©Department of Geography. Valahia University of Targoviste Annals of Valahia University of Targoviste. Geographical Series Tome 14/2014 Issues 2: 75-83 http://fsu.valahia.ro/images/avutgs/home.html

TERRITORIAL INEQUALITIES IN HEALTH STATUS OF IALOMIȚA COUNTY

POPULATION

Ana-Maria TALOȘ University of , Faculty of Geography, Department of Human Geography and Tourism, „Simion Mehedinți” PhD School, Nicolae Bălcescu Street, no 1, Bucharest, 1st district, code 010041, phone +4021- 3104551, Bucharest, , Email: [email protected]

Abstract

This study aims to assess and analyze some of the health status indicators in Ialomița county in order to identify the areas with health problems, to determine the causes and to outline an overview of health status in Ialomița county. The analysis of health status in Ialomița county was achieved using health indicators (general mortality, mortality by causes, and specific morbidity). The indicators were analyzed between 1990-2000, 2000-2012, and 2008-2012, following two aspects: their dynamics/evolution and their territorial distribution. There were calculated multiannual rates for mortality and morbidity, in order to compare their dynamics and territorial inequalities. The health data were analyzed in comparative and dynamic perspective, and for a better relevance was considered the multiannual average rate. The results will be useful in highlighting and explaining the differences that exist in the county regarding health status, very important for health policy or health funds orientation.

Keywords: territorial inequalities, health status, mortality and morbidity, Ialomița county population

1. INTRODUCTION

Health is very important for a person to have a high quality life. It can be said that health is part of the structure of life quality, defined as "global welfare of the people in society" (Fahey et all, 2003). There are several definitions for health, from different points of view: medical, social, psychological etc. The most important definition remains the one from 1948, when health has been defined as being „a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). For people, a good health is necessary in achieving the everyday goals and tasks. To have a good health status is essential for the human welfare, as health is a value and a key element in the society for the country competitivity (Albert & Kohler, 2004). Sometimes we don′t appreciate enough health and it was considered that health is a value that we start to appreciate when it is missing (Blaxter, 1990). Health status is a key component of the life quality and it is influenced by different factors like genetic inheritance, behaviors, attitudes and values, lifestyle, social position, but it seems that lifestyle has the largest share with 51%, comparing to 20% of biological factors, 19% of ambient and health services with 10% (Dumitrache, 2004). Beside the factors stated above, it is important to mention the adaptation of the body to these factors: “States of health or disease are the expressions of the success or failure experienced by the organism in its efforts to respond adaptively to environmental challenges” (Dubos, 1965).

75 The geographical factors that influence health are physical (climate, relief, soils and hydrography), human (standard of living, population density, religious customs) and biological (prevalent diseases, vegetable life). After studies made in the world, were noticed variation in the prevalence of cancers. It was reported that pulmonary cancer does not exist in Iceland and Korea, pancreatic cancer is common in Finland and that gastric cancer is not as common in England as on the European continent (May, 1952). Moreover, the place and the environment in which people live can influence the health status. There are advantages in living in a clean environment with clean water and sanitation facilities, and then to have a job in a clean and safe environment, which do not require physical or mental stress (Doboș, 2003). As geographical environment has a big influence on health status, some diseases were associated to certain areas (Brown et all., 2010). In 1951, at the Oxford Symposium was established that primary cancer of the liver is relatively more common in Africa, India, Indochina and Philippine Islands; cancer of the stomach is relatively infrequent in Javanese, Africans and indigenous people of French North Africa; in India, Indonesia and Indochina an unusual number of malignant tumors of the cervical lymph nodes have been reported (May, 1952). Health research is using a range of methods that can help understanding health, illness and disease in contemporary society, but also to contribute to health policy development. The research can be clinical and social, both with an important role in providing health perspectives and knowledge (Saks, 2007). Worldwide, there are considered to be relevant the indicators that measure the absence of health: general and specific mortality, infant mortality, specific morbidity, and the indicators for appreciating the health status (fertility, life expectancy at birth) (Marcu, 2002). In the list that United Nations Organization made for defining ” life quality” there were 12 indicators, and population health status was in the top of the list. When presenting the health status, one can use objective or subjective indicators, at different levels (regions, counties, countries etc.). Among the health indicators used in international comparisons are: life expectancy at birth, general and specific morbidity, general and specific mortality, infant mortality etc. (Pop, 2010). Romania is a country which follows the European trend (demographic ageing, stress diseases, increasing life expectancy). Compared to other European countries, in 2010, Romania has a lower life expectancy at birth (73.5 years) than Switzerland, Norway, Montenegro, Slovenia, United Kingdom, Finland with values over 78 years (Eurostat Database, 2013). In EU, the main causes of death are circulatory system diseases and cancer, and in Romania, the main death causes are circulatory system diseases (tumors in the first place), followed by digestive diseases, respiratory diseases and injuries (with poisoning included) (National Institute of Statistics, 2012). Comparing the national data with the county ones, one can observe that the local problems are worse than the national ones. Between 2008-2010, in Ialomița county, life expectancy at birth was 72.32 years, and between 2009-2011was 72.59. In 2011, the infant mortality rate in Romania was 9.4‰ and in Ialomița county was above average, with 12.7‰. The general mortality rate was higher than the national rate (11.8‰ in Romania): 13.6‰ (National Institute of Statistics, 2012). Moreover, analysing the deaths by specific causes, it is visible the difference between national and county rates. For example, in 2011, in Romania there were 709.6 cases/100.000 due to circulatory system diseases and 863.4 cases/100.000 in Ialomița; 226.4 cases/100.000 due to cancers in Romania compared to 260.4 cases/100.000 in Ialomița; 58.3 cases/100.000 due to respiratory system diseases in Romania and 57 cases/100.000 in Ialomița; 67.9 cases/100.000 due to digestive system diseases in Romania compared to 61.2 cases/100.000 in Ialomița (National Institute of Statistics, 2012). The study area is Ialomița county, located in the south-east part of Romania, in Bărăgan Plain, close to Bucharest area, with a dominant rural population (54.2% in 2008), compared to national average (45% in 2008).

76 2. METHODS

The objectives of this study were to analyze in dynamic perspective the health status of Ialomița county population in order to explain the territorial differences in health status, to identify the areas with precarious health status and to find the determinants of health problems. Statistical analysis and spatial analysis were used in this study. The statistical analysis was based on health data from Ialomița Directorate of Statistics and D.S.P. (Ialomița Public Health Directorate). The data that have been used were: general mortality rate between 1990-2012, comparing the period 1990-2000 and the period 2000-2012, also mortality by causes and specific morbidity between 2008-2012. Multiannual average rate was used to have an overview of the territorial health status. The spatial analysis was based on map interpretation. The health data have been processed and were realized some thematic maps, using the open-source programme Quantum GIS, in order to show the territorial inequalities between the rural and urban areas in Ialomița county.

3. RESULTS AND DISCUSSION

It is well known that the urban population has better health status than the rural population (Blaxter, 1990). The causes are multiple: differential access to healthcare, medical technology, information and promotion paths, different mentalities etc. This happens also in Ialomița county, where the rural population has a significant share, and the education and incomes are different than the urban area. People from the countryside tend to call the medical services only in cases of extreme need. As incomes rise, changes in diet and activity patterns lead to emergence of new disease problems and increased disability; in the last stage, however, behavior “begins to reverse the negative tendencies” and makes possible a “successful ageing” (Popkin, 2003). Many diseases seem to occur consistently more often among the poor than among the affluent. There seems to be a sociopathological complex, made up in large part of stress, lifestyle, diet, housing, polluted air, old paint, and old pipes. Physical, social, and mental diseases have similar patterns within urban areas. Some diseases, such as tuberculosis, are traditionally associated with the poor. Others, such as breast cancer, have more often affected the affluent (Harpham et all., 1988). From the health indicators that are used to analyze the health status, were chosen: general mortality, mortality by causes, and specific morbidity (due to circulatory system disease, respiratory system diseases, digestive system diseases and cancer). In Ialomița county, in the period 1990-2010, the values for general mortality, specific mortality and morbidity have varied. In 1990 the general mortality was 10.2‰, in 2000 was 10.8‰ and in 2010 reached 11.8‰. The general morbidity grew from 293.8 cases/100000 in 1990 to 388.7 cases/100000 in 2000 and 889.6 cases/100000 in 2010 (Ialomița Public Health Directorate).

3.1. General mortality

Figure 1 shows the differences between urban and rural areas (mortality rate values are higher in rural areas, like , , Brazi, Bărcănești compared to urban areas as , , Feteşti), but also between different periods (1990-2000 and 2000-2012) regarding general mortality rate (Figure 1). One can notice that the health status became worse: there are more villages with high rates of general mortality in the period 2000-2011, and the problems are dominant in the rural areas. If during the period 1990-2000, only Drăgoești village had serious problems with general mortality rate (more than 23‰), between 2000-2011, more villages have a rate over 21‰: Bărcănești, , Balaciu, Grivița, Brazi, Albești, Valea Măcrișului, Gârbovi, Armășești, Brazi, Adâncata, Movilița, .

77 a.

b. Figure 1. Territorial disparities: a. general mortality rate (multiannual average for 1990-2000); b. general mortality rate (multiannual average for 2000-2012) source: Ana-Maria Taloș

Multiannual average rates show that in the period 1990-2000 the mortality was balanced in the county, but after the year 2000 the East part of the county has a low mortality rate than the West side of the county, were are the localities with a mortality rate over 19‰.

3.2. Mortality by causes

In Ialomița county, that local patterns of mortality and morbidity do not overlap, because there are differences in their structure: respiratory system diseases are the leading cause in the morbidity model, but not the main cause of death, being easily detected and treated (Figure 2 and 3). Maps show that there are significant differences between specific mortality rate: mortality due to circulatory system disease are higher (the minimum is 105.9 cases/100.000 inhabitants) than mortality due to respiratory system disease (minimum is 9.4 cases/100.000 inhabitants), mortality due to digestive system diseases (minimum is 11,6 cases/100.000 inhabitants) and mortality due to cancer (minimum is 75,9 cases/100.000 inhabitants). Respiratory and digestive diseases are related to air quality, water quality and living area, while circulatory system disease and cancers are related to lifestyle (lack of physical activity, nutrition), age, bad behaviors (smoking, salty food, alcohol consumption), genetics, stress level. (Figure 2)

78 Nowadays less people die from infectious diseases or nutrition problems, but living longer they are exposed to risk factors for cardiovascular diseases, which is called” epidemiological transition” (Curtis & Taket, 1996) . These heart diseases are specific to developed countries and are closely related to people's behaviors on health.

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b.

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79 d. Figure 2. Mortality local pattern: a. mortality due to circulatory system diseases; b. mortality due to respiratory system diseases; c. mortality due to digestive system diseases; d. mortality due to cancer (2008-2012) source: Ana-Maria Taloș

Meanwhile the localities with mortality due to circulatory system diseases are in the West side of the county (Bărcănești, Axintele, Drăgoești, Adâncata, Brazi, Maia, Dridu, Movilița), the localities with mortality due to respiratory system disease are located in the central part of Ialomița county: Cocora, Reviga, Miloșești, Traian, Grivița, Andrășești, Perieți. Some localities have a low mortality rate in both cases: Țăndărei, Platonești, Movila, Mărculești, Căzănești. The localities with a significant number of deaths due to digestive system diseases are in the West part of the county: Fierbinți-Târg, Brazi, Gârbovi, Grindu, Valea Măcrișului, and those with deaths due to cancer are all over the county: Brazi, Movilița, Balaciu, Buești, , Sudiți (Figure 2).

3.3. Specific morbidity

Comparing the local mortality pattern (Figure 2) with the morbidity local pattern (Figure 3), one can notice that serious diseases such as circulatory system diseases and cancers are poorly diagnosed, because of the low percentage in the structure of morbidity, and the cause is the lack of control and lack of serious periodic diagnosis. The symptoms of respiratory and digestive system diseases are more visible and easy to detect, but the circulatory system disease and cancer′s symptoms are not so painful and can easily be overlooked. People tend to go to the doctor only in extreme cases of pain. Differences exist between urban and rural areas when it comes about morbidity or mortality pattern, as the health status in rural areas is pooper than in urban areas. The areas with the highest rate of morbidity due to circulatory system disease are located in the South-East side of the county (Făcăeni, Bordușani, , Vlădeni), but problems are also in some central localities (Balaciu, Reviga, Căzănești, Munteni-Buzău, Cocora). On the other side, localities as Movila, Mărculești, Ciulnița, Buești, Gârbovi, Drăgoești have a low morbidity rate, although some of them have a big mortality due to circulatory system disease as Drăgoești, which demonstrates the lack of periodical medical control and a bad medical addressability (figure 3). Some localities have high specific mortality and morbidity due to cancer: Săveni, Sudiți, Cosâmbești, Balaciu, Valea Măcrișului, Bărcănești, Movilița, Brazi, which show a better medical control, but in the same time the great incidence of the cancers. The areas with the biggest rate of morbidity due to respiratory system disease are located in the West side of the county (Dridu, Maia, Urziceni, Armășești, Bărcănești, Axintele), in central part (Reviga, Perieți, Cocora) and East side (Bordușani, Sudiți, Valea Ciorii). On the other side, low

80 morbidity rates are in localities as Movilița, Roșiori, Gârbovi, Armășești, Miloșești, Amara etc. (Figure 3). Some localities have a high rate of morbidity in both cases of disease (Bordușani, Valea Ciorii, Bărcănești, Valea Măcrișului, Balaciu, Cocora, Reviga), and others have a low rate in both cases: Movila, Mărculești, Drăgoești (Figure 3). The reasons are the same: different addressability, different medical behavior, variate ages and lifestyles.

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81 d. Figure 3. Morbidity local pattern: a. morbidity due to circulatory system diseases; b. morbidity due to respiratory system diseases; c. morbidity due to digestive system diseases; b. morbidity due to cancer (2008-2012) source: Ana-Maria Taloș

4. CONCLUSIONS

In this study were analyzed health statistics in order to observe the local problems, to identify the main areas with major diseases and to start a local research. It is also important to see the real situation in the area, because the data may be different from the reality, so a health survey will be useful. According to this study, Ialomița county has a poorer health status than the national average and this fact can be explained through different reasons: population ageing, low accessibility and addressability to doctors, unhealthy lifestyles, bad medical services. Comparing the periods 1990-2000 and 2000-2012, it was visible a higher mortality rate in the period 2000-2012 and a poor health status for the period 2008-2012. The main cause of death are circulatory system diseases, but the main cause of illness are respiratory system diseases. The health inequalities in rural areas can be explained by specific rural elements: the social environment, economic status, traditions, customs and local mentality that have significance for health. It is important to reduce the differences existing between rural and urban, meaning that the authorities have to improve the access to healthcare, change the medical technology, invest in education and information about healthy lifestyles.

REFERENCES

1. Alber, J. & Köhler, U. 2004, Health and care in an enlarged Europe, Luxembourg, Office for Official Publications of the European Commission 2. Blaxter, M. 1990, Health and lifestyles, Routledge, London 3. Brown T., McLafferty S. & Moon G. 2010, A companion to health and medical geography, Wiley-Blackwell Publishing, UK 4. Curtis, S. & Taket, A. 1996, Health and Societies: Changing Perspectives, London: HodderArnold 5. Direcția Județeană de Statistică Ialomița (Ialomița Directorate of Statistics), Baza de date a județului Ialomița- anul 2012 [Ialomița county database 2012], Slobozia [in Romanian] 6. Direcția de Sănătate Publică Ialomița (Ialomița Public Health Directorate), Baza de date a județului Ialomița- anul 2012 [Ialomița county database 2012], Slobozia [in Romanian]

82 7. Doboş, C. 2003, Accesul populaţiei la serviciile publice de sănătate [Population access to public health services], Rev. Life Quality, XXI (3–4): 3–14 [in Romanian] 8. Dubos, R. 1965, Man adapting, New Haven, CT: Yale University Press 9. Dumitrache, Liliana 2004, Starea de sănătate a populației României. O abordare geografică [Health status of the Romanian population. A geographical approach], Editura Univers Enciclopedic, Bucharest [in Romanian] 10. European Commission, Eurostat Database 2013, available online: http://epp.eurostat.ec.europa.eu/portal/page/portal/statistics/search_database 11. Fahey, T., Nolan, B. & Whelan, Ch.T. 2003, Monitoring quality of life in Europe, Luxembourg, Office for Official Publications of the European Commission 12. Harpham, T., Lusty, T., & Vaughan, P. 1988, In the shadow of the city: Community health and the urban poor, New York: Oxford University Press 13. Marcu, A. 2002, Metode utilizate in monitorizarea stării de sănătate publică [Methods used in monitoring public health status], Public Health Directorate, Bucharest [in Romanian] 14. May, M.J. 1952, History, definition, and problems of medical geography: a general review, Soc. Sci. & Med., Vol. 12D: 211-219, Pergamon Press Ltd. 15. National Institute of Statistics 2012, Anuarul Statistic al României [Romanian Statistical Yearbook], Bucharest [in Romanian] 16. Pop Cosmina-Elena 2010, Starea de sănătate a populaţiei din România în context european. O abordare din perspectiva calităţii vieţii [The health status of the Romanian population in the European context. An approach in the terms of life quality], Rev. Life Quality, XXI(3–4): 274– 305p. [in Romanian] 17. Popkin, B. M. 2003, The nutrition transition in the developing world, Development Policy Review, 21(5–6), 581–597p. 18. Saks, M., Allsop, Judith 2007, Researching health- qualitative, quantitative and mixed methods, Sage Publications, London 19. W.H.O. 1948, Constitution of the World Health Organization, Geneva, World Health Organization

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