ISSN 1980-5772 eISSN 2177-4307 Revista ACTA Geográfica, ANO IV, N°7, jan./jul. de 2010. pp.07-23. HEALTH GEOGRAPHY IN THE IBERIAN PENINSULA: A VIEW SINCE THE JOHN SNOW MAP Paula Cristina Remoaldoi Universidade do Minho Helena Guilhermina Nogueiraii Universidade de Coimbra Jesús M. González Péreziii Universitat de les Illes Balears Resumo À escala internacional, a evolução da Geografia da Saúde foi ocorrendo essencialmente à custa da investigação empírica, enquanto a abordagem conceitual emergiu apenas nos anos oitenta do século XX. De fato, só a partir daquela década assistimos ao desenvolvimento de uma investigação mais estruturada, alicerçada no enfoque epistemológico e realizada exclusivamente por geógrafos. Foi nessa década que também surgiu, em Portugal e na Espanha, uma investigação mais sustentada no seio da Geografia da Saúde. O presente texto faz uma análise do status quo da Geografia da Saúde da Península Ibérica, dando especial relevo às origens deste domínio de investigação, ao contributo para a sua evolução à escala internacional e às perspectivas de futuro. Para tal, foi usado um enfoque qualitativo, alicerçado na análise dos artigos, obras e actas publicados pelos geógrafos portugueses e espanhóis, no seio de cada país, e também à escala internacional. Concluímos que a Geografia da Península Ibérica se tem centrado mais na Geografia dos Cuidados de Saúde (um dos ramos tradicionais da Geografia da Saúde) do que na Ecologia da Doença (outro ramo tradicional) e que a Geografia da Saúde se desenvolveu primeiro pela mão dos geógrafos espanhóis. Também são de opinião que foram encetados, até ao momento, poucos esforços para a concretização de um tabalho em rede, que aproveite o trabalho realizado pelos poucos geógrafos que se preocupam com a saúde. Não obstante, tem aumentado o número de geógrafos que tem trabalhado em equipes multidisciplinares, ainda que estas sejam maioritariamente coordenadas por médicos e economistas. Por último, alertamos para a necessidade de desenvolverem esforços mais sustentados no sentido de mostrarem à sociedade a aplicabilidade da análise territorial em diferentes escalas. Palavras-chave: Península Ibérica; Epistemologia; Geografia da Saúde; Investigação Empírica; Investigação Conceptual. Abstract It is known worldwide that the evolution of Health Geography is due mainly to empirical works rather than conceptual ones. We had to wait for the 80's of the last century to witness a more structured investigation, centred on the epistemological questions and done most exclusively by geographers. It was at this time that in Portugal and Spain Health Geography emerged as a relevant discipline to the evolution of this field at an Iberian scale. This paper tries to analyse the state of Heath Geography in the Iberian Peninsula, mainly its origins, evolution and contribution to the evolution of this field at an international level as well as making some predictions concerning the future of Health Geography in the Iberian Peninsula. The qualitative methods of bibliographic research used were papers and publications held at international level by the Portuguese and Spanish Geographers and their interventions in the most important Congresses held in each country as well as their personal publications. We conclude that Iberian Geography was more centred on the Geography of Health Care (one of the traditional branches) than on Disease Ecology (another traditional branch) and that the Spanish works began earlier that the Portuguese ones. We are sure that until now few efforts have been made to work in teams, even if we noticed a rise in the number of geographers that work in multidisciplinary teams, albeit managed by physicians or economists. We also conclude that Iberian Health Geographers must try harder to show society the applicability of the territorial analysis of health issues at different scales. Keywords: Iberian Peninsula; Epistemology; Health Geography; Empirical Works; Conceptual Works. actageo.ufrr.br Enviado em maio/2010 - Aceito em julho/2010 INTRODUCTION 08 concerned with transmissible diseases as For a long time research in the field of humanity was in its first period of Health Geography was related to two Epidemiological Transition. According to traditional branches: Disease Ecology (also some authors, the most important map related called Geography of Disease) and Geography with Health Geography was done by John of Health Care. The first one, exploring various Snow in 1854 (CLIFF & HAGGETT, 1993, p. dimensions of health and illness, is related to 51). John Snow, during a violent outbreak of a medical epidemiology while the second one, cholera epidemic (500 hundred deaths in only related to medical care (ROSENBERG, 2005, p. ten days) mapped the deaths in six blocks of 20), is concerned with the consumption of care houses in the city of London, a methodology with respect to such matters as distribution which allowed the identification of a pump as and accessibility. There were also for a long the source of contamination and of the time references in the Portuguese and Spanish epidemic. Deemed nowadays as current works. procedure, this was a novelty at the time it. Disease Ecology is concerned with the This paper is the first effort to analyse the relationship between the physical and social evolution of Health Geography at the Iberian environment and disease, with spatial and level, exploring what happened in Portugal social inequalities of morbidity and mortality and Spain since the John Snow map, even if it and aetiology and diffusion of disease. It has was only in the last century that a more been well supported by copious cartography, structured investigation in this field began. We compiled in atlases at large and small scales focus on the main theme developed in recent dealing simultaneously with space and time. years comparing with investigations Disease Mapping is one of the main branches undertaken at an international scale. of Disease Ecology, and its first works were published at the end of the eighteenth century, METHODS even if its relevance persists in the last decades As it is an epistemological research, we of the last century, especially in the United used qualitative methods to characterize and Kingdom with Andrew Cliff and Peter understand the evolution of Health Haggett. Geography at an Iberian Scale. We centred our One of the first efforts to make a disease analysis on bibliographic research such as the map was undertaken in the United States by papers and publications held at an some physicians concerning yellow fever international level by the Portuguese and (SEAMAN, 1798). From that time, firstly Spanish geographers, especially the ones physicians and then geographers were aware presented in the meetings of the International of the potential of cartographic approaches in Geographical Union (I.G.U.). the identification of casual relationships of We also analysed 252 papers published disease. In the beginning of the eighteenth between February and September 2008 in the century the dot maps as those presented by Journal “Social Science & Medicine” trying to Seaman or the one by Pascalis were the most identify the main problems published and famous ones (also on the yellow fever in New using them to understand what has been done York in 1798). Maps were nearly always at the Iberian scale. The most important national meetings were also a support of our urban planning. In Spain, the contribution of investigation as well as some personal geographic studies to health research has been publications that began to appear more progressive; among others, we can highlight frequently in the 1990's. the works developed by Olivera (1986, 1993, 1996), González (1998, 2000, 2005a, 2005b), THE EVOLUTION OF HEALTH Rodríguez et al. (1990, 1993, 1994, 2003) and GEOGRAPHY IN THE IBERIAN Mota-Moya (2006), about the history of Health PENINSULA Geography, territorial planning, ageing, quality of life and migrations. Similarly to SOME HISTORICAL FACTS what occurred at an international level we Paul (1985), Phillips (1985), Barret (1986) witnessed in the Iberian Peninsula a relevant Jones & Moon (1987), Verhasselt (1993), empirical development, but only in this new Olivera (1993), Earickson (2000a, 2000b), millennium did some geographers try to show, Picheral (2001), Gatrell (2002) and Rosenberg in a more consistent way, some (2005), are some of the geographers that have epistemological reflections centred on the been concerned since the eighties with the evolution of Health Geography (e.g., evolution of Health Geography at an REMOALDO, 2005; SANTANA, 2005; international level. In 1985, Bimal Paul NOGUEIRA, 2006). presented “The seven branches of Health But where were the Portuguese and Geography” (PAUL, 1985) and later David Spanish Health Geographers in the meantime? Phillips acknowledged that this paper was Was the investigation in Health Geography probably the first one that tried to shed light on relevant to the evolution of Geography at an some conceptual aspects of the evolution of Iberian scale? Health Geography at an international level The influence of French Geography in (PHILLIPS, 1985). Until that, Health Portuguese and Spanish Geography is one of Geography showed an important empirical the explanations for the rare research done in development, but a clear delay in conceptual the field of Health Geography and for the delay and theoretic works. In spite of the early in empirical and conceptual investigation. Like empirical research on Health Geography in the French Geography, Spanish and Portuguese Iberian Peninsula we witnessed the growth of Geography adopted the terminology the research in this area only in the 80's, at the “Géographie de la Santé” (Health Geography), same time of other fields, such as Geography of when analysing the complex relationship Gender and Geography of Tourism and between space, society and health. Its Leisure. In Portugal, Simões (1989), Santana evolution was quite irregular, characterized by (1993, 2002, 2005), Nossa (1995, 2000, 2005), short periods of scientific dynamism between Nogueira (2001, 2007) and Remoaldo (1999, decades of nonexistent production. As the 2002, 2005) present the works done in the last Spanish geographer's community is larger decades. The main themes are related to access than the Portuguese one (50 Departments or and use of health services, the HIV/AIDS areas of Geography in Spain and only five in epidemic, ageing, infant mortality and healthy Portugal) it is easy to understand the earlier 09 10 publication in Spain of Medical Palaeography These true medical cartographies (Paleografías Médicas) in the hygienist period of inspired the elaboration of other studies the middle and final parts of the eighteenth carried out in several other Spanish cities century, similar to that of international between the late nineteen century and early research. twentieth century. At the same time, the Spanish Medical Palaeography had a publication of the first Spanish hygienist law of crucial role in the Spanish hygienic-sanitary that period (Ley de Mejora y Reforma Interior de movement, having contributed with 25% of all las Grandes Poblaciones, 1895 – Law of the published literature about hygiene improvement and interior reform of the great between 1800 and 1936 (URTEAGA, 1980) populations, 1895) occurred. (more than 300 works). Among them, Olivera After decades of little scientific (1986) highlighted the work developed by two production and distance from the European physicians, Fernández Navarrete (1737) and networks, at the end of the 1950's, a new Pérez de Escobar (1788), as the most relevant. increase in Health Geography investigation The main theme was related to the paradigm of occurred. Oliveira (1986) highlighted the that time, which was the regional theme. special contributions of García Fernández Regional classic geographies began with the (1958), Corchón (1961) and Quirós (1967). In geographical localization and a detailed 1973 we registered the first PhD concerning description of climate, relief, vegetation, Health Geography, at the University of economy, agriculture, followed by the analysis Barcelona entitled “La Geografía Médica y su of industries and cities. Generally, research aplicación a algunos casos españoles” was focused on the relationship between (Medical Geography and its application to urban/rural residence and consequences in some Spanish cases) by Á. Martínez Navas and health status. In the nineteenth century, a directed by Professor J. Vilà Valentí. A year Catalan engineer and urbanist, Ildenfonso before, the first paper about cancer, more Cerdà, developed research based on a specifically about the relationship between cartographic approach (CABRÉ & MÚÑOZ, tourism and melanoma was presented (and 2002). Studying the city of Barcelona in the later published) at the XXII International preindustrial period, he made several maps Geographical Congress by Nájera (1978). pointing out the degradation of intra-city In Portugal, we had to wait until 1977, to space, using interesting disease mappings see the publication of an article in the about all-cause mortality and cholera Portuguese Geographical Journal Finisterra mortality (FIGURE 1). (University of Lisbon), concerning the Cerdà's maps (FIGURE 1) showed that diffusion of infectious hepatitis. Emília Arroz higher population density is associated to tried to apply the Spatial Diffusion Theory of higher mortality rate by cholera. As stated Torsten Hägerstrand to the spatial diffusion of above, cartography was an excellent tool to that disease (ARROZ, 1977). Previously, in the show causal relationships between 40's, Amorim Girão, a Professor from the phenomena, as John Snow showed, at the same University of Coimbra, had done some work time, also with the cholera epidemic in on Population Geography that brings up, London. although superficially, the Health Geography Density of Occupation (persons per housing), 1859 Mortality Rate (1856-1865) 11 Mortality Rate by Cholera (1865) Mortality Levels FIGURE 1: The city of Barcelona (Spain) in the middle of the nineteen century. Source: CABRÉ & MÚÑOZ (2002) p. 42-43 from Teoría General de la Urbanización. 12 theme. Analysing the distribution of mortality scientific fields. In 1993 the first book entirely for all-cause and for TB mortality between 1936 about Health Geography was published (this and 1940, Girão concluded that areas with the was also its title) by Ana Olivera Poll. highest all-cause mortality had, Analysing the number of Spanish PhD simultaneously, the lowest values of TB theses, as well as presentations at conferences mortality. This dissonance was explained and publications, we noticed a considerable through geographical factors related to climate growth in Spanish Health Geography. (humidity) and population (density). He According to Lázaro and Torres (2002), five concluded that “The mountain builds the man; PhD theses on Health Geography were done in the town consumes him” (GIRÃO, 1941, p. the 90's. Along with the emergence of 288). But it was only during the 80's (1989) that increasing production and more diverse we witnessed the first PhD about Health themes there was also the adoption of new, Geography, by José Simões from the independent methodologies. However, University of Lisbon, entitled “Saúde: o considering the last five conferences of the Território e as desigualdades” (Health: the International Geographic Union (UGI) Territory and the Inequalities) (SIMÕES, 1989). (Washington D.C., 1992; The Hague, 1996; The 90's stressed a shift on the relative Seoul, 2000; Glasgow, 2004; and Tunis, 2008), inactivity of Iberian Health Geographers; this only in 2008 did the presentation of a paper on decade was characterized by a more diverse this theme occur. Analysing the proceedings of investigation in Health Geography (more the last eight Spanish geographical diverse themes) and a higher number of conferences (TABLE 1), results are also geographers concerned with this field. At the discouraging: to an average of 100 same time, the field began to attract an presentations per conference, only three were increasing number of people from other within the scope of Health Geography. Several Meeting, university, year Papers (total) XIII, Sevilla, 1993 95 XIV, Salamanca, 1995 XV, Santiago, 1997 XVI, Málaga, 1999 XVII, Oviedo, 2001 117 117 104 117 XVIII, Barcelona, 2003 XIX, Santander, 2005 XX, P. Olavide, 2007 57 88 113 Papers on Thematic Health Geography 2 Territorial sanitary planning 1 None None None Health and development: urban/rural differences None None None TABLE 1: Presentations on Health Geography at Spanish Meetings held by the Association of Spanish Geographers (A.G.E.) (1993-2007). Source: Analysis of Proceedings of Spanish Meetings. factors can explain this low participation; the it is possible that Health Geography will rise as themed sessions, hardly ever concerned about a strong discipline in Geographical Degrees, as health, were determining. a result of the actual restructuring established Conversely, analyzing themed scientific by the Bologna process. meetings, the increasing importance of Health In Portugal, in the 90's, only two PhD Geography in the last two decades emerged, theses were presented in the field of Health mainly with presentations about “Population Geography; one about “Access to Health and Health” and “Population, Health and Services” (SANTANA, 1993); the other about Well-being”. For example in 1995, in the Fifth “Morbidity and Infant Mortality” Congress of the Spanish Population held in (REMOALDO, 1999), highlighting the Barcelona by The Spanish Geographers' differences of population behaviour living in Association, seventeen papers about Health different (rural and urban) settings. In the new Geography were presented. Since 2000, a more millennium, more and more PhD studies positive tendency in geographic studies of about Health Geography were carried out, health has emerged. The Sixth Congress of related to health inequalities and inequalities Urban Geography, held in León in 2002, and in the access of H.I.V. infected persons to the Sixth Congress of the Spanish Population, health care (NOSSA, 2005) and urban held in Granada in 2004, organized themed variations on health and healthy planning sessions concerning several aspects of health (NOGUEIRA, 2007). Health Geography (the former had a session related to “The city appeared in the Portuguese Universities' and public health” and the latter a session on curricula in 1995; later than in Spain (1993) and “Population and Health”). has, at the moment, only two optional In 2005, two Spanish geographical disciplines in the Degree of Geography in the journals published special issues on Health University of Coimbra (since 1995) and the Geography: on the one hand, the journal degree of Geography and Planning in the Territoris compiled ten diverse papers (among University of Minho (since 1998). them some were concerned with the evolution The participation of Portuguese of Health Geography); on the other hand, the geographers in international conferences journal Serie Geográfica published a special organized by UGI has shown an increasing issue on the use of Geographical Information trend; in 2003, in Moscow, a presentation about Systems (GIS) on health. Spanish Health AIDS Geography has definitively entered a new took place in Munich (one about health and phase, characterized by more diverse and deprivation and other concerning regional numerous productions. Nowadays, the most variations in health); on 2007, in Bonn, four important step is probably the development of communications were presented (concerning Health Geography at the Universities, as a local environment and obesity, social and discipline of basic geographical studies. This is physical neighbourhood environment and important both to the development of health health status, healthy cities and traffic geographic research and to the affirmation of accidents involving children). this research at a social level. In the next years, occurred; in 2004, two presentations The presentations in the seven national 13 meetings done to the present, organized by the meeting. In the absence of a national research Association of Portuguese Geographers group dealing with Health Geography, the (A.P.G.) between 1991 and 2007 (TABLE 2), meetings organized by the Commission on show that the presence of Portuguese Health Health and the Environment (from IGU) were Geographers is regular but only with an the main events for geographers to meet other average of two papers presented at each geographers working in the field. Meeting, university, year I, Lisbon, 1991 II, Coimbra, 1995 Papers (total) 53 Papers on Thematic Health Geography 2 Geographic research on health 55 2 Use of differentiated health services Access to health services HIV/AIDS 14 III , Oporto, 1997 75 1 Quality of health data IV, Lisbon, 2001 64 1 Physical, functional and economic accessibility to health care V, Guimarães, 2004 111 2 Prevention and infant traffic security VI, Lisbon, 2007 122 2 Infertility and familiar wellness GIS and HIV/AIDS prevention Urban planning and infant safety TABLE 2: Presentations on Health Geography at Portuguese Meetings held by the Association of Portuguese Geographers (A.P.G.) (1991-2007). Source: Analysis of Proceedings of Portuguese Meetings. INVESTIGATION HELD AT AN there has been the contribution of a number of INTERNATIONAL AND NATIONAL LEVEL publications of a themed number on Health Policies). - Some themed investigation at an international level Inequalities in health is another important theme dealing with the fact, for Undertaking an investigation of 252 example, that in modern cities individual or papers published in Social Science and household deprivation (for example, low Medicine between February and September income or education) is amplified by levels of 2008 (TABLE 3) we conclude that Health area deprivation (for example, lack of jobs or Policies were the main issue (to this ranking good schools), in ways which damage the Thematic investigation Nº Health Policies Health Inequalities Mental Health Chronic Diseases Women Health Bioethics Reproductive Health Children Health Access and Use of Health Services Social Determinants of Health HIV/AIDS Place, Identity and Health Health Adolescent Aging Doctor-patient communication Socioeconomic Status Smoking Drug Dependence 33 30 27 14 13 10 10 10 8 7 7 6 6 5 4 4 4 4 TABLE 3: Main themes' investigation done at an international level published in Social Science & Medicine between February and September 2008. Source: Analysis of abstracts and papers published in Social Science & Medicine health of the poorest and increase health discrimination and social inequality are also inequalities (MACINTYRE & MACDONALD related to this disease and some studies deal & ELLAWAY, 2008). Racial and ethnic with risk of sex workers. disparities in health care, access to services or In chronic issues the illness experience the consequences of a decentralized healthcare (e.g., in fibromyalgia syndrome or Parkinson's governance model and access to health care or Alzheimer's diseases) goes along with services by disabled persons (CHOU & LEE & obesity, diabetes, cancer or even the LIN & CHANG & HUANG, 2008) were also reconsidering patient empowerment in important themes. chronic illness (AUJOULAT & Mental health is also an important issue MARCOLONGO & BONADIMAN & focusing on mental health status among DECCACHE, 2008). Women's health has been adolescents, the cultural construction of for a long time an important theme but in depression, post-traumatic stress disorder developed countries it is now related, for (e.g., Tsunamis or violent conflicts) or the example, to osteoporosis among Norwegian association between poverty and mental women, obesity, nutrition, abortion or the health (e.g., BJELLAND & KROKSTAD & association between maternal working MYKLETUN & DAHL & TELL & TAMBS, conditions and birth outcomes. Access to 2008). HIV/AIDS is still an important field but maternal health services is still an important the impacts of this disease and the bioethical theme mainly in less developed countries and questions must also be considered. Stigma, the meaning of the survivor identity for 15 16 women with breast cancer has also been epidemiological studies (BUJ, 1999), especially considered as it has increased worldwide the ones that treated disease of significant (KAISER, 2008). geographical components in its analysis and Access and use of services by older distribution. The most important examples are people (geriatric services), the relationship the HIV/AIDS disease (GONZÁLEZ, 2005a) between race/ethnicity and access, and the and skin cancer (GONZÁLEZ, 2005b). Another emerging immigrants has been in focus in interesting field has emerged, related to developed countries. In developing countries territorial sanitary planning (GONZÁLEZ, maternal and child health are still relevant as 1998, 2000, 2002). However, Health Geography showed in July 2008 by Kimberley & and remains mostly related with Population Sulzbach for Senegal, Mali and Ghana. Geography and Geography of Services. We also notice an increasing importance In Portugal and Spain the main themes of papers done on the relationship between developed in the last twenty years are place – identity – health (TABLE 3), mainly in presented in Table 4. Some attention was paid the last ten years. These investigations uses in the last fifteen years to HIV/AIDS because of qualitative methods, centred on interviews its expression in these two countries, mainly in and searching for the meaning of place Portugal, which is at the top both in the number affecting health and health care (CUMMINS, of persons infected with H.I.V. per one million CURTIS, DIEZ-ROUX & MACINTYRE, 2007; of inhabitants and in the number of deaths by BERNARD, CHARAFEDDINE, FROHLICH, AIDS, considering more than fifty countries of DANIEL, KESTENS & POTVIN, 2007). the European Region of the World Health Organization. Some papers were published on - Some thematic investigation at national level this theme (SANTANA ET AL., 2001; Figure 2 shows the new diversity of the SANTANA AND NOGUEIRA, 2003, 2005, Spanish research on Health Geography, 2006), as well as a Masters and a PhD on dealing with epidemiological analyses applied Geography of AIDS (NOSSA, 1995, 2005). to new problems, such as climate change and After dealing with more traditional urban heating; the figure points out the issues of reproductive health (e.g., access to relationship between hot weather and the maternal services) or child health mortality rate during the heat wave of July and (REMOALDO & CANTEIRO, 2006) since 2004 August 2003. some works were done on medical procreation Some of the old Spanish medical (REMOALDO & MACHADO & REIS, 2004, topographies have been reprinted in the last 2006; REMOALDO & MACHADO, 2007, 2008, years (HAUSER, 2005) and an increasing 2009). interest on the analysis of this previous work can be reported (MORALES, 1980; CASAS, THE FUTURE OF HEALTH GEOGRAPHY 1996; UTANDA, 1997; FEO, 1997, 2004; FALP, IN THE IBERIAN PENINSULA 2000; FERNÁNDEZ, 2001-2002; CALVO, After the above summary on the 2003). But we cannot forget other research evolution of Health Geography in the Iberian concerned with Geography of Disease and Peninsula, questions about its future emerge. 17 FIGURE 2: Mortality Rate of old people (65 and more years) in the Madrid city during the heavy heat in Summer 2003. Source: GARCÍA & ALBERDI (2005): Mortality in the Madrid city during the heavy heat in Summer 2003: GeoFocus, 5: 19-39 (http://geofocus.rediris.es/2005/Articulo2_2005.pdf). - Clarification of the text in Spanish on the map: semana= week; leyenda= caption; tasa de mortalidad= mortality rate. Analysed points Portugal Spain Main themes investigated in HIV/AIDS; Cancer; Access, the last decades use and satisfaction with health care; Reproductive health and children’s health; Promotion of healthy cities; Physical activity and health promotion; Infertility. Beginning of a structured 80’s of twentieth century investigation held mainly in universities First PhD presented in 1989 universities Universities that contribute Lisbon, Coimbra and Minho the most to investigation Health and Spatial Planning; Morbidity and mortality; Quality of life; Ageing; GIS and health; Immigration and health 80’s of twentieth century 1973 CSIC, Autónoma de Madrid, Complutense de Madrid, Autónoma de Barcelona, Balearic Islands and Alcalá Presence of Health Geography As optional discipline since As optional discipline in University Curricula 1995 since 1993 TABLE 4: Some divergences and convergences of Health Geography in Portugal and Spain. 18 We could have an optimistic discourse, but it teams, those teams were managed by would not be a wise one, because even if we physicians or economists, not by geographers. have good and dynamic investigators trying to Thirdly, it seems that geographers compete work on Health Geography in these two and do not collaborate with the physicians for countries, the results are unpredictable. instance. Recently, physicians have discovered Firstly, Iberian geographers have done the powerful ability of geographers to deal little effort to work in teams, because each with space and GIS, when mapping at a large University has, at most, one or two scale. Physicians began to value geographical investigators working on Health Geography, studies and, mainly in Spain, many and some Universities do not have any. So, geographers participated in degrees of health health geographers' work, most of the time, is professionals teaching sanitary demography. done alone; furthermore, when working in Nonetheless, most geographers are ignored by teams, the central theme is not Health many private and public institutions Geography. This reflects itself in a scarce (including the Ministry of Health and most number of PhD theses, few investigation regional institutions dealing with health projects dealing with Health Geography and a planning). deficient importance of this field in the All these considerations make us think university curricula, mainly in degree studies that the future of this field is uncertain. But we of Geography. Secondly, even if the last years, want to be optimistic and be certain that we and mostly in Spain, saw a rise in the number of must try harder to show society the geographers that worked in multidisciplinary applicability of territorial analyses at different scales in what concerns health, where it is easy explain this dynamic relation between place to analyse geographical attributes like spatial and health, improving people's health through segregation, social inequalities or territorial the knowledge and the capability of improving imbalance. Perhaps the main task posed to their daily spaces. Iberian Health Geographers is a didactic one, showing other professionals, both in private ACKNOWLEGEMENTS and public institutions and even to other We gratefully acknowledge the work of geographers the ability and valuable Filomena Louro and Bernarda Esteves from contribution that health geographers can bring the Scientific Editing Programme of to health and to geographical research. Universidade do Minho for revising this article. CONCLUSION We conclude stressing the importance of NOTE making some efforts to change the established i scenario. The first one is to work more in teams no Departamento de Geografia da as Portuguese and Spanish health Universidade do Minho (Portugal); geographer's work, most of the time, is carried Pesquisadora do Núcleo de Investigação em out alone and when working in teams the Geografia e Planejamento (NIGP). central theme is not health. We must also try E-mail: cris.remoaldo@gmail.com Doutora em Geografia; Professora Associada harder to be on equal terms with physicians or economists that managed till present the ii multidisciplinary teams where geographers Departamento de Geografia da Universidade also work. Finally, we ought to try harder to de Coimbra (Portugal); Pesquisadora do show communities, policy makers and overall Centro de Estudos de Geografia e society the applicability of territorial analyses Ordenamento do Território (CEGOT). at different scales, highlighting the increasing E-mail: helenamarquesnogueira@hotmail.com Doutora em Geografia; Professora no importance of place in a global world and the role of place in achieving better health and in iii health promotion (CUMMINS, ET AL., 2007; Departamento de Ciências da Terra da BERNARD, ET AL., 2007). In 2002, Gatrell Universitat de les Illes Balears (Espanha); (2002) reminded us that where we live affects Pesquisador do Grupo de Investigação em our risk of disease or ill-health. Where we live Sustentabilidade e Território (GIST). affects how accessible or available are our E-mail: jesus.gonzalez@uib.es Doutor em Geografia; Professor Titular no many resources such as good and affordable food, clean water, and decent housing. REFERENCES Consequently, it is nowadays known that ARROZ, M.E. Difusão espacial da hepatite health and health promotion goes beyond infecciosa. Finisterra, Lisboa, 14, 27, p. 36-69, health care, being a shared goal of different 1979. political sectors. Place and health are AUJOULAT, I. et al. Reconsidering patient interrelated; Health Geographers can help empowerment in chronic illness: A critique of 19 20 models of self-efficacy and bodily control. CUMMINS, S. et al. 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