The social geography of medicine and health

Book reviews

Growing timber to burn

fertilizer and pesticides to produce plant material for burning is considered by many to be a good idea if the plants ENERGY cals would, of course, greatly increase are trees, but objectionable if the plants EVALUATlON OF FORESTRY RESEARCH INSWEDEN the wood yield per ha, but it is doubtful are wheat or barley. It is even more whether the sixfold increase in annual curious that many Americans consider edited by P.J. Newbould, 8. Nihlgard, growth is attainable if large areas are it acceptable for intensively cultivated R. Km&r, D. Wiion and S. Berglund converted maize to be converted to alcohol for to energy plantations. Furthermore, it is stated that energy use as motor fuel, yet if the maize were National Swedish Board for Energy forestry is ‘likely to be fairly labour shovelled into furnaces as boiler fuel Source Development, Stockholm, intensive’. The prospect for economic there would almost certainly be a public 1981,97pp production of fuel from plantations is outcry. It is difficult to see the logic in poor, unless supporters of this form of this, especially as in economic terms The report comprises a review of the energy production are willing to work there would seem to be no problem; cultivated plants cannot compete with on the plantations at low rates of pay. energy forestry research projects The Evaluation Group concludes fossil fuels or wood from commercial currently underway in Sweden. Twenty-one projects are described and that ‘the overall prospect for energy forests, and the position is very unlikely evaluated, and recommendations for forestry in Sweden are good, especially to change in the foreseeable future. on agricultural land; it may be rather future research are made. Experilonger before energy forestry on mire mental data are not given. Bernard Gilland sites attains good productivity.’ It is From the beginning of Swedish Espergaerde, Denmark energy forestry research in 19X-76 to curious that using agricultural land, 1980-81, 33 m kroner (B m) were expended on the programme, which is to continue for several years before any societal and cultural dimensions or commercial energy forest plantations THE SOCIAL GEOGRAPHY OF environments, whilst in the developing are established. Energy forestry can be MEDICINE AND HEALTH countries, financial constraints have defined as the intensive cultivation of now led to the World Health Organizatrees for fuel, and essentially involves by J. Eyles and K.J. Woods tion’s (WHO) adoption of primary the application of modem agrotechnology to silviculture. The basic idea is Croom Helm and St Martin’s Press, health care programmes which stress preventative medicine, community to use agricultural land and peatland by Beckenham, UK, 1983, f 16.95. involvement and the widespread use of planting and harvesting fast growing trees, mainly willow (S&x), and to a For reasons that are generally obvious medical auxiliaries. Without question lesser extent birch (B&AZ), alder health and disease, no less than the the increased interest in this broadly has industries and professions that depend defined disease environmentalism (Alnus) and poplar (Pop&s). been a beneficial development in It has been estimated that the econ- upon them, have recently attracted or at least unravelling, omic break even point for energy increasing lay interest and not a little understanding, criticism. Few medical the complex etiologies of non-comforestry is an annual wood yield of 12 t academic per ha. This can be compared with the specialisms have escaped the strictures municable diseases. Planners and paraverage annual yield of 1.3 t per ha of critics in fields like economics, law or ticularly those involved in physical development planning in tropical or from the 23 mha of productive forest in social studies or the demythologizing Sweden, and the gross annual growth inquisitions of television and the other other areas of expanding settlement, of 2 t per ha. Only 5% of Sweden’s media. Public debate on health care show increasing awareness of ‘environannual wood production of 50 m cubic delivery systems and the financing of mental containers’ and their links with metres (30 mt) is for fuel, the rest con- national or private health services has disease hazard, health status and the displayed remarkable longevity. That more general quality of life. Whether sisting of timber and pulpwood. orthodox scientific medicine has come medical schools or the medical professTheoretically, energy forest plantations could considerably increase fuel pro- under increasing pressure to justify its ion across the spectrum from clinical emphasis upon curative, high cost and practice to research or administration duction, but this would be expensive. a commensurately posiOil currently costs $200 per tonne; if high technology therapy is evident at demonstrate wood is to compete as an energy source, the global scale; in the West the medi- tive response is far less certain. In the it must sell at $80 per tonne (one tonne cal profession is accused of being ill UK the status of general practice has of wood yields as much energy as 0.4 trained and ill equipped to deal with been raised to the level of a specialism tonne oil). This is little more than the the psychosocial disorders and wedded by departments of family and communcurrent price of fuelwood. Yet it is pro- to simplistic models of disease causa- ity medicine at the medical schools, for posed to cultivate trees in the same way tion owing much to scientific reduc- example, but pressure on the student as cereals, ie with heavy applications of tionism and little if anything to ‘holistic’ syllabus seems unlikely to make more fertilizer and pesticides. These chemi- theories on the nature of man and his time available for ‘peripheral studies’

Mapping

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health care

LAND USE POLICY January 1984

Book reviews

than has traditionally been devoted to spatial epidemiology on the one hand and to health care planning on the psychiatry, behavioural psychology, alternative medicine or medical sociol- other. Today there is much uncertainogy; environmental and social factors ty, even confusion, over the proper tasks of medical geography vis-a-vis will, in short, continue to be regarded as irrelevant in the diagnosis and treat- health geography and this book exemplifies an uncomfortable intrusion ment of disease in a hospital-orientated into territory conventionally reserved system. At best orthodox epidemiology, which may be defined as the study for the more substantial disciplines of of the distribution of a disease or a medicine per se. physiological condition in human populations and of the factors that inSpatial patterns fluence this distribution, will simply extend still further its concern for the The dilemma is heightened by the occurrence of such diseases by time, authors’ exploration of a specifically place and persons and ignore the for- social geography of medicine and midable outpouring of research by health, where it is argued that spatial other professionals. For this reason the patterns shaped by social phenomena publication of any book which might offer a good starting point for examining the relationships between medinot only demonstrate the importance of the patient’s ‘case geography’ as well cine, health and society. Their book as his ‘case history’ but also stand some falls into seven chapters covering three chance of being added to a recom- broad subject areas; perspectives and mended reading list at some stage of definitions forming the background, clinical or specialist training, is impor- disease environments forming the raw tant at a time of potentially radical material and health care policies forming the response. In their discussion of changes in public and private thinking changing conceptions of health and about health and medicine. Described on the dust-jacket as the health care, the authors concentrate first text ‘which sets the central pro- upon the UK experience particularly blems of medical geography in a broad and on capitalist societies more gensocial context as well as a spatial one’, erally, elaborating on what they term physical, mental and social health. the book forms part of an encouraging involvement by publishers in a little These are seen in effect as stages in a known area of geographical writing. broadening of the definition of health as such and as falling roughly into the Geographers have long been interested three periods up to the turn of the last in the spatial (chiefly distributional) and ecological characteristics of health century, from then to 1945, and thereand disease. Concern with medical after, as reformist and ‘welfarist’ forces topography and nosogeography by brought about a shift from what are termed civil to social rights in health. military hygienists and other sanitarians The Victorian city provides a subject dates from at least the early 19th century. The specifically medical field of for examination of physical health, the broader urban environment one for geomedicine developed in Germany, giving rise to medical geography in the case studies of mental ill health and modem sense from around 1931. Much some passing comment on psychiatry as of this latter’s research has been orien- a form of social control. One learns, for tated towards the problems of tropical instance, that psychiatrists in Germany medicine, using techniques of a bio- ‘were part of the imperialist-capitalist meteorological or geoecological sort, class and had in the post Bismarck new and finding direct applications in devel- economic order the function of regulatopment planning and land use policy - ing the insane and social misfits’ -or of a situation paralleled by the USSR’s the failure of environmental controls emphasis upon geomedical compon- imposed by the norms of city life where ents of territorial planning. The unseen structures and factors like the ‘rational, calculating way of life that increased concern with quantitative techniques and computer graphics by dominates late capitalism’ are disrupgeographers has brought some medical tive of peace of mind and the quality of geographical research much closer to life. From this progression it is but a LAND USE POLICY January 1984

short step to the alleged links between ill health and urban deprivation epitomized by such external symptoms as ‘housing stress’ and ‘social defects’. The final consideration of social construction and the fetishism of health permits the authors to air some of the better known criticisms of the medical profession in its relationships with its clients or its arguably outmoded perception or rationale of its tasks. In the third chapter the authors come closest to medical geography in a review of man, disease and environmental associations. These are related to physical, mental and social ill health and draw on a mixed selection of case studies by such well known practitioners as Learmonth, Pyle and Howe, condensed to the point that they become little more than map-illustrated abstracts. The statement in the opening paragraphs that ‘Medical geography can be viewed as being concerned with the spatial aspects of this branch of epidemiology’ - this branch referring to descriptive as opposed to analytic studies - appears to imply that medical geography is in fact a part of epidemiology. A more thorough and far reaching knowledge of the subject, particularly of the pioneering German language literature, would have avoided a damning admission of this kind and permitted the writing of a chapter which more fairly represented unquestionably geographical approaches in the multidisciplinary investigation of disease ecology. Similarly, greater attention to detail in such writing is called for, particularly if the medical readership is to be persuaded of the subject’s intrinsic value. One instance is the statement that ‘Girt (1974) has argued that the transmission of nonvectored disease influenza, cholera, smallpox, measles, infectious hepatitis - is normally from one human to another’. A simple check on J.L. Girt’s original 1974 chapter in J.M. Hunter’s The Geography of Health and Dkease’ would have shown that he actually wrote: ‘Nonvectored infectious diseases . . .’ and went on to observe specifically that ‘Examples include the common cold, influenza, cholera . . .‘. (Reviewer’s italics) Girt was evidently aware that there is still scientific doubt over the possible

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Book reviews

vectoring by flies of cholera or hepatitis, for example, notwithstanding the prevailing view that they are directly transmitted, but unlike the authors, he did not know that smallpox would have been declared officially eradicated by the WHO in 1978. Indeed, does one ever need to ‘argue’ this piece of common knowledge? Does the writing really intend to mean that nonvectored diseases are five in number? Or, when summarizing the scientific writings of J.M. May on the ecology of infectious diseases, to represent his ideas inaccurately, as in the lines ‘May identified five pathogens: the causative agents (viruses, protozoa, rickettsiae); vectors (which may spread the causative agents to man; flies, ticks, lice)‘. Reference to May’s original 1950 paper would confirm that his list of pathogens did not exclude spirochetes, bacteria, fungi or metazoa, as the reader might suppose, nor imply that, for instance, vectors stopped short of such arthropods as beetles, cockroaches, mites or mosquitoes. From this not uncomplicated area the authors move to associations between disease levels and social class and occupational groupings, viewing the differential impact of disease and ill health as inextricably linked through class to the operation of the economic system. In their next three chapters the authors develop themes relating to the location and allocation of health services and to such questions as the optimal distribution of available resources or problems of accessibility. Real world constraints are then examined in regard to historical, social and professional influences which shape, or have shaped, resulting systems in advanced industrial countries like the UK, Australia, the USSR or of those developing countries, like China and Cuba that have re jetted ‘the necessity for the predominance of a Western-style system’; the authors lay considerable emphasis upon social justice in health care provision and the ‘moral values’ - such as freedom, equality and fraternity which they interpret, along with concepts like equity and equality, as ameliorating the conditions of the disadvantaged and resulting in the different health care systems evident in the

ments and conceptualizations which challenge the more reasonable of the assumptions underlying medicine or regard it, as presently constituted, as a form of social control, shaping and supporting the capitalist social order amongst other things. To dismiss ‘the scientific view of medicine and health’ (ie the belief that improvement in health depends upon knowledge of the body and technological developments to its diseases) as removing ‘these categories from the experience and capabilities of individuals’ is probably unlikely to alter in any way the existing jurisdiction of the medical profession over most matters of ill health. It is unfortunate that some of the occasionally interesting ideas, many of which are culled from subject areas unknown to most professional geographers, are couched in an English which is often unclear, sometimes ambiguous and nowhere marked by refinement or elegance of style. If medical school cunicula are to respond to changes in the social and environmental context of human ill health it will in part depend upon the accessibility of non-medical research literature as lucid and persuasive prose. Of even more imporially concerned with the distribution of tance is the fact that medical geodisease and ill health, the search for graphy, even on its social geographical explanation must take us beyond this fringe, is likely to achieve its main consubject’s traditional parameters, to temporary effectiveness and appeal in look specifically at the totality of life applications such as environmental circumstances’. (Reviewer’s italics). I health planning particularly in the am reminded of Andrew Learmonth’s developing countries. If it is not to be modest suggestion in G.M. Howe’s lost in the academic no-man’s land of monumental synopsis A World Geo- ideology, phenomenology or behavgraphy of Human Dbeases2 that ‘surely iourism, which other subjects handle with greater panache, it will have to it is possible that geographical analysis may complement other approaches in work alongside rather than outside and abandon ideas of a elucidating problems that remain of medicine essentially non-disciplinary, grand, both academic and practical importance’ - he was writing of malaria - and synthesis to those who address a very wonder how any scholar in the awe- different and less sceptical readership. some field of disease could contemJ. A. Helen, plate any other than a multidisciplinary Lleparlrnent of or interdisciplinary approach to the Geography, totality of life circumstances, albeit University of rooted in competence in some scientific Newcastle upon Tyne, field. UK With such views of their discipline ‘J.M. Hunter, ed, The Geography of Health one is perhaps prepared for an unconventional approach to geography’s and Disease, University of North Carolina, Chapel Hill, NC, 1974. role, but it seems doubtful how far the 2G.M. Howe, ed, A World Geography of medical establishment or the individual Human Diseases, Academic Press, clinician will be convinced by the argu- London, 1977.

world, and on what they call the ‘dialectic between conceptions of health and policies of health care and the social, economic and political structure’. In the final chapter the authors set out ways in which ‘the understanding of medicine and health may be advanced’ through social geographical research into what they term the totality of health experience, as in comparative analyses, institutional analyses, models of society and health care, lay concepts of health and illness and the nature of change itself. At various points in the book the authors state their position quite clearly, and it is on this that their claims to have set the central problems of medical geography in a broad social context must be judged. On page 11 they note that they see ‘social geography as being part of the broader social science concern with the dissolution of academic boundaries in attempting to understand the social world’ (Reviewers italics), and 18 pages later repeat a view that ‘social geography’s greatest achievement may yet turn out to be the acceleration of its own destruction’. By page 100 they indulge the view that ‘although as geographers we are init-

LAND USE POLICY January 1984