64 the cultural landscape key issuegeo107.weebly.com/uploads/2/1/7/3/21735412/chapter... · 68 the...

64 THE CULTURAL LANDSCAPE

KEY Issue4Why Do Some RegionsFace Health Threats?• Epidemiologic Transition• Infectious Diseases• Health Care

Learning Outcome 2.4.1Summarize the four stages of the epidemiologictransition.

As world NIR slows and the threat of overpopulation re-cedes, at least at a worldwide scale, geographers increas-ingly turn their attention to the health of the record num-ber of people who are alive. Medical researchers haveidentified an epidemiologic transition that focuses ondistinctive health threats in each stage of the demographictransition. Epidemiologists rely heavily on geographic con-cepts such as scale and connection because measures tocontrol and prevent an epidemic derive from understand-ing its distinctive distribution and method of diffusion.

Epidemiologic TransitionThe term epidemiologic transition comes from epidemiol-ogy, which is the branch of medical science concernedwith the incidence, distribution, and control of diseasesthat are prevalent among a population at a special timeand are produced by some special causes not generallypresent in the affected locality. The concept was originallyformulated by epidemiologist Abdel Omran in 1971.

STAGE 1: PESTILENCE AND FAMINE(HIGH CDR)In stage 1 of the epidemiologic transition, infectious andparasitic diseases were principal causes of human deaths,along with accidents and attacks by animals and otherhumans. Malthus called these causes of deaths "naturalchecks" on the growth of the human population in stage 1of the demographic transition.

History's most violent stage 1 epidemic was the BlackPlague (bubonic plague), which was probably transmittedto humans by fleas from migrating infected rats:• The Black Plague originated among Tatars in present-

day Kyrgyzstan.• It diffused to present-day Ukraine when the Tatar army

attacked an Italian trading post on the Black Sea.

• Italians fleeing the trading post carried the infected ratson ships west to the major coastal cities of SoutheasEurope in 1347.

• The plague diffused from the coast to inland towns andthen to rural areas.

• It reached Western Europe in 1348 and NorthernEurope in 1349.

About 25 million Europeans- at least one-half of the conti-nent's population-died between 1347 and 1350. Five otherepidemics in the late fourteenth century added to the tollEurope. In China, 13 million died from the plague in 1380.

The plague wiped out entire villages and families,leaving farms with no workers and estates with no heirs.Churches were left without priests and parishioners,schools without teachers and students. Ships drifted aimlessly at sea after entire crews succumbed to the plague.

STAGE 2: RECEDING PANDEMICS (RAPIDt.:DECLINING CDR)Stage 2 of the epidemiologic transition has been called thstage of receding pandemics. A pandemic is disease that oc-curs over a wide geographic area and affects a veryproportion of the population. Improved sanitation, nutri-tion, and medicine during the Industrial Revolution re-duced the spread of infectious diseases. Death rates didnot decline immediately and universally during theyears of the Industrial Revolution. Poor people crowdedinto rapidly growing industrial cities had especially highdeath rates. Cholera-uncommon in ruralan especially virulent epidemic in urban areas duringIndustrial Revolution.

Construction of water and sewer systems hadcholera by the late nineteenth century. However, cholerapersists in several developing regions in stage 2 of the de-mographic transition, especially sub-Saharan AfricaSouth and Southeast Asia, where many people lackto clean drinking water (Figure 2-31). Cholera has alsofound on Hispaniola, the island shared by Haiti and theminican Republic, especially in the wake of anin 2010 that killed 200,000 and displaced 1 million.

A computer-based Geographic Information Systeminvented in the twentieth century, but the idea oflaying maps to understand human and natural patternsmuch older. A century before the invention of computers.GIS helped to explain and battle stage 2 pandemics.

Dr. John Snow (1813-1858) was a British physician,a geographer. To fight one of the worst nineteenth century!pandemics, cholera, Snow created a hand-made GIS in 1854.On a map of London's Soho neighborhood, Snowtwo other maps, one showing the addresses of cholera vic-tims and the other the location of water pumps-whichthe poor residents of Soho were the principal source offor drinking, cleaning, and cooking (Figure 2-30).

The overlay maps showed that cholera victims weredistributed uniformly through Soho. Dr. Snow showed

_ Areas reporting outbreaks

Countries to which cholera diffused

~ FIGURE 2-31 CHOLERA Countries reporting cholera in recent years are found primarily in sub-Saharan Africaand South Asia.

a large percentage of cholera victims were clustered aroundone pump, on Broad Street. Tests at the Broad Street pumpsubsequently proved that the water there was contami-nated. Further investigation revealed that contaminated

Water pump

• Cholera victim

~ FIGURE 2-32 SIR JOHN SNOW'S CHOLERA MAP In 1854. Dr. JohnSnow mapped the distribution of cholera victims and water pumps to provethat the cause of the infection was contamination of the pump near the cornerof Broad and Lexington streets.

Chapter 2: Population and Health 65

sewage was getting into the water supply near the pump.Although no longer operative, the contaminated pumpstill stands in London and can be seen in the photo onpage 42.

Before Dr. Snow's geographic analysis, many believedthat epidemic victims were being punished for sinful be-havior and that most victims were poor because povertywas considered a sin. Now we understand that cholera af-fects the poor because they are more likely to have to usecontaminated water.

STAGE 3: DEGENERATIVE DISEASES(MODERATELY DECLINING CDR)Stage 3 of the epidemiologic transition, the stage of degen-erative and human-created diseases, is characterized by adecrease in deaths from infectious diseases and an increasein chronic disorders associated with aging. The two espe-cially important chronic disorders in stage 3 are cardiovas-cular diseases, such as heart attacks, and various forms ofcancer. The global pattern of cancer is the opposite of thatfor stage 2 diseases; sub-Saharan Africa and South Asia havethe lowest incidence of cancer, primarily because of the rel-atively low life expectancy in those regions.

Pa(ise and Reflect 2.4.1 ,.In ~hat (,:iim~tezone are 'bfbst of the countries thathave experienced cholera recently?

---'.--40"


If(.~STAGE 4: DELAYED DEGENERATIVEDISEASES (LOW BUT INCREASING CDR)

Learning Outcome 2.4.2Summarize the reasons for Stage 4 and a possiblestage 5 of the epldemioloqic transition ..

Omran's epidemiologic transition was extended by S. JayOlshansky and Brian Ault to stage 4, the stage of delayeddegenerative diseases. The major degenerative causes ofdeath-cardiovascular diseases and cancers (Figure 2-33)-linger, but the life expectancy of older people is extended

16O"-~;-- ~D-~--;;i--~''~80'~ ... ;'~

/~'-

4O'---'----t--

PACIFICt _?_~f~N L20' i .... ·-- --._

0'

160'I

140'\

120'

20'Male cancer death rateper 100,000 populaUon• 150 and above.126-149

100-125 ~\Below 100

\'no dataHIO' 80' 60' 40' 20' 0' 20'

through medical advances. Through medicine, cancerspread more slowly or are removed altogether. Operatiosuch as bypasses repair deficiencies in the cardiovasculasystem. Also improving health are behavior changes sueas better diet, reduced use of tobacco and alcohol, and exercise. On the other hand, consumption of non-nutritioufood and sedentary behavior have resulted in an increasin obesity in stage 4 countries (Figure 2-34).

Pauseand Reflect 2.4.2Have you had a parent or gr~ndparent whoselifespan was extended by modern medical advances?

40'I

60' 160' 1110'I

80" 100' 120'

... FIGURE 2-33 MALE CANCER Cancer is an example of a cause of death for men that is higher in developedcountries than in developing ones.

,_ ._. __ ~40'

'0'

PACIFICI OCEAN

20- ;.::--- / -~,

O'J __J_ II I

180' 140' \ \

Percent obese' 20.1- __L__• 30 and above -. ----y------.20-30 \

10-19.9 \ \Below 10 40'-~.- ____l_no data \ \

• body mass Indexat least 30kg/m'

120" 100"

... FIGURE 2-34 OBESITY Obesity is a health problem in the United States and in Southwest Asia.

~i! \ \ \ 40"

i40'

/l(lO1 120' 1~ 1IiD'

New TB cases per100,000 population

Below 100

100-299 ~---T---+---1--~~--~~+---~=-~~~~-F~-+~&4~~300 and above 2,000 4,0,90 Miles

·2, 4.000 Kilomet;;lsno data . / /

1000 80" 80" ~ 20" 0" 20" ~ 80" 80" 100" 120" 140" 180" 180'

A FIGURE 2-35 TUBERCULOSIS (TB) CASES Death from tuberculosis is a good indicator of a country's ability:0 invest in health care, because treating the disease is expensive.

Infectious DiseasesRecall that in the possible stage 5 of the demographic tran-sition, CDR rises because more of the population is elderly.Some medical analysts argue that the world is moving intostage 5 of the epidemiologic transition, brought about bya reemergence of infectious and parasitic diseases. Infec-tious diseases thought to have been eradicated or con-trolled have returned, and new ones have emerged. Aconsequence of stage 5 would be higher CDRs. Other epi-demiologists dismiss recent trends as a temporary setbackin a long process of controlling infectious diseases.

In a possible stage 5, infectious diseases thought tohave been eradicated or controlled return, and new onesemerge. Three reasons help to explain the possible emer-gence of a stage 5 of the epidemiologic transition: evolu-tion, poverty, and increased connections.

REASON FOR POSSIBLE STAGE 5:EVOLUTIONInfectious disease microbes have continuously evolvedand changed in response to environmental pressures bydeveloping resistance to drugs and insecticides. Antibiot-ics and genetic engineering contribute to the emergence ofnew strains of viruses and bacteria.

Malaria was nearly eradicated in the mid-twentiethcentury by spraying DDT in areas infested with the mos-quito that carried the parasite. For example, new malariacases in Sri Lanka fell from 1 million in 1955 to 18 in 1963.The disease returned after 1963, however, and now causesmore than 1 million deaths worldwide annually. A majorreason was the evolution of DDT-resistant mosquitoes.

~+----r---+----~r.-~'80" 140" 120"


REASON FOR POSSIBLESTAGE 5: POVERTYInfectious diseases are more prevalent in poor areas thanother places because unsanitary conditions may persist,and most people can't afford the drugs needed for treat-ment. Tuberculosis (TB) is an example of an infectious dis-ease that has been largely controlled in developed countriesbut remains a major cause of death in developing coun-tries (Figure 2-35). An airborne disease that is often called"consumption" and that damages the lungs, TB spreadsprincipally through coughing and sneezing. TBwas one ofthe principal causes of death among the urban poor in thenineteenth century during the Industrial Revolution.

The death rate from TB declined in the United Statesfrom 200 per 100,000 in 1900 to 60 in 1940 and 4 today.However, in developing countries, the TB rate is more than10 times higher than in developed countries, and nearly 2million people worldwide die from it annually. TB is moreprevalent in poor areas because the long, expensive treat-ment poses a significant economic burden. Patients stoptaking the drugs before the treatment cycle is completed.

-.. -------------


of AIDS). The impact of AIDS has been felt most stronglyin sub-Saharan Africa, home to 23 million of the world's34 million HIV-positive people (Figure 2-36).

AIDS diffused from sub-Saharan Africa through relo-cation diffusion, both by Africans and by visitors to Af-rica returning to their home countries. AIDS entered theUnited States during the early 1980s through New York,California, and Florida (Figure 2-37). Not by coincidence,the three leading U.S. airports for international arrivals arein these three states (Figure 2-38). Though AIDS diffused toevery state during the 1980s, these three states, plus Texas(a major port of entry by motor vehicle), accounted for halfof the country's new AIDS cases in the peak year of 1993.

The number of new AIDS cases dropped rapidly in theUnited States during the 1990s and in sub-Saharan Africain the 2000s. The decline resulted from the rapid diffusionof preventive methods and medicines such as AZT. Therapid spread of these innovations is an example of expan-sion diffusion rather than relocation diffusion.

REASON FOR POSSIBLE STAGE 5:INCREASED CONNECTIONS

Learning Outcome 2.4.3Descri.bethe diffusion -of AIDS,

Several dozen "new" pandemics, such as HINI (swine)flu and severe acute respiratory syndrome (SARS), haveemerged over the past three decades and have spreadthrough the process of relocation diffusion, discussed inChapter 1. Motor vehicles allow rural residents to havegreater connections with urban areas and for urban resi-dents to easily reach rural areas. Airplanes allow residentsof one country to easily connect with people in othercountries. As they travel, people carry diseases with themand are exposed to the diseases of others.

The most lethal pandemic in recent years has beenAIDS (acquired immunodeficiency syndrome). World-wide, 30 million people died of AIDS from the beginningof the epidemic through 2010, and 34 million were liv-ing with HIV (human immunodeficiency virus, the cause

Pause and Reflect 2.4.3Have other pandemic diseases diffused rapidly inrecent years?

.... FIGURE 2-36 DIFFUSION OF HIV/AIDS The highest rates of HIV infection arein sub-Saharan Africa and Russia.

Percent HIV positive amongages 15-49 years, 1990

1.0 and above0.1-0.9Below 0.1no data

II II .;;;;l; .. "\ I ,.,,~,;t( l \ r ",

ff-t---t-160' 140'

Percent HIV positive amongages 15-49 years, 2012_ 1.0 and above

~0.1-0.9Below 0.1no data

----- --

New AIDS cases per 100,000 populaHon• 60 and above _ 2!l-39 1-9

• 4!l-59 ~ 1!l-19 Below 1


Cumulative AIDS cases

• 100,000 and above

• 50,000-99,999

m10,00()-49,999

1,000-9,999

Below 1,000

.. FIGURE 2-37 DIFFUSION OF HIV/AIDS IN THE UNITED STATES AIDS diffused from states with relatively high immigration rates,such as California, Florida, and New York. The AIDS Memorial Quilt was assembled as a memorial to people who have died of AIDS.

~ FIGURE 2-38 INTERNATIONAL PASSENGERARRIVALS AT U.S. AIRPORTS 2011 BecauseAIDS arrived in the United States primarily through airtravelers, the pattern of diffusion of AIDS inFigure 2-37 closely matches the distribution ofinternational air passenger arrivals,

- - ---~

----==----- - ----- - -- - -


Health CareLearning Outcome 2.4.4Understand reasons for variations in health betweendeveloped and developing countries, -

Health conditions vary around the world. Countries pos-sess different resources to care for people who are sick.

INDICATORS OF HEALTHTwo important indicators of health in a country are theinfant mortality rate and life expectancy. The infantmortality rate (IMR) is the annual number of deaths ofinfants under one year of age, compared with total livebirths (Figure 2-39). As is the case with the CBR and CDR,the IMR is usually expressed as the number of deathsamong infants per 1,000 births rather than as a percent-age (per 100). In general, the IMR reflects a country's

D'-t- t- I160' 140" 120"

Infant Mortality Rate 120'per 1,000 live births_ 60andabove

40-5920-39Below 20no data

20'- "

0"-160' 141l"

Ute expectancy atbirth in years I 20'._ 80 and above

_75-79_70-74

60-69Below 60no data

80'

40'

~ 60' 60' 40' 20' 0" 20'- 4Il" 60' • • ~ _ _ _

4()"

60'-.~,

40'

40' 2ir 0"

Pauseand Reflect 2.4.4Why do men have lower life expectancies thanwomen in most countries?

health-care system. Lower IMRs are found in countrieswith well-trained doctors and nurses, modern hospitals,and large supplies of medicine.

The global distribution of IMRs follows the pattern thatby now has become familiar. The IMR is 5 in developedcountries and 80 in sub-Saharan Africa, meaning that 1 in12 babies die there before reaching their first birthday. Lifeexpectancy at birth measures the average number of yearsa newborn infant can expect to live at current mortalitylevels (Figure 2-40). Like most of the mortality and fertil-ity rates discussed thus far, life expectancy is most favor-able in the wealthy countries of Europe and least favorablein the poor countries of sub-Saharan Africa. Babies borntoday can expect to live to nearly 80 in Europe but only toless than 60 in sub-Saharan Africa.

~ FIGURE 2-39 INFANTMORTALITY RATE (IMR) The highestIMRs are in sub-Saharan Africa, and thelowest are in Europe and South Pacific.

.---.-40'

,. _"~"" __;;;iP~" L_lro2lC_Qf_c_ancer\F-'l.._q.:.--tc- . --'':'-20-

PACIFIC'OCEAN

i

0'

>;20'

60'

~ FIGURE 2-40 LIFE EXPECTANCYAT BIRTH As with IMRs, the highestlife expectancies are in sub-SaharanAfrica, and the lowest are in Europeand South Pacific.

..------'r---4O'

4Il"

100' 120" 1-40' 160' HID·

PROVISION OF HEALTH CAREEven if they survive infancy, children remain at risk in de-veloping countries. For example, 17 percent of childrenin developing countries are not immunized against mea-sles, compared to 7 percent in developed countries. Morethan one-fourth of children lack measles immunization inSouth Asia and sub-Saharan Africa (Figure 2-41).

Developed countries use part of their wealth to protectpeople who, for various reasons, are unable to work. Inthese countries, some public assistance is offered to thosewho are sick, elderly, poor, disabled, orphaned, veterans ofwars, widows, unemployed, or single parents. Annual percapita expenditure on health care exceeds $1,000 in Europeand $5,000 in the United States, compared to less thanS100 in sub-Saharan Africa and South Asia (Figure 2-42).

Expenditures on health care exceed 15 percent of totalgovernment expenditures in Europe and North Americacompared to less than 5 percent in sub-Saharan Africa andSouth Asia (Figure 2-43). Countries in Northern Europe,including Denmark, Norway, and Sweden, typically pro-vide the highest level of public-assistance payments. Sonot only do developed countries spend more on healthcare, they spend a higher percentage of their wealth onhealth care.


o 5 10 2515 20Percent Not Immunized

A FIGURE 2-41 CHILDREN LACKING MEASLES IMMUNIZATIONThe lowest rates of immunization are in sub-Saharan Africa and South Asia.

~ FIGURE 2-42 HEALTH CAREEXPENDITURES The lowest levels of percapita health care expenditure are insub-Saharan Africa and South Asia.

140'

Health care expendituresper capita_ SI,OOO and above

5300-5999 -~toJ~ 40'Sloo-$299Below $100

01 .2,000 4,OOOKflometlll1I, I I

4QoI

liO'no data 100' 80' 60' 40' 20' 20' 60' 80' 100' 140' 160' 180'

~ FIGURE 2-43 GOVERNMENTEXPENDITURES ON HEALTH CARE Thelowest levels of government expenditures arein Africa and Asia.

40' -I PACIFICI OCEAN-- (' - - -/--

2O'T'I-,I

0'180' 140' 120'

Government expenditureon health as a percentage 20'-,-of total government -expenditures

13.0 and above 40'9.0-12.9 I5.0-8.9 \ I IBelow 5.0 100' 0' 20' 40' 100' 120' UO' 160'

no data

30

-----

----------------- -------------- ---- -

_...


MEDICAL SERVICES

Learning Outcome 2.4.5Understand reasons for variations in/health betweendeveloped and developing countries.

Health conditions vary around the world. Countries pos-sess different resources to care for people who are sick.

The high expenditure on health care in developedcountries is reflected in medical facilities. Most countriesin Europe have more than 50 hospital beds per 10,000 peo-ple, compared to fewer than 20 in sub-Saharan Africa andSouth and Southwest Asia (Figure 2-44). Europe has morethan 30 physicians per 10,000 population, compared tofewer than 5 in sub-Saharan Africa (Figure 2-45).

In most developed countries, health care is a publicservice that is available at little or no cost. Governmentprograms pay more than 70 percent of health-care costsin most European countries, and private individuals payless than 30 percent. In developing countries, private in-dividuals must pay more than half of the cost of health

40'

/160'

_ 50 and above_30-49.10-29

Below10nodala

40' -

PACIFIC IOCEAN

- -----I20' ,,~-

0' ___j160' 140'

PhysiCians per10,000 population 1201: -+--BI 300 and above ' ,

150-29950-149Below50no dati

4()<~ \ ----j-

60' 40'120' 100' 80' 20' 0' 20' 40'

- - ----'~~"-==--=;=;;.....;;;==--'="'--~=-~

care (Figure 2-46). An exception to this pattern isUnited States, a developed country where privateuals are required to pay an average of 55 percent ofcare, more closely resembling the pattern incountries.

Developed countries are hard-pressed to maintaincurrent levels of public assistance. In the past, rapidnomic growth permitted these states to finance generous]programs with little difficulty. But in recent yearsnomic growth has slowed, while the percentage ofple needing public assistance has increased. Governmentshave faced a choice between reducing benefits and increas-ing taxes to pay for them. In some of the poorest coun-tries, threats to health and sustainability are not so muchfinancial as environmental. For a case in point, read thefollowing Sustainability and Inequality in Our Global Vil-lage feature.

Pauseand Reflect 2.4.5Why,might levels-of hospital beds and physiciansbe lower in.North America than in other developedcountries?

:::"~~60'

80' 100' 120' 1~0' 160' 180'

... FIGURE 2-44 HOSPITAL BEDS PER10,000 PEOPLE The lowest rates are in sub-SaharanAfrica and South Asia.

... FIGURE 2-45 PHYSICIANS PER 10,000PEOPLE The lowest rates are in sub-SaharanAfrica.

Pr1va1Bexpenditureas percent 01 totalexpenditure on health

60 and above40-59.920-39.9Below 20no data 2Q' 0'

6. FIGURE 2-46 PUBLIC EXPENDITURES ON HEALTH CARE AS A SHARE OF TOTAL HEALTH CAREEXPENDITURES The highest percentages are in Europe.


40'

140' 180'

SUSTAINABILITY AND tNEQUALITY IN OUR GLOBAL VILLAGE

Overpopulation in Sub-Saharan AfricaOverpopulation-too many people forthe available resources-does not ap-pear to be an immediate threat to theworld, even in India, where the sevenbillionth human was said to havebeen born on Octobe;r 31}2011 (FigJ,JIe2-47). However, it does threaten areaswithin sub-Saharan Africa.

Sub-Saharan Africa was not clas-sified in Key Issue 1 as one of theworld's population concentrations.Geographers caution that the size,density, or clustering of populattonIaa region is not an indication of over-population. Instead, overpopulationis a relationship between populationand a region's level of resources. Thecapadty of the land to sustain life de-rives partly from characteristics of the

~ FIGURE 2-47 THE WORLD'S SEVENBILLIONTH HUMANNargis Kumar, born October 31,2011, to Vinita andAjay Kumar, of lucknow, India, was declared theworld's seven billionth person by Plan International, anongovernmental organization for children's' welfare.

CHECKIN~KeY'SSUE4Why Do Some Regions Face Health Threats?

./' The epidemiologic transition has four stages ofdistinctive diseases.

./' A resurgence of infectious diseases may signal apossible stage 5 of the epidemiologic transition .

./' The provision of health care varies sharplybetween developed and developing countries.

natural environment and partly fromhuman actions to modify the envi-ronment through agriculture, indus-try, and exploitation of raw materials.See for example, the image of Mali onpage 44.

The track toward overpopula-tion may already be irreversible inAfrica. Rapid population growth hasled to the inability of the land to sus-tain life in parts of the region. As theland declines in quality, more effort isneeded to yield the same amount ofcrops. This extends the working dayof women, who have the primary re-sponsibility for growing food for theirfamilies. Women then regard havinganother child as a means of securingadditional help in growing food.

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