Geographic research at the end of the century: papersfrom the Eighth International Symposium on Medical

Geography

The International Symposium on Medical

Geography had its inception in 1984 in the UK. The

concept has been so popular that it has now become a

biennial ®xture on the conference calendar for health

geographers. The eighth in the series (Baltimore) was

the last in this century, with the ninth meeting sched-

uled in Montreal in the year 2000.

For those who experienced the inaugural symposium

in Nottingham, it is noteworthy that recent symposia

have featured many new faces, but the basic subject

matter has remained much the same. The themes of

infectious and chronic disease, environmental health,

quantitative methods, health inequalities, and historical

geography of disease are all familiar topics in the

papers that have emanated from these symposia. Some

new directions in subject matter and methodology are

inevitable, however, in any viable discipline. Veterans

in the ®eld will recognize that more attention is being

paid lately to health care for the elderly, health risk

perception, and qualitative methodology.

This issue opens with two papers on the historical

geography of disease. Frank Barrett's research career

has appeared in installments in these symposia. The

latest of his many papers focuses on one of the earliest

of the world disease maps, produced by Leonhard

Finke in the late 18th century. Barrett argues that

Finke's map appeared much earlier than any world

disease map previously known. In the second paper,

Kari McLeod revisits John Snow and the cholera epi-

demic of mid-nineteenth century London. She notes

that there have been many versions of Snow's map

published over the years, but she wonders which map

did Snow actually use, if any? And, did the removal of

the Broad Street water pump handle play a part in the

demise of the epidemic? With the drama of the water

pump being called into question and the map being

relegated to a more illustrative than central role what

is the true story of Snow's involvement?

Infectious disease has always been with us, but until

recently, it was no longer considered a major problem

outside the developing world. Jon Mayer discusses the

emergence of new diseases and the resurgence of fam-

iliar infectious diseases in both developing and modern

nations. He synthesizes the major characteristics of

emerging diseases and suggests that the framework of

political ecology is a useful method of analysis.

Continuing in the vein of health problems in develop-

ing countries, Folasade Iyun and Adewale Oke dis-

cusse the e�ect of di�ering ecological and sociocultural

conditions that a�ect the use of oral rehydration

therapy in Nigeria and similar geographical areas.

Maternal ignorance remains a factor in the ine�ective-

ness of ORT, but pollution of available drinking water

also inhibits the e�ective use of ORT in some areas.

Ezekiel Kalipeni's paper examines the disease complex

and deteriorating health conditions in southern Africa.

HIV has undermined the optimism felt in Africa

twenty years ago that infectious diseases were in

retreat and that life expectancy in the continent would

soon increase dramatically. Kalipeni uses the concept

of vulnerability theory to examine deteriorating health

care conditions, disease and mortality. He concludes

that a more equitable and healthy future for Africans

depends greatly on increasing female empowerment.

Two methodological papers appear next; one is

quantitative, the other qualitative. Steven Reader's

research focuses on clustering in spatial point patterns.

He uses cancer patterns in England over the 1974±

1983 time period to illustrate a new approach to the

analysis of spatial point patterns based upon survival

analysis. Reader argues that the method may be

applied to any positively-valued, continuous variable,

and has epidemiological applications in conjunction

with K-function clustering analysis. The team of Sarah

Curtis, Wil Gelser, Glenn Smith and Sarah Washburn

focuses on the problem of sampling in qualitative

Social Science & Medicine 50 (2000) 911±913

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research. They explore a framework that evaluates

sampling strategies employed in three examples of theauthors' research in `healing places', rural places whichincorporate national anti-malarial policies, and a sub-

population of chronically ill or disabled young males.The next three articles deal with problems of ageing.

Paula Santana pursues the question of why regionalinequities in health and access to health care for theelderly persist in Portugal. She contends that proactive

policies to prevent illness and promote health are rela-tively under developed in the nation's health service.Such things as housing, diet and occupational health

hazards continue to be problematic, but poor accessi-bility to health services is the most serious barrier for

segments of the aged population. Ge Lin examined re-gional variation of elderly disability in the UnitedStates, using data derived from two new questions on

mobility and self-care limitations in the 1990 census.Again, we are reminded that the American South is aregion that just will not go away; there remains a bur-

den of disability for Southerners, cutting across socioe-conomic and racial lines. The study suggests policy

interventions much di�erent from those based on ge-ography per se. A holistic approach (echoing Santana's®ndings) should be applied to health inequalities, with

the goal of reducing regional disparities in health sta-tus. Denise Cloutier-Fisher and Alun Joseph remind us

of longstanding health care provision problems inrural Canada. They use a study of two small ruraltowns to explore the service-user and service-provider

perspectives on service co-ordination issues, particu-larly for elderly people who need costly communityservices in order to stay in their homes, to continue to

`age in place'. This of course runs headlong into thegovernment's aggressive strategies to reduce de®cits.

Will Canada's elderly ultimately be forced into insti-tutions?Mary Shaw, Scott Orford, Nicola Brimblecombe

and Daniel Dorling mapped standardised mortalityratios for 160 subregions in the 15 countries of the

European Union. This ambitious analysis revealed thatwhile most regions of Europe had decreasing SMRsbetween 1990 and 1994, they increased for the ten per-

cent of the population with the highest SMRs, increas-ing the gap between the most and least healthyregions. Does this demonstrate growing health inequal-

ities, or simply artifacts of problems with data collec-tion and aggregation? Kelvyn Jones, Myles Gould and

Craig Duncan apply their quantitative expertise todata from a Health and Lifestyle (HAL) survey in theUK which spans more than a decade of the late 80 s

and early 90 s. They argue that whereas social classplays a role in variations in mortality, it occurs only athigh-levels of deprivation. This exploratory study,

employing a wide range of models, will be the subjectof more rigorous analysis as the HAL mortality study

proceeds. Myles Gould and Graham Moon examined

funding and provision of health services to island com-munities in Britain. Focusing on the Isle of Wight, theresearchers conclude that the notion of island diseco-

nomies of scale may be exaggerated, but it is an issuethat requires more intensive study. Additionally,Gould and Moon call into question the district-based

weighted capitation model of the NHS, and askwhether there is any means for taking into account the

problems of health care provision to island commu-nities.The next three papers focus on particular disease

problems and human behaviour patterns in a varietyof places and human populations. David Paschane and

Dennis Fisher investigated the process, particularly therole of migration, involving substance abuse amongAlaskan residents who periodically migrate to take ad-

vantage of shifting employment opportunities. Theauthors contend that understanding patterns of beha-viour in the migration process is a key factor in help-

ing public health planners identify steps to reducingdisease prevalence. Yo-Eun Kim, Anthony Gatrell and

Brian Francis used data obtained between 1991 and1995 to examine geographical variation in cancer survi-val in southern England. They focused on the distance

between patient residence and the treatment centre,and the district of treatment to ascertain whether area

deprivation had any impact on survival. Controllingfor possible confounders, the researchers concludedthat statistical results were mixed, with evidence that

the `geography of survival' manifests itself morethrough where patients are treated than through areadeprivation variables or relative location. Liz Twigg,

Graham Moon and Kelvyn Jones employed the nowfamiliar and e�ective technique of multilevel modeling

to investigate smoking and problem drinking in theUK. A plethora of formerly intractable problemsinvolving di�erent geographic scales have been

attacked with multilevel modeling. In the UK and else-where, this has often involved combining national sur-vey data and local census information. The authors

stress that even with relatively unsophisticated models,this analysis can take advantage of local data that may

be collected more frequently than the decennial census,thus o�ering more timely information on local health-related behaviours.

The last three papers are related to risk analysis andrisk perception. Clive Sabel, Anthony Gatrell, Markku

Loytonen, Paula Maasilta and Matti Jokelainen colla-borated to address the issues surrounding an individ-ual's exposure to potential environmental risk factors

which can be implicated in the aetiology of a disease.Here, a space-time approach is adopted to assess thelatency period between initial exposure to potential

pathogens and the physical emergence of MotorNeurone Disease in Finland. Following on earlier

Introduction / Social Science & Medicine 50 (2000) 911±913912

research by Rushton and associates, the authorsassume a risk surface over the study area. Was the dis-

ease distribution caused by a single environmentalevent, or was the disease transmitted by a mechanism?The answer helps to de®ne where and at what age clus-

ters of this rare disease might occur. Sarah Wake®eldand Susan Elliott report on the ongoing assessment ofenvironmental health in eastern Canada. Based on the

theories of risk society of Beck and Giddens, theauthors build on the work of health geographersattempting to link the social and contextual with the

medical. The association between risk, process andimpacts are investigated using a conceptual frameworkthat incorporates site and process factors, e�ects ondaily life, and Giddens' conception of `ontological

security'. This is another excellent example of howquantitative and qualitative techniques may be e�ec-tively applied to a decision-making process. The last

paper involves the work of several members of the en-vironmental health team at McMaster University,Isaac Luginaah, Martin Taylor, Susan Elliott and John

Eyles (Martin Taylor has since taken an administrativepost in western Canada). Readers familiar with pre-vious symposia will recognize the petroleum re®nery as

the longstanding usual suspect of health concerns

among residents in southern Ontario. Between 1992and 1997, the re®nery implemented extensive odour re-

duction measures. The local population was questionedabout odour and ill health before and after the odourreduction. An analysis of these surveys established that

the population in southern Ontario perceives a connec-tion between odour and ill health symptoms, yetreporting of general illness symptoms among adults

and children was virtually unchanged after the odourwas reduced.This issue provides an example of how the whole is

greater than the sum of its parts. These geographers(and associated professionals) have again demonstratedtheir ability to apply theory and methods e�ectively toproblems of morbidity, mortality, service provision,

and the analysis of public policy as it applies to illnessand health in a variety of cultural and political set-tings. Although not made explicit in most of these stu-

dies, it becomes obvious to the reader that the qualityof place is indeed an integral component in processesthat involve human health.

Robert EaricksonSenior Editor, Medical Geography

Introduction / Social Science & Medicine 50 (2000) 911±913 913