Health and Inequality

Geographical Perspectives

Sarah E Curtis

• Publisher: SAGE Publications Ltd
• Year: 2003
• ISBN:
  9781446225936
• Edition: 1
• Topic: Physical Sciences
• Subtopic: Geography
• Index: Geography

`At last! A tour de force on cities and health by someone who knows that geography matters. This is a groundbreaking text, preoccupied as much with health and well-being as with death, disease and despair. It is concerned with who wins and who loses from the social and spatial patterning of risk… Combining breadth of coverage with depth of analysis, Health and Inequality provides an intricate map of harmful spaces and healing places, together with some guidelines on how to get from one to the other? - Professor Susan Smith, Ogilvie Professor of Geography, University of Edinburgh

?Too often as health professionals we remain embedded in nursing and medical literature neglecting the opportunities offered through engaging with other bodies of knowledge. Such an opportunity presents itself in this book which draws on work undertaken by geographers that can help us in our thinking about health inequalities. The strength of this work lies in its aim to ensure that place and space are recognised as significant factors in health inequalities? - Community Practitioner

Health and Inequality presents a comprehensive analysis of how geographical perspectives can be used to understand the problems of health inequalities. The text has three principal themes: to discuss the geography of health inequality and to examine strategies for reducing disadvantage; to review and develop the theoretical basis for a geographical analysis of these problems - the discussion will illustrate how theoretical developments can help in the design and evaluation of intervention; and to explain how different methodologies in the geography of health, both quantitative and qualitative, can be applied in research - demonstrating the complementarity between them. By relating theoretical arguments to specific landscapes, Health and Inequality will be a key resource for understanding the articulation between theory and empirical methods for understanding health variation in urban areas.

1	Introducing Geographical Perspectives on Health and Inequality

Varying individual and social constructions of health and illness

Varying accounts of what determines health and illness

Ecological versus atomistic views of health

Spaces of risk for health and geographical perspectives on the strategy of preventive medicine

Variations in health at different geographical scales

Health and human development: the epidemiological transition

The importance for health of urbanization

Sustainable cities?

The significance of the ‘urban penalty’

Health inequalities in rural areas

Understanding health inequality: the whole system perspective

Landscapes of health inequality

Further reading

Objectives and questions

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In societies around the world there is debate about the inequalities in health and health care that we observe among populations and among places. Research seeks to improve understanding of the causes of health variation. Such knowledge should provide evidence about how best to influence the causes of health inequality and produce health gain for human populations.

These questions are preoccupying geographers as well as researchers in other disciplines, and this book aims to show how geographical perspectives on health help us to understand health variation. The book aims to review and develop the theoretical and empirical basis for geographical analysis of health inequality. Questions to be addressed include:

• Why is it useful to understand health inequality in terms of characteristics of places as well as people?
• Why is population health in some parts of cities relatively poor?
• What are likely to be effective strategies for reducing health disadvantage for these populations?

A number of theoretical strands need to brought together to inform our understanding of the health of disadvantaged populations. Research in geography and related fields has begun to provide more integrated theoretical frameworks, as well as a large body of empirical evidence.

The discussion in the following chapters is also intended to illustrate and explain how different methodologies in the geography of health and health care can be applied in research on urban health inequalities. These methodologies cover a wide range of quantitative and qualitative approaches. These approaches are often pursued rather separately by different groups of researchers, but the discussion here aims to bring out the complementarity between them, as well as the particular strengths of each.

The discussion will be international in scope, using examples from different parts of high and low income countries. However, given the concentration on urban health, much of the discussion will focus on cities in high income countries which have the greatest degree of urban development, but which also show a good deal of intra-urban variation.

This chapter reviews some concepts of health and health care that are important for the discussion here. It also introduces some important aspects of health variation from a geographical perspective. The last part of this chapter introduces a general conceptual framework for discussion of the geography of health, which involves five types of landscapes that are important for health inequality. This sets the scene for a more detailed discussion in Section I of this book, where Chapters 2 to 6 aim to illustrate the theoretical and methodological strategies that health geographers have used to investigate these different types of landscape. In Section II, Chapters 7 and 8 illustrate how these different conceptual landscapes together produce whole systems of geographical variation in particular types of health problem, such as mental illness and risks of infectious disease (specifically tuberculosis). Chapter 9 discusses the relevance of these geographical perspectives for policy.

VARYING INDIVIDUAL AND SOCIAL CONSTRUCTIONS OF HEALTH AND ILLNESS

The concept of ‘health’ is open to differing interpretations. The biomedical perspective on health focuses on presence or absence of diagnosed diseases, but broader definitions include the idea of health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946: 100).

Health can also be viewed as a socially constructed phenomenon, having different meanings for different people. Our understanding of health relates strongly to our individually and collectively constructed ideas of identity and the nature and significance of the body. Many authors have discussed results from studies in fields such as anthropology, sociology and social geography which have demonstrated that individuals vary in their perception of what counts as healthy or unhealthy and in their definitions of illness (e.g. Cornwell, 1984; Fitzpatrick et al., 1984; Helman, 1984; Donovan, 1986a; Calnan, 1987; Eyles and Donovan, 1990; Miles, 1991; Stainton-Rogers, 1991; Scambler, 1997; Butler and Parr, 1999). People use different conceptual frameworks to understand health and often individuals work with more than one of these frameworks, producing complex and variable frames of reference. Frameworks for understanding and explaining health include:

• the idea of health as balance, or illness as ‘imbalance’;
• the notion of the body as a machine’ and of illness as ‘malfunction’ of the machine;
• the idea of locus of control (the perception of the degree of control the individual has over his or her own health);
• health or illness seen as the outcome of fate or divine will;
• ideas about health providing freedom or ‘release’ to do as one pleases, or as functional ability to carry out key roles, such as work as an employee or a homemaker;
• the concept of health as resilience against threats of infection or hazards;
• ideas about access to the means for good health, such as health care and a reasonable standard of living.

These ‘health beliefs’ are held by different individuals, in varying degrees. However, there is a tendency for some elements of health perception to be shared and reinforced collectively among people in the same society or social or ethnic group. This gives rise to what may be seen as culturally specific aspects of health belief, which may be typical of particular social and geographical settings.

VARYING ACCOUNTS OF WHAT DETERMINES HEALTH AND ILLNESS

Perception of the determinants of health (factors which produce health and illness) is also socially constructed and variable, depending on the temporal, social or geographical context. This has resulted in varying views on how to promote health and treat illness.

The social model of health sees the health of an individual person as the outcome of a range of socio-economic and political determinants, as well as medical care (e.g. Whitehead, 1995). Commentators such as Dubos (1960) and McKeown (1979) have made the case that medicine has a relatively small impact as a determinant of health of populations. They argue that aspects of living conditions, associated with varying levels of social and economic development, are more significant in determining whether or not people become ill. This perspective places strong emphasis on an understanding of the social and physical environmental factors influencing health. The geography of health shows how these vary from place to place, often in association with levels of socio-economic development, and this helps to explain population health differences between different parts of the world.

Other authors have argued that health care should be considered a crucial determinant of health in the population, and that differences in access to effective health care can have major impacts on health (Schofield and Reher, 1991; Bunker, 1995). According to this view, variations in the consumption of health care, in all its forms, contribute to differences in health between populations and individuals. Geographical variation in the provision and use of health care is therefore an important focus for the geography of health. These different perspectives are reflected in a variety of different medicines. The relationship of biomedicine to ‘complementary’ or ‘alternative’ therapies is increasingly being recognized as a matter for debate by health care professionals (Saks, 1992; Sharma, 1992; British Medical Association, 1993; Cant, 1999). Lay views, held by people in wider society, on how best to care for health also need to be understood as socially and individually constructed, and subject to variation and to debate.

Curtis and Taket (1996) argued that ‘health care’ extends beyond professional medical services to include the range of formal and informal services and activities which are intended to maintain good health and treat illness. These include action by lay people to care for their own health and provide informal care for others in their family, their social circle or their wider community. Thus, for example, Milligan (2001) has examined the role of the voluntary sector in geographies of care. Health care is delivered in a variety of settings, or ‘spaces of care’, ranging from institutions such as hospitals to community facilities or people’s homes and public places. These have been the subject of geographical studies which can help in understanding the processes involved in health care and can contribute to strategies to make health care more effective.

The discussion in this book also shows that there are many nonmedical services and resources which are not primarily intended to affect health but which do so indirectly, because they influence the determinants of health. These include, for example, services providing education, housing, access to employment and to social and leisure opportunities, sources of consumer goods, social support mechanisms operating in families and communities, as well as measures to control the physical quality of the environment.

ECOLOGICAL VERSUS ATOMISTIC VIEWS OF HEALTH

A large part of the body of knowledge concerning health variation comes from studies of health in geographically defined populations, focusing on aggregated groups of people. However, geography also helps us to understand the health of individual people, for example, by exploring the interaction between people and places.

There is ongoing debate over the value of ecological perspectives (using aggregated data for populations and their environment) as opposed to atomistic analysis (focusing on information at the level of individuals). Critics of the ecological approach argue that it may result in the ecological fallacy (wrongly attributing the average characteristics of the aggregated population to individuals within the population). Associations observed at the ecological (population group) level between health status and other factors may not mean that these variables are necessarily associated at the level of the individuals within the group. On the other hand, a perspective that concentrates only on associations observed at the individual level may also have limitations. A purely atomistic approach may not correctly identify processes operating at the collective level of whole communities or over whole areas (Schwartz, 1994). A geographical perspective argues for a consideration of how individuals interact with their wider environment. It seeks to develop theories to explain this interaction, which are the subject of this book. It often involves analyses that combine ecological data for areas with atomistic data for individuals.

SPACES OF RISK FOR HEALTH AND GEOGRAPHICAL PERSPECTIVES ON THE STRATEGY OF PREVENTIVE MEDICINE

Beck (1992) suggested that in modern societies inequality is conceptualized in new ways. Socio-economic variation has often been construed in terms of class divisions in the distribution of wealth. Beck argued that the idea of the ‘class society’ is now reinterpreted in terms of the ‘risk society’, in which hazards are unevenly distributed between social groups. This is associated with growing public concern about issues such as the impact of environmental pollution and degradation, global environmental change, and threats to security presented by war and violence. Media coverage of accidental chemical and nuclear emissions, floods and droughts, international conflicts and terrorist actions reflects these concerns.

Many of the hazards of concern in the risk society are hazards to human health. However, we cannot usually be certain...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of figures
• List of boxes
• Preface
• Acknowledgements
• 1 Introducing Geographical Perspectives on Health and Inequality
• SECTION I GEOGRAPHICAL LANDSCAPES OF HEALTH
• SECTION II INTEGRATING LANDSCAPE PERSPECTIVES: ASPECTS OF HEALTH IN URBAN SETTINGS
• References
• Index