of broken lines. Three different scales are considered: small (national to worldwide coverage); large (individual to regional coverage); and a combination of small and large scales. Interrelationships between approaches are shown by the crossing of continuous lines. The diagram also shows the two development periods of medical geography. Two different shades are used for the two periods. It is evident from this paper that different geographic regions have their own interests with respect to specific approaches. For example, in the United States, the main thrust of research in medical geography is on health-care planning, while in the United Kingdom the main emphasis is on disease mapping and regional synthesis of health problems. Finally, it is observed that areas such as behavioral aspects of illness, ethnomedicine and medical pluralism and nutrition, that are so crucial in the context of the Third World countries, have been neglected. More studies need to emphasize these areas. Acknowledgement~The Bhardwaj, Professor
author is grateful to Dr S. M. of Geography, Kent State University,
Ohio, for his helpful comments draft of this paper.
403 and suggestions
on an earlier
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COMMENTARIES DIRECTIONS FOR MEDICAL GEOGRAPHY IN THE 1980s: SOME OBSERVATIONS FROM THE UNITED KINGDOM DAVID R. PHILLIPS Department of Geography, University Mr Paul has provided an interesting overview of the evolutionary development of various strands of medical geography. It is important to view a subject in its historical context and relatively few analyses of medical geography to date have adopted such a perspective. Perhaps this has been because previously there were relatively few geographers who regarded themselves solely as medical geographers; at least this has been the case in Britain and North America. As a result, the conceptualisation of the subject has arguably lagged behind its empirical development.
of Exeter. Exeter, England
This picture has changed in the past decade, however, and medical geography has emerged as a strong and robust subject which has demonstrated the ability to adapt to changes in the discipline as a whole and even to advance certain methodological and philosophical developments itself, as has been illustrated with regard to postwar British medical geography [I 1. Indeed, some important advances in, for example, quantitative spatial analysis have been made by geographers working in medical fields; the individualistic research orientation of the behavioural revolution has also been
Copyright 0
0277.9536/85 S3.00+ 0.00 1985 Pergamon Press Ltd
APPROACHES TO MEDICAL GEOGRAPHY: AN HISTORICAL PERSPECTIVE BIMAL KANTI PAUL* Department
of Geography,
Kent State University,
Kent, OH 44242, U.S.A.
Abstract-This paper provides a brief account of the development of various approaches to medical geography through a tree diagram. It is possible to visually present six important aspects of medical geography through this diagram: various approaches to medical geography; the approximate time of their developments; the mother approaches from which they originated; their relationships with other approaches; scale; and extent of studies done in the past.
Disease ecology
INTRODUCTION Medical geography has now become a well recognized subfield of geography. From its inception in the late eighteenth century to its present state, a number of approaches have developed, which, in fact, have contributed to the development of this subfield. The aim of this paper is to introduce some of these approaches in a chronological order. Though Pyle [ 1 ] successfully performed this job in 1977, the main distinction here lies in the mode of presentation of the approaches. Pyle [ 1 ] summarized various approaches to medical geography through a cross-tabulation. He considered eight different approaches that evolved in medical geography prior to 1977. These approaches were shown horizontally against eight different geographic scales, ranging from worldwide coverage to those of no particularly specified geographical concern, which were shown vertically. This has resulted in sixty four square cells. Two different shades were used to fill some of these cells. The darker shade represented the areas where considerable work had been accomplished; the lighter shade symbolized fewer studies. The empty cells, on the other hand, were areas where very little works has been done. In this paper, the historical development of various approaches to medical geography is summarized through a tree diagram (Fig. 1). Besides showing the scale and extent of work done, the diagram also depicts the approximate time of development of various approaches; the mother approaches from which they originated; relationships with other approaches; and the two development periods of medical geography. MAJOR APPROACHES It is very difficult approaches to medical
‘Disease ecology’ or ‘geographic pathology’ is the oldest approach to medical geography. Though its origin may be traced back to the work of Hippocrates [2,3], a number of German physicians (e.g. Finke, Schnurrer, Fuchs, Muhry), whom Barrett [4] called ‘early geographical pathologists’, laid the foundation of the disease ecology approach in the late eighteenth and early nineteenth centuries [5]. Until the end of the nineteenth century, these German physicians tried to understand the pathology of diseases through the disease ecology approach. Unfortunately, little work was done on disease ecology from the late nineteenth to the middle of the twentieth century. May, who is considered the twentieth century exponent of the disease ecological approach to medical geography, almost single-handedly introduced the approach in the early 1950s through his association with the American Geographical Society [6]. He emphasized the holistic-interactive nature of disease systems and delineated the inter-relationships between living organisms, the physical and biological environments within which they interact and the role of human cultural behavior in the success of the disease system [7]. Most works of Armstrong, Audy. Dunn, Hunter, Learmonth and McGlashan fall within this approach to medical geography.
TO MEDICAL GEOGRAPHY
to objectively classify various geography because of the fact
that they are not mutually exclusive, but rather, have strong relationships with one another. Considering the multicausal and multidimensional nature of medical geography, a seven-fold classification is outlined here. Note that the number of approaches may vary from person to person since there is no basis for objectively dividing the approaches. *Bimal Kanti Paul, currently a University Fellow in Geography at the Kent State University, is Assistant Professor (on study leave) from the Department of Geography, University of Dhaka, Dhaka, Bangladesh.
Fig. 1. Development with: little works -; p-p;
399
period: early CD; modern a. Period numerous works __ Scale: large small and large
400
BIMAL KANTI PAUL
In the most general sense, disease ecology is the interaction of man with his total environment. The principal goal of disease ecology is to understand the dynamics of disease which vary according to climate, vegetation, mineral traces in water and bedrock minerals [8]. Disease is viewed by the disease ecologists as maladaptation between organism, culture and environment, requiring the coincidence in time and space of agent, pathogen and host [3,7,8]. Henschen [9] divides these into endogenous factors operating within the patient and exogenous or outside factors, such as culture. The theme of disease ecology has changed little since its inception in the eighteenth century as ‘geographic pathology’. Some conceptual differences, however, began to appear within the literature of disease ecology near the end of the 1960s. These differences can be partly attributed to the increased amount of attention some geographers were giving to the concept of disease causation through cartographic knowledge, as opposed to May’s increasing tendency to view medical geography as a question of understanding the processes of disease ecology [lo]. Disease mupping Disease mapping has been playing an important role in medical geography since the late eighteenth century. Probably the first attempt to produce a disease map was made in the United States by some physicians. In the words of Spencer [ 111, “the mapping of disease in America germinated in the virus of yellow fever and blossomed in the cholera vibrio”. A careful search of relevant documents indicates that the maps produced by Seaman and Pascalis are believed to be among the earliest examples of disease mapping [ 12,13 1. Seaman’s map, published in 1798, shows the locations of residences of persons affected by yellow fever in 1796 in New Slip, New York. Pascalis also mapped the distribution of yellow fever cases in the Old Slip area of New York. Both of them aimed, in producing these maps, at disproving the general notion prevailing at that time that yellow fever was contagious and an imported disease [ 141. The mapping of cholera in the United States started around the middle of the nineteenth century. As in the maps for yellow fever, the ‘dot’ method was used in the cholera maps to depict the localized epidemic pattern. In both cases, the scale of the map was fairly large. Apart from the ‘dot’ map, ‘progress’ maps were also used to illustrate the epidemic’s flow along the inland waterways. These were relatively small-scale maps. Both ‘dot’ and ‘progress’ maps were useful because they demonstrated a visual method of presenting the epidemic theories of the time. The first medical map in Germany was produced by Berghaus in 1847. This is also the first known map that attempts to show distribution of various diseases on a world scale [ 15, 16 3, Following Berghaus’ lead, Fuchs’ first German-language medical geography textbook included eleven maps [ 151. Muhry also included one map in his book, which appeared in 1856. In his map, Muhry related the distribution of diseases over the world to the climatic zones and marked isothermal lines, isocheims, etc. Since a considerable number of work was done on disease mapping during the late eighteenth and the
first half ofthe nineteenth century, Gilbert [ 171 termed this period the ‘golden age’ of medical geography. A waning interest in disease mapping. however, was observed during the second part of the nineteenth and the first part of the twentieth century. But the years since the Second World War have seen a considerable upsurge of interest in disease mapping [l&19]. an interest which is regarded as a ‘renaissance of medical cartography’ [20]. The World Atlas qf Disease, published by the American Geographical Society under the direction of May. represents a major landmark in the disease mapping of the twentieth century. The atlas contains both large and small-scale maps, in which diseases are shown by simple shading or symbols. A similar attempt was undertaken by Rodenwaldt and Jusatz, who produced the three-volume World Atlas qf‘ Epidemic Diseases [21]. The works of Rodenwaldt and Jusatz are monumental, in comattempts to define parison to previous environmentally-oriented diseases [22]. Howe’s [23] National Atlas of Disease in the United Kingdom is another addition to the mapping of diseases. Within the United States, Murray [24] developed comparable studies ofdisease mapping in the mid-1960s. Pyle [25] and Dever [26] also contributed in this area. Like the disease maps of the early developmental period, both small and large-scale maps have been produced in the period following World War II. But, more recently, the objectives of disease mapping have become more important than just producing maps as a means of illustration. Moreover, the period is characterized by the application of various cartographic techniques. Associatiue anulyses Although disease maps can identify certain kinds of causal links, such attempts are best strengthened by concurrent statistical or associative analyses. This led to the emergence, during the mid-to-late 1960s of a new approach to medical geography termed ‘associative’ by McGlashan [lo]. The principal aim of the associative analyses is to identify hypothesized risk factors for a given disease and to measure their statistical associations with the disease on different geographical scales, using univariate, bivariate or multivariate methods. Murray’s [24] studies ofdisease distributions within the United States and of differences among specific cultures and sub-cultures exemplify such a trend. McGlashan has successfully accomplished various types of probability mapping with statistical tests at the regional and urban levels. It is also possible, through the use of multivariate analyses, to offer multiple explanations of disease, as did Pyle [25] for chronic ailments within the Chicago area. A well designed research methodology is required for associative analyses. This is partly due to the fact that the interpretation of the results of associative studies largely depends on the geographic scale. Particular conclusions that might be reached at the international scale may not be substantiated at a microgeographic scale. Pyle [27] listed some of the errors of associative studies, which include sampling formulations, problems, control errors, improper misclassifications and spurious conclusions. The
Approaches
to medical
geography:
validity of any such associative studies basically depends on the reasonable and correct use of ‘bestfitting’ techniques.
Disease diflision Studies of disease diffusion largely utilize the formal geographical diffusion theory in the analysis of disease distribution and dynamics, and thus the approach evolved after diffusion had become an important ingredient in geographic research by early 1960. But the concept of disease diffusion is implicit in Hirsch’s (1883-1886) works of the late nineteenth century. His works represent accounts of mechanisms possibly contributing to the diffusion of disease from a pathogenetic point of view. Such an approach is particularly concerned with the influence of the physical environment. Thus Hirsch’s concept of the spread of disease has much in common with the disease ecological approach of medical geography. The particular advantage of the disease diffusion approach is that it makes it possible to simultaneously view time and space in relation to the disease being studied. Hunter’s [28] landmark 1966 study of river blindness is such an example. Other examples of disease diffusion include the works of Girt [27], Haggett [30], Kwofie [31], Patterson and Pyle [ 32,34 1. Most studies of disease diffusion have concentrated either on the development of highly abstract models of diffusion processes or on analyzing past outbreaks of communicable diseases. These studies have resulted in the understanding of many major principles of disease diffusion and processes of diffusion which might have been instrumental in predicting the spread of disease [34]. They also offer a variety of approaches and explanations to problems of disease diffusion. But they share some common ground in the sense that they test different hypotheses with a view to offering explanations beyond the generally more static descriptions resulting from disease mapping [35]. Geography of nutrition Geography of nutrition is one of the more recent approaches to medical geography to emerge. This approach finds its origin in some of the later works of May [36,37]. With the help of Donna, May [36] compiled a massive series of bench-mark surveys on the state of nutrition and of knowledge about nutrition and malnutrition over nearly all the world in the early 1970s. Following May, a few studies were done on nutrition or related aspects of health, particularly that of the Third World countries [38-421. The study of nutrition has a direct link with the ecological approach to medical geography, since many geographical factors are involved in nutrition. Among them, topography, climate and soil are very important. Climate, in most instances, affects the amount and nature of food available. Particular crops can only be grown under particular climatic and soil conditions. The direct effects of climate on health and disease are also important. For example, calorie requirements vary according to temperature conditions. Also, the need for salt is greater in tropical climates, as much is lost in the form of sweat.
an historical
perspective
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Geography of health care As noted earlier, medical geography has traditionally emphasized the spatial study of diseases and their possible etiologies, but the scope of study has recently been expanded. Since the mid-1960s geographers have paid increasing attention to such aspects as health-care planning, health-seeking behavior and health service provision. Thus, geographical concern with the provision of health-care services developed historically after the ecological approach to the study of medical geography. The development of this approach parallels, in many ways, the development of the geographical study of public services in general. This approach, however, is rooted deeply in location theory, theories of public service provision, transport geography and philosophical issues. From the onset, the goal of spatial studies of medical care has revolved around normative considerations, particularly those dealing with locational and distributional aspects of health-care facilities and health-care providers. Most of these studies evolved from the general exposition of location and central place theory. It is implicitly understood that in order to get the required service, a patient has to travel to the appropriate health facility. This usually depends on the type of specialities he requires. Thus, the system of health-care facilities can be viewed as a theoretical hierarchy of locations with equivalent degrees of attraction, and distances travelled will vary in a regular manner depending upon facility size and the range of specialities offered [43]. This concept and central place theory ultimately led to the development of spatial allocations models in health-care geography. Transportation, distance and hospital size are the main elements of the allocation models. The earliest form of this model is found in the work of Godlund [44]. Mulvihill [45], Bennett [46] and Mohan [47] recently applied the allocation models in health facility locations. Spatial studies of the use of health-care resources often produce results indicating various forms of maldistribution. In a detailed study of physician location behavior, Shannon and Dever [48] have offered several overlapping explanations. Important factors considered in such behavior include economic pull, the proximity to medical schools, the scale of facilities available, the attraction of metropolitan centers and especially of prosperous areas within them [49 I. Although there have been numerous studies of health service systems and of physician and provider distribution, most of these studies were conducted in an attempt to optimize access to health facilities. Of the two main dimensions of access (spatial and aspatial), geographers are more interested in the spatial aspect. Here again, distance plays a vital role because it is considered the principal constraint to spatial access to health-care facilities. Since a health facility is not always located in the center of its service area, there is often a spatial inequality or spatial disparity with regard to both availability and utilization of the resources. This may also happen if there exists a tremendous and unnecessary duplication in available services. This disparity, however, may be minimized to
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a greater extent by modifying the existing institutional settings and characteristics of both the delivery system and the potential users by relocating the facility. This sometimes involves regionalization of health-care, which has become a widespread goal of a number of developed countries [50]. Here, regionalization basically refers to the regional planning and coordination of health services delivery. Adequate health-care planning requires knowledge of the principles of disease distribution, dynamics and spread. As Mayer [51 ] noted, “certain types of regions will have particular public health problems associated with them that are absent or less significant elsewhere”. Moreover, there is the potential for developing predictive disease diffusion models to anticipate the movement of diseases, particularly communicable ones. This will show where there is a need for disease control strategies. Adequate health service planning further requires sophisticated epidemiological knowledge. This implies that optimal location policies are predicated on locating facilities in areas of need. The objective function of a locational problem, therefore, involves minimization of travel time or distance between areas of need and potential facilities’ locations. Too often, the distribution of population as a whole is used to estimate need. Since diseases are unequally distributed within a given population, it is preferable to use population at risk for disease to estimate need [5 1,521. Studies on health care providers have been accomplished, in general, on regional and local levels. It is, however, possible in such studies to develop highly sophisticated, process-oriented analyses of human responses to disease patterns and utilization of health-care facilities. Since health-care geography often deals with problems of access to health facilities, it can be linked to an important stream of thought in human geography, which is termed welfare geography [53]. Ethnomedicine
and medical
pluralism
The type of health systems existing in developing countries differ greatly from those of developed nations. The fundamental difference is that most nonWestern nations have dual medical systems: indigenous medicine and Western or modern medicine [54-561. According to some estimates, traditional medical practitioners-including herbalists, diviners, midwives, spiritualists and others-form the main body of primary health workers for up to 90 % of rural populations [57]. Moreover, evidence from Ghana, India, Kenya, the Philippines, Sri Lanka, Zambia and many other developing countries [54-56,581, shows that urban people also depend on and patronize traditional medical systems. It is well known that modern medical practitioners are few in number compared to the total population of the developing world. Moreover, they are unevenly distributed-concentrated primarily in the urban areas. Therefore, they are physically inaccessible to the vast majority of rural people. But widespread utilization of traditional healers and other indigenous health resources is not explained simply by inaccessibility to or shortage of modern medical practitioners. They are culturally, socially, and environmentally closer to the people and hence more
accessible. They are also more sympathetic and less expensive [59]. They use local resources (herbs, metals, etc.), local technology and local labor. Though hardly more than a dozen published works by geographers focus on the traditional medical systems ofdevelopingcountries, also called ethnomedicine and medical pluralism. this approach is slowly emerging. Recently, a number of medical geographers [5,34,55-571 made a plea for conducting research on ethnomedicine and medical pluralism. Good [57] contends that: It is long overdue for medical geographers (the “disease ecology” specialists as well as those doing health delivery systems analysis and planning) to ask why and how traditional medicine relates to our individual and collective research and teaching programs. Furthermore, Good [55,57] recently outlined the probable areas of research on traditional health-care systems. In the context of the World Health Organization’s (WHO) recent recognition of the importance of traditional medicine and the subsequent incorporation of it in WHO’s Primary Health Care Strategy [60], the above plea is a timely one. In addition to WHO, some governments of Third World countries such as Bangladesh and India, have acknowledged the contributions of traditional medicine and have already taken steps to integrate it into the national primary health care system. CONCLUSION
An attempt has been made in this paper to provide an account of the development of various approaches to medical geography. The main points emerging from the paper are summarized here. It is evident from the above that the development of medical geography occurred in two distinct time periods. The early development of the discipline began in Germany in the late eighteenth century. Numerous studies were done during its early developmental period, which extended up to the 1860s and 1870s. During this period, two important approaches to medical geography (disease ecology and disease mapping) evolved. The modern period of the discipline, however, began after the Second World War. The remaining five approaches to medical geography, as listed earlier, developed during this period. Between the early and modern development period, little interest was shown in the study of disease patterns. It is interesting to note that it was the physician, not the geographer, who contributed solely to the early development of medical geography. In contrast, the current development of the discipline is being widely contributed to by the geographer. It is further evident that associative analyses developed from disease mapping in the mid-to-late 1960s. At about the same time, disease diffusion also evolved as an approach of medical geography. But the concept of disease diffusion may also be linked to the works of Hirsch (1883-1886). Since his works have much common ground with the disease ecological approach, disease diffusion is considered as having evolved from disease ecology. Geography of nutrition also developed from disease ecology in the early 1970s. Ethnomedicine and medical pluralism, on the other hand, are emerging as an independent approach to
Approaches to medical geography: an historical perspective medical geography from the geography of health-care. The classification outlined in the present paper indicates that various approaches to medical geography are relevant to one another. Disease ecology, disease associative analyses, disease mapping, diffusion and nutrition studies are interrelated since all of these approaches either directly or indirectly aim to understand the multiplicity of geographical factors involved in disease causation. The basic tenet of disease ecology is to study relationships between natural environment and diseases, while the researchers interested in disease mapping and associative analyses try to develop various methodologies for detailed mapping of disease patterns in order to identify the causal links between diseases and other factors, Some medical geographers produce analyses of the geographical spread, or diffusion of diseases, from endemic foci to other places in time and space with a view to identifying the factors involved in the diffusion processes. Health-care geography, on the other hand, is related to ethnomedicine and medical pluralism. Thus, the suggested seven approaches do seem to represent viable clusters of approach specialization. Indeed, we find two such clusters which correspond to the two major approaches of medical geography: ecological approach and health-care approach. Based on the points summarized in this section, it is possible to visually express the historical development of medical geography through a tree diagram (Fig. 1). The diagram depicts six important aspects of medical geography: varidus approaches to medical geography; the approximate time of their developments; the mother approaches from which they originated; their relationships with other approaches; scale; and extent of studies done in the past. As can be seen from the diagram, bold and thin lines are used to indicate the extent of work done so far on various aspects of medical geography. If a period is shown by a thin line, it means few studies were done during that particular period. The bold line, in contrast, indicates the reverse situation. Geographical scales of studies are shown by three different types of broken lines. Three different scales are considered: small (national to worldwide coverage); large (individual to regional coverage); and a combination of small and large scales. Interrelationships between approaches are shown by the crossing of continuous lines. The diagram also shows the two development periods of medical geography. Two different shades are used for the two periods. It is evident from this paper that different geographic regions have their own interests with respect to specific approaches. For example, in the United States, the main thrust of research in medical geography is on health-care planning, while in the United Kingdom the main emphasis is on disease mapping and regional synthesis of health problems. Finally, it is observed that areas such as behavioral aspects of illness, ethnomedicine and medical pluralism and nutrition, that are so crucial in the context of the Third World countries, have been neglected. More studies need to emphasize these areas. Acknowledgement~The Bhardwaj, Professor
author is grateful to Dr S. M. of Geography, Kent State University,
Ohio, for his helpful comments draft of this paper.
403 and suggestions
on an earlier
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COMMENTARIES DIRECTIONS FOR MEDICAL GEOGRAPHY IN THE 1980s: SOME OBSERVATIONS FROM THE UNITED KINGDOM DAVID R. PHILLIPS Department of Geography, University Mr Paul has provided an interesting overview of the evolutionary development of various strands of medical geography. It is important to view a subject in its historical context and relatively few analyses of medical geography to date have adopted such a perspective. Perhaps this has been because previously there were relatively few geographers who regarded themselves solely as medical geographers; at least this has been the case in Britain and North America. As a result, the conceptualisation of the subject has arguably lagged behind its empirical development.
of Exeter. Exeter, England
This picture has changed in the past decade, however, and medical geography has emerged as a strong and robust subject which has demonstrated the ability to adapt to changes in the discipline as a whole and even to advance certain methodological and philosophical developments itself, as has been illustrated with regard to postwar British medical geography [I 1. Indeed, some important advances in, for example, quantitative spatial analysis have been made by geographers working in medical fields; the individualistic research orientation of the behavioural revolution has also been