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5 GEOGRAPHY AND DISPARITIES IN HEALTH CARE Thomas C. Ricketts, ITI This paper examines how health status, access to health care, and health outcomes vary by geographic location. It also examines which aspects of location appear most to affect health care access, services, and utilization. There are clear geographic differences in health status that vary according to the level of aggregation. At the national level, overall mortality rates are much higher in the Southeast, the Appalachians, and parts of the Intermountain West (Pickle et al., 1996~. That pattern changes for Black mates to include very high rates in the urban East and Midwest. For White females higher rates cluster in the Midwest and Mississippi Valley. There are likewise differences among states that mirror regional patterns. Within states, differences are associated with areas with lower incomes, higher numbers of minority populations, and cultural and historical risk factor patterns that contribute to higher rates of morbidity and mortality. The same gradients can be seen within cities and counties where neighborhoods and census tracts reflect similar patterns of health disparities. These differences are both apparent and persistent when subjected to statistical controls and comparisons (Geronimus et al., 1999~. 5-~. GEOGRAPHY Geography is often thought of as the generation and interpretation of maps that describe the physical world. Geography is far more than that, but the physical description of boundaries has a great deal to do with how we view communities and how we construct society (Giddens, 1984~. The physical aspects of a community are usually defined by boundaries that may have been developed for a specific public purpose, but that often create gradients that separate one population group from another. This can be apparent in zoning 149

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1 50 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT rules or in the creation of jurisdictions that have different systems of social support. Areas can also become different through social and economic processes that create regions or communities whose boundaries are essentially invisible. When speaking of health, the domain of medical geography is most often invoked. Medical geography, however, is more aligned with the study of disease and disease diffusion without explicit consideration of other aspects of human interaction. The structure of health services and how people use health services in ways that reflect and create disparities are factors that span the human and the medical parts of geography. The discourse of the geographer involved in describing health care delivery and health status has become controversial within the discipline itself. While space and place in health care delivery are important, their structure and interpretation are, to some, irrelevant to practical decision making because they are the result of overwhelming social forces and power relationships. To others, a point of view that includes spatial and landscape perspectives can be useful for local purposes and for broader policy development (Mohan, 1998~. Nevertheless, the power of geographic comparisons and boundary setting is real in the policy world, and the application of policy is very sensitive to location and scale. As one leading researcher has observed: There is no agreement about how to best define a geographical area in terms of socioeconomic position or about which area-based measures of socioeconomic position are most informative, especially across multiple kinds of health outcomes (Krieger, 2002~. This paper does not contradict that conclusion, but does recognize that there are options for understanding the geography of health disparities as well as for implementing solutions. For example, regions, states, and localities are different in several ways. Regional differences show that history, environment, culture, and politics have combined to create disparities that cross state boundaries. Those regional differences--apparent in the Southeast, Appalachia, portions of the Tntermountain West, and selected parts of the Southwest--point

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5: GEOGRAPHY AND DISPARITY IN HEALTH CARE 151 to the need for interstate collaboration or federal coordination and sharing of resources. Urban-rural comparisons do not reveal consistent patterns of dispanty, but rural and inner city conditions tend to magnify differences associated with other social, economic, and health system characteristics. There are variations in rates of illness and access to appropriate care that reveal themselves in comparisons across states. These consistent variations imply that there are state- level policy levers that can be used to reduce disparities. Town, city, and county boundaries may describe communities that can develop solutions using local government or social, religious, or external systems. The small area geographies used most often to depict health status are appropriate for identifying and verifying health status disparities. They include units of census geography such as tracts and block groups, counties, ZIP code areas, and clusters of ZIP codes. These can be used to construct service or market areas that contrast health outcomes and utilization for primary care, general hospital care, and tertiary care. But the level of intervention appropriate to specific patterns of disparity is not always coterminous with those boundaries. While we may identify disparities in rates using zIP code areas or census tracts, it is not easy to mobilize an intervention based on those boundary sets. People do not feel a sense of "membership" or citizenship to such areas, and neither government nor the health care system is structured to act at those levels unless the boundaries identify real neighborhoods or communities. There is no consensus on a fundamental unit of geography to use in measuring health and health care in the United States or elsewhere. There are many reasons for this, including the problems of relating individual events to population rates. However, the most important reason lies in the way in which health data are reported (Meade and Earickson, 2000~. Data are compiled according to the political and administrative organization of governments and, to a lesser extent, society. Denominators in rates are most often expressed as the population of some political unit such as a state. It would be more clinically useful to express rates in terms of gender, age, or even occupation. Those relate more directly to health care delivery, to health status, and to outcomes for individuals.

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1 52 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT 5-2. INTERSTATE GEOGRAPHY Interstate geography includes several different units commonly used to analyze health care delivery and service and to formulate health care policy. The following is a brief overview of two: regions and rural-urban areas. Regions Regional systems and structures have been developed to cope with health problems across state borders. They include the health care system development of the Tennessee Valley Authority (TVA) and the Appalachian Regional Commission (ARC) as well as work in the Tower Mississippi Delta. The ARC remains active in this field and supports work that illustrates disparities in health status and access through the University of Kentucky (www.mc.uky.edu/RuraTHealth /ARC_AHPAC/ahpac.htm). There are regional initiatives in the Mississippi Delta through various organizations and governments. A regional study of asthma supported by the Trust for America's Health is illustrative (health-track.org/reports/msO420/~. The Health Resources and Services Administration (HRSA) announced a program to improve health care by supporting rural hospitals in the Delta region in late 2001. Similar cross-state efforts such as the U.S.-Mexico Border Health Commission are underway along the U.S.-Mexico border (www.borderhealth.gov/~. These regional initiatives are supported through affiliations of state governments such as the Southern Governors' Association or the Southern Growth Policies Board or ad hoc groups of governors or state agency heads. Rural-Urban Areas One view of the geographic structure of the nation contrasts how the population is distributed between cities and rural areas. There are more than 60 million people classified by the U.S. Bureau of the Census as "rural" and 55 million living in "nonmetropolitan" counties in 2000. This is a population group comparable in size to the United Kingdom. Rural America would be among the top 20 nations in population. The structure of the Congress, which gives equal representation to states in the Senate, means that the rural issues that

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5: GEOGRAPHY AND DISPARITY IN HEALTH CARE 153 are important in sparsely populated western states such as Idaho, Wyoming, Montana, and North and South Dakota are given careful consideration in Congress. The political as well as physical geography of the U.S. makes rurality an important concept. The two most common designations of rurality used in describing populations are those of the U.S. Bureau of the Census and the U.S. Office of Management and Budget (OMB). "Urbanized areas" are defined by the U.S. Bureau of the Census according to a complex set of characteristics that takes into consideration the economic nature of a place, transportation patterns, and the number of people living in a fixed area. That definition is undergoing revision and a final rule is expected to be published soon. For the 2000 census, rural areas are considered places outside urbanized areas. Urbanized areas are composed of "core census block groups or blocks that have a population density of at least 1,000 people per square mile and surrounding census blocks that have an overall density of at least 500 people per square mile" (www.census.gov/geo/www/ua/ua_2k.htmI). This delineation has not been used often to determine effects on health and health care. More often the OMB Metropolitan-Nonmetropolitan classification of counties is used for comparisons. The OMB designation classifies counties as metropolitan or nonmetropolitan based on whether the county has a large city and a number of suburbs. It also takes into account a functional element that measures the extent to which peripheral counties are economically integrated with their surrounding metropolitan counties. A Metropolitan Area (MA) must contain either a place with a population of at least 50,000, or a census-defined urbanized area and a total MA population of at least 100,000, or reflect the economic activities of such a place. Various attempts to subclassify the counties within the metropolitan and nonmetropolitan categories exist, and they have been used to examine health care resource use and distribution and health status. In 2001 the National Center for Health Statistics (NCHS) included a rural-urban comparison in its Healthy People series. The NCHS report found that: . Residents of counties on the borders of large metropolitan areas generally are ranked highest on health indicators.

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1 54 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT Indicators of health, health care use, and health care resources can differ by level of urbanization. Regions do vary, which is reconfirmed by data. Nationally, residents of the most rural counties have the highest death rates for children and young adults, the highest death rates for unintentional and motor vehicle traffic-related injuries, and the highest mortality for ischemic heart disease and suicide among men (Eberhardt et al., 20011. These general comparisons are plagued by the problem of aggregation of widely divergent nonmetropolitan populations and communities into large, gross classifications that are meant to be consistent across the nation. There are regional patterns of rural disadvantage that are highly discernible. For example, there is higher infant mortality in the rural Southeast. Those conditions are clearly related to the income and educational differences between those rural regions and other parts of the nation. Geographic patterns of morbidity and mortality vary by race and ethnicity (Albrecht et al., 1998), and these differences are sometimes reinforced by rural location. Blacks and Whites living in nonmetropolitan counties have higher death rates from diabetes (Ricketts, 2001) and heart disease (Slifl OCR for page 149
5: GEOGRAPHY AND DISPARITY IN HEALTH CARE Access to Care in Rural Areas 155 Access to health care services in rural versus urban areas has been explored by health services researchers for decades. Rural residents are, on average, poorer, older, and, for those under age 65, less likely to be insured than persons living in urban areas (American College of Physicians, 1995; Hartley et al., 1994; Braden and Beauregard, 1994; Schur and Franco, 1999~. Rural Americans also report more chronic conditions and describe themselves in poorer health than urban residents. Further, injury-related mortality and the number of days of restricted activity are higher in nonmetropolitan areas. The degree to which Tower levels of access affect health outcomes and utilization for rural persons is at issue, however, given the conclusions drawn by Me6PAC in its Report to Congress (Me6PAC, 2001~. It is easy to challenge its flat assertion that an access gap does not exist. The analysis did not always include controls for health status, and the risk adjustment for prior use may have made the analyses inaccurate. The access study also did not differentiate between underserved and adequately served communities and did not reveal whether there was an independent rural or travel effect for the measures of access. But most importantly, the sample was drawn with the assumption that rural places compose a homogenous sample stratum. While the wide variation in access in urban systems is accepted and comparisons within and between metropolitan areas are usual in national surveys, this is not feasible for rural places given the current construction of these surveys (Schur et al., 1998~. Race, Ethnicity, and Rurality The interaction of race and ethnicity and rurality has been examined in a review of studies of six conditions highlighted by the U.S. Department of Health and Human Services (DHHS) in its disparities initiative. The conditions are infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection, and child and adult immunizations (Slifkin et al., 2000~. The review found that rural minorities are further disadvantaged compared to their urban counterparts in cancer screening and management, cardiovascular disease, and diabetes. The gaps between Whites and minorities appear to be greater for these conditions in rural places, but

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1 56 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT the studies that made up the review did not carefully control for many variables that might describe problems with access to care. Likewise, comparisons did not include controls for regional effects. There are clear limitations to drawing inferences from geographical classifications at the county level. In sum, there is credible evidence that being in a rural place has a strong and relatively consistent negative effect on one's economic chances. However, there is some difficulty in creating a strong claim that rurality has an independent and significant impact on people's health. The problem, it seems, is that the definitions of what are rural and nonmetropolitan are more closely tied to factors related to population and its density. These have a consistent economic effect, but an inconsistent health effect. Unfortunately, a definition of medical rurality is not at hand. Instead, various measures of medical underserv~ce, health professional shortages, and vulnerability are available. While those measures are place specific and tend to be more rural, they are also applicable to highly urbanized areas. The search for a perfect measure of rurality that will capture its health effects may be a useful exercise, but will require a careful analysis of the effects of distance, culture, occupational context, and the spatial characteristics of technology and information diffusion. Such a metric will have to overcome the strong bias in favor of existing, well-documented, and relatively consistent systems of classifications of rurality. To do so, it will have to have a transparent application to populations and health care systems as well as a clear application to policy. Distance as a Proxy for Rurality Distance to health care is one of the most important geographic features that may affect health status and health outcomes and that may contribute to disparities. The effects of distance on access to health care services have been a subject of research for some time. For example, Weiss examined how distance to a hospital combined with social class determines patterns of use (Weiss and GreenTick, 1970~. Conner and colleagues examined studies of distance to care to attempt to find standards for access (Conner et al., 1994~. While they found evidence of distance decay in use and some indication that quality of care suffered when care was provided to

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5: GEOGRAPHY AND DISPARITY [N HEALTH CARE 157 people who lived at some remove from services, they were unable to develop clear guidance for what would be a fair standard for physical accessibility. Nor were they able to develop clear guidance on how to measure it. They were able to contrast units of analysis classifying areas as "town/community/ZIP"; county; "market-share defined"; and national. However, they made no recommendations concerning their ability to detect differences that might reflect disparity. There is evidence that underserved populations are located at a greater physical distance from services in rural communities. Low-income populations in urban areas are often adjacent to a high density of health care resources (Bohland and Know, 1989~. 5-3. INTRASTATE GEOGRAPHY There are several geographic units that are often used to analyze health care delivery and services and to develop health care policy. The following briefly examines states, communities, local health department jurisdictions, census and postal geography, and market areas. States In the U.S., states are the fundamental polities for the support and regulation of most local health care delivery. When the federal government chooses to provide support for nationwide public health programs, each of its three major options involves the states: Grants-in-aid to states based on their populations, or so- called block grants; Formula grants that take into consideration some factors of need, with the Medicaid program an example of such a system; and . Program or project grants that involve states either as umbrella applicants or as passive reviewers, with community health centers an example.

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1 5 8 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT State public health systems and their mtal and health statistics reporting systems provide much of the data on health care dispanties. States have the primary responsibility for the protection of public health. As part of that responsibility, states have developed a coordinated system of data collection and repotting. They have also developed programmatic interventions that vary. State governments vary in the degree of support for public health and health care deliverer, and there are differences in the structures of their health care delivery systems that are due to their respective populations, cultures, and histones. The states vary as markedly in investment in health as they do in health outcomes. Figure 5-1 describes a potentially close relationship between per capita health spending and years of potential life lost (YELL). FIGURE 5-1 Variations among States in Life Years Lost and Per Capita Spending for Health Health Spenciing vs~ Life Years Lost: Wide Variations in State Performance 'term ~rort' I - ~~.J Years of =~tia: Bite ~ q~013 OD] 2000 ~~i - tODC . (~;~~ ~ ~ ~~ o; -~~~-~~~~~-~~~~~~~~~~~~~~-~~$~~~---~~~~-~~~~-~~~~~~~~-~~~~~~~-~-~1Ga $1 ,E30 {in Frorr, P'edi>~.ted Poi Ca pit`: He,alth Spend'ng (~01.3~.) blote. Fle;altf. sper,dirl~ yard c. Ii[e Ic's~il0D,Ct,30 are d - onions frt=`'9il~t't'.~lr.i Alp ,p=~;b~.~' Irk pot splat '''`~-r;~. Is ~8lclI3t~1frol~14lChl~ 'CFA data tle`~a .. *, ;~4Sk~ . - 10.3t,0 4' .* ~ LC~ Island a. ~~ - ~ I/~3SOth03>'ttS . LICE= * r~~i<.D~ SOURCE: (Conover, 1998. Reprinted with the author's permission.) Key to the identification of a substantial difference in health status or access between geographically defined populations or population segments is the degree to which the boundaries separate or include the population that is negatively affected or the degree to which the nature of the area itself affects health and health care. Maps of the United States at the state level show strong and important

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5: GEOGRAPHY AND DISPARITY IN HEALTH CARE 159 differences in mortality, morbidity, and access to care measures. There are different ranking and ratings systems that reveal health disparities at the state level, including those distributed by the UnitedHealth Group (UnitedHealth Group, 2000), Morgan Quitno (Morgan and Morgan, 2001), the National Conference of State Legislatures (Siegel, 1998), AARP (Lamphere et al., 1999), and the Urban Institute (Liska, et al., ~998~. The National Center for Vital and Health Statistics of the Centers for Disease Control and Prevention (CDC) does not explicitly rank states, but data it distributes can easily be ranked and grouped. Those rating systems are criticized for their inaccuracy and the inclusion of subjective judgments of what constitutes a summary measure of health (Gerzoff and Williamson, 2001~. There are other compilations of state-level data that allow for comparisons, but that do not specifically rank or rate states. These include the Kaiser Family Foundation "50 State Comparisons" web site (www.statehealthfacts.kif.org), state-level data that are compiled by the Maternal and Child Health Bureau in the Health Resources and Services Administration (HRSA) to track Title V progress (www.mchdata.net/), and a series of health profiles for states compiled by HRSA that covers a wide range of indicators (stateprofiles.hrsa.gov/StateProf~lesIndex.htmI). State agencies and the public pay close attention to these rankings systems, and they are sometimes used to guide policy decisions. The UnitedHealth Group rankings are circulated widely and commented upon regularly. The indicators used in that ranking system have been modified slightly for use as a performance measuring system for the state of Nebraska. States have attempted to lead in the implementation of comprehensive programs to improve health status and the coordination of services either through overt political refonm or through administrative emphasis on health (Nelson, 1994~. The degree of variation in state efforts to improve population health is illustrated by the variation of their policies. For example, the Robert Wood Johnson Foundation's State Coverage Initiative and its tracking of insurance coverage by states illustrates the range of coverage decisions and the potential for state-level policy to influence how health care is paid for (www. statecoverage.net/matrix.htm).

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1 70 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT for assessments of the adequacy of access and guidance for allocating resources. The review did not support the idea of access as a unifying concept that would lead to a consensus definition of an appropriate geographic unit. The general geographic size of places where access was most effectively measured was at the local level, usually consisting of small counties or clusters of ZIP areas. It was closely associated with the system that was meant to affect or provide access to primary care. In these areas, the fit between a measurable disparity in access closely approximated the area in which a solution could be achieved either through the enhancement of availability (for example, creating a clinic) or modifying some factor that reduced access (for example, developing a subsidy for care). However, many of the studies they reviewed made note of, but seldom measured, important effects and influences on the programs and projects from adjacent areas or state systems. Technical Problems with Community Indicators The determination of small area rates and indices describing the health status and health care resources available to populations is subject to varying degrees of error. In creating these rates and indicators, analysts rely on a largely dispersed and cooperative system of reporting that is based on local and state rules and laws, although the standards and guidelines are centrally agreed upon. Mortality rates, overall, are generally considered accurate, but there is evidence that cause of death is often miscoded on death certificates that are the source of mortality data (Kircher, 1985; Goodman and Berkelman, 1987~. The accuracy of health care resource data is not often called into question, but for secondary data analysis there are problems with national data sources that may skew a picture of a county or community. The American Medical Association (AMA) Masterfile is the most frequently used source for national estimates of physician supply down to the county level, but it has been shown to have a degree of error due to reporting lags and the high mobility of physicians (Cherkin and Lawrence, 1977; Grumbach et al., 1995; Williams et al., 1996~. For rural areas, the difference between the number of physicians reported in the Masterfile and the actual, locally verified number is striking in many places (Konrad et al., 2000; Ricketts et al., 2000~. At the state level, license and survey data

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5: GEOGRAPHY AND DISPARITY IN HEALTH CARE 171 indicate that the Masterfile may overestimate primary care physician supply by as much as 20 percent. Data for nurses, pharmacists, and other health professionals are far less accurate when drawn Dom national sources because of the lack of a national inventory system (Kresiberg et al., 1976; Osterweis et al., 1996~. Geographic Information Systems as Savior? GIS has been proposed by some as an all-purpose answer to problems of community characterization. It is touted as capable of solving resource allocation problems as well as of being an essential part of the field epidemiologist's armamentarium. The widespread use of GTS in public health came relatively late in the development of computer-assisted cartography and geographic analysis largely due to the lack of useful data to attach to geographic coordinates (Rushton et al., 2000~.3 Healthy People 2010 includes the goal of increasing "the proportion of all major national, State, and local health data systems that use geocoding to promote nationwide use of geographic information systems (GIS) at all levels" from a baseline of 45 percent to 90 percent (Office of Disease Prevention and Health Promotion, 2001, pp. B234~. Geographic information systems carry the strong promise of a new, liberating technology and are often advertised to have the capacity to allow complex information to be displayed clearly and transparently, making both problems and solutions apparent. However, GTS is not really a new technology, but an expansion and intensification of older technologies. The expansion of the use and capacity of computers has facilitated collection of data by using remote sensing or by tapping into administrative, statistical, or clinical datasets. However, the massive amount of data that is now available has not immediately led to marked improvements in health care, the identification of health problems, or the formulation of health solutions because the volume of data has outpaced our ability to understand it. 3 However, some of the first applications of automated cartography were used to address health services problems.

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1 72 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT GIS, however, has renewed interest in the use of spatial data as well as of statistical data of all types to explore questions, and to conduct surveillance of health systems and communities. The power of a map or data displayed in reference to space cannot be underestimated. The ability to quickly depict data in maps and graphs using GIS has made many problems seem more tractable because they can be understood in a context that is shared by analysts, policy makers, and stakeholders. At the same time, the classical errors of the mapmaker are repeated, and the ability to "lie with maps" is increasingly recognized as a threat to the validity of analysis on the order of more standard statistical misapplications (Monmonier, 1991~. 5-5. CONCLUSION Geographers who examine the relationship between place and health believe that it is formed less by the intrinsic nature of fixed places than by how people interact across space to make a particular place more or less healthy. The relationship between HIV infection and interstate highway locations represents a perfect example of a health consequence that is literally in motion and dependent upon place only to facilitate transmission. The consequences are felt at a distance. Injury prevalence is dependent on risks that are tied to geography: higher rates of trauma in rural areas are due to factors related to exposure and behavior (snowmobile use, chainsaws, tractors, higher highway speeds, Tower seatbeTt use) that reflect the interaction between human activity and space and places. These are disparities in risks are related to geography. Paradoxically, urban places tend to be a bit safer in terms of trauma. There are more guns in rural places, and firearm injury rates are higher. Also, the urban-rural differential in drug and substance abuse is no longer so great as to create clear contrasts in the net health effects of crime. There are obvious structural and physical differences between the decaying inner city of Scranton, Pennsylvania and of the "cotton trail" area of South Carolina. However, the health disparities in access, services, and quality are fundamentally the same and described in the same terms. Across geographies there is a convergence of human health status and of how we deal with it.

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5: GEOGRAPHY AND DISPARITY IN HEALTH CARE 173 While geographic location is associated with wide variations in access, health care use, and health status, two core geographic elements and their relationship to health disparities are not well understood. They are distance (time and topography fit under this heading as well) and weather. Measuring distance often involves the use of rough estimations that mask actual geographic patterns of use. In many studies of the effects of distance, populations are described by some geographic entity such as a ZIP code or county, and the "average" distance to some location of care using the center of the geographic unit is calculated. This means that the variation or disparity due to differences in distance that exist within this geographic unit is lost to the analysis. The option is then to examine the relationship between an individual's distance to care and health status or outcomes. The latter analytical approach is feasible, but the former is far less expensive. Much of what we know about the effects of distance on health is based on the former type of studies. The degree to which true effects of distance are missed by this ecological approach is not well understood. Similarly, analysts and researchers often ignore differences in weather and environment and their effects on access, especially in the United States. We are constrained by our boundaries in such a way that we may not be able to completely understand how geography does affect disparities. The relationship of neighborhood residence to health may be considered a form of pure geographic effect since neighborhoods are a combination of topography and social interaction. However, a reliable definition of neighborhood is elusive, and bringing some form of consistency to its measurement may be antithetical to a concept that strives to reflect the variety of human interaction. Measuring true geographic disparity has been difficult, and summary approaches that compare populations often mask evidence of disparity. We may have to begin to think of geography in the study of health disparities as more of an individual characteristic as opposed to a way to organize population analysis.

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