The Social Geography of Medicine and Health (RLE Social & Cultural Geography)

John Eyles, Kevin Woods

• Publisher: Routledge
• Year: 2014
• Print ISBN:
  9781138998100
• eBook ISBN:
  9781317907275
• Topic: Physical Sciences
• Subtopic: Geography
• Index: Geography

This book, originally published in 1983, drawing material from Europe, the USA, the Soviet Union and the Developing World, provides a comprehensive review of the key issues in medical geography. It sets the central problems of medical geography in a broad social context as well as in a spatial one and analyses changing conceptions of health and illness in detail. It also explores the pathological relationship between people and their environment and illustrates that social phenomena form spatial patterns which provide a good starting point for the examination of the relationship between medicine, health and society.

1	PERSPECTIVES ON HEALTH AND HEALTH CARE

It is not the purpose of this chapter to provide a review of all the many perspectives from which health and health care have been approached. We wish to explore briefly those perspectives that seem relevant and important to our own purposes, namely explicating the limitations and assumptions of present geographical endeavour and attempting to understand health and health care in terms of the definitions, meanings and social contexts by and in which such phenomena appear.

The Biomedical Perspective

It is perhaps true to say that the biomedical model is so deeply interwoven with ways of thinking about and working in medicine that it is often forgotten that this is but one perspective. It is often regarded, therefore, as the sole representation of reality. But like other perspectives, it defines, classifies and assesses relationships among phenomena in a particular way. Thus, it presupposes that there are specific disease entities each associated with specific biological processes. Aetiology is thus seen as biologically specific.

Mishler (1981) identifies four major assumptions of the biomedical perspective. First, disease is defined as deviation from normal biological functioning. Thus Cohen (1961, 169) suggests that ‘disease indicates deviations from the normal – these are its symptoms and signs’. Engel (1963) suggests that health involves an individual maintaining a balance so as to be reasonably free of pain and disability. Notions of balance and normality raise questions about the standards against which such assessments are made. Such questions are addressed more fully in Chapter 2. Suffice it to say here that workers within the biomedical perspective have begun to question the accepted meaning of normality. Redlich (1957), for example, asks normal for what and for whom, while Ryle (1961) suggests that even in physiological phenomena, variation is so constantly at work that no rigid pattern is discernible.

Secondly, there exists the doctrine of specific aetiology (see Dubos, 1960). The doctrine – the basis of modern Western medicine – suggests a movement from initial classification based on specific symptoms through a clustering of such symptoms into syndromes to identifying the specific pathogenesis and pathology of diseases. In particular, the presence of micro-organisms or disease vectors (see Chapter 3) seemed to explain the occurrence of disease. The bacterial origin of infectious disease, discovered by Pasteur, and the role of agents in epidemics, identified by Koch, pointed to the importance of medical interventions to eradicate such problems. Indeed, the role of scientific medicine cannot be overemphasised, not only in identifying the sources of disease and in providing preventive and therapeutic measures, but in also contributing to advances in hygiene (see McKeown, 1979). But, as Dubos (1963) observes, disease is rare given the number of parasites present in the environment. Disease only usually results when natural resistances have been undermined by the stresses and strains of life. Such stresses may in their turn be dependent on available coping mechanisms (Mechanic, 1978), especially the presence of informal, localised social support networks (Cobb, 1976; see Chapter 7). Thus, the doctrine of specific aetiology provides a simple cause and effect model which cannot adequately explain why specific individuals in specific places are sick or ill (see Chapter 3).

Thirdly, there is the assumption of generic diseases. In other words, ‘each disease has specific and distinguishing features that are universal to the human species. That is, disease symptoms and processes are expected to be the same in different historical periods and in different cultures and societies’ (Mishler, 1981, 9). It is, of course, important to recognise that biological events are observable, measurable and orderly. But there is an important distinction between a description of a biological process and definition of symptoms of illness. Western scientific medicine is only one way of defining illness. Lay concepts also define and, as we shall see in Chapter 6, there is much cultural variation in definitions of sickness and care. As Fabrega (1975, 969) argues Western medicine ‘thus constitutes our own culturally specific perspective about what disease is, and how medical treatment should be pursued; and like other medical systems, biomedicine is an interpretation which “makes sense” in the light of cultural traditions and assumptions about reality’.

Fourthly, there is the assumption of the scientific neutrality of medicine. Doctors see themselves as bioscientists and adopt the objectivity and neutrality of the scientific method. Medicine is thus seen as an isolated and independent section of society. Such a view has many ramifications for how medicine is seen and for how the relationships within medical practice are managed. Because of the importance of this assumption and its implied suggestion that medicine is divorced from social, economic and political concerns, we shall examine this topic in detail in Chapter 2. Suffice it to say, that the dislocation of medicine stems from the peculiar place of science in Western medicine. In small-scale societies this dislocation is not present. As Fabrega (1976, 290) suggests:

in a logical sense, disease among nonliterates is directly tied to the social behaviour of the person and to his ability to function. All types of disease raise social and personal questions about the individual and his immediate group. Thus, disease and medical care are directly woven into the social fabric. In our culture science has provided us with disease forms which, in logical grounds, are not connected to the social fabric.

This mediation between ill-health and environment by technological, professional and cultural practices will be a key element structuring Chapter 6.

It is possible to identify a fifth assumption of the biomedical perspective in that medical knowledge advances in a linear fashion, solving one problem for the entire population of sufferers before moving on to tackle yet another. This idea of sequential progress makes light of different predispositions to disease, different attitudes to sickness and differential access to medical resources dependent on differential power and advantage. It also assumes that financial resources are available to allow the technical solutions to be developed and applied to medical problems. In other words, it fails to identify competing wants and limited resources. It is essentially non-economic.

The Economic Perspective

Culyer (1976, viii) suggests that ‘economics, as the science of choice, can lay bare the necessary elements in making social choices about meeting needs for health care, and its techniques can also provide empirical estimates of the dimensions of some of the relevant concepts … Economics is the integrative element.’ The economic perspective recognises the scarcity of resources and the multiplicity of wants and values; to determine the fair and efficient allocation of health resources it is necessary to examine these wants and values.

The notion of need is problematic in the economic perspective. Culyer et al. (1972) suggest that ‘need’ should be removed from public policy as it is ambiguous with value implications and unclear cost implications. Williams (1974) further argues that as need is an evaluative and normative concept, it should be related to the end or goal being sought. In that way, need for health services is seen as a technical and economic matter: a matter for the providers of health services. It is not necessarily related to the individual’s own predisposition or choice. This perspective argues, therefore, that:

the need for health care is defined by reference to some third party’s view as to what a particular individual or class of individuals themselves ought to receive. The demand for health care, however, is indicated by the individuals themselves in making claims upon health care resources. (Culyer, 1976, 19)

While the economic perspective may make passing reference to some of the problems of lower income groups (dealt with in Chapter 3), it is dominated by the production of demand rather than the distribution of need and care. Smith (1977) points to the reluctance of economists to deal explicitly with questions of distribution until quite recently because of the ethical nature of interpersonal-utility comparisons. Indeed, the conventional treatment of distribution, seen in Culyer’s work, is based on Pareto optimality which exists when it is impossible to make anyone better off without at the same time making someone else worse off. Nothing is said about the existing distribution of health care. If it is highly unequal to start with, a welfare ‘improvement’ in Pareto’s terms may see the rich and healthy improve their lot while the poor and sick remain as they are. It is possible to argue that the private provision of health care in societies previously dominated by a state-provided system may represent such a condition (see Chapter 6).

Demand for health is seen as the crucial factor in this perspective. Such a demand is regarded as a demand for an investment good that yields services over a period of time. The demand is determined in part by the individual’s particular stock of health – a capital good which depreciates over time, but which can be increased by investment. The relationship between investment and the stock of health is dependent on the amount of time and money devoted to improving the stock. The key variables in investment – diet, exercise, housing, consumption habits, environmental factors, education and information – are under the variable control of the individual. If they are under his control then the individual chooses his preferred stock of health. As age increases and ‘costs’ rise, a lower stock is chosen. If income rises, investment is likely to rise, although some expenditures – alcohol, cars – may be harmful. Individual preference and consumer sovereignty are seen to reign – a triumph for neo-classical economic theory – and the market, the supplier of health care, responds to these consumer pressures.

From the economic perspective, health becomes a matter of the deliberate consumption of goods and services. Such consumption is seen as an investment in the stock of health of the individual. It is also regarded as being shaped entirely by individual preferences. The basic value judgement … is that the supply of goods and services, including medical care, should as nearly as possible be based upon individual preferences’ (Lees, 1961, 14). As Donnison (1975, 423) argues:

To rely wholly on evidence about short-run individual preferences as the criterion for collective action is unhistorical, because it takes too little account of the way in which preferences are shaped (and could be reshaped) by influences extending over long periods of time. It is unsociological because it treats people as atomistic individuals, deciding only for themselves, rather than as members of classes, families and other groups which support and constrain them (and could influence them in different ways if the social structure changed).

Such a conception, which we exemplify in critical detail in Chapters 4 and 5, also treats demand simply as a manifest phenomenon. It conveniently shelves the question of need which may or may not be manifested as demand. Demand is simply an individualistic response (see also Chapter 2), divorced from its social and economic context. Both demand and need must be seen as being societally derived. Indeed it is necessary to relate need, want and demand to each other. Smith (1977) suggests that a need implies an imperative while want suggests the source of an acquisitive desire. Bradshaw (1972) offers us four distinct definitions of need which help to relate the three terms: first, normative need based on bureaucratic determination and the remedial provision of minimum levels of adequacy – the basis of many means-tested health programmes (see Chapter 2); secondly, felt need, the stated wants of those for whom services are offered – the closest to the economic perspective and the basis of the location – allocation models discussed in Chapter 4; thirdly, expressed need – the lack of a good or service may provoke action or demand which may or may not be effective; and fourthly, comparative need, in which comparisons with others leads to a general recognition that a service is necessary.

Needs, wants and demands are, therefore, essentially social. Such phenomena in the field of health and health care are not simply a question of consumption satisfiable by market principles. They also depend on many intangible goods and bads that shape people’s lives. They depend, too, on other individuals and groups and how their perceptions and experiences interact one with another. Further, the needs and demands for health care are related to the type of society that contains them. In capitalist society, the satisfaction of needs often means the possession of objects. These needs often become impoverished and homogenised. Acquisitive desire (want), manifested as demand, appears to dominate and the satisfaction of such wants may help commoditise social relations and the social fabric (see Chapter 2). Further, the atomisation of the individual and his designation as a pre-social entity cannot be overcome within the economic perspective. Such considerations require an assessment of the sociality of man.

The Behavioural Perspective

It is possible in the social sciences in general to see the behavioural perspective as a corrective to the economic in that the former treats the individual as a social entity explicitly. During the late 1950s and early 1960s there was a surge of interest in behavioural studies. Economics began to lose its primacy as the explanatory social science. The notions of economic man and consumer sovereignity and the goal of maximising satisfaction (or welfare) began to be questioned. Increasing importance came to be attached to social and psychological variables in analysing human activity (see Eyles and Smith, 1978). The conventional conception of economic man fails then to account for much of the variation in individual behaviour. Such variation partially explains why the market fails to operate along the lines of neo-classical economic theory. Indeed, as Simon (1957, 198) argues;

The capacity of the human mind for formulating and solving complex problems is very small compared with the size of the problems whose solution is required for objectively rational behaviour in the real world – or even for a reasonable approximation to such objective rationality.

Simon suggests, therefore, that individuals ‘satisfice’ rather than ‘optimise’. In other words, they seek to discover and select satisfactory alternatives. An outcome – health status, access to health facilities – is judged to be satisfactory or unsatisfactory according to the aspiration level and stock of knowledge of the individual.

The behavioural perspective thus focuses attention on the individual, his social attributes and aspirations. In health and health care research, consideration of the individual is mainly seen in doctor-patient interaction studies. Most such studies have addressed the problem of communication in such interactions (see Korsch and Negrete, 1972; Waitzkin and Stoeckle, 1976). It has been shown that problems in communication – information disclosure, adequate explanation, etc. – vary according to the age, race and occupational status of the patient. Variations in communication also occur according to the medical facility attended – emergency room, outpatient clinic or inpatient ward. Other important studies in this area concern patient compliance: whether the patient follows the doctor’s recommendations. Dunbar and Stunkard (1979) discovered that between 20 and 82 per cent of patients do not follow the recommended regimens. It appears that patients are less compliant when there has been limited information exchange, dissatisfaction with the interview and restricted responsiveness by the doctor. In other words, the interaction depends not only on medical setting and patient attributes but also on the expectations taken to the setting by the patient. We introduce such studies here simply because they broaden the behavioural perspective to include consideration of the meanings and definitions taken to the health setting by the individual. Such meanings and the contexts that produce them are considered below.

The behavioural perspective has also been influential in medical geography and the assessment of the location of health facilities. Haynes and Bentham (1979) examined the influence of such individual attributes as age, sex, occupation status and personal mobility on the utilisation of community hospitals in rural England. In their study of Swansea, Herbert and Peace (1980) demonstrated how personal mobility affects the satisfaction of the elderly with community facilities. In a study of primary care – doctors’ surgeries in West Glamorgan – Phillips (1981) showed how social status, personal mobility and previous residence influence the surgery attended. In the case of the latter variable, many patients wish to remain with their doctor even when they move. Phillips (1979) termed such movement relict patterns of travel. He found that age of respondent and the presence of pre-school children in the household had little influence on surgery attendance. Such studies demonstrate the importance of the behavioural perspective in that they challenge the predictions of neo-classical economic theory and also central pla...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Orginal Title Page
• Original Copyright Page
• Table of Contents
• List of Figures
• List of Tables
• Preface
• Acknowledgements
• 1. Perspectives on Health and Health Care
• 2. Changing Conceptions of Health and Health Care in Urban Society
• 3. Man, Disease and Environmental Associations: From Medical Geography to Health Inequalities
• 4. Perspectives on the Location and Distribution of Health Services
• 5. Practical Responses: The Effects of Constraints
• 6. Societal Constraints and Systems of Health Care Provision
• 7. Directions for Social Geographical Research
• Bibliography
• Subject Index
• Author Index