Health, Disease and Society

A Critical Medical Geography

Kelvyn Jones, Graham Moon

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000577334
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Classes & Economic Disparity
• Index: Social Sciences

Originally published in 1987 this textbook is a comprehensive introduction to the rapidly developing field of medical geography. It illustrates the ideas, methods and debates that inform contemporary approaches to the subject, demonstrating the potential of a social and environmental approach to illness and health. The central theme is the need to reject an exclusively biological approach to health. The authors examine both the geography of health care and outline a selection of health service planning initiatives in both North America and Europe.

CHAPTER 1 The social context of disease, health and medicine

Introduction: Medical geography

We have been asked many times ‘What are geographers doing looking at disease and health?’, the implied criticism being that we should leave these matters to relevant experts such as physicians, surgeons and biochemists. Implicit in such a view is the belief that the causes of disease will be found in biomedical research and that the only effective treatment is intervention by chemical, electrical or physical means to restore the body to its normal biological functioning, that is technological medicine. Our reply is that this dominant ‘biomedical’ viewpoint is both flawed and limited. There is an urgent need to ‘go outside the body’ to develop an alternative social and environmental perspective on health in which geography can play an important part along with other social sciences.

To provide an appetiser for the rest of this book, and to illustrate the diversity of interest of medical geographers, it is useful to begin with the changing nature of the subject by examining both the content of the discipline and the differing approaches that have been used. In terms of content, two distinct areas of study, or ‘traditions’, can be recognised. First, there is the disease ecology tradition with the geographer attempting to elucidate the social and environmental causes of ill-health; such work is closely allied to epidemiology, which itself is trying to discover the patterns and determinants of disease. The second, and more recent, area of study is the geography of medical care which is concerned with the consumption of care in respect of such matters as distribution and accessibility. This tradition draws on parallel work in economics and sociology.

It is possible to recognise several differing approaches to the study of medical geography but, as it is not uncommon to find individual researchers who use several approaches simultaneously, published work often cannot easily be forced into any rigid classification. For our purposes, and following Pyle (1979) and Phillips (1981), five approaches can be recognised. The cartographic approach is concerned with the mapping of spatial data; modelling attempts to quantify the relationships between variables; while the behavioural approach seeks to understand individual decision-making. The welfare approach attempts to answer the questions of who gets what and where, and how improvement in the quality of life can be achieved by the gradual reform of existing society. In contrast, a structuralist perspective stresses the need to consider phenomena in relation to the totality of society. Emphasis is given to societal constraints, and in a marxist version of this approach, it is presumed that genuine improvements can only be achieved by revolutionary change to a new form of society.

Using these two frameworks of ‘content’ and ‘approach’, the nature of medical geography is readily described by giving exemplars. The earliest work in the disease ecology tradition employs the cartographic approach to map rates of disease incidence. For example, Gilbert (1958) reviews Victorian pioneers in medical mapping, while the approach reaches its peak in the national atlases of mortality such as that of Howe (1963). Of course, once the diseases were mapped, other possible causal variables were also portrayed, and it was then but a short step to the quantitative calibration of models that relate disease rates to social and environmental variables. The quantitative approach reaches its most sophisticated in the modelling of the spread of communicable diseases with, for example, Cliff et al. (1981) attempting to predict measles epidemics in Iceland. Research using the behavioural approach has focused on the individual attributes that may determine health outcomes. For example, Girt (1972) used the ‘lifestyle’ variable of cigarette smoking to develop an ecological model of chronic bronchitis in Leeds. While the welfare geographers have not been greatly concerned with the development of explanations for disease patterns, they have used infant and adult mortality rates, along with many other variables, to derive indices of the quality of life. Using this approach, Knox (1975) examined geographical variations within England and Wales; Smith (1977, Chapter 10) provides equivalent results for the USA. Surprisingly, there has been little work by geographers that uses the structuralist approach to illuminate how health outcomes are related to the nature and organisation of society, and even commentaries which are sympathetic to societal explanations, such as Eyles and Woods (1983, Chapter 3) have to use examples from the work of non-geographers.

The earliest work in the medical-care tradition also used the cartographic approach with, for example, Coates and Rawstron (1971) mapping the geographical provision in Britain of such services as dentists and general practitioners; they found marked inequalities. The modelling approach has been extensively used to examine the geographical location of medical provision, with Shannon and Dever (1974) using central-place theory to explore the efficiency, in terms of distance minimisation, of the locations of hospitals. The behavioural approach has been used to study the decision of individuals of whether or not to attend for treatment; for example Girt (1973) examined the influence of distance in determining consultation at a general practice. A considerable amount of work using the welfare approach has been concerned with medical care and Knox (1982, Chapter 7) revealed the inequitable provision of primary care in Scottish cities and considered the measures needed to achieve a gradual improvement in effective assessibility. It is only in relatively recent years that the structuralist approach has been used by medical geographers but there are now a number of examples such as Mohan and Woods’s (1985) discussion of how the geography and type of medical provision are being restructured in Britain by the decisions of the Conservative government with regard to the needs of capital.

Before exploring further the nature of medical geography, we need to consider the social perspective that is the distinguishing characteristic of this book. It is only by providing this essential underpinning that current research can be described and evaluated. The remainder of this chapter is organised into four sections. First, a social constructionist viewpoint is developed which contrasts the scientific, biomedical approach to knowledge with a social perspective. Second, a social history of medicine is undertaken to reveal the way in which the biomedical approach became dominant and what alternatives were discarded on the way. Third, the major critiques that have developed of the biomedical approach in the last thirty years are outlined. The final section provides a framework for the remaining chapters.

Social construction

In an influential text Berger and Luckmann (1967) have argued that reality is constructed through human action and does not exist independently of it. We learn how to see, structure and organise the world from our parents, teachers, the media and our general social environment. Our attitudes and judgements may appear to be personal and individual but are, in fact, derived from societal viewpoints. In terms of medicine, so successful is this learning process that many people regard the biomedical view as reality and not as one view of reality. Here we try to expose the biomedical viewpoint as a belief system through a consideration of notions of disease.

Biomedical knowledge

For medical scientists, disease is biological fact and not something that human beings have thought up. Diseases are seen as objects which exist independently and prior to their discovery and description by physicians. Disease is seen as abnormal biological functioning and the physician, as expert, can make allowances for normal variation and spot these abnormal deviations. While laypeople are able to describe their illness in subjective terms, the doctor is expected to provide a scientific, objective diagnosis. The key act in western medicine is this diagnosis for it allows the physician to go back to the genesis of the disease and forward to the treatment. Diagnosis is based on the combination and severity of symptoms and the use of diagnostic tests. Such an approach is based on the presumption of generic diseases, that is each disease has specific and distinguishing features which are universal to human species. Any failure to diagnose is attributed to the current lack of medical knowledge or appropriate technical tests. At the same time, western scientific taxonomy is regarded as the best available and universally applicable codification of medical knowledge, having been refined by centuries of empirical scientific investigation. Medical knowledge is regarded as having unfolded in a linear fashion towards a more comprehensive and accurate understanding of reality. Indeed, histories of medicine are literally peppered with such phrases as victories, breakthroughs and remarkable advances (see Cox, 1983, Chapter 2).

Social knowledge

In contrast, from a constructionist viewpoint, diseases are seen as human constructs which would not exist without someone describing and recognising them. Disease may be defined as abnormal biological deviation but we must ask who decides what is normal, who decides what is normal variation, and who decides what is abnormal deviation? What is normal and abnormal is a social and moral judgement and this will vary according to society’s own norms, expectations and culturally shared rules of interpretation. Normality is what prevalent social values hold to be acceptable or desirable, and in contrast to the biomedical notion of universal generic diseases, the social view accepts that what constitutes disease can vary temporally, culturally, and indeed, geographically.

To illustrate the importance of belief in present-day medicine, we will examine through the eyes of a social anthropologist a disease which appears to be defined with considerable biological exactitude. Posner (1984) has examined the treatment of diabetics in a number of London clinics, and concluded that today’s treatment has much in common with magic ritual. Many adults are diagnosed as diabetic on the basis of routine tests showing high blood sugar levels in comparison to the general population. It is accepted that in such cases even though the symptoms of diabetes are not currently present, they will develop in time together with other complications including loss of sight and death from gangrene or thrombosis. Treatment should, therefore, start at once to reduce sugar levels to normality and continue for the rest of life. The choice of treatment is some combination of tablets, insulin and a change of diet.

Posner questions both the disease definition and the appropriateness of the treatment. High sugar levels are not the disease but they are equated in practice and this is despite the finding that successive tests with the same subject can vary as much as between different subjects. Indeed, what can be regarded as abnormally high in terms of the general population may be perfectly normal for an individual. While diabetes is a metabolic disorder which involves a complex of biochemical parameters, one easily measured parameter, blood sugar, takes on a symbolic meaning; as one doctor commented to Posner, ‘diabetes is what I say it is’. The scientific evidence linking high sugar levels with the disease and its complications is not strong, but there is evidence that drug treatment...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Preface
• 1 The social context of disease, health and medicine
• 2 The collection of epidemiological information
• 3 The causal analysis of epidemiological data
• 4 Communicable diseases
• 5 Concepts and issues in mental illness
• 6 Inequalities in health care
• 7 Explaining health care inequality
• 8 Planning, policy and the health services
• 9 Critical perspectives
• Author Index
• Subject Index