Medical Geography Third Edition Melinda S. Meade Michael Emch

Medical Geography 

Third Edition

Melinda S. Meade     Michael Emch


Medical Geography


    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


  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


  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 
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  



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 


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.)

Chapter 1

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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