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Copyrighted Material 1 Methodological Context This introductory chapter presents the methodological context of spatial analysis applied to epidemiology and health geography. It introduces the systemic approach to health research, the notion of risk in this context, and the various areas of research that use the methods and tools presented in this book. 1.1. A systemic approach to health A health phenomenon – the set of changes in the physiological or sanitary status of the individuals in a population linked to a pathology or a pathology-related characteristic – is the result of processes that are always determined by numerous parameters. Some parameters are affected by the individuals’ personal characteristics (general characteristics such as age or sex, biological characteristics, genetic characteristics, etc.), and were for a long time the only ones used by biology and medicine1. However, a health phenomenon is also determined by factors linked to behaviors and interactions: mainly relationships between individuals (contacts, spatial proximity relationships, behavioral relationships) or relationships between individuals and their environment (natural, social, economic, etc.). The general objective of epidemiology is to understand and model these processes. When studyingCOPYRIGHTED or analyzing the characteristics MATERIAL of populations, it is difficult to understand behaviors and interactions, and equally difficult, if not impossible, to describe their entire complexity at the individual level. Some of the individuals’ characteristics and their interrelations (for example, movements) are difficult to 1 The mesological approach associating man with his environment in the widest possible sense only emerged in the 19th Century as a continuation of the Lamarckian theory of interactions between biology and environment. 2 Epidemiology and Geography describe at the individual level: they are generally determined by probabilities, using statistical analysis of populations. Several levels of aggregation of individuals in a population are possible for their definition and description. These levels correspond to what is commonly known as a description scale, level or spatial granularity of data, concepts which simplify the empirical reality in a description model. The environment itself can be described at several scales, depending on how reality is modeled. Finally, individual characteristics can themselves be directly influenced by environment or behaviors. The global approach to health issues therefore requires a systemic perspective, in which the sole medical aspect (biological and individual), although essential, is not by itself conducive to explaining the phenomenon or mastering the impact on the individual or on the society. According to the systemic approach, a health phenomenon is a complex system, involving various groups of “agents” that act and interact depending on their characteristics and environments, according to processes which we will aim to decode from observed situations, and then model. The various groups of agents consist of: – Individuals (human or animal, potentially susceptible to being individually affected by the pathology or by the phenomenon, and to changing their health or physiological conditions); – Pathogens (virus, bacterium, parasite, fungus, prion, etc.) in case of infectious diseases; – Toxic substances or pollutants (asbestos, metals, radioactive products, chemical products, pesticides, etc.) that can cause certain non-infectious diseases; – Possibly, vectors (animal that transmits the pathogen to the host, such as mosquito, tick, rodent, bird, carnivore, etc.); – Possibly, reservoirs (animal that preserves and spreads the pathogen in the environment, while not necessarily being affected, such as civet, bat, bird, etc.). In the case of infectious diseases, individuals (human or animal) are often called hosts or potential hosts when they are susceptible of being infected. Most of the pathogens are mobile, and are carried by a host, a vector, or a natural element (air, water), or by mechanical transportation means (airplane, ship, truck, etc.). Many pathogens are also present in soils, and can therefore be considered immobile, with the exception of sediments carried by a water stream. The processes and mechanisms, which we are looking to model, and can enable the understanding of the health phenomenon as a whole, are considered to be global Methodological Context 3 mechanisms, identical throughout the studied territory. Many environmental factors are involved in these processes and directly influence, when exposed to them, the characteristics of the various agents, their behaviors and their relationships as individuals or as groups of individuals. A spatial distribution of the phenomenon is the result of all of these processes. EXAMPLE.– Temperature and rainfall influence the development of mosquitos, and therefore the transmission of a mosquito-dependent disease. Many viruses are sensitive to UV radiation and are rapidly damaged by a sunny environment. The health system (care and prevention for humans and for livestock) is also one of the “environmental” factors influencing the characteristics of a disease. Diseases which involve one vector (sometimes two) are called vector-borne diseases. They are obviously strongly dependent on the behavior of the vector, which is itself influenced by the environment. Many diseases do not involve pathogens (non-infectious diseases, such as diabetes, obesity, some cancers, growth abnormalities, etc.), but their study is not any less simpler, since it has been observed that individuals’ behavior and environmental factors (in broad terms) can also have a significant influence on non-infectious diseases. The systemic approach considers a health phenomenon as a complex system, consisting of various groups of “agents” that act and interact according to their characteristics and to their environments: hosts, pathogens, reservoirs and vectors (Figure 1.1). The health phenomenon can affect the state of a “host” and cause it to change from “healthy” to “sick” status. Complexity in studying a health phenomenon essentially arises from the dynamic aspect of the system and the interdependency of its components. Nonlinear interactions among elements may generate unexpected behaviors at a global level [MAN 16]. Box 1.1. Systemic approach The agents and environmental variables used to describe this system and that have an influence on the health phenomenon (increasing the disease probability) are called risk factors. These risk factors, and in particular the environmental ones, can be highly variable in space and time. Events of low or very low probability must sometimes be taken into account, which may potentially result in high instability of the overall system, and make a purely deterministic approach difficult, if not impossible, especially at the individual level. If process analysis and modeling (why, how) is nevertheless achieved, this random instability rarely makes it possible to fully predict a phenomenon (who, where, when). In these cases, we are able to calculate the probabilities for only some of the health phenomenon’s characteristics, and most often for groups of individuals rather than for individuals: the model allowing process simulation should involve many stochastic elements. 4 Epidemiology and Geography Figure 1.1. An infectious disease is a particularly complex system: numerous actors involved in complex mechanisms, at several scales, all interrelated, and in relation to their environments This systemic and multi-factorial perspective has led health research to become largely multidisciplinary. While medical research usually focuses on the medical and biological aspect of a health phenomenon, at the level of the individual, treated as a patient, health research now involves many disciplines, for which the individual is not necessarily a patient, nor the main focus of study. The health system also plays a specific role: it is simultaneously the central factor influencing a health phenomenon (since it seeks to manage and reduce it), and at the same time it is key for collecting epidemiological information used to evaluate and analyze this phenomenon (at the population level) and to measure its own impact. It should be kept in mind that in epidemiology, data reflect the effects of the disease (measured by the health system), and not the disease itself. Health research involves many disciplines, including, in particular: – medicine for the study of pathologies, patients, care and treatments; – biology and virology for the study of pathogens; – epidemiology for the study of etiology and risk factors, with a population-based statistical approach; – entomology, biology, ecology, zoology for the study of vectors and reservoirs; Methodological Context 5 – ecology and geography for the study of the environment; – social sciences (geography, anthropology, sociology, economy) and geomatics for the analysis of the health system, resource analysis and optimization, characterization of vulnerabilities and the study of their mechanisms; – mathematics, statistics, information sciences for phenomenon characterization, process modeling, development of monitoring and early warning systems. Box 1.2. Health research involves many disciplines Spatial analysis is used in the systemic study of a health phenomenon as most of the actors (agents, environmental factors) are localized in space and in time, and many relationships are proximity-based. The use of spatial analysis for an observed situation
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