The Russian presence – a cause to an un-equal social structure of today.

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Medical geography – a subject introduction

Medical geography regards as a specialised sub field in the discipline of Human geography. The field is divided into two just as important interacting parts; medical science and geography. These are nevertheless interacting at the same level of science. They rather overlap each other with the same purpose, but with different perspectives – to find out the causes and effects of decease and ill-health – its routs and outcome, especially over the, in many ways, today’s globalized world. As the medical science concentrates on the biological mechanisms, the geographical part of the field focuses, not only on the mapping of the spatial outcome of deceases, its locations and spreading routs, but just as much on social and cultural factors in a geographical context. The social and cultural approach regards as vital factors for explaining, for which the discipline of Human geography, with its interdisciplinary methods makes an important contribution to medical science. The spatial point of view is an important ingredient in the aim to understand the causes and spreading routs of deceases and ill-health. This is thus not a new recognition. The insight that our surrounding affects health is so much as 2500 years old, as known.1 Health is therefore consequently depending on location. However, our biological mechanisms and so also the medical science it self, exists in a social reality. The social structures are not un-isolated (in fact, nothing is). The biological perspective in which the medical science focuses on is therefore very much depending on the social sphere.2 Human action, as will be discussed later on, is therefore a major cause to the biological outcome.
Even though the understanding of health has a long history in geographical terms, for as long as 2500 years as said before, Medical geography as a scientific approach is a relatively new field. Especially in Sweden medical geography as a field of study is quite marginalised.3 In Sweden there are only a few people involved in the field. However, Anders Schærström, a central person within Swedish research in medical geography (Beside of he’s research in Medical geography, he is an employee at the National institute of Public health in Sweden), demonstrates in an article that the field now is increasing within Sweden to.4 In the autumn 2005, for an example of the field’s increased importance in Sweden, Södertörns University College and Karolinska institute in Stockholm is starting a new undergraduate program with Medical geography.5 Medical geography as a scientific approach is as said before becoming much stronger, not at least in Sweden. The main reason regards to be that man’s lifestyle has changed rapidly over the last decade – consequently the needs for solutions have grown stronger than ever.

Critics of Medical geography

Geography of today has of some people been criticised for being a discipline that doesn’t focuses on serious matters in the society as it should be doing.6 The discipline needs to be applied in serious matters in the society, like in the medical science for a to this essay fitting example. Social processes in space regards as important to take into consideration, in which the Human geographic perspective is especially important. In the field of Medical geography, one other task (the previous is also addressed to Medical geography) is that the field should apply a more critical view in research. The field of Medical geography has also been criticized for not taken into consideration a multi-dimensional perspective.7 One example of a lacking point of view in Medical geography regards to be the gender perspective.
Further, it is uncertain if Medical geography as a definition fits its purpose as a field of Human geography.8 As it is formulated today, Medical geography regards to be a part of Medical science, instead of geography. Medical geography is thus a field within Geography, in which the definition ought to be changed to better fit its discipline. The quest for a new and more fitting definition is thus still unclear, even if there are suggestions. At the Inaugural Nordic Geographers Meeting (ngm) in Lund, 2005, The Medical geography sessions were named as Health geography (for an example of one other definition).9

Human action as a central cause

As was told before human action is a central cause to changing health outcome. Human action in the space is consequently also the cause to different health conditions spatial differentiation and therefore also the spatial differentiation of diseases and ill-healthiness. One can wonder what makes the world so spatial differentiated when it comes to terms of poorness and wealth, when these different conditions often lead to different biological as well as relative (as will be discussed later on) health conditions. This picture is for an example common in Atlases, were the beginning pages normally demonstrate different geographic themes over the globe. World wide health statuses are one example of a theme. Although human action isn’t the only cause of explaining, human action regards as a central part of explaining, especially in modern time.
Schærström is talking about recently and still changing patterns in the world as “the post-transitional situation”.10 Basically “the post-transitional situation” is a concept that points at the situation of the modern time’s change and intensified world with different birth -rates and mortality and also changing disease patterns. While many diseases have been taken under control, many others have increased (some of them relatively new) – results of an enhanced way of living. One can look at the changing birth-rates and mortality-rates in Africa south of Sahara or at an analogical example, at the same rates that took place in Europe in the beginning of the especially 20-century – improved birth-rates and decreased mortality (particularly in Europe), and in other areas the opposite (particularly in Africa south of Sahara), also because of man’s changing lifestyles. As the world is becoming smaller in terms of globalization, human interaction is becoming more intensified than ever. What have ones been “without” reach for mankind, is today instead within reach because of man’s much more increased mobility.11 As a result the world wide geographical pattern has changed, and in a deeper point of view, the changed mobility has resulted in intensified interactions between people and cultures and for our matter; diseases and ill-healthiness.

Mobility and spreading sources – the spreading of diseases

As discussed, man’s mobility has changed dramatically over the last decade. The changed mobility pattern is also concerning other variables, direct or indirect affected by human action. These other variables is thus not only outcomes of human action, but indeed, very much affected by it (especially notable in post-modern time). Changing social structures does also make changes within different elements in nature. Schærström speaks about four different spreading sources.12 These are nevertheless functioning isolated from each other. Instead they are supporting each other, and they are also rather a product of each other in a time geographical perspective. The time geographical perspective activates because that each spreading source’s change has a geographical dimension, though they changes because of mobility in space over time. I will now give a brief overlook over each spreading source discussed by Schærström.
One of the spreading sources distinguishes from the other sources (which are natural spreading sources). The technosphere is maintained by means of man.13 As technique has improved radically over the last decades, the effects on the environment has appeared to be just as changed as the technique it self. One of many malignant consequences of man’s improved technique is diseases and ill-healthiness. As told before the different spreading sources are non-isolated from each other. The technical sphere as a spreading source (or rather a spreading cause), which indeed is a central one, is therefore in strong relation with the natural spreading sources as discussed below.
Via the atmosphere diseases can easily spread over the globe. Intensified climatic changes has resulted in not only well known outcomes as the ozone weakening, which has made way for a hole new range of skin cancer because of increased rates of melanoma. Climatic changes have also changed the disease patterns (geographical as rate and scope-based) caused by climate change.14
One not just as easy-explained spreading source as the atmosphere, but then just as influent one is the lithosphere. The lithosphere which contains soils and rocks, attracts the scientists because its man- and environment-relation through especially our needs of eating and drinking.15 This perspective is sometimes called Medical geology. 16 Schærström is also discussing the lithosphere as a spreading source through the atmosphere in terms as “diffusion” from volcanoes (among other transmission themes).
As the earth contains approximately 75 percent water, and because of our needs for it, water is therefore an important spreading source of diseases and ill-healthiness. Again human action is a central cause to changed conditions on the earth, and so also in the water (or with other words in the hydrosphere) – wide spread in a spatial differentiation. Water can therefore be regarded as a medium of both natural and man-made elements.17 One example of the hydrosphere as a medium for man-made elements is when toxic objects are dumped into the sea by some industries – leading not only to spreading of the toxic objects, but also to devastation of water as a resource (water regards as a finite resource18).
The purpose with this sub-chapter was to demonstrate human action as a central cause to diseases and ill-healthiness. It is a matter of course that only living beings can get diseases and bad health, and not the environment it self. It is thus the relation between the environment (which includes the natural spreading sources as discussed above) and human’s that results into diseases and ill-healthiness.19 The cause to diseases is thus not the relationship in it self. Indeed human action is, with the environment as the tool and carrier. As man’s mobility has increased over the last decade, it is even more complicated to mapping where a specific disease aroused.20 The person carrying the disease might travel far before he or she transmits the disease to someone else (not for mention because of the environment, as discussed above, as a carrier and tool), and because of that different diseases have different incubation or latency periods, the approach to trace its roots is difficult.

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Health and awareness of health

Health is the central purpose within Medical geography. Health can also be seen as an outcome in a “clean” geographical perspective with social and cultural factors as determinants. It is therefore vital to get an understanding for the concept in it self, for which I will give a brief survey.
As have been refereed to Atlases, health can differ from one place to one other. Health is thus a relative concept in it self. Though the concept of ones health can vary from one place to one other (at a hypothetic relative scale from worse to excellent health), health is also very much depending on other variables as well. Valuations are shaped, not only from specific ideas moulded from ones child-hood, but also indeed, formed on a broader social base and context.21 Bourdieu is for one example arguing that ones “habitus” is the creation of that person’s society.22 “Habitus” is in this meaning the outcome of understanding and ideas, shaped of the cultural structures within a society. However, as social structures changing continuously, “habitus” is also under constant changing – continuously re-shaping ones understanding and ideas in a broader sense. In this point of view, one society’s perspective and understanding of health doesn’t necessary have to coincide with other society’s perspective and understanding of health. The same differences can consequently also be found on an individual level.
As health obviously is a relative concept, it is therefore a complex and very much uncertain task to examine, especially when it comes to comparing variables of health. However, one way to examine a person’s or a group of person’s health is to use a self-rated research approach. The self-rated approach is a recognized tool within the World Health Organization (WHO), where it is used for calculating people’s self-rated health.23 The self-rated approach of research doesn’t considerate only the “clean” medically variables, such as one person’s physical disease pattern. Instead it is a combination of both physical and mental factors, and is further diagnosed by interviews. Biological as well as social and psychological aspects are considered in the interviews in order to get the results. As the self-rated research approach also is social constructed, the self-rated way of method can therefore differ depending to where it is used. The social structures are for an example in many fields not the same in Sweden and in Estonia. The differences can then also be seen in other levels of perspectives, for an example between regions or even sections of a city, and so on.
WHO’s definition of health regards to be the least controversial of many.24 This definition has thus been criticised for being “just a utopia without ambition for reality”. But though different persons social situation can vary, WHO’s health definition with its combination of both physical and mental factors is seen as the best way to generalise a concept with such of different meaning. However, the method must thus fit in the context. The self rated approach may therefore not be suitable in all contexts, were other methods may be more suitable, such as taking the medical biological outcomes in consideration. Of course, as these outcomes are integrated in the social reality, even social variables should be applied.
With this introduction of Medical geography in the mind, it is now time to explore Estonia and later on its internal health problematic, not at least in an ethnic point of view.

Table of contents :

1. Introduction
1.2. Aim and framing of questions
1.3. Disposition
1.4. Methodological problems and limitations
1.5. Method and sources
2. Medical geography – a subject introduction
2.1. Critics of Medical geography
2.2. Human action as a central cause
2.3. Mobility and spreading sources – the spreading of diseases
2.4. Health and awareness of health
3. Estonia – a country of differentiation
3.1. Estonia’s history of modern time
3.1.1. The first period – Estonia as a new independent state
3.1.2. The second period – the Estonian SSR
3.1.3. The third period – the Estonian Republic, once again
3.2. The ethnic population structures
3.3. Russians as Estonia’s largest minority group
3.4. The Russian presence – a cause to an un-equal social structure of today.
4. Estonia’s medical geography
4.1. Regarding the social and ethnic structures
4.2. Methods and considerations when calculating and comparing the data.
4.3 Estonia in whole – non medical variables
4.3.1. Medical variables – Mortality trends
4.3.2. Conclusions of the mortality trends – the country as whole
4.4. Ida-Virumaa – non medical variables
4.4.1. Medical variables – Mortality trends
4.4.2. Conclusions of the mortality trends – Ida-Virumaa
4.5. Läänemaa – non medical variables
4.5.1. Läänemaa – medical variables
4.5.2. Conclusions of the mortality trends – Läänemaa
5. Discussion
6. Conclusions
Sammanfattning (summary in Swedish)
List of references 


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