Alun E. Joseph

Space in its place: Developing the link in medical geography

This paper argues that a re-examination of the interrelationship between constructs of place and space is crucial to geographys involvement in the broader endeavour of health research. Place has re-emerged as nexus of ascribed meaning within contemporary social theory. Places, however, are related in space, by distance or proximity. The distinction needs to be made between this orthodox (geometric) view of space and two types of social space: the (experienced) space described by humanist geographers; and the more recent (socio-spatial) conceptualization which is both experienced and (re)produced by societal structures and advocated by social theorists in geography. We argue that advancing a recursive understanding of space and place is an appropriate direction in medical geography. This direction will include both an understanding of the ways in which space shapes the character of places and how the particularities of places resist or set in motion (orthodox) spatial processes. Illustrations are drawn from studies of mental illness and mental health care and primary health care in a remote area of New Zealand.

Agricultural land protection in China: a case study of local governance in Zhejiang Province

Chinas rapid economic development following the 1978 reforms has resulted in significant economic, social and environmental change. One consequence of this change has been the accentuation of an existing trend of agricultural land loss and degradation. Although the 1978 reforms and their impacts have been subjected to considerable scrutiny, relatively little research has been directed towards the relationship between the evolution of local government structures and practices and the implementation of agricultural land protection policies. This paper presents an analysis of this relationship in Huzhou Municipality, Zhejiang Province. Zhejiang Province is situated on the eastern seaboard and exhibited the highest average annual per capita growth in China between 1978 and 1995. Huzhou Municipality is a growth centre in the northern part of the province. A synthesis of the factual knowledge and perceptions of 40 key-informants suggests that despite the development of a comprehensive legal framework for agricultural land protection, the interpretation of policy at local levels continues to permit the loss of agricultural land (and attendant environmental costs) to be traded-off against increased economic growth. This suggests a need to re-evaluate the role of local levels of government in China with respect to agricultural land protection issues; to look as much at the ways policies are implemented as at policies themselves. The devolution of administrative responsibility in China and the increasing influence of powerful local economic interests will provide an impetus for such a re-focussing of research at local levels.

Restructuring health and rural communities in New Zealand

The recent restructuring of health-care provision has particularly a•ected rural communities in New Zealand, a nation characterized by an emerging biculturalism in its policies and outlook. In this article we develop a framework linking health care, the rural experience of place and the national cultural fabric. After presenting the stories of two North Island communities undergoing transition, we consider the role of health care in influencing the broader health of rural settlements as communities. We conclude that for communities as well as their residents, health and place are mutually constituted through the activities of health-care provision.

Deinstitutionalization meets restructuring: the closure of a psychiatric hospital in New Zealand

Abstract This paper examines the impending closure of Tokanui (Psychiatric) Hospital in the Waikato region of New Zealand. We view this event as both a single occurrence in the unfolding narrative of deinstitutionalization and a specific manifestation of restructuring. Following a consideration of the particularities of mental health care deinstitutionalization and health care restructuring in New Zealand and guided by a descriptive model of service localization, documentary sources and media reports are used to illuminate distinctive threads of alternative discourse on the closure of the hospital. The planned transfer of service location and modality, from a rural institution to an urban-centred network, is seen to have considerable and diverse implications for ( and within) ‘origin’ and ‘destination’ communities. In the rural settlements near Tokanui, we observe accepting communities that have voiced support for the institution and their disappointment at the impending loss of jobs and part of their symbolic identity. We identify Maori as particularly affected by the closure, for reasons of special treatment at Tokanui as well as employment. In Hamilton, the planned site of relocated services, we observe social opposition consistent with the NIMBY (‘not in my backyard’) catchcry. The paper concludes with a critical (re)evaluation of the methods employed in the study and of opportunities for further research.

Growing old in place: a view from rural New Zealand

Abstract This paper examines the interface between the perceptions of people growing old in New Zealands rural communities and the ‘objective’ impacts of economic and social restructuring on their communities. A case study of two communities in the Waikato region indicates that the elderly are concerned more with the immediate impact of local business failures and service withdrawals than they are with the long-term sustainability of their lives. Strong attachment to place, together with the perceived inaccessibility of alternative housing, provides a powerful incentive for ‘staying on’ in service-depleted communities. In the face of a prevailing government ideology of personal responsibility and well-established problems of providing rural services, rural communities will likely be left to cope as they may with the needs of growing numbers of elderly.

Elderly migration and its implications for service provision in rural communities: an Ontario perspective

Abstract Following a discussion of the role of migration in the aging of rural populations and of consequent implications for service provision in rural communities, a case study featuring demographic and service use data for Grey County, Ontario, is presented. Cohort Survival Analysis of census data for the period 1971–1986 indicates a consistent net in-migration of elderly into the county and a complex but predictable pattern of elderly relocation from townships to villages and towns within Grey. The demographic analysis is complemented and extended by the examination of survey data on the residential history and service use of a sample of elderly residents drawn from two communities in Grey County. The survey results provide valuable clues for the interpretation of the demographic analysis and reveal residential history to be a potentially important pre-condition of dependence on formal services intended for the maintenance of elderly persons in the community. The paper concludes with a discussion of the need for local analysis of migration impacts and of the relationship between such impacts and longstanding problems of rural service provision.

Casey House: interpreting the location of a Toronto AIDS hospice.

This paper focuses on an overtly geographical issue, the introduction of a housing facility for people living with AIDS (PLWAs) into the urban landscape. Specifically, we critically analyze the location of Casey House, an AIDS hospice in Toronto and presently the only facility of its kind in Canada. Three questions are addressed: (i) how did Casey House come to exist?; (ii) why is Casey House located at the corner of Huntly Street and Isabella Street?; and (iii) will Casey House be reproduced? In our response to the first two questions, we draw selectively upon three perspectives (accessibility, structuralist and humanistic) that have been appealed to in analyses of (controversial) health care facility location processes. In the concluding discussion, three relevant spheres of reproduction are considered: locational, institutional and social. In consideration of the obvious constraints on reproduction, we conclude that the creation and location of Casey House may well be a unique geographical event in Canada.

Social and environmental regulation in rural China: bringing the changing role of local government into focus

Abstract China’s rapid economic growth following the 1978 reforms has resulted in significant economic, social and environmental change. These reforms and their outcomes have been subjected to considerable scrutiny. However, relatively little research has been directed towards the relationship between the changing role of local government, which has itself been subject to substantial restructuring, and the local mediation of the social and environmental impacts of rapid economic growth. This paper investigates the local manifestation of social and environmental change in Zhejiang Province. In particular, it considers the changing role of local government in the regulatory process, and features a case study of Huzhou Municipality. A synthesis of the factual knowledge and perceptions of 48 key-informants from government and public institutions and rural industries is used as the platform for an analysis of the changing nature of local regulation with respect to the provision of key public services (health care and education) and environmental protection (water pollution control). The results reveal the ability of local government to selectively implement national and provincial policies in light of local priorities, which is taken as indicative of the emergence of local agency within local development processes. The case study suggests a need to re-evaluate conventional wisdom on the absence of autonomy at local levels of government in China, particularly as it relates to the continued devolution of administrative responsibility and the emergence of increasingly powerful economic interests.

Locational variation in mental health care utilization dependent upon diagnosis: A Canadian example

Abstract Numerous empirical investigations have shown the impact or facility location upon rates of mental health care service utilization to be substantial but complex. Following a brief discussion of the conceptual basis of distance decay effects in utilization, the role of diagnosis as a modifier of such effects is explored through analysis of data for a mental health care catchment area in central Ontario. The results produced demonstrate clearly the importance of diagnosis; the strength of distance decay effects is negatively correlated with the severity of diagnosis. This points toward the severe constraint imposed by assumptions on the uniformity of observations (patients) and on their response to facility location

A framework for modeling the consumption of health services by the rural elderly.

This paper reports on an ongoing research program which seeks to assess the implications of population aging for housing, services and transportation in rural communities in the Province of Ontario. Specifically, the focus is on the modeling of health and social service consumption by elderly (over 65) persons. Following a review of the literature on service provision to senior citizens in Ontario, a modeling framework conceptualizing the process of service utilization at both the aggregate (user and nonuser characteristics) and individual (decision-making) levels is introduced. Data on use of community support services drawn from a survey of elderly residents in two communities in Grey County, Ontario (Meaford, population 4380 in 1986, and Markdale, population 1226 in 1986) are used to illustrate the general features of the modeling framework. Particular attention is paid to the ability of the modeling framework to yield insights into the origins of notable variations in service use rates between men and women. Overall, the results are taken to be supportive of the usefulness of the modeling framework as a template for guiding empirical analysis of service utilization patterns. At the same time the case study testifies to the complex and dynamic nature of service provision issues in rural communities. The challenge of providing services effectively to an elderly rural population located in scattered villages and small towns will continue to tax the imagination and resources of responsible agencies.