Remaking Medical

Mark W. Rosenberg Department of Geography. Queen’s University (Canada) Chairperson, IGU Commission on and Environment [email protected]

Kathleen Wilson Department of Geography and Planning. University of Toronto at Mississauga (Canada) [email protected]

Territoris (2005), 5: 17-32 Territoris Universitat de les Illes Balears 2005. Núm. 5, pp. 17-32 ISSN: 1139-2169

REMAKING

Mark W. Rosenberg Kathleen Wilson

ABSTRACT: Medical geography has a long tradition of examining the spatial distribution of and medical care resources. With the shifts in theory, methodology, and changing health issues, medical geography is remaking itself in three complementary modalities. First, in taking into account new theories it is remaking itself as the geography of health and . Secondly, in taking into account new methodologies, it is contributing to the global interest in seeking new ways of understanding the spatial distribution of diseases and medical resources. Thirdly, in focusing on issues such as HIV/AIDS, health and the environment and vulnerable populations such as the elderly and immigrant women, it is increasingly contributing to public policy at various geographic scales. KEYWORDS: Medical geography, , geography of diseases, geography of medical care.

RESUM: La geografia mèdica té una llarga tradició en l’examen de la distribució espacial de les malalties i dels recursos mèdics. Aquesta ciència s’ha subdividit en tres modalitats complementàries, a causa dels canvis en la teoria, la metodologia i els problemes de salut. En primer lloc, es manté com a ciència, prenent en consideració noves teories, amb la denominació de geografia de la salut i de l’assistència mèdica. En segon lloc, adopta noves metodologies, per contribuir així a l’interès global per trobar noves formes d’explicar la distribució espacial de les malalties i dels recursos mèdics. En tercer lloc, amb l’atenció als problemes com la sida, la salut i el medi ambient i les poblacions més vulnerables, com la tercera edat i les dones immigrants, contribueix de manera creixent a la política pública en diferents escales geogràfiques. PARAULES CLAU: geografia mèdica, geografia de la salut, geografia de la malaltia, geografia de l’assistència mèdica.

1. Introduction highlighted are new methodologies and the growing interest among medical geo- This discussion of medical geography is graphers in policy relevant research. Within predicated on making a distinction between the section on the Geography of Health and Medical Geography as it has been conven- Health Care, particular emphasis is given to tionally approached through the division a more diverse health geography which between studies of the geography of focuses on groups such as women, visible and the geography of medical care and more minorities, the disabled and gays and current approaches based on a Geography of lesbians who have been under-researched in Health and Health Care. Within the Medical Geography. conventional approach, not only are dis- Research conducted within Medical tinctions drawn between research on disease Geography and within the Geography of and medical care delivery, but also Health and Health Care can be distinguished Rosenberg, Mark W. and Wilson, Kathleen Remaking Medical Geography

by their distinct approaches to space, place the social, economic and political context in and health. Medical geographic research is which individuals and groups live their lives characterized by the spatial patter- (see below). ning/locational analyses of disease, illness How dominant conventional Medical and medical care, while research within the Geography has been and continues to be can Geography of Health and Health Care be gauged by books and articles which embraces approaches which can be linked to continue to employ the theories and methods the «new » and critical of disease and cultural and spatial theories of the state in linking health and analytic approaches. Learmonth (1978, place. 1987), Mayer (1986) and Meade et al. (1988) were among the best known proponents of the use of disease and cultural 2. Medical Geography ecology in Medical Geography through the 1970s and 1980s. In the case of Mayer and The research conducted within Medical Meade, they have continued to argue for its Geography is usually characterized as importance (see Mayer, 1996; Mayer and belonging to two, sometimes overlapping, Meade, 1994; Meade and Earickson, 2000) strands. The first strand explores various albeit re-interpreted in light of both theo- dimensions of health and illness, while the retical and methodological challenges from second examines aspects related to medical those seeking a Geography of Health and care (see Jones and Moon, 1987). The con- Health Care (see below). ventional approaches to space and place In contrast, the importance of spatial within Medical Geography are characterized analytic approaches in Medical Geography by spatial and locational analyses and continues, and some might argue remains disease and cultural ecology. Generally, the dominant paradigm in understanding the space has been viewed in two ways: i) as a geography of disease and the geography of container of things; and ii) as an attribute of medical care. Major works exemplifying this characteristics (Eyles, 1993). In viewing tradition include Cliff and Haggett (1988), space as a container of things, Eyles (1993) Cliff et al. (2000), Gould, (1993), Joseph argues that space represents the stage upon and Phillips (1984), Shannon and Dever which social relations are carried out. In this (1974) and Thomas (1992). sense, space is independent from the social Research that has explored spatial phenomena that it contains (Curtis and patterns of illness and disease is extensive Jones, 1998). This view of space dominates and wide-ranging. Some of the research spatial analytic approaches. focuses on morbidity and mortality in Within Medical Geography, place and general while other studies are disease health have also historically been explored specific. For example, Pampalon (1991) through a lens of location. That is, much of examines the variation in morbidity rates the research that has explored the link across three rural areas in Québec. In a between place and health, has defined place similar vein, Langford and Bentham (1996) through: i) the social and/or physical examine regional variations of mortality characteristics of different geographical rates in England and Wales. Studies, which scales (e.g., cities, ); and ii) coor- are disease specific, generally examine dinates on a map. In this context, health has variation in incidence rates over small usually been defined narrowly in terms of (urban/rural divides) or large (county/po- specific medical conditions abstracted from litical levels) geographic areas. Particular

20 Territoris, núm. 5. 2005 Remaking Medical Geography Rosenberg, Mark W. and Wilson Kathleen illnesses have received more attention than been dominant issues among medical others, such as cancer (see e.g., Brody et al., using statistical and mathe- 1996; Drapeau et al., 1995; Gbary et al., matical frameworks. Research has explored 1995; Glick, 1982; Schneider et al., 1993; the factors associated with the use of phy- and Thouez et al., 1994), and in more recent sician and nursing services (see e.g., Birch et years, AIDS and HIV (see e.g., Cliff and al., 1993; Eyles et al., 1993; Newbold et al., Smallman-Raynor, 1992; Dutt et al., 1987; 1995), specialized care (see e.g., Kirby, Gardner et al., 1989; Loytonen, 1991; 1995; Ross et al., 1994), hospitals and Shannon and Pyle, 1989; Shannon et al., medical clinics (see e.g., Barnett and 1991; Thomas, 1996; Wallace et al., 1995; Kearns, 1996; Kloos, 1990) as well as the Wood, 1988). factors which impede accessibility (see e.g., Research conducted within Medical Haynes, 1991; Oppong and Hodgson, 1994). Geography has also focused on spatial Within the traditions of Medical analyses and place-specific examinations of Geography, two demographic groups in par- the geographic distribution of medical care ticular have received more attention than facilities/professionals and access/utilization most others; the elderly population and the to medical care services. Research focusing mentally ill. While early research focused on on the spatial variation of medical facilities the concentration of the elderly population and medical professionals is important for and the facilities they require (see e.g., exploring inequalities and identifying under Phillips et al., 1987; Phillips and Vincent, or over-serviced areas (see e.g., Anderson 1988), other research has examined a wider and Rosenberg, 1990; Cromley and range of services and the implications of Craumer, 1990). In addition, studies have restructuring of health care services in examined the characteristics of medical care various national contexts (see e.g., Cloutier- in certain locations and across larger Fisher and Jospeh, 2000; Joseph and geographic units, paying particular attention Chalmers, 1995, 1996; Joseph and Cloutier, to health policy, medical insurance, and 1990; Evans and Welge, 1991; Rosenberg medical coverage over time and across space and Hanlon, 1996). (see e.g., Finkler, 1995; Rip and Hunter, Research on the mentally ill can be 1990). Since the beginning of the 1990s, the grouped around four themes: the concen- use of geographic information systems (GIS) tration of the mentally in particular parts of have increasingly been employed to plan for the city (see e.g., Giggs 1988; Nutter and future medical care service provision and Thomas, 1990; Saunderson and Langford, allocation in different localities (see e.g., 1996, Wolch, 1980); coping in the Bullen et al., 1996; Cromley and community (see e.g., Dear and Taylor, 1982; McLafferty, 2002; Twigg, 1990). Research Elliott et al., 1990; Laws and Dear, 1988; has also shed light on the importance of Kearns et al., 1991); locating mental health examining health-related behaviours. A few facilities and community reaction to them studies have done so by exploring (see e.g., Hall, 1988; Moon 1988; Sixsmith, inoculation and immunization in various 1988; Taylor, 1988; Milligan, 1996); and the contexts. Two examples are Pyle (1984), links between restructuring of mental health who examined uptake of immunization services and deinstitutionalisation (see e.g., against influenza, and Gatrell (1986), who Eyles, 1988; Joseph and Kearns, 1996). focused on whooping cough. While the spatial analytic approach Accessibility to and utilization of remains dominant within Medical Geo- medical care services and facilities have graphy, Medical Geography appears to be

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moving in several new directions. First, links between the tension for development, there are those who are taking advantage of environmental degradation and health (see new statistical techniques (e.g., multi-level e.g., Akhtar, 1991; Good, 1987; Iyun, et al., modeling and spatial autocorrelation) and 1995; Phillips, 1990; Phillips and GIS to investigate everything from the Verhasselt, 1994). More recently and as a spatial distribution of diseases to the result of the HIV/AIDS epidemic importance of various geographic scales in particularly as it has swept sub-Saharan health behavior (see e.g., Duncan et al., Africa, medical geographers have sought to 1993, 1996; Gatrell and Löytönen, 1998; contribute to the remaking of medical Jones and Duncan, 1995; Langford, 1991; geography (see e.g., Kalipeni et al., 2004). Thomas, 1986, 1988, 1990, 1992; In reflecting on research by medical Tiefelsdorf, 2000). Secondly, there is geographers in the developed and growing interest in linking medical geo- developing world and new ways of thinking graphic research with public policy (see e.g., about a geography of health and health care Asthana, et al. 1999; Hanlon and Rosenberg, (see next section), Phillips and Rosenberg 1998; Mohan, 1988, 1990; Moon, 1990, (2000) have warned against creating new 2000, 2001; Newbold, et al. 1998; Poland, divisions among medical and health 2000; Smith et al. 1997; Wilson et al. 2001). geographers from the developed and Other examples are those seeking to developing world. illuminate the policy relevant factors underlying access to health care in specific urban and rural settings (see e.g., Guagliardo 3. Geography of Health and Health et al., 2004; James, 1999; Ricketts et al., Care 2001), relationships among poverty and health (see e.g., Rosenberg and Wilson, Even as Medical Geography began to 2000; Ross et al., 2001) and the outbreak of move in new directions, in the late 1980s new emergent diseases and their impacts on there were signals that some medical health care delivery (Affonso et al., 2004). geographers were searching for a break with Thirdly, there is renewed interest in health tradition. Precursors of this shift can be and the environment where much of the found in the publication of Jones and research is also closely linked to a critical Moon’s (1987) textbook, Health Disease analysis of public policy (see e.g., Eyles, and Society: A Critical Medical Geography 1997; Eyles, 2002; Greenberg and and selected chapters in Wolch and Dear Schneider, 1999; Iannantuono and Eyles, (1989). 1999; Jerrett et al., 1997, 1998; Wakefield et While one cannot deny the important al., 2001). emphasis placed upon spatial and locational Within Medical Geography, there is also analyses within Medical Geography, these a long tradition of carrying out research on types of analyses tend to limit concep- the geography of disease and the geography tualizations of space and place to stages of medical care in developing countries, upon which human activities occur. As which reflects the approaches discussed Jones and Moon (1993, 15) argue, place is above. What mainly distinguishes this «merely the canvas on which events happen literature is the attention paid to ethno- (while) the nature of the locality and its role medical practices, how colonialism and in structuring health status and health-related current international financial institutions behavior is neglected». From a spatial are skewing medical care and the explicit analytic viewpoint, place is viewed merely

22 Territoris, núm. 5. 2005 Remaking Medical Geography Rosenberg, Mark W. and Wilson Kathleen as a location while the deeply entrenched acting as gathering places and arenas of meanings of places and how they shape information exchange» and «what goes on health are overlooked. within [those] facilities potentially A small but influential group of medical contributes to the strengthening of people’s geographers have argued that research belonging to, and perception of place». requires more meaningful examinations of While experiences of place contribute to place and a more holistic view of health. health, the inverse also holds true. In other This has resulted in the development of a words, individual experiences of health «post-medical geography». A post-medical contribute to the meanings people ascribe to geography goes beyond spatial and places. In particular, Dyck (1995) has locational perspectives on health and health explored the links between space, place and care by recognizing the dynamic and the health experiences of women suffering reciprocal relationship between place and from Multiple Sclerosis. Her research fo- health (see Kearns, 1993, 144). In particular, cused on women who had left the workplace Gesler (1991) and Kearns (1993) have due to their illness and the strategies they argued that places represent much more than employed to make places within the home geographic locations related by distance more accessible. In a similar vein, Laws and within space. They suggest that medical Radford (1998) examined the place geographers incorporate a socio-spatial experiences of developmentally and phy- conceptualization of space and place that sically disabled adults living in Toronto. acknowledges the close interconnections of Their research showed that disabilities pose social processes and territory. Further, they space-time constraints on individuals, which assert that the health-related characteristics restrict where and how they experience of places need to be examined. Critiquing place. Further, their study demonstrates that spatial analytic viewpoints of health and meaning is attributed to illness within the place, Gesler (1991, 167) argues that, constraints and opportunities experienced in «[G]eographic studies rarely pay attention to home, neighbourhood and workspaces. the meaning of places in health care In addition, an expanding body of delivery… In fact, most geographic studies research within the Geography of Health and of health care delivery are based on an Health Care has begun to explore the healing abstract analysis of space as opposed to an benefits associated with particular places analysis of place. Where a hospital lies and/or landscapes. Situating himself within a spatial distribution of hospitals is between the new cultural geography and given more importance than what goes on health geography, Gesler first introduced within that particular hospital (original geographers to the term ‘therapeutic emphasis).» landscapes’ in his 1991 book The Cultural Following this lead, researchers within Geography of Health Care. Gesler (1993, the Geography of Health and Health Care 171) defined therapeutic landscapes as have demonstrated that the meanings places with «an enduring reputation for ascribed to places as well as individual achieving physical, mental, and spiritual experiences of places contribute to health healing» and argued that by incorporating and healing (see e.g., Abel and Kearns, theory from cultural geography such as 1991; Dyck, 1995; Gesler, 1996; Kearns and sense of place and symbolic landscapes, Barnett, 1999). Kearns (1991, 529-530) health geographers could begin to examine argues that facilities contribute «to the ‘locations of healing’ as symbolic systems. broader health of [the] communities by Also, out of the new cultural geography

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«have come suggestions for an ‘asylum addition, research on dis-Ability has geography’» (see e.g., Parr and Philo, 1996). uncovered the ableist epistemologies This moves health geography beyond underlying much of the research in Medical mere locational analyses of health care Geography and demonstrates the importance delivery to more in-depth examinations that of framing the body as socially constructed. explore places as sites of meaning. Gesler Recent research has also highlighted the argues this is necessary for recognizing that significance of addressing sexuality in societies, through ideologies and the use of health research (see e.g., Wilton, 1996) and symbols, create therapeutic landscapes of groups marginalized by race and racism (see healing. For example, in The Cultural e.g., Wilson, 2003; Wilson and Rosenberg, Geography of Health Care, Gesler explores 2002). the development of therapeutic landscapes Health geographers such as Gesler in the treatment of the mentally ill in (1991) have also acknowledged the Europe; the protection of British Colonial existence of ‘other’ ways of perceiving the soldiers from malaria in Sierra Leone; and link between health and place and have the use of spas in the United States. expressed the need for research to focus on Since Gesler first introduced the concept ethnicity, alternative and ethno- of therapeutic landscapes in 1991, some medical systems (see e.g., Andrews, 2003; health geographers have taken on the task of Wiles and Rosenberg, 2001). In a similar applying this new body of theory to our vein, Kearns and Dyck (1995, 137) argue understandings of the interconnections that «geographical studies of health and between place, identity and health (see place need to be centred on ‘culturally safe’ Williams, 1999). Using this body of theory, research practice». That is, it is not enough researchers have successfully demonstrated to include others within research, but the healing benefits associated with the researchers must acknowledge diversity, symbolic and material aspects of particular difference and the existence of multiple places such as spas, baths, places of identities and their role in shaping health. pilgrimage, and hospitals (see e.g., Bell, The Geography of Health and Health 1999; Geores, 1998; Gesler, 1993; Gesler, Care has also opened the door to a more 1996; Gesler, 1998; Palka, 1999). activist approach to the examination of Within the Geography of Health and medical and mental health services. Health Care it is becoming increasingly Although suggested in the late 1980s by recognized that the voices and experiences Dear and Wolch (1987), Rosenberg (1988) of ‘others’ have historically been overlooked and Greenberg et al. (1990), there is a new and/or marginalized within Medical generation of health geographers who are Geography. As such, there have been forging connections among health and movements towards creating a more activism in areas ranging from HIV and inclusive Geography of Health and Health AIDS to women’s health to health and Care. Feminist writers, in particular, have development (see e.g., Brown, 1997; Cra- drawn our attention to the role of gender in ddock, 2001; Dyck et al. 2000). shaping health (Dyck et al., 2001), access to Methodologically, much of the research health care (see e.g., Kobetz et al., 2003; cited above also reflects a shift in ways of Wiles, 2002) and have highlighted the collecting data and analysis from quan- important intersections between the titative research to qualitative research (see embodiment of health/illness and daily Baxter and Eyles, 1997). Qualitative (see e.g., Moss, 1997). In methods including in-depth interviews,

24 Territoris, núm. 5. 2005 Remaking Medical Geography Rosenberg, Mark W. and Wilson Kathleen focus groups, participant observation and health care». Nursing and Health Care textual analysis, are being used to provide a Management and Policy, 45, pp. 568-578. more detailed and nuanced understanding of AKHTAR, R, ed. (1991): Health Care how the meaning of place affects health and Patterns and Planning in Developing health care. Countries. New York, Greenwood Press. ANDERSON, M., and ROSENBERG, M. W. (1990): «Ontario’s Underserviced 4. Concluding Comments Area Program revisited: an indirect analysis». and Medicine, In many respects, the divisions between 30(1), pp. 35-44. Medical Geography and the Geography of ANDREWS, G. J. (2003): «Placing Health and Health Care and between those consumption of private complementary studying the geography of disease and the medicine: everyday geographies of older geography of medical care in contrast to the peoples’ use». Health and Place, 9, pp. 337-349. geography of health and health care are ASTHANA, S.; A. J. GIBSON and E. M. artifices used to make sense of how Medical PARSONS (1999): «The geography of Geography developed in the latter part of the fundholding in southwest England: twentieth century and is moving forward in implications for the evolution of primary the twenty-first century. Researchers in care». Health and Place, 5(4), pp. 271-278. Medical Geography and the Geography of BARNETT, J. R. and KEARNS, R. Health and Health Care share the same (1996): «Shopping around? Consumerism interests in understanding how and why and the use of private accident and medical diseases spread over time and space, the clinics in Auckland, New Zealand». Envi- links between the users and the deliverers of ronment and Planning A, 28, pp. 1053-1075. medical care and the mediating role of space BAXTER, J. and EYLES, J. (1997): and place in the linkages and connections «Evaluating qualitative research in social among human activity, health and the geography: establishing ‘rigour’ in interview environment. What is changing in Medical analysis». Transactions of the Institute of Geography and the Geography of Health and British Geographers, 22(4), pp. 505-525. Health Care are the theoretical frameworks BELL, M. (1999): «Rehabilitating and analytical techniques chosen, a growing Middle England: the integration of ecology, emphasis on linking research to policy and aesthetics and thics», in Williams, A. ed. activism and the creation of a more inclusive Therapeutic Landscapes: The Dynamic Medical Geography. Between Place and Wellness. New York: University Press of America, pp. 15-27. BIRCH, S.; EYLES, J. and NEWBOLD, References K. B. (1993). «Equitable access to health care: Methodological extensions to the ABEL, S. and KEARNS, R. (1991): analysis of physician utilization in Canada». «Birth places: a geographical perspective on Health Economics, 2, pp. 87-101. planned home birth in New Zealand». Social BRODY, J.; RUDEL, R. and Science and Medicine, 33, pp. 825-834. MAXWELL, N. (1996): «Mapping out a AFFONSO, D.D.; ANDREWS, G. J. and search for environmental causes of breast JEFFS, L. (2004): «The of cancer». Reports, 111, pp. SARS: paradoxes and dilemmas in Toronto’s 494-507.

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