Mapping for Health Equity in your Community | Jacqueline Curtis, PhD

Jacqueline Curtis, PhD

The Power of Maps

As a spatial epidemiologist, I am a proponent of the power of maps! They can raise awareness of environmental injustice and move people to positive action – for example, in the Flint, Michigan water crisis.¹ Maps can communicate current scientific data in a way that is accessible for broad public engagement, as we saw when we used the Johns Hopkins COVID-19 Tracker. ² They can even reveal historical patterns that shape our current health, like seen with redlining maps. ^3,4

I have also witnessed someone I love suffer due to a gynecological cancer, opening my eyes to opportunities for extending the power of maps in service to the lives of our patients. Here, too, in gynecological oncology, my colleagues and I have found geographic patterns that can be instructive for us in understanding and advocating for health equity.

To start, there are several national level resources that provide maps of all cancer types which are worth exploring to gain a sense of higher level geographic patterns. For example, the National Institutes of Health (NIH) hosts the State Cancer Profiles interactive mapping resource ⁵ (Fig. 1). In addition, the Centers for Disease Control and Prevention (CDC) provides the U.S. Cancer Statistics (USCS): Data Visualizations ⁶ (Fig. 2). They enable users to choose a variety of ways to map cancer data. I think you will find that they contribute one, 30,000 foot view, approach to knowing about population health equity in gynecological cancers.

Despite the value of these maps for seeing national patterns, they are not intended for local level, clinical use. For this, you need to move to maps, used internally, where each point on the map is a patient’s home address. You can see them in relation to your clinic (e.g. proximity to care), in relation to one another (e.g. hotspots/clusters of certain outcomes), and in relation to the numerous conditions that shape health (e.g. social determinants) (Fig. 3). I believe that this is where the power of maps meets clinical practice to drive local health equity!

This is an example of what we really do with mapping patient data. Previously unknown patterns of health inequity are often made visible, and then can be clearly communicated with decision-makers in health systems and other relevant public health partners.

The Power of Maps in Your Practice

While the widespread use of mapping in current clinical practice is in its nascence, clinicians have a long and notable history of using this approach to serve their patients, from John Snow⁷ to Mona Hanna-Attisha¹, to my gyn oncology colleagues Jennifer Gordon⁸ and Stacy Smrz.⁹ As mapping applications become easier to use and more widespread as a part of health systems, the demand is increasing. Therefore, I want to share some insights on what has worked for us so far in the hope that it will inspire you too.

Collaborate with Good Mapping Partners:

• Ask for help from your local university geography department, public health department, or medical school.
  • We have had success including Master of Public Health (MPH) and PhD students in this activity, once appropriately trained and credentialed.
  • If you are part of a large health system, chances are good that they already use a Geographic Information System (GIS) for mapping. Ask for their help.

Collect Meaningful Data for Meaningful Maps:

• Keep collecting patient home addresses, even (and especially) when they move.
  • Do not overwrite or otherwise delete their old home addresses. If they are residentially mobile, that is a risk in itself, often indicative of eviction in lower income patients.
  • Consider that the concept of a home at a traditional address is not equally meaningful to all patients (i.e. people experiencing homelessness, etc.)
  • Do not accept a P.O. Box as an address. P.O. Boxes are for mailing only (billing) and cannot be meaningfully mapped.

Keep an Eye on Patient Privacy in you Maps:

Finally, (and this is so important that it gets its own section), please do not ever publicly display a map of patient home locations. These mapped locations can be reengineered to actual addresses of patients.¹⁰

Conclusion

With this overview, it is my hope that you will consider adding mapping to your existing strategies to improve understanding of conditions relevant to health equity and to aid advocacy for the health of all lives in your communities.

References

1. Hanna-Attisha, M., LaChance, J., Sadler, R.C. and Champney Schnepp, A., 2016. Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. American journal of public health, 106(2), pp.283-290.
2. Johns Hopkins COVID-19 Tracker. Available online: https://coronavirus.jhu.edu/map.html. Last accessed: 08/28/2023
3. Interactive Redlining Map Zooms In On America’s History of Discrimination. The Two-Way, National Public Radio (NPR). Available online: https://www.npr.org/sections/thetwo-way/2016/10/19/498536077/interactive-redlining-map-zooms-in-on-americas-history-of-discrimination Last accessed: 08/31/2023.
4. Nardone, A., Casey, J.A., Morello-Frosch, R., Mujahid, M., Balmes, J.R. and Thakur, N., 2020. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. The Lancet Planetary Health, 4(1), pp.e24-e31.
5. NIH State Cancer Profiles. Available online: https://statecancerprofiles.cancer.gov/map/map.noimage.php Last accessed: 08/31/2023
6. USCS Data Visualizations. Available online: https://gis.cdc.gov/Cancer/USCS/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcancer%2Fdataviz%2Findex.htm#/CongressionalDistricts/ Last accessed: 08/31/2023
7. Johnson, S., 2006. The ghost map: The story of London’s most terrifying epidemic–and how it changed science, cities, and the modern world. Penguin.
8. Gordon, J., J. Curtis, O. Kovalenko, A. Miller, J. Ajayakumar, S. Smrz, F. Schumacher, S. Avril. (2022) Geospatial approaches for surveillance of disparities in clinical trial enrollment. Annual Meeting on Women’s Cancer of the Society of Gynecological Oncology (SGO), Phoenix, Arizona.
9. Smrz, S., J. Gordon, F. Schumacher, J. Ajayakumar, A. Miller, S. Avril, and J. Curtis. (2022) One Regional Health System, Two Distinctly Different Geographic Patterns in Locally Advanced Cervical Cancer: Implications for Informing Public Health Efforts for Intervention. Society for Gynecological Oncology (SGO) Annual Meeting on Women’s Cancer, Phoenix, Arizona.
10. Curtis, A., Mills, J.W. and Leitner, M., 2006. Keeping an eye on privacy issues with geospatial data. Nature, 441(7090), pp.150-150.

Jacqueline Curtis, PhD, is an associate professor at the Case Western Reserve University School of Medicine in Cleveland, Ohio.