Medical Geography
Third Edition
Melinda S. Meade Michael Emch
THE GUILFORD PRESS New York London
Medical Geography
Preface
Much has changed in the world and in the discipline of geography since the second edition of this text was published in 2000. For the most part, progressing globalization has extended and intensified the processes of ecological simplification, demographic transition, and cultural/economic/technological connectivity that result in world patterns of disease. These and other processes and their impacts are integrated in place, in region—in geography, which spatially analyzes and socially explains patterns in cause of death and etiology of health or disease. This text is about both geography as integration in place, and geography as spatial analysis. Specific post-2000 changes worthy of attention here include the following: • World population has grown to about 6.7 billion; its fertility rate has dropped to 2.6 children; and its growth rate has decreased to only 1.2% a year. The richest European countries (and Japan) have raised life expectancy to about 80 years, but their birth rates have dropped so low that they have negative population growth today. The youthful rural population that resulted from the high fertility rates of 20 years ago has picked up and headed for the cities, sometimes internationally. • The poorest countries still have the highest mortality: More than 10% of infants in these countries never reach their first birthday, and life expectancy remains less than 50 years. A million of the poorest still die every year from tuberculosis, and another million from malaria. • Whereas AIDS had just emerged before 2000, it now causes 2 million deaths annually. About 30 million people are HIV-positive, with the highest prevalence rates of about 25% in southern Africa. AIDS has become a modern global plague of enormous demographic and social impact; however, we are little closer to a cure for it than we were two decades ago. Although there has been great progress in developing treatments for this disease—enough that some people in the richest countries are starting to consider AIDS a chronic disease—there are huge disparities in who gets the drugs. • China has developed faster than any other society in history. It has completed one massive project of environmental engineering (the Three Gorges Dam) and has plans for others, all concerned with redistributing the flow of water from south to arid north. There has been devastating environmental degradation associated with this alteration, as well as industrial growth and insatiable coal burning. • Other new diseases have emerged; old diseases have been redistributed; and the basis for horrific epidemics of cancer and chronic diseases has been laid in a world population no longer as young as it once was. • What may be the first impacts of climate warming on human health have been expressed in increasing drought conditions in arid lands and increasing flooding and cyclone severity, which have already destroyed crops and villages and have displaced tens of millions in sub-Saharan Africa and South Asia. Health promotion has become the world theme. Biomedicine has been forced off its pedestal. A genetic component has been discovered for many diseases; however, the environmental context for the expressions of those genes is more than ever something that must be explored in order to understand the diseases’ complex etiologies. Social science has developed an interdisciplinary theoretical perspective and a new vocabulary for addressing old processes. Geographic information systems (GIS), with their ability to manage and portray spatial data, have become the dominant tools in geography and have transformed the structuring of public data and health analyses. Medical geography as a subdiscipline has become less concerned with the optimization of health service delivery or a dichotomy between health service and disease ecology (etiology). Instead, it has become increasingly concerned with health geography as a behavioral and social construction, and with disease ecology as an interface between the natural (physical world) and cultural dimensions of existence. This text still endeavors to provide a broad-based, comprehensive survey of the rich diversity of medical geography for upper-division undergraduates and graduate students, while also serving as a sound reference for the complexities of classifications, processes, and systems. Our perspective remains holistic and international. We still hope to provide the necessary biological background for geographers to understand disease processes, as well as the necessary geographic background for health researchers to understand spatial processes. Students who have used the text in the past decade have included medical doctors pursuing doctorates in epidemiology; graduate students in geography working on their doctorates; graduate students from such public health disciplines as epidemiology, biostatistics, health behavior, nutrition, health administration, and public policy; undergraduate geography majors; and premedical undergraduates with majors in chemistry or biology, but little background in the social sciences or geography. It is difficult to meet the needs of such varied students, with their different competencies in statistics, mapping, and geography. The vignettes (fewer than in past editions) offer focused discussions, usually of techniques or other topics that not all teachers will want to go into (in chapters). Some may want to teach the vignettes with chapters other than the ones in which they are presented. We have added a chapter on GIS in health and disease research, and have expanded the chapter on spatial analysis. We have also added a chapter on neighborhoods and health, which is an area that has grown exponentially during the past decade. Something also needs to be said about references. We have attempted to write a general textbook that can be read without the constant interruption of strings of citations, most of which are publications themselves citing the common source of an idea/term or general knowledge in a field (“It is hot in the tropics [x, 1958]” or “The malaria plasmodia (schistosome, tick, etc.) has several life stages [y, 1999]”). Where possible, we have referenced the seminal ideas and influential discussions, not all of which represent the most recent applications of those ideas. Our references are not meant to be comprehensive bibliographies of works in medical geography. The approaches, information, or examples we have consulted (i.e., actually used in writing the chapter) are listed under “References.” Students can usually identify relevant material simply by its title. “Further Reading” contains relevant geographic studies or foundations that have not actually been used in writing the chapter. Some of the “Further Reading” entries were cited in past editions or are important, somewhat parallel, works. Many of them are suitable for term papers and further study. Finally, specific original ideas, quotes, or individual studies used for data are specifically cited in the body of the text. Thus the chapter on disease diffusion has more references than the others, because so many of the ideas, methodologies, and research findings have been contributed by a few individuals, and so few of these have yet become general knowledge. Our hope is that this text will be a sound foundation for the future development and practice of medical geography, and that it will inspire geographers and others to bring their own special subdisciplinary knowledge and theoretical approaches to enrich and advance this growing course of study. Finally, we wish to acknowledge and appreciate the examples and even words in this text that belong to the three coauthors of the first and second editions, John W. Florin, Wilbert M. Gesler, and Robert J. Earickson, whose work has become an indistinguishable part of the text. We also acknowledge Cameron Taylor, a University of North Carolina at Chapel Hill medical geography undergraduate student, who helped with graphics, cartography, and picture taking in Malawi. Melinda S. Meade Michael Emch
Contents
1. Questions of Medical Geography 1
What’s in a Name? 2
A Brief History of Medical Geography 9
Definitions and Terminology 17
The Challenge of Medical Geography 21
References 22
Further Reading 24
2. The Human Ecology of Disease 26
Health 27
The Triangle of Human Ecology 30
Transmission and Creation of Infectious Disease 44
Nutrition and Health 55
Conclusion 65
References 65
Further Reading 67
VIGNETTE 2.1. Biological Classifications of Importance to Health 68
3. Maps and Geographic Information Systems in Medical Geography 73
Cartography of Disease 74
Types of Maps: Some Issues 77
Geographic Information Systems 83
Disease Maps on the Web 91
Conclusion 93
References 94
Further Reading 95
ix
x
4. Landscape Epidemiology 98
Regions 99
Transmissible Disease Systems 100
The Landscape Epidemiology Approach 110
The Cultural Dimension of Water-Based Disease Transmission 116
The Cultural Ecology of Tick-Borne and Other Transmissible Diseases 131
Regionalization 136
Ecological Complications 138
Conclusion 142 References 142
Further Reading 143
VIGNETTE 4.1.
Field Mapping for Landscape Epidemiology 145
5. Transitions and Development 149
Ecologies of Population Change: Multiple Transitions 150
Major Impacts of Population Change 162
Nutrition in Transition 165
The Mobility Transition and Time–Space Geography 168
Disease Ecologies of the Agricultural Frontier 173
Other Development Impacts on Rural Ecologies 180
World Urbanization and Changing Disease Ecologies 184
Globalization of Movements 192
Conclusion: Emerging Diseases in Your Future 195 References 196 Further Reading 199
VIGNETTE 5.1. Age Standardization 201
VIGNETTE 5.2. Microspatial Exposure Analysis 204
6. Climate and Weather: Influences on Health 207
Direct Biometeorological Influences 209
The Influences of the Weather 215
Seasonality of Death and Birth 221
How Climate Change Is Likely to Affect Health and Disease 227
Conclusion 232
References 234
Further Reading 236
VIGNETTE 6.1. Monthly Indexes 236
VIGNETTE 6.2. Seasonality of Birth 238
VIGNETTE 6.3. Physical Zonation of Climates and Biomes 244
7. The Pollution Syndrome Toxic Hazards of Natural and Economic Origins 248
Outdoor Air Pollution 249
Indoor Air Pollution 259
Water Pollution 260
Radioactive Pollution 265
Risk Assessment and Prevention 271
Globalization and the Perception of Health Hazards 272
The Geometry of Hazards, Power, and Policy 274
Conclusion 276
Contents
xi
References 276
Further Reading 279
8. Political Ecology of Noncommunicable Diseases 281
The Dimension of Mortality 283
The Poverty Syndrome 288
Race in the Study of Health Risks 292
Gender: Women’s Health 294
Causal Reasoning and Epidemiological Design 300
Disease Ecology: Cancer 304
Disease Ecology: Cardiovascular Disease 314
Unknown Etiology and Other Questions 325
The Precautionary Principle and Some Political Ecology of Research 329
Conclusion 333
References 334
Further Reading 337
9. Neighborhoods and Health 339
The Concept of Neighborhood Health 339
Neighborhood Definition and Units 341
Analyzing Neighborhood Effects on Health 345
Effects of the Built Environment on Health 346
The Challenges of Neighborhood Health Studies 347
Conclusion 348
References 348
Further Reading 350
10. Disease Diffusion in Space 351
Terminology 352
Disease Diffusion 358
Modeling Disease Diffusion 359
Influenzas 375
Geographic Approaches to the Pandemic of AIDS 380
Other Epidemics 398
References 398
Further Reading 401
VIGNETTE 10.1. Diffusion Waves or Stochastic Simulation of Individual Contact? 403
11. Health Care and Promotion 407
Asclepius: Provision of Medical Care 409
Asclepius Unrobed: Cultural Alternatives and Perceptions 431
Hygeia: Health Promotion 442
References 444
Further Reading 447
VIGNETTE 11.1. Application of Spatial Statistics to Health Care Delivery 448
12. Scale, Spatial Analysis, and Geographic Visualization Some Issues of Scale 454
The Ecological Fallacy 454
xii
Contents Scale of Analysis and Units of Observation 455
Sources for Spatial Disease Data 458
Visualizing and Summarizing Disease Distributions 459
Spatial Analysis 463
Spatial Statistics 466
Conclusion 468 References 468
Further Reading 469
VIGNETTE 12.1. Chi-Square Statistical Test 471
VIGNETTE 12.2. Regression Analysis 474
VIGNETTE 12.3. Spatial Autocorrelation 479
13. Concluding Words 483
Index 486
About the Authors 498
On Airs, Waters, and Places Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces (for they are not at all alike, but differ much from themselves in regard to their changes). Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. In the same manner, when one comes into a city to which he is a stranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or setting sun. These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking. From these things he must proceed to investigate everything else. —Hippocrates (c. 400 B.C.)
Questions of Medical Geography
Medical geography uses concepts and methodologies from the discipline of geography to investigate health-related topics. The viewpoint is holistic, dealing within a variety of cultural systems and a diverse biosphere. Drawing freely from the facts, concepts, theories, and techniques of other social, physical, and biological sciences, it approaches health and disease through its own core questions and perspectives, and uses its own techniques of spatial analysis. Health/medical geography is an integrative, multistranded subdiscipline that has room within its broad scope for a wide range of specialist contributions. Medical geography is both an ancient perspective and a new specialization. As illustrated by the quotation preceding this chapter, Hippocrates (c. 460–377 B.C.) was familiar with the importance of cultural–environmental interactions more than 2,000 years ago. The study of these interactions, which are important to disease etiology, health promotion, and health service provision alike, continues to this day as medical geography. As old diseases, almost forgotten, are reemerging amidst new risks; as the majority of the world’s population becomes urban and moves toward stabilization of numbers; as biotechnology transforms medicine, agriculture, and our understanding of the nature of life; and as climate change, air and water pollution, metastasizing consumption, and parasitic inequalities transform the ecology of disease—so the ancient study about how people, their cultures and societies in different environments, create and spread disease, promote health, and provide care for the ill has never been more relevant. It is important to understand the interactive processes of cultural and environmental change, as well as the importance of distance and location. By doing this, medical geography can not only advance knowledge, but be useful for analysis and have applied outcomes. This first chapter undertakes three things. First, it introduces medical geography and health geography. To do so, it presents a framework for the complexity of this specialization and explains something of the divergence of “ecological” para
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