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The development and current status of medical geography in Canada
SW Sit Mrrl Vol ISD. pp 21 to 26 Perpmon Press Lid 1981 Prmwd m Great Br~laln
0160-8002 81 :OX~321-06102.W 0
THE DEVELOPMENT AND CURRENT STATUS OF MEDICAL GEOGRAPHY IN CANADA FRANK A. BARRETT Department of Geography, Atkinson College, York University. Downsview. Ontario. MiJ 2R7. Canada
Abstract-Medical Geography is a recent development in Canada. Although a few individuals have conducted medical geographic research in the past there was no sustained commitment to either such research or to teach courses on the subject. The current growth can be attributed to several factors. Among these factors is an increasing number of Canadian geographers with Third World experience the restating of relevancy concerns as applied to research and the recent development of medical geography in the United States, Britain and France. In 1976 Thouez organized the Canadian Working Group in Medical Geography as a sub-section of the Canadian Association of Geographers. In the previous year he had initiated the first graduarr course in Medical Geography in Canada at the French Language University of Sherbrooke. At Windsor Innes succeeded in funding a 6 month visiting professorship in 1977 for Howe of Great Britain and launched a semester undergraduate course. Starting in 1974 Barrett at York had devoted increasingly larger sections of his course on population geography to medical geography. In 1977-78 he offered for the first time in Canada a full-year undergraduate course in medical geography. Meanwhile at Queen’s. Tinline had been continuing his long-term commitment to disease research for the Ontario government and in 1977 he offered a half-course in medical geography. Increasingfy papers on medical geography were offered at the regionai and national meetings of the Canadian Association of Geographers with at least one special session on medical geography from 1976 to the present. The current status of medical geography in Canada is that of a small but dedicated group. Student response has been very encouraging and is growing although one would not see it as a major subdiscipline of the field. A tremendous chailenge confronts medical geographers as governments try to reduce health costs and improve quality of life. The spatial problems and the mismatch between humans and their environment exist. The unanswered question is to what degree will Canadian medical geographers be involved in the analysis of these problems?
in. and the teaching of medical geography in Canadian universities is a recent development. Although a few isolated articles appeared in the past, there was no sustained commitment by any individual to engage in medical geographic research, nor to teach courses on the subject. The current growth of the discipline can be attributed to several factors. Among these factors are: the impact of the nomothetic revolution in geography which focused research on locational analysis and model-building an increasing number of Canadian geographers with Third World experience where the interrelationships between disease, health facilities, environment and patient are highly observable, the restating of relevancy concerns as applied to research, and current developments in medical geography in other countries with the greatest impact coming from the United Kingdom. the United States for anglophones. and from France for francophones. Research
DEVELOPMENTS IN RESEARCH
Previous to 1970 only a few articles on what might be considered medical geography were published by Canadians. In the indices for The Canadian Geographer. the journal of the Canadian Association of Geographers [I]. medical geography is not listed in the subject index, nor in fact was a single paper in the discipline published from the journal’s inception in
1951 until Girt’s paper in 1973 [2]. There were only a few isolated papers in this early period. For example. Camille Laverdiere, a plant geographer with the Federal Government, wrote an article on the distribution of poison ivy in Quebec and the health problems related to skin rash E33. Other examples of a marginal 3 interest during the late 1950’s and early 1960’s are found in some of the many articles and theses on pollution, the environment and ecology, etc. The best reference on the work of Canadian geographers is the annual ‘~ew~~erte~ [4], published by The Canadian Association of Geographers, which lists both research being conducted, and articles recently published in all Canadian geography departments. It was not until the late 1960’s. however, that medical geographical titles began to be listed in “Current Research in Progress” in the association’s annual report. For the period 1965-69 only five titles of current medical geographical research were listed, and of these. only one was actually reported as being subsequently published [5]. The earliest identifiable research is the work of John Girt, a British geographer trained at Leeds. and Rowland Tinline, a Canadian whose undergraduate training was at Queen’s University in Kingston, Ontario. but whose doctoral work was at Bristol. Both of these scholars were of the new generation post-quantitative revolution stream and were interested in modelling disease occurrence. In the late 21
22
FRANK A. BARRETT
1960’s Girt joined the faculty at Memorial University in Newfoundland and conducted research on the health care facilities in the island’s outports. In 1969 he moved to the University of Guelph, Ontario. For the first half of the I97o’s John Girt was by far the most active researcher in medical geography in Canada, publishing work on chronic bronchitis as related to the urban ecological structure, the effect of distance on the use of medical care, and the geography of non-vectored infectious diseases [S, 6.71. Meanwhile, in 1970, Tinline had returned from working with Haggett at Bristol to his alma mater department at Queen%. He had published the first of two articles on the spread of the epizootic foot and mouth disease [S, 91. The earliest reference to completed research on the geography of health care appears to be Bottomley’s 1971 M.A. thesis from the University of British Columbia on “Physician Office Site Characteristics: A Co~itive-~ha~oural Approach [lo]. From 1975 onwards there was an encouraging increase in work. Michael Dear, a British undergraduate at Birmingham and Ph.D. from the University of Pennsylvania, was appointed to McMaster University in Hamilton, Ontario and began to publish his continuing work on mental health facilities El I-171. At York University, in Toronto, Ontario, the historical geographer, Arthur Ray, published work on the diffusion of diseases as a result of the nineteenth century fur trade in Canada [19,20]. Also at York, Frank Barrett, a Canadian trained at Toronto, Minnesota and Michigan State and with African experience, published a study on the geomedical aspects of endemic goitre in Africa [21]. Another Canadian, Robert Stock, an undergraduate at the University of Western Ontario, London, who studied medical geography with John Hunter at Michigan State is currently completing his dissertation under the guidance of Manse11 Prothero at Liverpool. He published the first known medical geography written by a Canadian, Cholera in Africa [23]. When Stock graduates he will be the first Canadian trained as a medical geographer in both M.A. and Ph.D. degrees. In Quebec, Jean-Pierre Thouez, a French undergraduate at Poitiers and a doctoral student at Grenoble, was a faculty member at the French language University of Sherbrooke from 1970 to 1979. His early work was in urban geography but by the mid-1970’s he was devoting much effort to medical geography. His study on the geography of health care in the Eastern townships of Quebec, Espace ~~g~una~ et Sank, appears to be the first book to be published on a medical geography on some part of Canada [24]. So the first medical geography book on a part of Canada and the first medical book written by a Canadian are both recent events. Thouez has published also on mapping disease problems and on the debate about the relationship between drinking water and heart disease [25-271. B. Hyma, an Indian geogrtipher at the University of Waterloo, Ontario, pub~shed a book on Cholera and Malaria Incidence in Tiil Nadu, fndia and also on problems in the use of health data in medical geographic research [28,29]. David Ingram, another Briton who did his undergraduate work at Nottin~am
and his graduate work at McMaster in Hamilton. and who taught at York. has conducted research on spatial analysis of the use of health care facilities [30]. Simon Kevan at St John Abbott in Quebec has recently published on seasonal variation in mortality rates in Canada [31.32]. By 1980 the number of researchers in medical geography had increased, as witnessed by the authors in this book. (BARRETT F. A. Canadian studies in medical geography. Geogr. Monographs No. 8. Department of Geography, York University. 1980). Currently in Canada there is a small core of medical geographers who are supported by other geographers whose research interest overlaps into medical geography. MAPPING
DISEASE AND
HEALTH
The preceding gives a fairly complete view of medical geographical research in Canada. however it does not cover medical maps related to this country. There is no known complete bibliography on medical geographical maps for Canada. Janet Allin, the map librarian at York University, has compiled a list (see Appendix A) which may be of assistance. What is evident from this list is that there is much and important work for medical geographers to do in the area of mapping disease, and the broad spectrum of health care analysis. Thouez and his co-researchers are Ieading the way in this type of endeavour with their French language atlas of medical aspects of the Eastern Townships (Atlas rn~dica~de la rPgion des Cantons de f’Est, QuebPc, t980 [33]). He is also in the final stages of producing an atlas of cancer mortality for the province of Quebec. The Canadian government published in 1980 a two volume atlas titled, Morn&v Atlas of Canada [34}. Volume 1, Cancer, is devoted to a nation-wide examination of neoplasia deaths and Volume 2, General Mortality, gives a parallel coverage for other causes of mortality. THE TEACHING
OF MEDICAL
CANADIAN
GEOGRAPHY
IN
UNI)‘ERSITIES
In Canada there are currently 48 “units” of geography at the post-secondary level (Directory 1979). Of these, 33 are university departments offering a programme in geography. At present. only four universities have courses in medical geography and these courses are centred on individuals, rather than on any departmental policy to offer medical geography. In 1975 Thouez offered the first graduate course in medical geography in Canada at the francophone University of Sherbrooke. He has continued to give this course since then but recently moved to the faculty of the University of Montreal. He does not offer an undergraduate course. At the anglophone universities in Canada there are courses at Queens. Windsor. and York. Two hall-courses of 13 weeks are offered at Queen’s University. Kingston (R. Tinline) and at Windsor (F. Innesj-both in rather different ways linking disease ecology with health care and access to it. At York University Barrett has been building up the biggest offering of courses so far in Canada. so that a student seriously interested in this field can
C‘urrcnt status of medical geography in Canada Medical . . Anthropology
I
2 5 ..XP glti
HEALTH,
MEDICINE (fwst
/
and yeor
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i SOClDi Work
Medtcoi Sociotopy
SOCIAL
23
SCIENCES
i Medical EtXXtOmlCs
,Medlcal Biology
Health Core Adm~~tstmtto~
----------_
_
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GEOGRAPHY
I I
r HEALTH
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DISEASE
t Reglonoi
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& Facilittes “J Hearfh $ $ r f J i:
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t tionship
NUTRITtCtN t Dlseose and Nut rit,m
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I
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and and
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I
SEMINAR
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Production SUPPlY ~lnut~tion Def tciency EIcss3
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Pattents Demogiaphvz Economic Cutturot %ehovrourol 34%
2
I
ECOLOGY
Pathogens Parosltes Substances
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I
GEOGRAPHY Research in: Djstftbutton
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-------
_t____--__ MEDICAL
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ES (3
56 3.3
Fig. I. Medical Geography at York University.
courses illustrated in Fig. 1. From 1977-8 onwards there has been a full course of 25 weeks on medical geagraphy, quite broadly conceived. This core course is followed, for the committed student, by a Ibweek half-course on the geography of nutrition (from 1979) and from 1980 a course on the geography of health care systems. From 1980-81 Barrett offered an advanced full course seminar in medical geography for students who have already taken the earlier courses or have related experience. From 1979 there has aiso been a graduate half-course on demand (563.3 on Fig. f), and from 1981-2 (at the top of the diagram) there will be a preparatory level, interdisciplinary course on Mea& take a series of integrated
Medicine and the Social Sciences.
Fuller details, including extracts from university calendars, will be found in Barrett’s opening paper in C~~~~~ Studies in Medical Ge~~a~h~ (1980) (York University, Downsview, Ontario M3J 2R7). In several universities graduate research in medical geographical topics is being conducted, but as of yet no list of research in progress or completed is available. Among this type of research Innes has supervized several B.A. and an M.A. theses C36.371. At York University, Clarke [383 worked with Ingram and Murdie, Hunter [39] was supervised by Found. There are undoubtedly other works which have yet to be recognized. A cursory examination of the List of Theses and Dissertations on Canadian Geography [35]
under the subject index key words of “Disease”, “Health”, “Health Care”‘. “Medical Geography”,
“Mortality”, or “Morbidity” does not contain any entries up to 1972. There may be an index problem, however, since reference has already been made to Bottomley’s f97f M.A. thesis [IO-J and his thesis is not listed under any of the “key” words. PROSPECFS The prospects for medical geography in Canada are very good since there is a need for trained medical geographers, students are enthusiastic and the current researchers are dedicated to their task. Instrumental in the growth in medical geography has been the formation of an informal organization, the Canadian Working Group in Medical Geography, an interest group within the Canadian Association of Geographers. Established in 1976 on Thouez’s initiative, the group has met annually at the parent body’s conference. In addition, Thouez has been editing a newsletter, now in its fifth year, with approximately 50 academics on the mailing list. A major international event within Canada during the 1970’s was Girt’s organization of a pre-conference Medical Geography Symposium at Guelph University in 1972 as part of the ~ntematiohal Geographical Congress in Montreal. Innes at Windsor has made a very important contribution to the development of medical geography in Canada by obtaining a six month visiting professorship for Melvyn Howe of Strathclyde, U.K. in 1977 and organizing a threeweek lecture tour of Ontario, Quebec and Michigan
FRANK A. BARRETT
24
for Andrew Learmonth
of the Open
University,
U.K.
in 1980. Current
research in progress include Barrett’s work on the conceptual basis of 18th and 19th century medical geography [22], Innes’ work on disease pat-
terns in Windsor, Thouez’s work on the Eastern Townships and Tinline’s seminal work on the rabies
control in wildlife populations for the Ontario government. G. Walker at York is continuing work on the diffusion of methadone treatment for narcotics users in Toronto [40]. Three setbacks for medical geography occurred at Canadian universities during the decade-the resignation of Ingram at York to take up a position at Birmingham, U.K., Stock’s terminal appointment due to financial constraints, at the University of Manitoba and Girt’s decision to enter the Federal civil service. In retrospect medical geography has experienced a gradual but substantial growth at Canadian universities during the 1970’s. A tremendous challenge confronts medical geographers as governments try to reduce health costs and improve the quality of life. The conditions in the impoverished regions of the world cry out for any small improvement that can be made. The spatial problems and the mismatch between humans and their environment still exists. The unanswered question is to what degree will Canadian medical geographers be involved in the analysis of these problems?
REFERENCES
1. Canadian Association of Geographers (n.d.)
Author and Index of the Publications of the Canadian Association of Geographers 1951-1967: Canada. Selected Bibliography on Canadian Geography, Bibliographical Series No. 33. Geographical Branch, Dept of Mines Subject
and Technical Surveys,-Ottawa,
1965.
2. Girt J. L. Distance to medical practice and its effects 3.
4. 5.
6.
7.
8.
on ill-health in a rural environment. Can. Geogr. 17, 154, 1973. Laverdiere Camille. La distribution gkographique de I’herbe g puce dans le Quebec et sap&&e Hu lac Sainte-Jean. Rev. can. Ghoar. 9. 185. 1955: Book A. N. A Study of Sulphur Dioxide Pollution in the Sudbury Area. Unpublished B.A. Thesis, University of Western Ontario. 1968; Simpson W. L. A Study of Water Pollution of the Thames-River in London,.Ontario. Unpublished B.A. Thesis. Universitv of Western Ontario, 1969. Canadian Association of -Geographers (1965-1966) Newsletter: Canadian Association of Geographers (1977-1979) Directory. Girt J. L. Simple chronic bronchitis and urban ecological structure In Medicui Geography: Techniques and Field Studies (Edited by McGlashan N. D.), pp. 21 l-232, Methuen, Londdn, 1972a. Girt J. L. The location of medical services and disease ecology-some conclusions on the effect of distance on medical consultations in a rural environment. Geographia. Medica. 2, 43, 1972b. Girt J. L. The geography of non-vectored infectious diseases. In The Geography of Health and Disease (Edited by Hunter J. M.), pp. 81-100. University of North Carolina, Department of Geography, Studies in Geography No. 6, 1974. Tinline R. Lee wave hypothesis for the initial pattern of spread during the 1967-68 foot and mouth epizootic. Nature 227, 860, 1970.
9. Tinline R. and Hugh-Jones M. E. Studies on the 1967-68 foot and mouth disease epidemic: incubation period and herd serial interval. .I. Hyg.. Camh. 77. 141. 1976. 10. Bottomley J. Physician Office Site Characteristics. A Cognitiv&Behavioral Approach. Unpublished M.A. Thesis. Universitv of British Columbia. 1970: Sooerel C. M. An Anal&is of Non-Hospital Based Mkdical Practitioners’ Office Locations in London, Ontario. Unpublished B.A. Thesis, University of Western Ontario, 1974. 11 Dear M. The neighborhood impact of mental health facility siting. Discussion Paper Series No. 84. Regional Science Research Institute, Philadelphia, 1975. 12. Dear M. Planning community health services in Arctic Canada. Musk-Ox, 28, 1976. 13. Dear M. Impact of mental health facilities upon property values. Comm. Menr. Hlrh J. 13. 150. 1977a. 14. Dear M. Locational factors in the demand for mental health care. Econ. Geogr. 53. 223, 1977b. 15. Dear M. Psychiatric patients and the inner city. Ann. Ass. Am. Geogr. 67, 588, 1977~.
16. Dear M. Planning for mental health care: a reconsideration of public facility location theory. Inr. Reg. Sci. Rev. 3, 93. 1978. 17. Dear M. and Taylor S. M. Community Attitudes Toward Neighbourhood Public Facilities. Report submitted to the Social Sciences and Humanities Research Council of Canada, 1979. 18. Dear M., Wolpert J. and Crawford R. Satellite mental health facilities. Ann. Ass. Am. Geogr. 65, 24, 1975. 19. Ray A. Smallpox: The epidemic of 1837-38. Beaver Auiumn, 8, 1975. 20. Rav A. The diffusion of diseases in the western interior of Canada, 183&1850. Geogra. Rec. 66, 139, 1976. 21. Barrett F. A. Geomedical aspects of simple endemic goitre in Africa. Can. Ass. Afr. Stud. Proc. Toronto. 1975. 22. Barrett F. A. Medical geography as a foster child. In Conceptual and Methodological graphy. (Edited by Meade
Issues in Medical
Geo-
M.). University of North Carolina at Chapel Hill pp. l-15, 1980. 23. Stock R. Cholera In Africa; Diffusion of the Disease 1970-75
with
Particular
Emphasis
on
Wesr
Africa
African Environment Special Report 3. International African Institute, London, 1976. 24. Thouez J.-P. Espace Rdgional et Santl: La Ghographie HospitaliPre des Cantons de L’Esr (Quebec). Editions Naaman, Sherbrooke, 1978a. 25. Thouez J.-P. Cartographie automatiske et GCographie psvcho-sociale. Can. Cartoa. 14. 139. 1977. 26. .TGouez J.-P. La durete de beau potable en la mortalitk certbrale vasculaire dans l’est du Qukbec. Bull. Ass. Gtiogr. fr. 451, 115, 1978b. de 27. Thouez J.-P. Caractbristiques physico-chimiques I’eau potable et la mortalitt ischimique du coeur: application aux municipalit& des cantons de I’est (QuCbec). Can. Geogr. 23. 308, 1979. 28. Hyma B. and Ramesh A. Cholera and Malaria Incidence in Tamil Nadu. India: Geography. University of
Case Studies
in Medical
Waterloo, Department Geography Publication Series No. 9, 1977.
of
29. Hyma B. and Ramesh A. Problems influencing types of health data used in medical geographical research: a case study from Tamil Nadu. Geographica Medica 8. 103, 1978.
30. Ingram D. R.. Clarke D. R. and Murdie R. A. Distance and the decision to visit an emergency department. Sot. Sci. Med. 12, 55. 1978. 31. Kevan S. The seasonal behaviour of Canadians. Can. Ment.
HIth
26. 16, 1978.
32. Kevan S. Season of life-season Med. 13D. 227, 1979.
of death. Sot.
Sci.
25
Current status of medical geography in Canada 33. Thouez J.-P.. Castonguay A~IA.s MidicA/
J.. Fortin R. et Munan L.
37. Christou E. Spatial Variations of Selected Chronic Disease in Ontario: 1970-1972. Unpublished B.A. Thesis. University of Windsor, 1977. 38. Clarke D. R. Selected Factors Relating to the Utilization of a Hospital Emergency Department. Unpublished M.A. Research Paper. York University. 1975. 39. Hunter M. R. Elements in Planning the Ambulance System in Metropolitan Toronto. Unpublished M.A. Research Paper, York University. 1977. 40. Walker G. Report to rhe NowMedicAl Use of Drugs Directorate. Health and Welfare Canada. 1977.
de /A Rigion des Canrons de PEst (Qu&
hrc). Editions Naaman. Sherbrooke. 1980. 34. Canada. M~rt~!if_~ Atlas of CAnAdA: Vol. 1 Cnncer, Vol. 2 Genera/ MorrA/ity. Health and Welfare Canada and Statistics Canada. 1980. 35. Canadian Committee for Geography. List of Theses And Dissertations
on CAfIAdiAn
Geography Supplement.
Ottawa, 1972. 1973. 1975. 36. Quenneville G. M. J. The Distribution of Physicians in Ontario 1964-1974. Unpublished B.A. Thesis. University of Windsor, 1975.
APPENDIX A ATLASES AND MAPS Canada
Birth/Death
Infant Mortality
Infant Mortality:
Atlas p. 50, Maps Social Atlas 1957
rates
No. 9
Hospitals-General,
Mental
Special
of Canada, 1957 of Economic and Disadvantage of Canada, p. 92
Location of Medical Service Facilities and Public Hospitals Medical Services Branch Facilities (1970) Medical Services Branch Facilities (1971) Medical Services Branch Facilities (1972) Maritimes
Indices de mortalitt Mortalite in infantile Nataliti et mortalite
de PAcadie, p. 5 de l’Acadie, p. 6 Atlas de I’Acadie, p. 7
Atlas Atlas
Halifax
Halifax City-hospital
St John
Location
of Professional
Workers
Quebec
Medicins
omnipraticiens,
1965
Dentistes,
(Physicians,
Hospitals,
Equipment
Rimouski
Mortalite
hospitalier, infantile
Montreal
La mortalite
Ontario
Death/Life
Toronto (Metro)
Toronto
Atlas RPgional du Bas St Laurent
1963
Atlas RPgional du Bas St Lourent, B-3
1956-60
dans les aires sociales de la region metro-Montreal Economic Atlas of Ontario, p. 23
birth rate
implications
of contaminants
urban analysis
Health care facilities, Accessibility
in fish
No. 17 Dist. of Hospitals
Metro Toronto,
(city)
Saskatchewan
Health
Districts-Statistical
Facilities
Services
Data,
(notes hospitals)
Economic Atlas of Ontario
(2 sheets)
to health care facilities by transit and auto
Public Health Community
and Doctors
1971
Suicide 1968-78 (by census tract) Infant Deaths 1970-72 Social Disease 1971 Parry Sound
New-
Atlas du QuibecSecteur Tertiare Atlas du QuhbecSecteur Tertiare
Distribution of schools and hospitals in Toronto Health care facilities, Metro Toronto, 1971
Toronto
Dentists) Atlas oj St John’s, foundland, p. 12A
1964
Quebec-Gaspe
Health
and bed capacity
Metro Tor. Trans. Plan Rev. 63, 77 Metro Tor. Trans. Plan Rev. 63, 7-31 Metro Tor. Trans. Plan Rev. 63, 7-31 Metroplan No. 3, P. 68 Metroplan NO. 3, p. 59 Metroplan No. 3, p. 60
1971 Parry Dist
Atlas,
p. 26
Atlas of Sask. pp. 168-9
FRANK A. BARRETT
26
Alberta
.4/fwrfrr Rrsoorce p. 73. 1976 .4flus qf .4lhrrfu. p, 127 .ilrlas of’ .Alherra p. 55
Hospitals
Maps.
Health Services Vital Statistics (fertility/birth/death Vancouver
Vancouver
Winnipeg
Fertility
urban analysis
Ratio
rates)
No. 17 Dist. of Hospitals
and Doctors Al/as of k%‘irmipq. p. 36
0160-8002 81 :OX~321-06102.W 0
THE DEVELOPMENT AND CURRENT STATUS OF MEDICAL GEOGRAPHY IN CANADA FRANK A. BARRETT Department of Geography, Atkinson College, York University. Downsview. Ontario. MiJ 2R7. Canada
Abstract-Medical Geography is a recent development in Canada. Although a few individuals have conducted medical geographic research in the past there was no sustained commitment to either such research or to teach courses on the subject. The current growth can be attributed to several factors. Among these factors is an increasing number of Canadian geographers with Third World experience the restating of relevancy concerns as applied to research and the recent development of medical geography in the United States, Britain and France. In 1976 Thouez organized the Canadian Working Group in Medical Geography as a sub-section of the Canadian Association of Geographers. In the previous year he had initiated the first graduarr course in Medical Geography in Canada at the French Language University of Sherbrooke. At Windsor Innes succeeded in funding a 6 month visiting professorship in 1977 for Howe of Great Britain and launched a semester undergraduate course. Starting in 1974 Barrett at York had devoted increasingly larger sections of his course on population geography to medical geography. In 1977-78 he offered for the first time in Canada a full-year undergraduate course in medical geography. Meanwhile at Queen’s. Tinline had been continuing his long-term commitment to disease research for the Ontario government and in 1977 he offered a half-course in medical geography. Increasingfy papers on medical geography were offered at the regionai and national meetings of the Canadian Association of Geographers with at least one special session on medical geography from 1976 to the present. The current status of medical geography in Canada is that of a small but dedicated group. Student response has been very encouraging and is growing although one would not see it as a major subdiscipline of the field. A tremendous chailenge confronts medical geographers as governments try to reduce health costs and improve quality of life. The spatial problems and the mismatch between humans and their environment exist. The unanswered question is to what degree will Canadian medical geographers be involved in the analysis of these problems?
in. and the teaching of medical geography in Canadian universities is a recent development. Although a few isolated articles appeared in the past, there was no sustained commitment by any individual to engage in medical geographic research, nor to teach courses on the subject. The current growth of the discipline can be attributed to several factors. Among these factors are: the impact of the nomothetic revolution in geography which focused research on locational analysis and model-building an increasing number of Canadian geographers with Third World experience where the interrelationships between disease, health facilities, environment and patient are highly observable, the restating of relevancy concerns as applied to research, and current developments in medical geography in other countries with the greatest impact coming from the United Kingdom. the United States for anglophones. and from France for francophones. Research
DEVELOPMENTS IN RESEARCH
Previous to 1970 only a few articles on what might be considered medical geography were published by Canadians. In the indices for The Canadian Geographer. the journal of the Canadian Association of Geographers [I]. medical geography is not listed in the subject index, nor in fact was a single paper in the discipline published from the journal’s inception in
1951 until Girt’s paper in 1973 [2]. There were only a few isolated papers in this early period. For example. Camille Laverdiere, a plant geographer with the Federal Government, wrote an article on the distribution of poison ivy in Quebec and the health problems related to skin rash E33. Other examples of a marginal 3 interest during the late 1950’s and early 1960’s are found in some of the many articles and theses on pollution, the environment and ecology, etc. The best reference on the work of Canadian geographers is the annual ‘~ew~~erte~ [4], published by The Canadian Association of Geographers, which lists both research being conducted, and articles recently published in all Canadian geography departments. It was not until the late 1960’s. however, that medical geographical titles began to be listed in “Current Research in Progress” in the association’s annual report. For the period 1965-69 only five titles of current medical geographical research were listed, and of these. only one was actually reported as being subsequently published [5]. The earliest identifiable research is the work of John Girt, a British geographer trained at Leeds. and Rowland Tinline, a Canadian whose undergraduate training was at Queen’s University in Kingston, Ontario. but whose doctoral work was at Bristol. Both of these scholars were of the new generation post-quantitative revolution stream and were interested in modelling disease occurrence. In the late 21
22
FRANK A. BARRETT
1960’s Girt joined the faculty at Memorial University in Newfoundland and conducted research on the health care facilities in the island’s outports. In 1969 he moved to the University of Guelph, Ontario. For the first half of the I97o’s John Girt was by far the most active researcher in medical geography in Canada, publishing work on chronic bronchitis as related to the urban ecological structure, the effect of distance on the use of medical care, and the geography of non-vectored infectious diseases [S, 6.71. Meanwhile, in 1970, Tinline had returned from working with Haggett at Bristol to his alma mater department at Queen%. He had published the first of two articles on the spread of the epizootic foot and mouth disease [S, 91. The earliest reference to completed research on the geography of health care appears to be Bottomley’s 1971 M.A. thesis from the University of British Columbia on “Physician Office Site Characteristics: A Co~itive-~ha~oural Approach [lo]. From 1975 onwards there was an encouraging increase in work. Michael Dear, a British undergraduate at Birmingham and Ph.D. from the University of Pennsylvania, was appointed to McMaster University in Hamilton, Ontario and began to publish his continuing work on mental health facilities El I-171. At York University, in Toronto, Ontario, the historical geographer, Arthur Ray, published work on the diffusion of diseases as a result of the nineteenth century fur trade in Canada [19,20]. Also at York, Frank Barrett, a Canadian trained at Toronto, Minnesota and Michigan State and with African experience, published a study on the geomedical aspects of endemic goitre in Africa [21]. Another Canadian, Robert Stock, an undergraduate at the University of Western Ontario, London, who studied medical geography with John Hunter at Michigan State is currently completing his dissertation under the guidance of Manse11 Prothero at Liverpool. He published the first known medical geography written by a Canadian, Cholera in Africa [23]. When Stock graduates he will be the first Canadian trained as a medical geographer in both M.A. and Ph.D. degrees. In Quebec, Jean-Pierre Thouez, a French undergraduate at Poitiers and a doctoral student at Grenoble, was a faculty member at the French language University of Sherbrooke from 1970 to 1979. His early work was in urban geography but by the mid-1970’s he was devoting much effort to medical geography. His study on the geography of health care in the Eastern townships of Quebec, Espace ~~g~una~ et Sank, appears to be the first book to be published on a medical geography on some part of Canada [24]. So the first medical geography book on a part of Canada and the first medical book written by a Canadian are both recent events. Thouez has published also on mapping disease problems and on the debate about the relationship between drinking water and heart disease [25-271. B. Hyma, an Indian geogrtipher at the University of Waterloo, Ontario, pub~shed a book on Cholera and Malaria Incidence in Tiil Nadu, fndia and also on problems in the use of health data in medical geographic research [28,29]. David Ingram, another Briton who did his undergraduate work at Nottin~am
and his graduate work at McMaster in Hamilton. and who taught at York. has conducted research on spatial analysis of the use of health care facilities [30]. Simon Kevan at St John Abbott in Quebec has recently published on seasonal variation in mortality rates in Canada [31.32]. By 1980 the number of researchers in medical geography had increased, as witnessed by the authors in this book. (BARRETT F. A. Canadian studies in medical geography. Geogr. Monographs No. 8. Department of Geography, York University. 1980). Currently in Canada there is a small core of medical geographers who are supported by other geographers whose research interest overlaps into medical geography. MAPPING
DISEASE AND
HEALTH
The preceding gives a fairly complete view of medical geographical research in Canada. however it does not cover medical maps related to this country. There is no known complete bibliography on medical geographical maps for Canada. Janet Allin, the map librarian at York University, has compiled a list (see Appendix A) which may be of assistance. What is evident from this list is that there is much and important work for medical geographers to do in the area of mapping disease, and the broad spectrum of health care analysis. Thouez and his co-researchers are Ieading the way in this type of endeavour with their French language atlas of medical aspects of the Eastern Townships (Atlas rn~dica~de la rPgion des Cantons de f’Est, QuebPc, t980 [33]). He is also in the final stages of producing an atlas of cancer mortality for the province of Quebec. The Canadian government published in 1980 a two volume atlas titled, Morn&v Atlas of Canada [34}. Volume 1, Cancer, is devoted to a nation-wide examination of neoplasia deaths and Volume 2, General Mortality, gives a parallel coverage for other causes of mortality. THE TEACHING
OF MEDICAL
CANADIAN
GEOGRAPHY
IN
UNI)‘ERSITIES
In Canada there are currently 48 “units” of geography at the post-secondary level (Directory 1979). Of these, 33 are university departments offering a programme in geography. At present. only four universities have courses in medical geography and these courses are centred on individuals, rather than on any departmental policy to offer medical geography. In 1975 Thouez offered the first graduate course in medical geography in Canada at the francophone University of Sherbrooke. He has continued to give this course since then but recently moved to the faculty of the University of Montreal. He does not offer an undergraduate course. At the anglophone universities in Canada there are courses at Queens. Windsor. and York. Two hall-courses of 13 weeks are offered at Queen’s University. Kingston (R. Tinline) and at Windsor (F. Innesj-both in rather different ways linking disease ecology with health care and access to it. At York University Barrett has been building up the biggest offering of courses so far in Canada. so that a student seriously interested in this field can
C‘urrcnt status of medical geography in Canada Medical . . Anthropology
I
2 5 ..XP glti
HEALTH,
MEDICINE (fwst
/
and yeor
the 1x5.61
i SOClDi Work
Medtcoi Sociotopy
SOCIAL
23
SCIENCES
i Medical EtXXtOmlCs
,Medlcal Biology
Health Core Adm~~tstmtto~
----------_
_
[MEDICAL
GEOGRAPHY
I I
r HEALTH
CARE
DISEASE
t Reglonoi
systems
Inferrein
lnternotlo~af Notional LOCO1 Spatioi
& Facilittes “J Hearfh $ $ r f J i:
0
t tionship
NUTRITtCtN t Dlseose and Nut rit,m
Of
Diet Envrmnment Economy Culture Ltte style
Enwonment physrcal Cuitu fOI
lnrerr@lat~onshtps
Personnel
Food
I
3
346.6
IN
L*terotwe DisallS%
MEDICAL t
Rewew OCCurance
Nutrition Heatin Care
and and
Patterns
347.3
I
SEMINAR
Distribution
Production SUPPlY ~lnut~tion Def tciency EIcss3
Host
Pattents Demogiaphvz Economic Cutturot %ehovrourol 34%
2
I
ECOLOGY
Pathogens Parosltes Substances
FTOVHlClOl
3
1
I
GEOGRAPHY Research in: Djstftbutton
Systems 42 1.6
-------
_t____--__ MEDICAL
r 22
A Survey
of
GEOGRAPHY Concepts,
Data
ond
Techniques
ES (3
56 3.3
Fig. I. Medical Geography at York University.
courses illustrated in Fig. 1. From 1977-8 onwards there has been a full course of 25 weeks on medical geagraphy, quite broadly conceived. This core course is followed, for the committed student, by a Ibweek half-course on the geography of nutrition (from 1979) and from 1980 a course on the geography of health care systems. From 1980-81 Barrett offered an advanced full course seminar in medical geography for students who have already taken the earlier courses or have related experience. From 1979 there has aiso been a graduate half-course on demand (563.3 on Fig. f), and from 1981-2 (at the top of the diagram) there will be a preparatory level, interdisciplinary course on Mea& take a series of integrated
Medicine and the Social Sciences.
Fuller details, including extracts from university calendars, will be found in Barrett’s opening paper in C~~~~~ Studies in Medical Ge~~a~h~ (1980) (York University, Downsview, Ontario M3J 2R7). In several universities graduate research in medical geographical topics is being conducted, but as of yet no list of research in progress or completed is available. Among this type of research Innes has supervized several B.A. and an M.A. theses C36.371. At York University, Clarke [383 worked with Ingram and Murdie, Hunter [39] was supervised by Found. There are undoubtedly other works which have yet to be recognized. A cursory examination of the List of Theses and Dissertations on Canadian Geography [35]
under the subject index key words of “Disease”, “Health”, “Health Care”‘. “Medical Geography”,
“Mortality”, or “Morbidity” does not contain any entries up to 1972. There may be an index problem, however, since reference has already been made to Bottomley’s f97f M.A. thesis [IO-J and his thesis is not listed under any of the “key” words. PROSPECFS The prospects for medical geography in Canada are very good since there is a need for trained medical geographers, students are enthusiastic and the current researchers are dedicated to their task. Instrumental in the growth in medical geography has been the formation of an informal organization, the Canadian Working Group in Medical Geography, an interest group within the Canadian Association of Geographers. Established in 1976 on Thouez’s initiative, the group has met annually at the parent body’s conference. In addition, Thouez has been editing a newsletter, now in its fifth year, with approximately 50 academics on the mailing list. A major international event within Canada during the 1970’s was Girt’s organization of a pre-conference Medical Geography Symposium at Guelph University in 1972 as part of the ~ntematiohal Geographical Congress in Montreal. Innes at Windsor has made a very important contribution to the development of medical geography in Canada by obtaining a six month visiting professorship for Melvyn Howe of Strathclyde, U.K. in 1977 and organizing a threeweek lecture tour of Ontario, Quebec and Michigan
FRANK A. BARRETT
24
for Andrew Learmonth
of the Open
University,
U.K.
in 1980. Current
research in progress include Barrett’s work on the conceptual basis of 18th and 19th century medical geography [22], Innes’ work on disease pat-
terns in Windsor, Thouez’s work on the Eastern Townships and Tinline’s seminal work on the rabies
control in wildlife populations for the Ontario government. G. Walker at York is continuing work on the diffusion of methadone treatment for narcotics users in Toronto [40]. Three setbacks for medical geography occurred at Canadian universities during the decade-the resignation of Ingram at York to take up a position at Birmingham, U.K., Stock’s terminal appointment due to financial constraints, at the University of Manitoba and Girt’s decision to enter the Federal civil service. In retrospect medical geography has experienced a gradual but substantial growth at Canadian universities during the 1970’s. A tremendous challenge confronts medical geographers as governments try to reduce health costs and improve the quality of life. The conditions in the impoverished regions of the world cry out for any small improvement that can be made. The spatial problems and the mismatch between humans and their environment still exists. The unanswered question is to what degree will Canadian medical geographers be involved in the analysis of these problems?
REFERENCES
1. Canadian Association of Geographers (n.d.)
Author and Index of the Publications of the Canadian Association of Geographers 1951-1967: Canada. Selected Bibliography on Canadian Geography, Bibliographical Series No. 33. Geographical Branch, Dept of Mines Subject
and Technical Surveys,-Ottawa,
1965.
2. Girt J. L. Distance to medical practice and its effects 3.
4. 5.
6.
7.
8.
on ill-health in a rural environment. Can. Geogr. 17, 154, 1973. Laverdiere Camille. La distribution gkographique de I’herbe g puce dans le Quebec et sap&&e Hu lac Sainte-Jean. Rev. can. Ghoar. 9. 185. 1955: Book A. N. A Study of Sulphur Dioxide Pollution in the Sudbury Area. Unpublished B.A. Thesis, University of Western Ontario. 1968; Simpson W. L. A Study of Water Pollution of the Thames-River in London,.Ontario. Unpublished B.A. Thesis. Universitv of Western Ontario, 1969. Canadian Association of -Geographers (1965-1966) Newsletter: Canadian Association of Geographers (1977-1979) Directory. Girt J. L. Simple chronic bronchitis and urban ecological structure In Medicui Geography: Techniques and Field Studies (Edited by McGlashan N. D.), pp. 21 l-232, Methuen, Londdn, 1972a. Girt J. L. The location of medical services and disease ecology-some conclusions on the effect of distance on medical consultations in a rural environment. Geographia. Medica. 2, 43, 1972b. Girt J. L. The geography of non-vectored infectious diseases. In The Geography of Health and Disease (Edited by Hunter J. M.), pp. 81-100. University of North Carolina, Department of Geography, Studies in Geography No. 6, 1974. Tinline R. Lee wave hypothesis for the initial pattern of spread during the 1967-68 foot and mouth epizootic. Nature 227, 860, 1970.
9. Tinline R. and Hugh-Jones M. E. Studies on the 1967-68 foot and mouth disease epidemic: incubation period and herd serial interval. .I. Hyg.. Camh. 77. 141. 1976. 10. Bottomley J. Physician Office Site Characteristics. A Cognitiv&Behavioral Approach. Unpublished M.A. Thesis. Universitv of British Columbia. 1970: Sooerel C. M. An Anal&is of Non-Hospital Based Mkdical Practitioners’ Office Locations in London, Ontario. Unpublished B.A. Thesis, University of Western Ontario, 1974. 11 Dear M. The neighborhood impact of mental health facility siting. Discussion Paper Series No. 84. Regional Science Research Institute, Philadelphia, 1975. 12. Dear M. Planning community health services in Arctic Canada. Musk-Ox, 28, 1976. 13. Dear M. Impact of mental health facilities upon property values. Comm. Menr. Hlrh J. 13. 150. 1977a. 14. Dear M. Locational factors in the demand for mental health care. Econ. Geogr. 53. 223, 1977b. 15. Dear M. Psychiatric patients and the inner city. Ann. Ass. Am. Geogr. 67, 588, 1977~.
16. Dear M. Planning for mental health care: a reconsideration of public facility location theory. Inr. Reg. Sci. Rev. 3, 93. 1978. 17. Dear M. and Taylor S. M. Community Attitudes Toward Neighbourhood Public Facilities. Report submitted to the Social Sciences and Humanities Research Council of Canada, 1979. 18. Dear M., Wolpert J. and Crawford R. Satellite mental health facilities. Ann. Ass. Am. Geogr. 65, 24, 1975. 19. Ray A. Smallpox: The epidemic of 1837-38. Beaver Auiumn, 8, 1975. 20. Rav A. The diffusion of diseases in the western interior of Canada, 183&1850. Geogra. Rec. 66, 139, 1976. 21. Barrett F. A. Geomedical aspects of simple endemic goitre in Africa. Can. Ass. Afr. Stud. Proc. Toronto. 1975. 22. Barrett F. A. Medical geography as a foster child. In Conceptual and Methodological graphy. (Edited by Meade
Issues in Medical
Geo-
M.). University of North Carolina at Chapel Hill pp. l-15, 1980. 23. Stock R. Cholera In Africa; Diffusion of the Disease 1970-75
with
Particular
Emphasis
on
Wesr
Africa
African Environment Special Report 3. International African Institute, London, 1976. 24. Thouez J.-P. Espace Rdgional et Santl: La Ghographie HospitaliPre des Cantons de L’Esr (Quebec). Editions Naaman, Sherbrooke, 1978a. 25. Thouez J.-P. Cartographie automatiske et GCographie psvcho-sociale. Can. Cartoa. 14. 139. 1977. 26. .TGouez J.-P. La durete de beau potable en la mortalitk certbrale vasculaire dans l’est du Qukbec. Bull. Ass. Gtiogr. fr. 451, 115, 1978b. de 27. Thouez J.-P. Caractbristiques physico-chimiques I’eau potable et la mortalitt ischimique du coeur: application aux municipalit& des cantons de I’est (QuCbec). Can. Geogr. 23. 308, 1979. 28. Hyma B. and Ramesh A. Cholera and Malaria Incidence in Tamil Nadu. India: Geography. University of
Case Studies
in Medical
Waterloo, Department Geography Publication Series No. 9, 1977.
of
29. Hyma B. and Ramesh A. Problems influencing types of health data used in medical geographical research: a case study from Tamil Nadu. Geographica Medica 8. 103, 1978.
30. Ingram D. R.. Clarke D. R. and Murdie R. A. Distance and the decision to visit an emergency department. Sot. Sci. Med. 12, 55. 1978. 31. Kevan S. The seasonal behaviour of Canadians. Can. Ment.
HIth
26. 16, 1978.
32. Kevan S. Season of life-season Med. 13D. 227, 1979.
of death. Sot.
Sci.
25
Current status of medical geography in Canada 33. Thouez J.-P.. Castonguay A~IA.s MidicA/
J.. Fortin R. et Munan L.
37. Christou E. Spatial Variations of Selected Chronic Disease in Ontario: 1970-1972. Unpublished B.A. Thesis. University of Windsor, 1977. 38. Clarke D. R. Selected Factors Relating to the Utilization of a Hospital Emergency Department. Unpublished M.A. Research Paper. York University. 1975. 39. Hunter M. R. Elements in Planning the Ambulance System in Metropolitan Toronto. Unpublished M.A. Research Paper, York University. 1977. 40. Walker G. Report to rhe NowMedicAl Use of Drugs Directorate. Health and Welfare Canada. 1977.
de /A Rigion des Canrons de PEst (Qu&
hrc). Editions Naaman. Sherbrooke. 1980. 34. Canada. M~rt~!if_~ Atlas of CAnAdA: Vol. 1 Cnncer, Vol. 2 Genera/ MorrA/ity. Health and Welfare Canada and Statistics Canada. 1980. 35. Canadian Committee for Geography. List of Theses And Dissertations
on CAfIAdiAn
Geography Supplement.
Ottawa, 1972. 1973. 1975. 36. Quenneville G. M. J. The Distribution of Physicians in Ontario 1964-1974. Unpublished B.A. Thesis. University of Windsor, 1975.
APPENDIX A ATLASES AND MAPS Canada
Birth/Death
Infant Mortality
Infant Mortality:
Atlas p. 50, Maps Social Atlas 1957
rates
No. 9
Hospitals-General,
Mental
Special
of Canada, 1957 of Economic and Disadvantage of Canada, p. 92
Location of Medical Service Facilities and Public Hospitals Medical Services Branch Facilities (1970) Medical Services Branch Facilities (1971) Medical Services Branch Facilities (1972) Maritimes
Indices de mortalitt Mortalite in infantile Nataliti et mortalite
de PAcadie, p. 5 de l’Acadie, p. 6 Atlas de I’Acadie, p. 7
Atlas Atlas
Halifax
Halifax City-hospital
St John
Location
of Professional
Workers
Quebec
Medicins
omnipraticiens,
1965
Dentistes,
(Physicians,
Hospitals,
Equipment
Rimouski
Mortalite
hospitalier, infantile
Montreal
La mortalite
Ontario
Death/Life
Toronto (Metro)
Toronto
Atlas RPgional du Bas St Laurent
1963
Atlas RPgional du Bas St Lourent, B-3
1956-60
dans les aires sociales de la region metro-Montreal Economic Atlas of Ontario, p. 23
birth rate
implications
of contaminants
urban analysis
Health care facilities, Accessibility
in fish
No. 17 Dist. of Hospitals
Metro Toronto,
(city)
Saskatchewan
Health
Districts-Statistical
Facilities
Services
Data,
(notes hospitals)
Economic Atlas of Ontario
(2 sheets)
to health care facilities by transit and auto
Public Health Community
and Doctors
1971
Suicide 1968-78 (by census tract) Infant Deaths 1970-72 Social Disease 1971 Parry Sound
New-
Atlas du QuibecSecteur Tertiare Atlas du QuhbecSecteur Tertiare
Distribution of schools and hospitals in Toronto Health care facilities, Metro Toronto, 1971
Toronto
Dentists) Atlas oj St John’s, foundland, p. 12A
1964
Quebec-Gaspe
Health
and bed capacity
Metro Tor. Trans. Plan Rev. 63, 77 Metro Tor. Trans. Plan Rev. 63, 7-31 Metro Tor. Trans. Plan Rev. 63, 7-31 Metroplan No. 3, P. 68 Metroplan NO. 3, p. 59 Metroplan No. 3, p. 60
1971 Parry Dist
Atlas,
p. 26
Atlas of Sask. pp. 168-9
FRANK A. BARRETT
26
Alberta
.4/fwrfrr Rrsoorce p. 73. 1976 .4flus qf .4lhrrfu. p, 127 .ilrlas of’ .Alherra p. 55
Hospitals
Maps.
Health Services Vital Statistics (fertility/birth/death Vancouver
Vancouver
Winnipeg
Fertility
urban analysis
Ratio
rates)
No. 17 Dist. of Hospitals
and Doctors Al/as of k%‘irmipq. p. 36