Sot. Sci. & Med..
Vol. 11, pp. 679 to 682
Pcrgamon
Ress
1977. Printed
in Great
Britain.
INTERNATIONAL COMMUNICATION MEDICAL GEOGRAPHY
AND
GERALD F. PlLE University of Akron
Learmonth’s recent communication explaining the termination of the International Geographical Union Commission on Medical Geography marked the end of an era as regards the international communication of medico-geographic research findings, concepts, and potential applications [l]. Founded in 1949 by Jacques May, Maximillien Sorre and Arthur Geddes, the Commission served in such a communications capacity for more than two and one-half decades. International interest within the scienti6c community in medical geography increased gradually within that time period to reach a peak during the mid-1970s. As an outgrowth of the Commission’s elIorts, a journal (Geographica Medico) was attempted; the publication was unfortunately not destined to continue. During the period 19724976, the Newsletter of the IGU Commission on Medical Geography, publishing notes of interest and bibliographies, served as the sole vehicle for international communication in medical geography. While the Commission and the Newsletter have now been terminated, interest in medical geography has continued to grow; and a new era in inter-
national communication has been inaugurated with the publication of issues of Social Science and Medicine devoted to medical geography.
THE GENERALAREA OF INTERm
It is important to realize at the onset of this publication endeavor that no single, comprehensive detinition of the term “medical geogkaphy” has withstood the rigorous tests of time. Rather, conceptual trends have evolved over the past 25 years in a manner analogous to the discipline of geography in general. The incorporation of May’s classic work within this volume is offered as an historic benchmark [2]. May’s efforts represent a dramatic beginning to what has become a multidimensional body of knowledge about spatial aspects of human healtb problems [3]. Drawing from a wide variety of natural and social scientific uently utilized and/or approaches, writers have sub developed equally diverse stu “%1‘es falling under the general medical geography rubric.
lnhrnotionol National
Regional
interurban
Introurban
HOuwhold
Individual
Not sped
id
Fig. 1. Approaches to medical geography in relation to scale. 679 S.I.M.
II--14116--*
680
GERALD F. PYLE SPECIFIC APPROACHES
The medical geography literature of the mid-1970s can be summarized conceptually within the frame work presented here as Fig. 1, wherein overlapping yet reasonably distinct topical approaches are shown in relation to a spectrum of geographic scale ranging from worldwide, or international, coverage to that of no particularly specified geographical concern. The intent of such a cross-tabulation is primarily to place studies within some sort of meaningful context, as opposed to attempting to indicate any one approach or scale as more “appropriate” than any other. Thus, much of the pioneer work of May can be considered as disease-ecologically oriented with emphasis placed upon broad international coverage. Such an interpretation is shown by the heavier hatched pattern. Combinations with less emphasis are shown with the diagonal symbolization. Those empty cells are areas where little work has been accomplished; however, this implies neither a pressing need to “fill the empty slots” nor any lesser degree of scientific value. In essence, certain topical approaches have. more merit at some scales than others. It is also worthy of note that many studies in medical geography address spatial concepts without empirical testing at any specified scale [4].
Disease ecology The disease-ecological approach to medical geography is primarily concerned with the natural scientific explanations. Research on such topics attracts scholars with interests similar to those of May. For example, it can be proven that climate, vegetation, mineral traces in water, bedrock minerals, and different biological complexes have different effects on the human health condition[5]. Traditional tropical medicine has long utilized such explanations in studies of a medical geographic nature. While useful, these studies often extract data from limited sample areas and attempt to apply findings at the national and international levels. Placed in the proper perspective in terms of the limitations of findings, such studies can be extremely useful in explaining environmental risk factors [6]. Disease mapping General forms of disease mapping have historic roots in the 19th century[7-j. Major attempts to de velop such studies on national, regional, and urban scales began in Britain shortly after World War II. Examples include Melvyn Howe’s National AC/US of Disease Mortality in the United Kingdom [S]. Within the United States in the mid-196Os, Malcolm Murray developed comparable studies of disease mapping [9]. In addition, Howard Hopps had perfected several types of disease-mapping skills appropriate at national and regional levels [lo]. Intraurban disease mapping was accomplished by Pyle in the late 1960s [l 11, and Dever developed certain kinds of household disease mapping during the same time period [12]. Recently, attempts have been made to research the mapping of individual disease patterns [13]. In general, these studies have attempted to perfect various kinds of mapping skills which have evolved into sophisticated computer useage. While it
is conceivable to examine disease maps and deduce certain kinds of associative patterns, such attempts are best strengthened with concurrent statistical or associative analyses. Thus, in terms of overall research design, while the various types and scales of disease mapping certainly provide very important information to the policy maker, if the maps are not explained properly within a research context in terms of the meaning of the results, many studies often have little internal validity. Associative analyses To add validity to studies of disease distributions, associative analyses have evolved from simple disease mapping Due to the nature of certain statistical techniques, most meaningful emphasis has been placed at the regional and urban levels for such kinds of studies Our modem technology has greatly augmented such analyses, allowing for stochastic and deterministic approaches to understanding disease distributions. While some conventional disease mapping researchers initially viewed associative statistical analyses with some bit of skepticism, recent interpretations have offered muvh information to the policy maker [14]. Such techniques as univariate, bivariate, and multivariate analyses have often raised the issue of multiple explanations to disease problems, thus adding degrees of scientilic explanation. McGlashan, for example, has successfully accomplished various types of probability mapping with statistical tests at the regional and urban levels [l!IJ It was also possible through the use of multivariate analysis to offer multiple explanations of chronic ailments within the Chicago area and proceed to disease forecasting in the early 1970s [16]. Such studies have further made it possible to better address the issue of causation and have added more validity to research design in the process. Still, this kind of research has been accomplished only at given points in time, sometimes not explaining process well enough. For example, while the statistical methods may suggest certain trends, it is well known in scientific research that trends often reverse themselves. Such conclusions have subsequently led to studies of disease diffusion. Disease dijkbn Related, but not identical to traditional research in epidemiology, are studies of disease diffusion. Many of these approaches utilize particular epidemiological methods, but much more emphasis is placed on environmental determinants of the spread of disease. The particular advantage in such an approach is that it is possible to simultaneously view time and space. For example, it has been possible to examine such topics as the diffusion of disease within a country quite successfully [17J. In addition, Hunter and Young recently examined the diffusion of influenza in England and Wales and added to our knowledge of the spread of disease [18]. A recent study of measles within a medium-sized manufacturing city added some explanation to socio-economic obstacles and constraints, both in terms of research and the impact on human illness due to public policy [19]. The development of more understanding of disease diffusion between and among individuals
International communication and medical geography and human
settlements is now of particular impOrtance due to the threat of influenza-pneumonia mortality within the United States. Such an analysis is now being accomplished at The University of Akron [ZO]..Having gained some knowledge of how disease mapping, statistical associations, and research into disease diffusion can be accomplished it is esSential to develop an understanding of human reactions to illness in terms of health care-seeking patterns. Patient travel
Since the mid-1960s geographers have paid increa~ing attention in their research endeavors to aspects of patient travel in relation to the presence of disease problems[21]. As indicated within Fig. 1, these studies have been accomplished at all but the national and international scales, with particular emphasis on intraurban patient travel patterns. Shannon and Dcver have summarized and added to our knowledge of such research in several ways [22]. It is possible in such studies to develop highly sophisticated, process-oriented, analyses of human responses to disease patterns. Given the incidence of a particular disease, it is also possible through statistical applications to for -,cast that incidence of disease and subsequently estimate future demands for the use of particular facilities. One particular area, however, which IX&S further exploration is the identification of segments of the population not necessarily responding to the availability of facilities for various social, behavioral and economic reasons. Historically, these problems initially resulted from inequitable distributions of facilities. As health planning in the United States has increased, particularly within the last decade, legislative changes have had some impact on the health status of populations [U]. While it is anticipated that further public programs will continue to close the gap as regards access and availability of health services, there are, nonetheless, certain cultural and behavioral aspects which must be further researched. Cultural-ecological
Clearly, there is substantial overlap conceptually between environmental and cultural determinants of human disease. Quite often unique indicators of specific cultures help explain chronic health problems. In addition, research about the larger triangular association among natural environment, disease, and behavior attributed to different cultures is identified as paramount in understanding the cultures. This approach needs some clarification, as certain anthropological specifics can be the end results of such studies, and an understanding of medical geography may not be developed. Clearly, it is impossible to separate culture from diet, and culture-nutrition hypotheses have been offered [24]. Diet and nutrition
Recently, Knight and Wilcox have summarized dietary balance, i.e. the differences between excessive and deficient caloric consumption, on an intemational scale [25]. In fact, some of May’s last research dealt with nutrition problems in relation to human health [26]. This approach has been concerned primarily with world nutrition problems, and little has been accomplished at the regional and urban scales.
681
Such studies of urban populations would indeed contribute much to our understanding of medical geography and represent excellent prospects for future research. Behavioral
aspects It is imperative that future medical geography consider all aspects of illness behavior. Shannon’s contribution about illness behavior to this volume has certainly added much to our knowledge of geographic aspects of human health problems [273. In addition, Girt has forwarded certain methodologies which need further research [28]. In terms of past approaches, emphasis has been placed at the household, intraurban, and sometimes individual scales of analysis. As a result, it is possible within such studies to identify substantially different activity spaces within cities in accordance with the socio-eco*omic structure of the city, as has been recently accomplished by Shannon and Spurlock [29]. FUTURE PROSPECTS The advent of these special issues devoted to medical geography represents the culmination of dozens of years of interest in spatial aspects of human health problems by an even larger number of scientific researchers. Social Science and Medicine has offered an international vehicle for future publication of important research findings in this area. Those approaches within Fig. 1 cross-tabulated by scale help place past studies within an overall conceptual context and, hopefully, offer some direction for future endeavors. Clearly, there are many approaches not specified within such a general overview, and the entire conceptual spectrum of medical geography is in need of expansion as well as clarification. It is anticipated that future contributions to this journal will assist in attaining those goals.
REFERENCES
1. Jnternational Geographical Union Commission on Medical Geography, Newsletter, No. 17, Winter 1976/17. This was the last issue of this communication. Reprintqare available from Gerald F. Pyle, Dept. of Urban Studies, University of Akron, Akron, OH 44325, U.S.A. 2. May J. M. Medical geography: its methods and objeo tives Geograph. Rev. 51, 9, 1950. 3. Pyle G. F. Introduction: foundations to medical geography. Econ. Geog. 5x95, 1976. 4. Hunter J. M. (Ed) The Geography of Health and Dis ease. University of North Ckolina at Chapel Hill, Dept of Geography, Studies in Geography, No. 6, 1974. 5. May J. M. The Ecology ofHuman Disease. M.D. Publications, New York, 1958. 6. Roundy R. W. Altitudinal mobility and disease hazards for Ethiopian populations Scott. Geog. 52, 103, 1976. 7. Hirsch A. Handbook of Geographical and Historial Pathology, 3 ~01s. (Translated by Creighten C. Jr.). New Sydenham Society, London, 1883-1886. 8. Howe G. M. National Atlas of Disease Mortality in the United Kingdom (19%58). Nelson, London, 1963. 9. Murray M. Geography of death in the United States and the United Kingdom. Ann/s Ass. Am. Geogr. S7, 301, 1967.
682
GERALD F.
10. Hopps H. Computer produced distribution maps of disease. Annls N.Z Acad. Sci. 161, 1969. 11. Pyle G. F. Heart Disease, Cancer and Stroke in Chi-
12. 13. 14.
15. 16. 17.
18.
19.
cago. University of Chicago, Dept. of Geography, Research Paper No. 134, 1971. Dever G. E. A. A Temporal-spatial analysis of leukemia occurences. Geogr.-medi&No. 3, 107, 1972. Pvle G. F. and Cook R. M. California encephalitis in’ man. Geog. Rev. 1978 (in preparation). _ Learmonth A. T. A. Viewpoints on medical cartography: a selective review. American Geographical Society, Geography and Map Division, Bulletin .No. 78, December, 32-38, 1969. McGlashan N. D. The reality of spatial variations of morbidity and mortality. S.A. med. J. August, 1621, 1974. Pyle G. F. Heart Disease, Cancer and Stroke in Chicago (= Clll). Brownlea A. A. Modellmg the geographic epidemiology of infectious hepatitis. In Medical Geography: Techniques and Field Studies (Edited by McGlashan N. D.).-Methuen, London, 1977. Hunter J. M. and Young J. C. Diffusion of influenza in England and Wales. &mls Ass. Am. Geogr. 61, 637, 1971. Pyle G. F. Measles as an urban health problem: the Akron example. Econ. Geog. 49, 344, 1973.
PYLE
20. Slaymaker N. Influenza diffusion and public policy. Master’s research in progress, The University of Akron, Dept. of Urban Studies. 21. Shannon G. w.. Bashshur R. L. and Metzner C. A. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Rev. 26, 143. 1969. 22. Shannon G. W. and Dever G. E. A. Health care delivery: spatial perspectives. McGraw-Hill, 1974. 23. Pyle G. F. and Lauer B. M. Comparing spatial configurations: Hospital service areas and disease rates. Econ. Geog. 51, 50, 1975. 24. Hunter J. M. Geophagy in Africa and in the United States. Geog. Rev. 74, 170, 1973. 25. Knight C. G. and Wilcox R. P. Triumph or Triage: The World Food Problem in Geographical Perspective. New York, Association of American Geographers. Resource Paper No. 75-3. 1976. 26. May J. M. The geography of nutrition. In The Geography of Health and Disease (Edited by Hunter J. M.) (see C41). 27. Shannon G. W. Space, time and illness behavior. S(IC. Sci. Med. 11, 683, 1977. 28. Girt J. L. Distance to general medical practice and its effect on revealed ill-health in a rural environment. Can. Geogr. 2, 154, 1973. 29. Shannon G. W. and Spurlock C. W. Urban ecological containers, environmental risk cells, and the use of medical services. Econ. Geog. 52, 171, 1976.
Vol. 11, pp. 679 to 682
Pcrgamon
Ress
1977. Printed
in Great
Britain.
INTERNATIONAL COMMUNICATION MEDICAL GEOGRAPHY
AND
GERALD F. PlLE University of Akron
Learmonth’s recent communication explaining the termination of the International Geographical Union Commission on Medical Geography marked the end of an era as regards the international communication of medico-geographic research findings, concepts, and potential applications [l]. Founded in 1949 by Jacques May, Maximillien Sorre and Arthur Geddes, the Commission served in such a communications capacity for more than two and one-half decades. International interest within the scienti6c community in medical geography increased gradually within that time period to reach a peak during the mid-1970s. As an outgrowth of the Commission’s elIorts, a journal (Geographica Medico) was attempted; the publication was unfortunately not destined to continue. During the period 19724976, the Newsletter of the IGU Commission on Medical Geography, publishing notes of interest and bibliographies, served as the sole vehicle for international communication in medical geography. While the Commission and the Newsletter have now been terminated, interest in medical geography has continued to grow; and a new era in inter-
national communication has been inaugurated with the publication of issues of Social Science and Medicine devoted to medical geography.
THE GENERALAREA OF INTERm
It is important to realize at the onset of this publication endeavor that no single, comprehensive detinition of the term “medical geogkaphy” has withstood the rigorous tests of time. Rather, conceptual trends have evolved over the past 25 years in a manner analogous to the discipline of geography in general. The incorporation of May’s classic work within this volume is offered as an historic benchmark [2]. May’s efforts represent a dramatic beginning to what has become a multidimensional body of knowledge about spatial aspects of human healtb problems [3]. Drawing from a wide variety of natural and social scientific uently utilized and/or approaches, writers have sub developed equally diverse stu “%1‘es falling under the general medical geography rubric.
lnhrnotionol National
Regional
interurban
Introurban
HOuwhold
Individual
Not sped
id
Fig. 1. Approaches to medical geography in relation to scale. 679 S.I.M.
II--14116--*
680
GERALD F. PYLE SPECIFIC APPROACHES
The medical geography literature of the mid-1970s can be summarized conceptually within the frame work presented here as Fig. 1, wherein overlapping yet reasonably distinct topical approaches are shown in relation to a spectrum of geographic scale ranging from worldwide, or international, coverage to that of no particularly specified geographical concern. The intent of such a cross-tabulation is primarily to place studies within some sort of meaningful context, as opposed to attempting to indicate any one approach or scale as more “appropriate” than any other. Thus, much of the pioneer work of May can be considered as disease-ecologically oriented with emphasis placed upon broad international coverage. Such an interpretation is shown by the heavier hatched pattern. Combinations with less emphasis are shown with the diagonal symbolization. Those empty cells are areas where little work has been accomplished; however, this implies neither a pressing need to “fill the empty slots” nor any lesser degree of scientific value. In essence, certain topical approaches have. more merit at some scales than others. It is also worthy of note that many studies in medical geography address spatial concepts without empirical testing at any specified scale [4].
Disease ecology The disease-ecological approach to medical geography is primarily concerned with the natural scientific explanations. Research on such topics attracts scholars with interests similar to those of May. For example, it can be proven that climate, vegetation, mineral traces in water, bedrock minerals, and different biological complexes have different effects on the human health condition[5]. Traditional tropical medicine has long utilized such explanations in studies of a medical geographic nature. While useful, these studies often extract data from limited sample areas and attempt to apply findings at the national and international levels. Placed in the proper perspective in terms of the limitations of findings, such studies can be extremely useful in explaining environmental risk factors [6]. Disease mapping General forms of disease mapping have historic roots in the 19th century[7-j. Major attempts to de velop such studies on national, regional, and urban scales began in Britain shortly after World War II. Examples include Melvyn Howe’s National AC/US of Disease Mortality in the United Kingdom [S]. Within the United States in the mid-196Os, Malcolm Murray developed comparable studies of disease mapping [9]. In addition, Howard Hopps had perfected several types of disease-mapping skills appropriate at national and regional levels [lo]. Intraurban disease mapping was accomplished by Pyle in the late 1960s [l 11, and Dever developed certain kinds of household disease mapping during the same time period [12]. Recently, attempts have been made to research the mapping of individual disease patterns [13]. In general, these studies have attempted to perfect various kinds of mapping skills which have evolved into sophisticated computer useage. While it
is conceivable to examine disease maps and deduce certain kinds of associative patterns, such attempts are best strengthened with concurrent statistical or associative analyses. Thus, in terms of overall research design, while the various types and scales of disease mapping certainly provide very important information to the policy maker, if the maps are not explained properly within a research context in terms of the meaning of the results, many studies often have little internal validity. Associative analyses To add validity to studies of disease distributions, associative analyses have evolved from simple disease mapping Due to the nature of certain statistical techniques, most meaningful emphasis has been placed at the regional and urban levels for such kinds of studies Our modem technology has greatly augmented such analyses, allowing for stochastic and deterministic approaches to understanding disease distributions. While some conventional disease mapping researchers initially viewed associative statistical analyses with some bit of skepticism, recent interpretations have offered muvh information to the policy maker [14]. Such techniques as univariate, bivariate, and multivariate analyses have often raised the issue of multiple explanations to disease problems, thus adding degrees of scientilic explanation. McGlashan, for example, has successfully accomplished various types of probability mapping with statistical tests at the regional and urban levels [l!IJ It was also possible through the use of multivariate analysis to offer multiple explanations of chronic ailments within the Chicago area and proceed to disease forecasting in the early 1970s [16]. Such studies have further made it possible to better address the issue of causation and have added more validity to research design in the process. Still, this kind of research has been accomplished only at given points in time, sometimes not explaining process well enough. For example, while the statistical methods may suggest certain trends, it is well known in scientific research that trends often reverse themselves. Such conclusions have subsequently led to studies of disease diffusion. Disease dijkbn Related, but not identical to traditional research in epidemiology, are studies of disease diffusion. Many of these approaches utilize particular epidemiological methods, but much more emphasis is placed on environmental determinants of the spread of disease. The particular advantage in such an approach is that it is possible to simultaneously view time and space. For example, it has been possible to examine such topics as the diffusion of disease within a country quite successfully [17J. In addition, Hunter and Young recently examined the diffusion of influenza in England and Wales and added to our knowledge of the spread of disease [18]. A recent study of measles within a medium-sized manufacturing city added some explanation to socio-economic obstacles and constraints, both in terms of research and the impact on human illness due to public policy [19]. The development of more understanding of disease diffusion between and among individuals
International communication and medical geography and human
settlements is now of particular impOrtance due to the threat of influenza-pneumonia mortality within the United States. Such an analysis is now being accomplished at The University of Akron [ZO]..Having gained some knowledge of how disease mapping, statistical associations, and research into disease diffusion can be accomplished it is esSential to develop an understanding of human reactions to illness in terms of health care-seeking patterns. Patient travel
Since the mid-1960s geographers have paid increa~ing attention in their research endeavors to aspects of patient travel in relation to the presence of disease problems[21]. As indicated within Fig. 1, these studies have been accomplished at all but the national and international scales, with particular emphasis on intraurban patient travel patterns. Shannon and Dcver have summarized and added to our knowledge of such research in several ways [22]. It is possible in such studies to develop highly sophisticated, process-oriented, analyses of human responses to disease patterns. Given the incidence of a particular disease, it is also possible through statistical applications to for -,cast that incidence of disease and subsequently estimate future demands for the use of particular facilities. One particular area, however, which IX&S further exploration is the identification of segments of the population not necessarily responding to the availability of facilities for various social, behavioral and economic reasons. Historically, these problems initially resulted from inequitable distributions of facilities. As health planning in the United States has increased, particularly within the last decade, legislative changes have had some impact on the health status of populations [U]. While it is anticipated that further public programs will continue to close the gap as regards access and availability of health services, there are, nonetheless, certain cultural and behavioral aspects which must be further researched. Cultural-ecological
Clearly, there is substantial overlap conceptually between environmental and cultural determinants of human disease. Quite often unique indicators of specific cultures help explain chronic health problems. In addition, research about the larger triangular association among natural environment, disease, and behavior attributed to different cultures is identified as paramount in understanding the cultures. This approach needs some clarification, as certain anthropological specifics can be the end results of such studies, and an understanding of medical geography may not be developed. Clearly, it is impossible to separate culture from diet, and culture-nutrition hypotheses have been offered [24]. Diet and nutrition
Recently, Knight and Wilcox have summarized dietary balance, i.e. the differences between excessive and deficient caloric consumption, on an intemational scale [25]. In fact, some of May’s last research dealt with nutrition problems in relation to human health [26]. This approach has been concerned primarily with world nutrition problems, and little has been accomplished at the regional and urban scales.
681
Such studies of urban populations would indeed contribute much to our understanding of medical geography and represent excellent prospects for future research. Behavioral
aspects It is imperative that future medical geography consider all aspects of illness behavior. Shannon’s contribution about illness behavior to this volume has certainly added much to our knowledge of geographic aspects of human health problems [273. In addition, Girt has forwarded certain methodologies which need further research [28]. In terms of past approaches, emphasis has been placed at the household, intraurban, and sometimes individual scales of analysis. As a result, it is possible within such studies to identify substantially different activity spaces within cities in accordance with the socio-eco*omic structure of the city, as has been recently accomplished by Shannon and Spurlock [29]. FUTURE PROSPECTS The advent of these special issues devoted to medical geography represents the culmination of dozens of years of interest in spatial aspects of human health problems by an even larger number of scientific researchers. Social Science and Medicine has offered an international vehicle for future publication of important research findings in this area. Those approaches within Fig. 1 cross-tabulated by scale help place past studies within an overall conceptual context and, hopefully, offer some direction for future endeavors. Clearly, there are many approaches not specified within such a general overview, and the entire conceptual spectrum of medical geography is in need of expansion as well as clarification. It is anticipated that future contributions to this journal will assist in attaining those goals.
REFERENCES
1. Jnternational Geographical Union Commission on Medical Geography, Newsletter, No. 17, Winter 1976/17. This was the last issue of this communication. Reprintqare available from Gerald F. Pyle, Dept. of Urban Studies, University of Akron, Akron, OH 44325, U.S.A. 2. May J. M. Medical geography: its methods and objeo tives Geograph. Rev. 51, 9, 1950. 3. Pyle G. F. Introduction: foundations to medical geography. Econ. Geog. 5x95, 1976. 4. Hunter J. M. (Ed) The Geography of Health and Dis ease. University of North Ckolina at Chapel Hill, Dept of Geography, Studies in Geography, No. 6, 1974. 5. May J. M. The Ecology ofHuman Disease. M.D. Publications, New York, 1958. 6. Roundy R. W. Altitudinal mobility and disease hazards for Ethiopian populations Scott. Geog. 52, 103, 1976. 7. Hirsch A. Handbook of Geographical and Historial Pathology, 3 ~01s. (Translated by Creighten C. Jr.). New Sydenham Society, London, 1883-1886. 8. Howe G. M. National Atlas of Disease Mortality in the United Kingdom (19%58). Nelson, London, 1963. 9. Murray M. Geography of death in the United States and the United Kingdom. Ann/s Ass. Am. Geogr. S7, 301, 1967.
682
GERALD F.
10. Hopps H. Computer produced distribution maps of disease. Annls N.Z Acad. Sci. 161, 1969. 11. Pyle G. F. Heart Disease, Cancer and Stroke in Chi-
12. 13. 14.
15. 16. 17.
18.
19.
cago. University of Chicago, Dept. of Geography, Research Paper No. 134, 1971. Dever G. E. A. A Temporal-spatial analysis of leukemia occurences. Geogr.-medi&No. 3, 107, 1972. Pvle G. F. and Cook R. M. California encephalitis in’ man. Geog. Rev. 1978 (in preparation). _ Learmonth A. T. A. Viewpoints on medical cartography: a selective review. American Geographical Society, Geography and Map Division, Bulletin .No. 78, December, 32-38, 1969. McGlashan N. D. The reality of spatial variations of morbidity and mortality. S.A. med. J. August, 1621, 1974. Pyle G. F. Heart Disease, Cancer and Stroke in Chicago (= Clll). Brownlea A. A. Modellmg the geographic epidemiology of infectious hepatitis. In Medical Geography: Techniques and Field Studies (Edited by McGlashan N. D.).-Methuen, London, 1977. Hunter J. M. and Young J. C. Diffusion of influenza in England and Wales. &mls Ass. Am. Geogr. 61, 637, 1971. Pyle G. F. Measles as an urban health problem: the Akron example. Econ. Geog. 49, 344, 1973.
PYLE
20. Slaymaker N. Influenza diffusion and public policy. Master’s research in progress, The University of Akron, Dept. of Urban Studies. 21. Shannon G. w.. Bashshur R. L. and Metzner C. A. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Rev. 26, 143. 1969. 22. Shannon G. W. and Dever G. E. A. Health care delivery: spatial perspectives. McGraw-Hill, 1974. 23. Pyle G. F. and Lauer B. M. Comparing spatial configurations: Hospital service areas and disease rates. Econ. Geog. 51, 50, 1975. 24. Hunter J. M. Geophagy in Africa and in the United States. Geog. Rev. 74, 170, 1973. 25. Knight C. G. and Wilcox R. P. Triumph or Triage: The World Food Problem in Geographical Perspective. New York, Association of American Geographers. Resource Paper No. 75-3. 1976. 26. May J. M. The geography of nutrition. In The Geography of Health and Disease (Edited by Hunter J. M.) (see C41). 27. Shannon G. W. Space, time and illness behavior. S(IC. Sci. Med. 11, 683, 1977. 28. Girt J. L. Distance to general medical practice and its effect on revealed ill-health in a rural environment. Can. Geogr. 2, 154, 1973. 29. Shannon G. W. and Spurlock C. W. Urban ecological containers, environmental risk cells, and the use of medical services. Econ. Geog. 52, 171, 1976.
