‘Seattle Geographies’ aims to decode the city’s many contradictions

Professor Emeritus Richard Morrill and Professor Michael Brown

The Seattle Times has profiled the Geography Department’s new anthology, Seattle Geographies, edited by professor Michael Brown and Emeritus Professor Dick Morrill. The book, which is being unveiled this week at the AAG Conference in Seattle,  emphasizes Geography’s unique spatial perspective on the Seattle region’s many “paradoxes”, including:

• Seattle may have a reputation as liberal and tolerant, “but it can also be quite controlling,” Brown says. For example, it has adopted stringent rules about social behavior that give police the authority to exclude people from parks if they violate rules or laws.

• The area has a long-standing fear of big government, but voters seem willing to tax themselves significantly, Morrill says.

• Though Seattle has a reputation as a high-tech mecca, one-third of the local economy is still fueled by manufacturing, notes Professor Emeritus William Beyers.

The book includes article by faculty, graduate students and undergraduates, and addresses such diverse cultural, social and ecnomic isues as voting patterns in presidential elections across the region, to relatively small, such as the politics of locating and building a skateboard park, and what that issue says about social and generational tensions.

The Seattle Times article also talks about the UW Geography Department, pointing to a “renaissance” in the discipline, and emphasizing our  accountability to place, field-based research, and community engagement.

Challenges for Geographers in the April 2011 issue of the American Journal of Public Health

The current issue of the American Journal of Public Health has many articles that speak directly to issues of direct relevance to areas of current concern in geography and in population health. “Global Health and the Global Economic Crisis” by Benatar, Gill, and Bakker (pp. 646-653) pursues several arguments, and among them are that 1)global inequities in health reflect inequities in power; 2) the profit driven global economic system is a driver of inequities in health, and of collective poor health; and 3) a new paradigm is needed, versed in ethics, and culturally sensitive, creative, and innovative long term policy.

“The Social Determinants of Tuberculosis” by Hargreaves and colleagues (pp. 654-662) is very close to what I do in Ghana, and brings the understanding of tuberculosis into the realm of social epidemiology, social science, and the movement that has been termed “the social determinants of health” for the past 30 years or so. It is a label that I do not like since it is too—deterministic. I would much rather see “social influences on health.” It does not help to have a biologic determinism and a social determinism competing with one another–the whole problem is that health is not the result of determinism and the underlying causes of either ill-health or good health are not deterministic in nature. Be that as it may….this interesting article reviews the social factors that underlie contemporary TB epidemiology, including mobility and urbanization. In the US, for example, the main driver of TB is the influx of foreign-born individuals, for the simple reason that some are originating from areas that have high rates of TB; thus, percent foreign born, in any area in the US gives that area a high relative risk of having a TB prevalence rate well above the median. One of my recent doctoral graduates in the Department of Epidemiology, Eyal Oren, PhD, discovered a great deal of spatial clustering of incident TB cases in this state, and, based upon chart reviews and medical records, in King County.

The final article that I will mention is a spatial analysis of major trauma and injury in the North America. The article, titled “Trauma in the Neighborhood: A Geospatial Analysis and Assessment of Social Determinants of Major Injury in North America” (pp. 669-677) examines the spatial patterns and clustering of major trauma using GIS and a commonly used clustering algorithm, SatSCan. It is another example of examining health phenomena using the “social determinants” approach. In this case, I would call it the “social correlations” approach. Even if the relationships were deterministic, and they were not, there was no causation established here.

This issue of AJPH is unusually full of interesting articles that will interest geographers in many specialties.

Cholera in Haiti: 800,000 cases?

An article that is forthcoming in The Lancet concludes that there will have been a prevalence of nearly 800,000 cases of cholera in Haiti by the end of November, 2011–nearly double the number projected by WHO. WHO’s estimates have themselves been increasing dynamically and are not based on any knowledge of transmission dynamics–in short, they are educated guesses. The reference paper, posted online on March 16, 2011 (www.thelancet.com) is based upon a detailed knowledge of transmission dynamics and interventions, and is a recursive mathematical model by two well known disease modelers (Andrews JR and Basu S. Transmission dynamics and control of cholera in Haiti: an epidemic model. Lancet DOI:10.1016/S0140-6736(11)60273-0) Geographers and spatial epidemiologists will recognize that the model is a multiregional form of disease model that is based on the number of susceptible people, infected individuals, and recovered individuals (“SIR” models) that have been the basis for growth models for decades. Moreover, and perhaps *most importantly*, anticipated early declines in cholera incidence in the coming months are predicted to be part of the natural course of the epidemic, and not the result of any specific public health interventions.

Cholera is a waterborne bacterial disease, transmitted via the fecal-oral route, that can progress from asymptomatic stages to death within a period of less than 18-24 hours. The only effective treatment is oral or intravenous rehydration using physiologically balanced water/electrolyte solutions–with the electrolytes in clean water only. When available, this can be combined with oral or IV doxycycline, ciprofloxacin, or other appropriate antibiotics. Oral rehydration in this form–a fundamentally simple and low-tech treatment–was devised by Dr. Richard Cash of the Harvard School of Public Health, credited with saving millions of lives.

In Health Care, Geography is Destiny

There is tremendous unexplained variation in rates of surgical procedures from hospital catchment area to hospital catchment area, and region to region that cannot be explained by epidemiologic factors. For example, colleagues and I discovered in 1992 (see Spine, 1992) that the 15 fold difference in surgical procedures on the spine in Washington State was inexplicable by almost all population and diagnostic factors.

These sorts of studies were first called “small area analyses” by John Wennberg, MD, of Dartmouth Medical School–a specialist in internal medicine who then combined this with epidemiology and geography and who has a profound impact on understanding our heath care system–and those of other countries. His work has figured prominently in recently passed health reform, and figured prominently in policy alternatives in the Clinton administration. Quite simply, geographic variation is explained largely by different practice styles–and the greater the spatial variation, the less the consensus on the evidence base for proceeding in any given direction from a medical point of view. Put another way, the weaker the evidence base clinically, the greater the spatial variation in practice patterns. As Wennberg writes:

In Health Care, Geography is Destiny
Early in my career, I was hired as director of a federally sponsored program whose goal was to ensure that all Vermonters had access to recent advances in the treatment of heart disease, cancers, and stroke. As part of the program, my colleagues and I developed a data system that we thought would help us identify which Vermont communities were underserved, and thus in need of the program’s help. As the results came in, however, rather than evidence for underuse (i.e., patients not getting care they needed), we found extensive and seemingly inexplicable variation in the way health care was delivered from one Vermont community to another. In Stowe, for example, the rate of tonsillectomy was such that by age 15, about 60% of children were without tonsils, while in the bordering town of Waterbury, only 20% had undergone the surgery by that age. Among communities, the chances that a woman would have her uterus surgically removed varied by more than fourfold, and the rate of gallbladder surgery varied by more than threefold. Rates of hospitalizations for a host of different medical conditions also varied in ways that made little sense; on a per capita basis, patients were hospitalized in Randolph two times more often for digestive disease than in Middlebury and three times more often for respiratory disease.

Wennberg was the moving force behind Dartmouth’s “Atlas of Health Care” center, and subsequent centers for comparative clinical effectiveness. His work has spearheaded the whole movement of evidence-based medicine, the necessity of which became obvious from the mysterious spatial variations in care–mysteries originally uncovered by Wennberg nearly 40 years ago that in some counties, only 20% of teenagers were missing their tonsils, whereas in other counties, 70% had had tonsillectomies–with no seeming underlying rationality.

Wennberg has now published a thought provoking analysis of the implications of his work. Most significantly, it may be possible to eliminate billions of dollars from our health care bill without negative consequences for health status. These are funds that could then be allocated to increasing the access for disadvantaged groups.

So I highly recommend Tracking Medicine: A Researcher’s Quest to Understand Health Care, Oxford University Press, 2010, not only because it is a prime example of how geographic reasoning has had a profound impact on health care legislation, but as a glimpse into the intellectual history of an individual who has one of the deepest understandings of what lack of evidence-based medicine has done to our society.

For a local perspective on place-based and race-based  health care provision and health outcomes, see the current American Prospect story, “Home Disadvantage,” about health disparities and people of color in Seattle’s South Park neighborhood.