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GIS and Public Health

Article  in  Annals of the Association of American Geographers · March 2003

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 Book Reviews
Moreover, not only are these concepts important indivi-
dually, but they must also be more convincingly linked.
In the ‘‘Techniques’’ section, chapter 8 treats GIS
software, the discussion of which is not fully useful and
could be reduced substantially. Chapter 9, on geographic
data modeling, discusses a number of constructs such as
network, TIN, and object-oriented models. This is fol-
lowed by a discussion of GIS data collection in Chapter 10,
in which methods of digitizing are described. Chapter 11
focuses on creating and maintaining geographic databases,
introducing concepts of SQL, geographic database designs,
and quadtrees. It would seem more logical to move the
discussion on data collection (chapter 9) up front and
consolidate data modeling and database designs (chapters
10 and 11), so that a more comprehensive and systematic
picture of data models and data structure could be
outlined. Data models and database design are the most
confusing topic in GIS, and this book’s treatment of them is
no exception. I consider these three chapters the weakest
in the volume, with lots of room for improvement.
Chapter 12 discusses visualization and user interaction,
highlighting issues relating to the effects of class intervals
on map interpretation, cartograms, and Internet GIS. I am
surprised to find that, based on the description in this
chapter, very little new theory on visualization has been
developed, despite the seemingly large body of research on
visualization in recent years. Chapters 13 and 14 focus on
geographic query and advanced spatial analysis, discussing
topics ranging from simple area and shape measurements
to complex spatial interpolation and optimization. Ob-
viously, some of the topics are not suitable for students at
an introductory or even intermediate level without a
background in mathematics and statistics. The final
chapter in the ‘‘Techniques’’ section, chapter 15, sum-
marizes the issues of uncertainty, error, and sensitivity and
discusses statistical tools for describing and modeling error
and uncertainty, such as the fuzzy approach. Although
GIS and Public Health. Ellen K. Cromley and Sara L. McLafferty, eds. New York: Guilford Publications, 2002. xx and 340
pp., maps, tables, diags., refs., and index. $45.00 cloth (ISBN 1-57230-707-2).
Reviewed by Russell S. Kirby, School of Public Health, University of Alabama at Birmingham, AL.
At last we have a comprehensive textbook exploring
the interface between geographic information systems
(GIS) and public health. Perhaps it was inevitableFthe
Third National Conference on GIS and Public Health,
held in San Diego in the summer of 1998, attracted
261
research on uncertainty in GIS is still quite limited, this
chapter turns out to be quite focused and informative.
The ‘‘Practice’’ section covers a variety of topics,
including GIS and management, GIS and business,
operational aspects of GIS, and partnerships at local,
national, and international levels. These chapters are rich
in information, provide a variety of examples, and are
interesting to read. The international perspective
throughout the discussion is a big plus and inspiring.
I am most impressed by the concluding chapter, the
epilogue, which is thought-provoking and vision-filled. It
echoes back to the previous chapters, thereby offering a
complete picture. In this chapter, the authors project
enthusiasm, optimism, and confidence regarding how GIS
has contributed and will continue to contribute to benefit
society. For example, GIS can play a significant role in
solving global problems. At the same time, however, the
authors also provide a cautionary account of how GIS
might fail if certain conditions occur, including poor
management, lack of well-trained staff, continued high
costs of software, limited availability of quality data, legal
restrictions, network inefficiency, and what might happen
if GIS loses its identity.
Overall, the authors are to be congratulated for making
an invaluable contribution to the field.
Key Words: geographic information science, geographic information
systems.
References
John Wiley Publishers. 2002. Presenting a complete GIS solution.
http://www.wiley.co.uk/gis/ (last accessed 30 October 2002).
Longley, Paul A., Michael F. Goodchild, David J. Maguire, and
David W. Rhind. 1999. Geographical information systems:
Principles, techniques, applications, and management. 2 vols.
2nd ed. New York: John Wiley and Sons.
approximately 700 participants, and the CDC/ATSDR
‘‘Public Health GIS Users Group’’ listserv now has more
than 5,000 subscribers.1 With all of this interest in the
application of GIS technologies in the public health arena,
one might reasonably ask why no authors or publishers
262 Book Reviews
have sought to fill this gap until now. Perhaps a closer look
at the contents of Ellen Cromley and Sara McLafferty’s
book will shed some light on this question.
The table of contents follows a predictable pattern.
Following a brief introduction, eleven chapters provide the
core content. The first chapter briefly describes geographic
information systems, providing general background while
including sufficient references that a reader unfamiliar
with these software applications, database structures,
and techniques for displaying information in map form
can obtain the necessary background to benefit
from the chapters that follow. While perhaps obligatory,
this chapter is of limited value to the GIS specialist
interested in potential applications in public health and
health care, while being insufficiently detailed for the
public health professional seeking to learn more about GIS
in general.
The two following chapters focus on spatial databases
generally and then on spatial databases for public health.
The first of these chapters provides a useful introduction to
spatial data structures, methods of data storage and
representation, spatial data acquisition, and basic carto-
graphic concepts and methods. The authors also introduce
the model for a public-health GIS, to which reference is
made throughout the remainder of the text. The next
chapter focuses on foundation databases for a GIS, followed
by descriptions of several public-health databases that
contain spatial data fields sufficient for geocoding to
support inclusion in a GIS application. In the time between
writing the book and its publication, an explosion of
interest in geocoding almost every imaginable public health
dataset has occurred. These databases include the supple-
mental Women, Infants and Children (WIC) nutrition
program, Medicaid, Medicare, emergency medical services,
and most environmental health databases. Increasingly,
public-health data sources are incorporated into GIS for
application not only at the county scale, but also at the
municipal and neighborhood scales. The section describing
methods and problem areas in the process of making health
data mappable alerts the reader to the complexity of this
task, but readers would benefit from more references to
resources that might simplify the process.
In chapter 4, the authors describe methods for mapping
health information. They review the topic succinctly yet
comprehensively, in a manner accessible to readers with
limited background in cartography or spatial analysis.
They introduce basic cartographic methods and termino-
logy and well-designed examples to illustrate their use.
Perhaps inevitably, the ubiquitous reference to John
Snow appears on page 111, this time to illustrate the
modifiable-areal-unit problem. The authors also discuss
the potential of GIS for visualization of spatial data. The
section on GIS and map publication is best read as an
introduction to the subject. Methods for Internet publica-
tion and computer technology and community-level
dialogue concerning public participation GIS are evolving
so rapidly that the authors can only identify trends,
methodological, and legal/political issues involved in
preparing Internet-accessible atlases and maps from pub-
lic-health GIS applications.
The next four chapters focus on the utility of GIS for
spatial epidemiology, examining, in turn, the issues of
disease clustering, environmental hazards, the spread of
infectious disease, and vector-borne illnesses. While each
of these topics is of some importance in public health, the
degree of emphasis the authors place on them differs from
that experienced by the typical public-health analyst. By
far the most common application of GIS in public health
will be in the area of disease clustering, either via creation
and interpretation of choropleth, isopleth, or probability
maps or in the investigation of putative health effects of
point- or nonpoint sources of environmental exposures.
However, these topics receive the same depth of treatment
as their counterparts. The chapter on analysis of environ-
mental hazards provides a useful introduction to this
subject, but could be enhanced through additional
discussion of methods for estimating exposures across a
spatial surface with environmental monitoring techniques.
The section on GIS and outcome discusses applications in
cancer, reproductive outcomes, and elevated blood levels,
but makes no mention of a broader range of chronic
diseases and perinatal outcomes (low birth weight, preterm
delivery, birth defects). In academic geography, GIS has
been applied more frequently to the analysis of infectious
disease outbreaks and epidemics. This chapter introduces
the topic effectively and provides several examples to show
the application of methods for smoothing, kriging, and
spatial-diffusion models. However, the chapter does not
include references to the theoretical literature on disease
transmission in human populations or to important
contributions in the field of medical geography (examples
include Island Epidemics by Haggett, Smallman-Raynor,
and Cliff and The Slow Plague by Gould). The fourth
chapter on applications of GIS to analysis of disease
patterns focuses on the ecology of vector-borne disease.
The authors explore these applications using Lyme disease
as a model, pointing out the methodological problems
resulting from reliance on disease-surveillance data and
the limited data on the location of the disease vectors.
While public-health researchers might not require a more
general introduction to models of disease transmission, this
would be useful for geographers and GIS specialists.
The final two topical chapters (chapters 9 and 10)
discuss applications of GIS in the analysis of access to health
 Book Reviews
services and the location of health services. The authors
provide a comprehensive and practical introduction to the
issues of health-care access, geographical accessibility, the
concept of potential access and its operationalization
through measurement of distances, activity spaces, meth-
ods for using GIS to identify health-facility service areas,
and local area variation in health-services utilization.
Chapter 10 covers the topics of health-care shortage areas,
mapping and analysis of client population distributions, and
normative models of facility location. The authors then
show how these can be integrated using GIS and conclude
with a brief discussion of spatial decision support systems. A
large theoretical and methodological literature exists on
each of these topics in both public health and medical
geography, but they are rarely discussed from a multi-
disciplinary perspective. The discussion here suffers some-
what from an academic social-science viewpoint that
overlooks some of the practical considerations in applying
these techniques in the field of public health.
The concluding chapter discusses applications of GIS in
community health. While the authors devote only
thirteen pages to this topic, it has the potential to
transform the interface between medical geography, GIS,
and public health and will undoubtedly become the
subject of a full text in the coming decade. The authors
provide a framework for conceptualizing the institutional
contexts of different agencies and stakeholders in relation
to their interest in the development and use of GIS
applications. The coming revolution in public-participa-
tion GIS will also impact public health, as will the
development of community-based public-health GIS. In
fact, the examples discussed in this chapter are far
outnumbered by developments that have occurred since
the text was written. The chapter would benefit from a
concrete discussion of what is meant by ‘‘community
health’’ and how it differs from ‘‘public health’’ or
‘‘population health,’’ if at all.
Although this text covers a broad range of topics in
spatial analysis of health issues and identifies areas where
GIS technologies can contribute, several topics are
overlooked or discussed only in passing. For example,
the Centers for Disease Control and Prevention (CDC)
initiative to integrate public-health databases at the state
level has been reinvigorated by the bioterrorism threat.
GIS could play a major role in this initiative. The book
contains limited discussion of data warehousing, the value
added to which by incorporating GIS as a central
methodology for data integration could transform these
applications in a number of ways. There should also be a
broader discussion of issues of confidentiality and privacy,
as well as the Health Insurance Portability and Account-
View publication stats
263
ability Act of 1996 (HIPAA) and its implications for GIS in
public health. For the public-health manager, a chapter
describing the practical obstacles to incorporating GIS
into a public-health agency at the municipal, county, or
state level and how to overcome them would also be
extremely useful.
As the first text on this subject, Cromley and
McLafferty’s book has much to offer. The text is well
written, logically organized, illustrated with effective
examples, and supported by an extensive list of references.
In the opinion of this reviewer, it will be more useful to the
geographer or spatial analyst interested in ways to extend
GIS techniques to public-health issues than to public-
health practitioners wishing to learn about GIS. The task
of integrating two distinct disciplines into a coherent and
accessible subject matter is daunting, and that undoubt-
edly helps to explain why this had not been attempted
previously. In the future, we might anticipate the devel-
opment of graduate courses both in public health and in
geography programs, and even specializations in GIS in
public health. The second edition of this text will
undoubtedly be in two volumes, with additional material
on methods for descriptive epidemiology and ecological
analysis of health data and more extensive discussion of
spatial analytic methods as applied to health issues,
including a CD-ROM with the model public-health GIS.
Hopefully this book will encourage many geographers, GIS
specialists, and public-health professionals to delve more
deeply into the opportunities for health promotion,
disease prevention, facilities location, and program man-
agement afforded by GIS technology, with appropriate
attention given to the limitations of databases, to
modeling methods, and to the presentation and inter-
pretation of the results.
Key Words: geographic information systems, health-services re-
search, medical geography, public health, spatial epidemiology.
Note
1. Readers may subscribe to this listserv at the CDC’s Web site
(http://www.cdc.gov/subscribe.html, last accessed 30 October
2002) by marking the appropriate checkbox.
References
Gould, Peter. 1993. The slow plague: A geography of the AIDS
pandemic. Cambridge, MA: Blackwell Publishers.
Haggett, Peter, Matthew Smallman-Raynor, and Andrew Cliff.
Island epidemics. Oxford: Oxford University Press.