Matthew Smallman-Raynor and David Phillips
The term ‘health’ (stemming from the Old English word hael, or ‘whole’) means different things to different people (Kiple 1993: pp. 45-110). In modern Western medicine, for example, a ‘healthy’ person or place is often judged according to the absence (or otherwise) of a medically defined disease or disorder. The charter of the World Health Organization (WHO) favours a broader definition of health as a ‘state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO: 1988: p. 1). At a more abstract level, health can be defined according to the unidirectional nature of time; as Hudson (1993) notes, unless other factors intervene, our genetic programmes are inexorably geared towards disease and death. Other medical systems have placed yet further interpretations on health. In ancient Greek medicine, for example, health was viewed in terms of a balance in the bodily humours (blood, phlegm, and yellow and black bile), while notions of balance and harmony also underpinned conceptions of health in ancient Chinese and other Asian medical systems (Shigehisa 1993).
There are numerous and varied examples of the ways in which health—however defined—can vary between individuals, groups of people and, equally importantly, between places (Vågerö 1991; 1995; Vågerö and Illsley 1993; West 1991; Wilkinson 1987). Moreover, health variations are apparent at every geographical scale, from the continents and macro-regions of the planet to the districts and sub-districts of a single city. Seminal studies by G. Melvyn Howe (1986) on the global and world regional incidence of cancers, Gerald F. Pyle (1971) on national and local patterns of heart disease and stroke in the United States, and John A. Giggs (1973; 1988; 1990) on schizophrenia, affective psychoses and substance abuse in the city districts of Nottingham, England, are illustrative of the breadth and geographical range of the problem.
Today, efforts to improve health status and to erase (or at least to substantially reduce) variations in the well-being of people and places lie at the heart of much global health policy. Spurred by the WHO’s Global Strategy for Health for All by the Year 2000, national governments and international agencies have launched a plethora of research initiatives to identify and monitor health inequalities (WHO 1994). The socio-spatial dimensions of the research issue have secured an important and growing role for medical and health geographers. In particular, geographers have brought an increasing methodological sophistication in spatial analysis and statistical modelling (Cliff and Haggett 1988; Cliff, et al. 1998; Thomas 1992), geographical information systems (Openshaw 1990; de Leper et al. 1995; Bailey and Gatrel 1995; Gatrell and Bailey 1996) and, most recently, qualitative techniques (Litva and Eyles 1995; Eyles 1997) to bear on the problem. At the same time, a traditional concern of medical geography with the spatial and environmental parameters of infectious and parasitic diseases (classic diseases such as cholera, malaria, measles and tuberculosis, but