Public health and geography

2.3 Links to other disciplines 9 3 CLASSICAL MEDICAL GEOGRAPHY 11 3.1 Geographical epidemiology 11 3.1.1 Human disease ecology 11 3.2 Health care geography 16 4 THE ‘NEW’ GEOGRAPHY OF HE

An introduction to medical and health geography

Background paper to a new bachelor course at the Faculty of Spatial Sciences of the University of Groningen

Maaike den Draak

Population Research Centre Working Paper Series 05-1, June 2005

Population Research Centre

PO Box 800

9700 AV Groningen The Netherlands Tel +31 50 363 3898 Fax +31 50 363 3901 www.rug.nl/prc

An introduction to medical and health geography

Background paper to a new bachelor course at the Faculty of Spatial Sciences of the University of Groningen

Maaike den Draak

Population Research Centre Working Paper Series 05-1, June 2005

The Working Paper Series of the Population Research Centre intend to facilitate the distribution of interim reports as part of the Centre’s programme of research and have only limited distribution

Editing by Nadja Jacubowski

 Copyright Maaike den Draak, 2005 No part of this report may be

EDITORIAL

With the shift to the Bachelor-Master system, the Department of Demography

at the Faculty of Spatial Sciences of the University of Groningen formulated a Minor in Demography The Minor is part of the Bachelor of Human Geography and Planning and started in the course year 2003-04

One of the new courses in the Minor Demography is Medical Geography The new course is actually a successor of the former course Population and Health which was part of the ‘old’ Masters in Population Studies that lasted two years One of the objectives of the course is to interweave the discipline of Demography with those of Geography and Planning

In the past years, the author of this Working Paper, Maaike den Draak, provided the course on Population and Health during a PhD assignment In the course year 2003-04, she was asked to formulate the new course in Medical Geography as based on her earlier experiences As the reader will see (Chapter 1), Maaike turned out to be the best person to formulate the new

course: already in the early 1990s – when the special issue of Geografie on

medical geography was published (Groenewegen 1993), she considered to study medical geography

In this paper, the author describes different ‘streams’ in the field of medical or health geography, the situation of medical or health geography in the Netherlands, and the contents of the course Medical Geography as developed for the course year 2003-04 The paper also includes a reflection on the first year course and provides recommendations for changes

I hope that this Working Paper will contribute to further development of the course and the discipline of Medical or Health Geography and to identification of possible joint research within the field of medical geography Prof dr Inge Hutter Groningen, February 1 2005

ABSTRACT

Since 2004, the Faculty of Spatial Sciences of the University of Groningen in the Netherlands offers a course on medical / health geography The course is part of the minor ‘Demography’ within the bachelor ‘Social Geography and Planning’ The development of this course constitutes the immediate cause for the present paper The paper provides a background setting and introduces the subdiscipline of medical and health geography to geographers, demographers, planners, and other colleagues at the Faculty of Spatial Sciences in Groningen The paper describes history, traditions, branches, frameworks, and themes in medical / health geography and refers to famous names, studies, and texts A

short introduction to the two traditions of classic medical geography, i.e

geographical epidemiology and health care geography, is followed by a discussion of the ‘new’ geography of health Subsequently, the paper discusses the history and the developments of the field in the Netherlands, and the new course at the University of Groningen As medical / health geography shows the links between geography and several other disciplines, the new course provides a good opportunity to the Faculty of Spatial Sciences in Groningen to strengthen bonds between geography and planning, and demography

Keywords • Medical geography • Health geography • Disciplinary development • Curriculum

2.3 Links to other disciplines 9

3 CLASSICAL MEDICAL GEOGRAPHY 11 3.1 Geographical epidemiology 11 3.1.1 Human disease ecology 11

3.2 Health care geography 16

4 THE ‘NEW’ GEOGRAPHY OF HEALTH 19

5 MEDICAL AND HEALTH GEOGRAPHY IN THE

LIST OF FIGURES

Figure 1 Dr John Snow and his map of cholera deaths in the Soho

area in London, 1854

5 Figure 2 An application of GIS in the health sector: Bodyviewer

developed by GeoHealth Incorporated (USA)

8 Figure 3 Diagram from “Medical geography as human ecology: the

dimension of population movement”, Meade (1977)

12 Figure 4 Map of the distribution of AIDS cases in the USA, 1988,

Gould (1989)

15 Figure 5 One of the maps in the Dutch National Atlas of Public

Health: mortality from diabetes mellitus 1999-2001, the

1 INTRODUCTION

In 1993, the Dutch geographical journal Geografie published an issue around

the theme of medical geography (vol.2, no.3, June 1993) In that year, I was a first-year student in human geography at the University of Amsterdam who was contemplating her future specialisation Medical geography sounded appealing to me but a quick search indicated that none of the geography departments in the Netherlands was offering any courses within this field I continued my education in demography at the University of Groningen, at both Master and PhD level, while keeping a focus on health issues Coincidentally, now, eleven years later I am organising and teaching the first course in the Netherlands (at least to my knowledge) on medical or health geography

The Dictionary of Human Geography describes medical geography as

“geographical analyses of health, disease, mortality and health care” (Johnston

et al 2000, p.494) and defines the geography of health and health care as “a

sub-discipline focused on the dynamic, and recursive, relationship between health, health services, and place, and on the impact of both health services and the health of population groups on the vitality of places” (p.330) Simply put, medical / health geography can be described as the branch in geography that uses the concepts and techniques of geography to study health, disease, mortality, and health care

The new course on medical/health geography in the Netherlands is part of the minor ‘Demography’ within the bachelor ‘Social Geography and Planning’ at the Faculty of Spatial Sciences (FRW) of the University of Groningen (RuG) The development of this course constitutes the immediate cause for the present paper The paper is intended to provide a background setting and to introduce the subdiscipline of medical and health geography to geographers, demographers, planners The background paper starts with a brief introduction to the subdiscipline of medical and health geography and its history in Section 2 Sections 3 and 4 describe its traditions, branches, frameworks, and themes, and refer to famous names, studies, and texts Subsequently, Section 5 focuses on the history and the developments in the field of medical and health geography in the Netherlands Finally, Section 6 discusses the new course at the FRW in Groningen

2 THE SUBDISCLIPLINE OF MEDICAL AND HEALTH

GEOGRAPHY

Medical geography has been acknowledged as a subdiscipline in geography since the 1950s The Commission on Medical Geography (Ecology) of Health and Disease presented its first report to the International Geographic Union (IGU) in 1952 (Meade and Earickson 2000) Also for the present period of

2000 to 2004, the IGU has established a commission that is concerned with medical / health geography: the Commission on Health and the Environment, which is chaired by Professor Mark W Rosenberg from Queen’s University

in Canada (CHE 2004) Some other large associations for geographers also have specialist groups working in the field, such as the Medical Geography Specialty Group of the Association of American Geographers (AAG 2004), the Geography of Health Research Group of the Royal Geographical Society / Institute of British Geographers (RGS 2004), and the Health and Care Study Group of the Canadian Association of Geographers (CAG 2004)

In the Netherlands, however, medical / health geography seems to be

a neglected subdiscipline as interest from human geographers has been

limited The website of the Royal Dutch Geographical Society, Koninklijk

Nederlands Aardrijkskundig Genootschap (KNAG) shows no indication of any activity in the field (see KNAG 2004) For more information about the situation in the Netherlands, please see Section 5 of this paper

Within the subdisicipline of medical geography, two areas of study or

‘traditions’ are recognised The first tradition is concerned with disease and mortality and studies the relation between ill-health and environment The second stream addresses the location, accessibility, and utilisation of health services The first branch has been referred to as ‘geographical epidemiology’,

‘geographic pathology’, ‘disease ecology’, or ‘disease geography’ (Mayer 1982; Kearns 1995; Pringle 1996; Kearns and Moon 2002) while labels for the second tradition include ‘health care geography’, ‘geography of medical care’, ‘geography of health service provision’ (Jones and Moon 1987; Pringle 1996; Kearns and Moon 2002)

Since the early 1990s, a new vision of health geography has come up and found recognition, running parallel with the recent discussions and shifts

in the disciplines of social geography and population geography (Kearns

1993, 1995; Rosenberg 1998; Kearns and Moon 2002) The new

For a discussion of the various branches of medical / health geography, please see Sections 3 and 4 Section 3 discusses the two traditions

in classic medical geography while Section 4 is about the ‘new’ geography of health The present section provides an overview of the history of the subdiscipline (Section 2.1), some recent developments that have affected the subdiscipline (Section 2.2), and its links with other disciplines (Section 2.3)

2.1 A brief history

According to Meade and Earickson (2000), medical geography is “both an ancient perspective and a new specialisation” (p.1) Medical geography has

been said to have its origins in Hippocrates’ treatise On airs, waters, and

places, dating from 400 before Christ In his work, Hippocrates pointed out that for the study of medicine one must consider the effects of seasons, winds, water, ground, as well as the life and lifestyle of the inhabitants (Pringle 1996; Meade and Earickson 2000) Since then, various scientists and thinkers have put emphasis on this perspective of health as an interaction between environment and man

Early development of the discipline of medical geography may further

be traced back to medical research and a number of German physicians in the

18th and 19th centuries, e.g Finke, Schnurrer, Fuchs, and Muhry (Paul 1985)

In 1792-1795, the physician Finke published a book entitled Versuch emer

ailgemeinen medicinisch-praktischen Geographie (Lawson and Williams 2001)

An important role in the history of classical medical geography has been for disease mapping Among the earliest examples of disease mapping are the maps for yellow fever in New York by Seaman and by Pascalis at the end of the 18th century Other maps include the first medical map in Germany published by Berghaus in 1847, the map by Rothenburg of cholera cases in Hamburg in 1832, and Acland’s map of cholera cases in Oxford in 1849 (Paul

1985; Pringle 1996; Shaw et al 2002) By far, the most famous map is the one

by anesthetist John Snow (1813-1858) showing the distribution of cholera deaths in the Soho area of London during the epidemic in 1854 (Figure 1)

Figure 1: Dr John Snow and his map of cholera deaths in the Soho area in

London, 1854

Source: Kamel Boulos (2000-2002)

The map showed a clustering of cases around the water pump on Broad Street and although the exact causal mechanism was not yet understood, Snow concluded that cholera was caused, in some way, by contaminated water He was able to convince the authorities to remove the pump and after its removal the epidemic receded within a few days (Pringle 1996; Young 1998) The interest in disease mapping and the large number of maps that were produced during the late 18th century and the first half of the 19th century inspired Gilbert (1958 cited by Paul 1985) to label this period as the ‘golden age’ of

Geographical Society published, under direction of May, The world atlas of

disease and between 1952 and 1961, Rodenwaldt and Jusatz published the

three volumes of the German Welt-Seuchen Atlas National atlases of

mortality have been produced in the UK, Japan, and the USA (Meade and

Earickson 2000) The first national atlas published in the UK was the National

atlas of disease mortality in the United Kingdom (1954-1958) by Howe, which dates from 1963 Twenty years later, in the 1980s, Gardner and

colleagues (1983) published an atlas of cancer mortality: Atlas of cancer

mortality in England and Wales 1968-1978 (cited by Lawson and Williams 2001)

During the 20th century, medical geography started to evolve as a subdiscipline within geography The founding father of the subdiscipline is generally regarded to be Jacques May (1896-1976), a French surgeon who worked in Siam (now Thailand) (Meade and Earickson 2000; Brown 2004) May was interested in the question why his patients in the tropics experienced disease and responded differently under surgery and medical care than did

European patients In 1950, he published an article entitled Medical

geography: its methods and objectives (Meade and Earickson 2000) His most

famous work, however, is the book The ecology of human disease (1958),

which was a strong impetus for the disease ecology tradition (see Section 3.1.1)

Since the 1950s, medical geography has been acknowledged as a subdiscipline within geography The Commission on Medical Geography (Ecology) of Health and Disease presented its first report to the IGU in 1952 (Meade and Earickson 2000) A more substantive interest in the field developed during the 1960s, 1970s, and 1980s Before, there were few geographers who regarded themselves as medical geographers (Phillips 1985) and even today, geographers working on health issues do not necessarily regard themselves as medical or health geographers The distinction between the two ‘traditions’ of geographical epidemiology and health care geography did not evolve until the 1970s (Pringle 1996) when geographers became interested in health care planning, health seeking behaviour, and health service promotion

2.2 Recent developments

More recent developments include the debate on theory, methodology, and themes during the 1990s (see before) Please refer to Section 4 for a discussion of the so-called ‘new’ geography of health

Other recent developments that have affected the subdiscipline include the advances in methods of analysis The development of geographical information systems (GIS), for example, has opened up a new range of possibilities (see Figure 2) A GIS is an integrated set of tools and methodologies for collecting, storing, retrieving, editing, integrating, analysing, and visualising spatially referenced data (Meade and Earickson

2000, p.461; Gatrell 2002, p.72) The new developments have lead to the

distinction by some of geomatics or geoinformatics as a whole new discipline

in science, which comprises GIS, remote sensing, and the global positioning

system (GPS) (Kamel Boulos et al 2001)

Though GIS-like systems first emerged in the 1960s, it is only relatively recently that health geographers have started to use their options (Gatrell

2002) The book GIS and health, edited by Gatrell and Löytönen (1998),

provides many examples of how GIS is being applied in studies of health In

2002, the journal Health & Place published a special issue on research

applications of GIS in health (vol.8, no.1, March 2002) During the same year,

the online journal International Journal of Health Geographics was launched,

which publishes papers on “all aspects of the application of geographic information systems and science in public health, healthcare, health services, and health resources” (International Journal of Health Geographics 2004) More information on GIS and its applications to public health can be found on the internet, see for example Matthews (2002)

The book GIS and public health by Cromley and McLafferty (2002)

is the first textbook on GIS and public health In the textbook by Meade and

Earickson (2000), Chapter 13 Scale, spatial analysis, and geographic

visualisation contains a section on GIS (pp.461-468) Also chapter 3 in the textbook by Gatrell (2002) contains a section on GIS and the use of GIS (pp.71-77)

Figure 2: An application of GIS in the health sector: Bodyviewer developed

by GeoHealth Incorporated (USA)

Source: Kamel Boulos (2000-2002)

2.3 Links with other disciplines

The account on the history of medical or health geography in the above section indicates the contribution of other disciplines, especially the biomedical sciences, to the field As Paul (1985, p.402) observes, “it was the physician, not the geographer, who contributed solely to the early development of medical geography” However, many of the developments in the discipline during the 20th century can be contributed to geographers, although many geographers who have been working on health issues may not see themselves as medical or health geographers In addition, the interest is no longer solely with medicine (Kearns and Moon 2002) Medical or health geography is “an integrative, multistranded subdiscipline that has room within its broad scope for a wide range of specialist contributions”, “drawing freely from the facts, concepts, and techniques of other social, physical, and biological sciences” (Meade and Earickson 2000, p.1) On the basis of Sections 3 and 4 in this paper, which describe the branches and perspectives in medical / health geography, the links with several other disciplines can be derived:

• geographical epidemiology and epidemiology, ecology, physical geography, biology, medical / health demography,

• health care geography and planning, medical sociology, health economics, social policy, public health, and

• the ‘new’ health geography and medical anthropology, medical sociology (see also Phillips 1985; Jones and Moon 1987)

3 CLASSICAL MEDICAL GEOGRAPHY

The present section provides a brief introduction to the two traditions of

classic medical geography, i.e geographical epidemiology (Section 3.1) and

health care geography (Section 3.2)

3.1 Geographical epidemiology

Geographical epidemiology studies the relationship between disease and the social and physical environment (Pringle 1996, p.23) The methods that are applied are diverse, but mainly quantitative, and include mapping, statistical

or associative analysis, spatial analysis (e.g Openshaw’s Geographical

Analysis Machine (GAM) for detecting clusters), modelling techniques, and the application of GIS Two important approaches or frameworks within geographical epidemiology are human disease ecology and disease diffusion They are relevant for the study of infectious diseases The study of degenerative diseases and mental illnesses generally applies associative and spatial analysis to identify the unknown causes and risk factors

The following sections, i.e Sections 3.1.1 and 3.1.2, provide an

introduction to the traditions of human disease ecology and disease diffusion, respectively

3.1.1 Human disease ecology

Human disease ecology approaches the geography of disease from an ecological viewpoint Ecology is the scientific study of the relationship of organisms to each other and to their environment (On-Line Medical Dictionary 1997-2004) Disease ecology can thus be interpreted as the study

of how disease interacts with humans, animals, plants, and the environment

As Meade and Earickson (2000) write “the human ecology of disease is concerned with the ways human behaviour, in its cultural and socioeconomic context, interacts with environmental conditions to produce or prevent disease among susceptible people” (p.21) Its principal goal is to understand the dynamics of disease and the disease cyle, which shows regional variations (May 1958 cited by Paul 1985; Cromley and McLafferty 2002)

intermediate host, a reservoir) and the geogens Based on this, disease is viewed as a “maladaptation between organism, culture, and environment, requiring the coincidence in time and space of agent, pathogen, and host” (Mayer 1982, p.217) Another classic framework is the ‘triangle of human ecology’ from Melinda Meade (1977 cited by Brown 2004; Meade and Earickson 2000) (Figure 3)

Figure 3: Diagram from “Medical geography as human ecology: the

dimension of population movement”, Meade (1977)

Source: Brown (2004)

The model defines health in terms of adaptability and suggests that health is the result of interactions between the three dimensions of habitat (environment), population, and behaviour (culture)

Additional conceptual frameworks are provided by landscape epidemiology and environmental epidemiology (Meade and Earickson 2000; Curtis 2004) Themes in geographical epidemiology thus include

biometeorology of health (e.g the influences of weather, seasonality), pollution and health (e.g air pollution, water quality, radioactive pollution),

and environmental change and health (e.g ozone depletion, global climate

change, changes in land use)

The foundation of the disease ecology tradition was laid by May (1950, 1958, 1960) Other well-known names in the tradition include

Armstrong (e.g 1973), Audy (e.g 1971), and John Hunter (e.g 1966) In

1988, Andrew Learmonth published the textbook Disease ecology: an

introduction More recent texts are provided in the books by Meade and Earickson (2000, chapters 2-7), Cromley and McLafferty (2002, chapter 6 on environmental hazards, and chapter 8 on the ecology of vector-borne disease), Gatrell (2002, chapters 7-9 on air quality, water quality, and global environmental change), and Curtis (2004, chapter 6) More information on

specific topics is also available, such as: air pollution (e.g Dunn and Kingham 1996; Ayres 1997), water quality (e.g Hunter 1997), ozone depletion (e.g

Armstrong 1994; De Gruijl and Van der Leun 2000), global climate change

(e.g McMichael and Haines 1997; Haines et al 2000; McMichael et al 2000), and emerging infectious diseases (e.g Greenwood and De Cock 1998;

Mayer 2000)

3.1.2 Disease diffusion

Disease diffusion studies are interested in the spatial structure and spatial form

of disease patterns, and put emphasis on trying to understand the way in which a disease diffuses over space during an epidemic, rather than on the biological causes (Mayer 1982; Pringle 1996) The foundation of the disease diffusion approach lies in the formal geographical diffusion theories, such as the famous work by Hägerstrand (1952, 1953, 1967) on the temporal and spatial spread of innovations The disease diffusion approach evolved after the early 1960s when diffusion became an important aspect in geographic research (Paul 1985) In addition to the geographic diffusion theories, mathematical models from epidemiology have been influential, such as the Hamer-Soper models (Haggett 2000; Meade and Earickson 2000)

Many disease diffusion studies have focused either on the development of abstract models of the diffusion process or on the analysis of past outbreaks of infectious diseases (Paul 1985) The methods and tools that

have been employed include mapping (e.g map sequences, animated maps), mathematical models, and simulation models (e.g Monte Carlo simulation)

the future? (i.e predictive models), and (3) what will happen in the future if

we intervene in some specified way? (i.e interdictive models) The approach

may thus be useful for the planning of interventions in public health Moreover, “careful analysis of diffusion patterns can lead to hypotheses about the behavioural, social, political and economic factors likely to explain the development of the epidemic” (Curtis 2004, p.162)

In the UK, Cliff, Haggett, Smallman-Raynor, and also Ord and Versey, have dominated the field together Much of their data have come from the reconstruction of historical records and they have used islands as

‘laboratories’ for their research (Rosenberg 1998) The work of Cliff and his colleagues has focused on the diffusion of influenza and measles (Haggett

1976; Cliff et al 1981; Cliff et al 1986; Cliff et al 1993) and, more recently, also on HIV/AIDS (Smallman-Raynor et al 1992) Other well-known diffusion studies on influenza have been by Pyle (e.g 1980), and on HIV/AIDS by Gould (e.g 1989, 1993) (see Figure 4), Löytönen (e.g 1991), and Wallace (e.g 1991) During the 1960s, Pyle (1969) also published a study

on the diffusion of cholera in the United States

Figure 4: Map of the distribution of AIDS cases in the USA, 1988, Gould

(1989)

Source: DiBiase (1999-2004)

A famous textbook is the Atlas of disease distributions: analytic approaches

to epidemiological data by Cliff and Haggett (1988) More recently, in 2000, four lectures by Haggett within the Clarendon Lectures in Geography and

Environmental Studies have been published under the title The geographical

structure of epidemics Other texts on disease diffusion are provided in the books by Learmonth (1988, chapter 6), Meade and Earickson (2000, chapter

3.2 Health care geography

The development of health care geography paralleled the development of the geographical study of public services in general (Mayer 1982) The geography

of health care is concerned with the provision and spread of health care services, the access to health care and the utilisation of services, and the planning of health care services Recurrent themes are: the spatial distribution

of services, patterns of utilisation, inequalities (or rather inequities) in access

to medical services and in service uptake, the extent to which use of services declines with distance from facilities, policy criterions and performance standards, variety in health care systems, and the reforms of national health care systems in the 1980s and 1990s (Pringle 1996; Rosenberg 1998; Johnston

et al. 2000) According to Meade and Earickson (2000), current topics in the field are the changes in medical systems and the integration of traditional and modern medicine

The studies in the field of health care geography are methodologically diverse and apply, for example, classical location analysis, location-allocation modelling, and shortest path analysis but also multilevel analysis, mathematical models, and concepts from political economy (Pringle 1996;

Rosenberg 1998; Johnston et al 2000) In addition to the above, GIS offers

many possibilities, especially for the planning of health services where it can

be used as a decision support tool The branch of health care geography has roots in location theory, theories of public service provision, and transport geography (Paul 1985) Concepts and frameworks in health care geography include equity, distance and distance decay, activity space, accessibility, efficiency, effectiveness, need and demand, utilisation models, health care hierarchy, and the ‘inverse care law’ (Meade and Earickson 2000; Cromley and McLafferty 2002; Gatrell 2002) The inverse care law, for example, states that the availibility of good health care tends to vary inversely with the need

of the population (Hart 1971 cited by Joseph and Phillips 1984) The health services tradition of medical geography has been criticised for assuming that health facilities are beneficial and the provision of health services is a desirable goal, but that institutions and structures must be altered to assure

adequate delivery of health services (Mayer 1982, p.221; Johnston et al

2000)

In the field of health care geography, some frequently cited authors

include Eyles (e.g 1987, 1988), Gesler and Ricketts (e.g Gesler 1991; Gesler and Ricketts 1992; Ricketts et al 1994), Jones and Moon (e.g 1990), Joseph (e.g Joseph and Cloutier 1990; Joseph and Chalmers 1996; Joseph and Hallman 1998), Mohan (e.g 1988, 1990, 1998), Phillips (e.g 1990, 1994;

Phillips and Verhasselt 1994), and Rosenberg (e.g 1988; Rosenberg and

Hanlon 1996) A classic text, though somewhat dated, is the book

Accessibility & utilization: geographical perspectives on health care delivery

by Joseph and Phillips (1984) Also somewhat dated are chapters 6-8 in the book by Jones and Moon (1987) More recent texts are included in the books

by Curtis and Taket (1996, chapters 5-6), Meade and Earickson (2000; chapters 9-11), Cromley and McLafferty (2002, chapters 9-10), and Gatrell (2002, chapter 5)

4 THE ‘NEW’ GEOGRAPHY OF HEALTH

Since the early 1990s, a new vision of health geography has come up and found recognition, running parallel with the discussions and shifts in the social sciences, social geography, and population geography (Kearns 1993, 1995; Rosenberg 1998; Kearns and Moon 2002) The debate on this ‘new’

geography of health was boosted by a series of articles published in The

Professional Geographer and Progress in Human Geography (Dorn and Laws

1994; Jones and Moon 1993; Kearns 1993, 1994a, 1994b, 1995) and the reactions to them (Mayer and Meade 1994; Paul 1994) Some of the reflected visions and issues in the debate, however, are not so new and were already

addressed during the 1980s (e.g Dear 1984; Pearson 1989) (Rosenberg 1998)

The debate reflects dissatisfaction with the approaches and methods in classic medical geography, such as the positivist philosophy, a lack of social theory, the lack of attention for social divisions (race, gender, disability, sexuality), and the neglected role of place and locality (Jones and Moon 1993;

Kearns 1993; Litva and Eyles 1995; Johnston et al 2000) The ‘new’

geographies of health have been referred to as medical geography’s cultural turn (Kearns and Moon 2002) There is a strengthened relationship with anthropology Key characteristics of the ‘new’ geography of health are:

• the adoption of sociocultural theories,

• a more critical perspective and the quest to develop critical geographies of

health (e.g opposition to unequal and oppressive power relations,

commitment to social justice),

• a renewed sensitivity to place (e.g therapeutic character of certain places)

and an awareness of place as a socially constructed phenomenon,

• the use of qualitative approaches,

• attention to individuals’ subjective experiences, and

• a greater attention to the body and an interest in corporeality

(Kearns 1995; Johnston et al 2000; Kearns and Moon 2002)

In summary, the transition from classic medical geography to the ‘new’ geography of health involves the following changes in perspectives:

The biomedical model sees people as patients or hosts to a disease and places emphasis on the monocausal origins of disease and the curative while the socio-ecological model of health involves an interactive set of relationships between a population and its social, cultural, and physical environment

(Kearns 1993; Johnston et al 2000) The developments further include a shift

from concern with diseases and curative medicine towards a focus on health and wellness (Kearns 1993; Kearns and Moon 2002) The focus on place is no longer as a region and passive container in which things are simply recorded, but place is seen as “an operational ‘living’ construct which ‘matters’” (Kearns and Moon 2002, p.609) and emphasis is put on constructed meanings and the experiential aspects of place Similarly, bodies are no longer regarded

as ‘dots on maps’ but as social constructs while attention is being granted to individual experiences of their bodies This perspective requires methodological pluralism in which the quantitative approaches from classic

medical geography are supplemented by qualitative methods, e.g narrative approaches (Johnston et al 2000; Kearns and Moon 2002)

The ‘post-medical’ developments have been accompanied by a growing preference for the terms ‘health geography’ and ‘geography of health’ over the label of ‘medical geography’ Kearns (1993) suggested that

“two interrelated streams be identified within the medicine/health/geography

nexus: medical geography and the geography of health The concerns of the

former are well known (…) The concerns of the latter would consider the dynamic relationship between health and place and the impacts of both health services and the health of population groups on the vitality of places” (pp.144-145)

- health and well-being

- place as a living construct

- embodied experiences

- methodological pluralism

Subjects of studies that apply new perspectives of health geography

include the therapeutic character of places (e.g Gesler 1992; Williams 1999), disability (e.g Butler and Parr 1999), women’s health and gender (e.g Dyck

et al 2001), and the experiences of persons with HIV/AIDS (e.g Brown

1995, Wilton 1996) Publications that focus on embodied geographies include Duncan (1996), Pile (1996), Teather (1999), and Longhurst (2001) Place awareness has been expressed in various studies (see, for example, Kearns and Gesler 1998; Gesler and Kearns 2002), including those employing multilevel

modelling (e.g Duncan et al 1998, 1999; Verheij et al 1999) A famous name within the ‘new’ geography of health is Dyck (e.g 1992, 1995), whose

work shows an interest in the experiences of individuals, the demedicalisation

of patients into persons, engagement with social theory, and the inclusion of the respondents as participants in the research process

A good overview of the new geography of health and a decade of new

perspectives is provided in the article From medical to health geography:

novelty, place and theory after a decade of change by Kearns and Moon (2002) Longhurst (1997) and Parr (2002) provide overviews of the

embodiment of health geography In 1995, the journal Health & Place was

launched to provide a forum for the ‘new’ health geography In the textbook

Health & societies: changing perspectives, Curtis and Taket (1996) discuss various theoretical and philosophical perspectives (chapters 1 and 2) The textbook by Gatrell (2002) also discusses various philosophical approaches in medical / health geography (chapters 1 and 2) and includes qualitative approaches in its overview of methods and techniques (chapter 3) The text by Curtis (2004) focuses on inequalities in health A model for teaching a gendered medical geography has been presented by Matthews (1993)