Sunday, July 23, 2006

Medical or Medicinal Geography

Medical or Medicinal Geography has been a new major for people to reasearch on and its study is iteslf a big challenge. Here at the geek blog, I have managed to post this entry with partial derivation from my brother who is currently working on his thesis or dessertation in " Medical Geography". Hope you will like the contents. Please, credit this article while using for any purspose(s).

EkendraLamsal.com is the official website for this information where I adapted from.

Medical geography by definition is the application of geographical information, perspectives, and methods to the study of health, disease, and health care. Medical geography can provide a spatial understanding of a population's health, the distribution of disease in an area, and the environment's effect on health and disease. The study is considered a brand of human geography, however, it requires an understanding of other fields such as epidemiology, climatology.

 

Epidemiology is the study of the distribution and determinants of disease in human populations (Rothman and Greenland), and the application of this study to control health problems (Last 2001).

 

Epidemiology is considered the cornerstone methodology in all of public health research, and is highly regarded in evidence-based clinical medicine for identifying risk factors for disease and determining optimal treatment approaches to clinical practice. Epidemiology is the scientific study of factors affecting the health and illness of individuals and populations, and, in this capacity, it serves as the foundation and logic of interventions made in the interest of the public’s health and preventive medicine.

 

The acting epidemiologist works on issues from the practical, such as outbreak investigation, environmental exposure, and health promotion, to the theoretical, including the development of statistical, mathematical, philosophical, and biological theory. To this end, epidemiologists employ a range of study designs from the observational to experimental with the purpose of revealing the unbiased relationships between exposures such as nutrition, HIV, stress, or chemicals to outcomes such as disease, wellness, and health indicators.

 

Epidemiological studies are generally categorized as descriptive, analytic (aiming to examine associations, commonly hypothesized causal relationships), and experimental (a term often equated with clinical or community trials of treatments and other interventions).

 

Epidemiologists work in a variety of settings. Some epidemiologists work "in the field", i.e., in the community, commonly in a public health service, and are at the forefront of investigating and combating disease outbreaks.

 

The term "Epidemiologic triangle" is used to describe the intersection of Host, Agent, and Environment in analyzing an outbreak.

 

Health Geography

 

GIS provides a holistic approach to public health that promotes the well being of human populations through organizing data about who we are, where we live, and how we live within a geographic framework.

 

The health of human populations reflects the complex interplay between population characteristics and the environment. Genetic makeup can predispose certain populations to chronic or acute conditions. Cultural factors, such as stress, economic status, and access to health care, can play a significant part in disease onset. For example, heart disease, cancer, and alcoholism--leading causes of death in the United States--are produced by multiple, interrelated factors rather than a single infectious agent.

 

GIS incorporates data that describes population characteristics, socioeconomic conditions, and the landscape, and analyzes the spatial relationship of these factors. In addition to integrating and analyzing health related data, this technology promotes data sharing through the use of standard formats and a highly efficient communication tool--the map.

Improving Research

 

Although GIS applications for market research, site location, and facilities management are used in the health industry, the classic use of GIS in the health arena has been public health. The Centers for Disease Control (CDC) and Prevention makes extensive use of GIS for investigating the cause and spread of deadly diseases such as polio, malaria, Guinea worm, and Lyme disease. As part of these efforts, CDC distributes Epi Map 2000 to public health practitioners and researchers around the world. Epi Map 2000 is a public domain GIS application developed by the CDC using Microsoft Visual Basic 6.0 and ESRI MapObjects 2.0a. It comes with boundary data in shapefile format and is available at no cost.

 

The National Center for Health Statistics, the principal vital and health statistics agency for the United States and part of the CDC, showcases its use of GIS on its GIS and Public Health Web site. It provides information on GIS use by the public health community via its newsletter, features maps from the Atlas of United States Mortality, and has links to GIS-related sites.

 

In the 1970s, the National Cancer Institute (NCI) mapped cancer data that had been available in tabular form for years and immediately geographic patterns in the data emerged. The NCI's innovative work contributed significantly to understanding regional differences in rates of lung and oral cancers. Subsequently, NCI has made extensive use of GIS for spatial analysis and visualization of data as well as database development. The Long Island Breast Cancer Study Project exemplifies the NCI's use of GIS for cancer research.

 

Although rates for many types of cancer have declined, breast cancer remains the most common form of cancer in women, accounting for one in every three cancer diagnoses. In 1993, Congress mandated a study of the possible environmental causes of breast cancer on Long Island, New York. This mandate included the creation of a prototype GIS called GIS-H. AverStar, Inc., of Vienna, Virginia, developed GIS-H for NCI. GIS-H helps researchers study the relationship between environmental exposures and occurrences of breast cancer.

 

The availability of powerful desktop GIS and spatially-enabled data has expanded the use of GIS beyond research institutes and state agencies to hospitals and medical centers. In addition to using GIS for organizing, linking, and presenting datasets, modeling local data can provide insights that lead to the development of programs that better serve the community.

 

Public health practitioners can use GIS marketing methodology to locate the most likely "customers" for prevention campaigns such as anti-smoking programs or cancer screening. The Late-Stage Breast Cancer Program sponsored by Baystate Medical Center in Springfield, Massachusetts, is an example of this type of GIS application. The program looks at women diagnosed with late-stage breast cancer during a 10-year period and evaluates factors such as community characteristics (e.g., educational attainment, socioeconomic status) and individual characteristics (e.g., age at diagnosis, distance to the nearest mammography center) that contribute to delayed diagnoses.

 

In addition to its increased use for public safety, GIS is also being incorporated into programs that safeguard public health against terrorist threats such as bioweapons. Although these threats may originate outside the country, initial response is always local. Monitoring disease levels in populations, maintaining current inventories of medicines and other supplies, and tracking the availability and location of trained personnel needed in emergencies are all activities enhanced by GIS.

Intelligent Use of GIS

 

Like all powerful technologies, GIS must be intelligently applied by practitioners versed in both public health methodologies and GIS. An understanding of epidemiological principles and methods is required to structure studies and interpret results. Mapping sophistication is necessary to generalize, symbolize, and classify data so that maps communicate effectively rather than distorting the data behind the map.

 

All consumers and custodians of medical data, not just GIS users, will be required by the Health Insurance Portability and Accountability Act (HIPAA) to maintain the confidentiality of medical records. The first of many regulations that protect patient privacy, HIPAA controls the dissemination of identifiable health data. Beginning in October 2002, HIPAA will require that organizations develop policies that prevent the identification of an individual's medical records. GIS is a helpful tool in formulating validation policies that prevent unintentional re-identification of individuals.

Expanding GIS Use for Health

 

Forces not specific to public health are also encouraging the spread of GIS. Data standardization and the development of the National Spatial Data Infrastructure support the use of GIS, not only for public health, but for all government and business applications. Geospatial boundary and demographic data is more readily available from government and commercial sources in a variety of vector and raster formats. An increasing percentage of vital statistics gathered by public health agencies are geocoded and public health practitioners are developing data partnerships.

 

The distribution of GIS software such as Epi Map 2000 and the development of Web-based GIS applications are putting GIS within the grasp of smaller organizations. Complementary technologies such as GPS and the development of ArcPad, a GIS for handheld devices, have made possible disease surveillance applications such as the one used by the State of Pennsylvania to monitor an outbreak of West Nile Virus.

 

ESRI continues to support organizations that are pioneering GIS use for public health. ESRI hosted the first International GIS Health Conference and has continued to aid the development of GIS tools for public health practitioners.

 

What is health geography?

 

Health geography is related to medical geography, but is much more (as discussed in the lecture). It should be obvious that GIS can play a major role in several areas of health geography. However, similarly, it should also be obvious that the use of technologies such as GIS must always be tempered by a critical social and cultural perspective on the issue.

 

A description of health geography prepared by Jamie Baxter (formerly at the University of Calgary, but now at UWO) for his old UC course on health geography is presented below. I've also included some references on health geography and related topics collected by him below:

 

There are three main themes in the geography of health care (or medical geography): disease ecology, health care delivery, and environment and health.  Disease ecology involves the study of infectious diseases (e.g., malaria, HIV/AIDS, infant diarrhea) including the spatial distributions of meteorological, biological and cultural phenomena associated with disease, as well as the social, political and economic barriers to positive change.  The study of health care delivery includes spatial patterns of health care provision and patient behaviour and includes issues like inequalities in health (health status and accessibility), and deinstitutionalization of the mentally ill. Environment and health is a relatively new focus for health geographers which draws geography's long tradition in environmental hazards research together with health geography. Topics within this new tradition include environmental risk assessment, as well as the physical and psychosocial health impacts of environmental contamination.

 

Human geography is a branch of geography that focuses on the systematic study of patterns and processes that shape human interaction with the environment, with particular reference to the causes and consequences of the spatial distribution of human activity on the Earth's surface. It encompasses human, political, cultural, social, and economic aspects. While the major focus of human geography is not the physical landscape of the Earth (see physical geography) it is hardly possible to discuss human geography without referring to the physical landscape on which human activities are being played out, and environmental geography is emerging as an important link between the two.

 

Medical Geography

Medical Geography (Health Geographics) is the branch of Human Geography that deals with the geographic aspects of health (status) and healthcare (systems). It seeks, along with related disciplines such as Medical Anthropology, Medical Sociology and Health Economics, to improve our understanding of the various factors which affect the health of populations and hence individuals. In other words, these interrelated disciplines can enhance the concepts or "models" we have about health and disease, and hence enhance the final outcomes of healthcare.

The concept that place and location can influence health is a very old and familiar idea in medicine. As far back as the time of Hippocrates (c. 3rd century BC), physicians have observed that certain diseases seem to occur in some places and not others. Even within the human body, many diseases and organisms are known to have a predilection for, or to exclusively affect specific body organs or systems (anatomico-physiological "locations" within the human body).


Geography Matters

In the following example we will use GIDEON (Global Infectious Disease and Epidemiology Network, an expert decision support system for Windows) to diagnose a simple case of diarrhoea in an infant (< 2 years old). The three screenshots below show the "Diagnosis Results" (with probabilities) for the same patient but with a different country of disease acquisition in each screenshot (France, Egypt, Jordan in this example). You can clearly see how the differential diagnosis and probabilities differ in each case by just changing the geographic location of disease acquisition. You can download GIDEON from the 'Resources' page. 

Disease Diffusion (Spread)

People have also been aware of the process of disease diffusion across geographic regions for centuries even during times when aetiology of infectious diseases was a mystery, e.g., the Black Death (plague, 1346-51 AD pandemic, which was carried along trade routes from China to Europe. Frequently, attempts to understand why certain diseases seem to only occur in certain places and not others has lead to new insights into the nature of the disease itself (e.g., environmental and socio-economic causes/factors). In the early part of the 20th century, for example, two dentists in Colorado discovered that children living in areas with high levels of naturally-occurring fluoride in groundwater had reduced dental caries.

In 1854, death and despair engulfed London. In the Soho district, when nearly six hundred people died from cholera in just 10 days, death tolls rang around the clock from the church bell tower. With no known cure, panic spread throughout the city and residents began thinking that they were somehow being infected by the buried corpses of plague victims who died during the European pandemic a century before. Housing had been built on the cemetery where those plague victims were buried. As cholera deaths occurred in these homes, and in homes surrounding the area, the residents feared that they were being infected by vapours coming from the ground.


Dr. John Snow's cholera maps, famous in epidemiological circles, are familiar to researchers and help them understand the power of mapping their study data.

Dr. John Snow, a London physician and anaesthesiologist, knew that to contain the disease, they would have to locate its source. Using maps showing the locations of water pumps and the homes of people who died of cholera, Snow was able to show that one pump, the public pump on Broad Street, was causing most of the disease. People could also see on this map that cholera deaths were not confined to the area around the cemetery and were therefore convinced that the infection was not due to vapours coming from it.

 

Snow suspected that infected water from the pump was the cause. He instructed the authorities to remove the handle to the pump, making it unusable; the number of new cholera cases dropped dramatically. The Broad Street pump proved to be the source of contaminated water and hence cholera, just as Snow had thought.

As Geography matured as an academic discipline in the 19th century, it was only a matter of time before geographers would also begin to study systematically the geographic aspects of health and disease. Today, with the growing world-wide incidence of HIV infection, the "return" of infectious diseases such as tuberculosis, and declining health budgets in many countries (especially in tropical regions and the "third world"), the significance of place in understanding health and disease seems stronger than ever.

The Geography of Disease

Physicians, public health professionals and medical geographers measure health strictly in terms of indicators of ill-health such as morbidity (illness and disease complications) and mortality (death). Three allied fields of medicine, namely Epidemiology, Public Health, and Medical Geography are concerned with examining the distribution of disease and death at various geographic scales, in an attempt to determine if the presence or absence of particular illness is associated with some factor(s) in the social or physical environment.

The "Time" Dimension

In the case of infectious diseases like influenza and AIDS, the study of their geographic distribution frequently involves examining the diffusion of the disease through space over a given period of time (spatio-temporal mapping and analysis). The animated map on the right represents the winter 1995-96 national influenza outbreak in France and was taken from SentiWeb, an interactive mapping site for public health surveillance operated by the French Ministry of Health.

Mapping vs. Analysing

Although the mapping of disease data can be relatively straightforward, interpreting spatially referenced disease data can sometimes be challenging, particularly for non-infectious and chronic diseases (e.g., coronary heart disease and diabetes mellitus). For example, a researcher might map the distribution of people with schizophrenia (a psychiatric mental disorder) in urban areas and find that they tend to reside in low-income, inner-city areas. At this stage, the researcher can understand how the data is distributed (she can see patterns or clusters — mapping), but explaining why it is distributed as such is another story and requires further research (analysis).

Spatio-temporal analysis is concerned with cluster validation, e.g., that a detected cluster is not due to mere chance factors, and with attribution of detected clusters to the appropriate factors that played a role in their occurrence. Analysis also includes doing comparisons with other relevant patterns/clusters (in the same place at different times and in other places) and again trying to methodically explain any spotted differences or trends. Thus, in the case of the schizophrenia example mentioned above where a cluster or pattern has been detected, many questions arise (new hypotheses) that need to be addressed. For example, does the stress of urban poverty cause mental illness, or are the mentally ill forced to live in cheap housing because their illnesses prevents them from earning a stable income? Or is there a circular relationship between poverty and mental illness?

Although the above example may seem trite, it is important to note that when people become seriously ill, they often 'respond spatially', i.e., they relocate. It is known, for example, that urban residents who contract a terminal disease often move back to their home towns, in order to be cared for by their family and friends in the final stages of the disease.

Regardless of difficulties in data acquisition, map representation, scale, statistical analysis, and the interpretation and utility of results, the study of disease distribution may well be the most challenging and fascinating research area within the entire discipline of geography.

The Geography of Health

Research shows that contact with nature can make us well.

By Francesca Lyman

One day last year, Howard Frumkin, M.D., sat in his office at Atlanta's Emory University, flinching as he watched bulldozers rip out a whole landscape of Georgia forest--two acres of hardwood oak and maple trees--to put up more medical buildings. The sight did not make him feel happy or healthy.

The longtime researcher in environmental and occupational medicine at the Rollins School of Public Health was struck by a fundamental irony. "It was a sad thing to watch," says Frumkin. "The once-beautiful forest view out my window is now a brick wall."

Besides shattering his lovely personal view, the event also changed his perspective on his profession. It got the doctor thinking about the neglected place of nature in contemporary health care. Despite a long tradition stretching from ancient Greece to the New England transcendentalists to conservationists like John Muir, healers seemed to have lost track of the idea that, "the human relationship with nature ... might be a component of good health," says Frumkin.

It may be that we humans are hard-wired to have "a deep-seated connection with the natural world," writes Frumkin. He quotes biologist E. O. Wilson, who describes in his book The Biophilia Hypothesis, "the innately emotional affiliation of human beings to other living organisms."

In addition to research and teaching, Frumkin sees patients injured by exposure to toxic chemicals and dirty air. Most environmental-health practitioners like himself, he says, are trained to look at the environment for its threats to health. But, he asserts, "the natural environment, broadly conceived, can also enhance health."

In an article in the April 2001 issue of the American Journal of Preventive Medicine, Frumkin argues for a new approach to environmental health and medicine, one that focuses on the curative powers of nature rather than on its hazards. Frumkin's investigations have augmented a growing body of evidence in a variety of disciplines--from biology to environmental psychology to landscape architecture--that natural surroundings may make us humans healthier, and maybe even happier and smarter.

Compiling data from surveys and case studies around the world, Frumkin found that clinics, hospitals, nursing homes, and even prisons that incorporate some element of nature--even just a nice view--show higher rehabilitation rates. His entrance into this field is helping boost attention to the decades-long research effort to track ways in which contact with nature might have restorative effects, both physical and mental. "Environmental psychologists have been tracking this for years," says Frances Kuo, is an environmental psychologist at the University of Illinois's Human-Environment Research Laboratory. "But physicians and public-health people know little about it, and environmental policymakers even less."

Recent evidence suggests, for example, that keeping ecosystems intact, with a variety of habitat for plants and small animals, provides hosts--or "sinks"--for viruses and bacteria that might otherwise spread to humans. Vector-borne diseases, such as Lyme's disease, would have formerly been kept in check by the critters of forest, field, and meadow.

Design With Nature in Mind

"Nature is in some fundamental way important for the human psyche, and as such it is really central to public health," says environmental psychologist Roger Ulrich, director of the Center for Health Systems and Design at Texas A&M University. A pioneer in the field, Ulrich has tested these theories on patients recovering from cardiac and abdominal surgery. Patients whose hospital rooms overlooked trees required less pain medication and recovered more quickly than those whose rooms overlooked brick walls, Ulrich found.

Scientifically creditable research in this area, researchers believe, could affect the future design of hospital interiors, gardens, urban landscapes, and real-estate development--and even make a new case for saving natural areas. Currently the public-health establishment is tracking a new community design movement intent on building compact, walkable communities. During the last few years, the Centers for Disease Control has begun to rally support for parks and open space, seeing them as a way to encourage a physically active lifestyle and stem the national tide of obesity, says Richard Killingsworth, national head of the Robert Wood Johnson Active Living by Design program. "We're ten years behind Canada in recognizing the need not just to promote fitness on a personal level, but in redirecting landuse policy to encourage walking, biking, and less dependence on cars."

Wild places, vistas, green sanctuaries--even a potted plant or a single flower--seem to draw people universally. Who hasn't retreated to the woods or taken a vacation in a beautiful natural spot to relieve stress or recover from illness? The neurologist and writer Dr. Oliver Sacks describes how, after a traumatic leg injury, he recovered best not in the hospital but at a rehabilitation center with a lovely garden. "A pure and intense joy, a blessing, to feel the sun on my face, and the wind in my hair, to hear birds, to see, touch and fondle the living plants," Sacks wrote in his book A Leg to Stand On. "Some essential connection and communion with nature was re-established after the horrible isolation and alienation I had known. Some part of me came alive, when I was taken to the garden."

Seeking solace in nature can cure psychic pain, too. Witness the way Americans, in the aftermath of the September 2001 terrorist attacks, flocked to places where they could ease their shock and sadness--to parks, flower gardens, overlooks, and other natural areas. Lynden B. Miller, a garden designer for Bryant Park and Wagner Park in New York City described in The New York Times how neighborhood parks there were transformed with "makeshift memorials" into "healing" centers all over the city.

What is this magic in nature to which we humans respond, to which we retreat for solace and restoration? Novelist Wallace Stegner once wrote that we need the connection to wild places as a reassurance of our common bond with other creatures. He called this connection to nature our "geography of hope."

Talk to John Beal, who undertook to clean up and restore his local stream, Hamm's Creek in Seattle, 23 years ago. He'll tell you that his bonding with nature didn't just improve his health--it saved his life. A Vietnam veteran, Beal suffered from post-traumatic stress disorder and had had three heart attacks, followed by a serious motorcycle accident that landed him in the hospital. Told that his heart condition gave him less than four months to live and advised by his doctor to find a hobby that would take his mind off his troubles, he didn't know where to turn.

"Then the idea came to me: If you're going to check out, try to leave this place better than it was when you left," says Beal. He turned to Hamm Creek--then filled with appliances, computers, old tires, garbage bags--and started pulling out the garbage. "When I yanked out this huge refrigerator, I thought it would surely kill me. Instead, I felt better."

Two decades later, thanks to his efforts, the once-polluted watershed is thriving with fish, beavers, and other animals. Beal also is drawing on the energies of hundreds of volunteers. He describes dozens of cases of people disabled physically or psychologically who benefit from the exercise and feeling of accomplishment but also, he says, from "the connection to something larger than themselves."

Lost Wisdom

For millennia people looked to nature not just for sources of food and medicinal plants but also, as psychologist Carl J. Jung put it, for "the nourishing soil of the soul." And philosophers since ancient times have prescribed nature as an antidote to stress and disease. Only a century ago Henry David Thoreau wrote that humans need "the tonic of wildness."

For the most part, however, this traditional wisdom seems to have been lost on modern medicine and psychology, and on design and planning. So says a new brand of "eco-psychologists," who believe our artificial environments are creating new stresses and neuroses. Our need for greenery may be intensifying in reaction to the dense, urbanized, technological environments in which we live.

"Humanity has gradually separated itself from the rhythms, images, and sensations of nature, so that many people complain of a deep emptiness inside but no longer know what is missing," writes Fran Segal in The Whole Mind: The Definitive Guide to Complementary Treatments for Mind, Mood and Emotion.

Howard Frumkin, too, argues that the concept of restorative qualities in nature is virtually nonexistent in contemporary health care. Nevertheless, he believes that because people are so instinctively drawn to nature, it merits more research attention. He adds,"Many environmentalists work to preserve nature for very good environmental reasons, but they forget that one of the major benefits may be human health."

Dozens of studies over the last ten years have suggested that humans benefit in measurable ways from even limited exposure to nature. Rachel and Stephen Kaplan, in one much-cited study, found that office workers with a view out their window enjoyed their job more and reported better health and greater life satisfaction than those who had no view. Another study by Terry Hartig of the Institute for Housing and Urban Research at Uppsala University in Gavle, Sweden, gave subjects a series of "attentionally fatiguing" tasks. Afterward, some test participants spent 40 minutes walking in a local nature preserve, while others walked in a city or sat quietly reading and listening to music. Those assigned to the nature group did best on a standard proofreading test and reported more positive emotions and less anger.

Bernadine Cimprich, Ph.D, of the University of Michigan School of Nursing, found in a study of women who had undergone breast cancer surgery that patients who had spent 20 to 30 minutes three times a week in nature activities--from walking in a park to tending an indoor plant--could think and concentrate better.

"Unfortunately, physical activity has been engineered out of our daily lives," notes Richard Killingsworth, because communities have been designed without enough access to parks and natural areas. The public-health community is realizing that the presence of nature and parks is a good way to ensure regular physical activity, which can reduce the risk of coronary heart disease, hypertension, colon cancer, osteoporosis, arthritis, and noninsulin dependent diabetes," he says.

Centuries before our own, such ideas were taken on faith. According to Roger Ulrich, the belief among earlier cultures, both Western and Eastern, that contact with nature can have beneficial health effects supported the creation of parks, gardens, and other landscaping in cities. The tradition of "healing gardens" in hospitals goes back to at least the 12th century in Europe. "Given the persistence of these intuitive notions, it is perhaps surprising that scientific studies to test them have begun to appear only in recent years," says Ulrich.

Does it seem ironic that, in our nature-alienated society, we seem to need studies, research, and data to prove what once seemed so intuitively true? "We need to put numbers to it. That's the coin of the realm," says Katherine Wolf, an environmental psychologist at the University of Washington. "During the last decade there's been a surge in this sort of research. The data are there."

References:

1.       Lang L. GIS for Health Organisations. California: ESRI Press. 2000 [ISBN 1-879102-65-X]

2.       Hall W. Just Another Medical Geography Page (Web site). URI:
http://www.geocities.com/Tokyo/Flats/7335/medical_geography.htm
(accessed 6 December 2000)

3.       Bill Davenhall, ESRI Health and Human Services Solutions Manager, http://www.esri.com/news/arcuser/0702/overview.html

4.       Online Encyclopedias, and http://en.wikipedia.org/

5.       The Geography of Health, http://www.tpl.org/tier3_cd.cfm?content_item_id=10709&folder_id=2225

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