Procesos de la Logística Inversa para Vehículos

Understanding geographical perspectives on health inequality ultimately lies in realizing the importance of place in relation to health. Geographers must consider how individuals interact with their environment and must attempt to develop theories to explain the relationships (Curtis 2007). Health/medical geographers typically examine spaces of risk. In order to

understand these spaces of risk, we must consider different combinations of health determinants to explain the variation in health for a given place (Curtis 2007).

Geographers are fascinated with location. As they study locations on the earth‟s surface and give them meaning, they become places (Gatrell and Elliot 2009). Places can vary in scale. Health/medical geographers‟ conceptions of study area size can vary as well. Some prefer to look at health from a global standpoint, some from a national perspective and others from a local angle. Geographical research can lead one to label a place as unhealthy or healthy. It is likely that one‟s perception of the place in which they live can also have a significant influence on their health.

Often, health and medical geographers will study health in a particular place, such as Mobile County, Alabama or will compare health between places (Gatrell and Elliot 2009). Though research on health across time and place has been accomplished in countries like the UK, it is relatively difficult to do in most regions of the world because health data is not designed to contribute to longitudinal studies. This is a challenging dilemma for those that study health. The dilemma can only be solved if researchers determine health inequalities that are unjust, compensate for those inequities, and then study that place over time to see if health improves.

In regards to the study of health from a health/medical geography perspective, Meade and Earickson (2005) presented their idea of the “state of health” through the triangle of human ecology (Figure 2.1). This model focuses on three components of human ecology that impact individual health: population characteristics, behavioral characteristics and habitat. Population includes the ability of humans to contend with issues of health and considers factors such as age, gender, and genetics. Behavior entails observations of culture, including mobility, cultural

practices, and technological interventions. Habitat is the environment in which people live; human ecology focuses on human interaction with the natural environment, the social environment, and the built environment.

Figure 2.1 The triangle of human ecology. After Meade and Earickson (2005, 25).

Population characteristics like age and gender can be significant from a health inequality perspective and there does appear to be an interest in studies on age and gender in relation to health (Tang, Petrie, and Prasada Rao 2007). Genetics may play a role in health inequality, but are not necessarily associated with health inequity. Behavior is similar to genetics in that certain actions may lead to health inequality, but that does not mean that an inequity exists. In terms of the triangle of health ecology, the most likely component associated with inequity would be habitat.

Though there may be many areas classified in the social environment as being inequitable, it is the built environment where inequity is visibly noticeable. In the past, consideration of the built environment typically dealt with the characteristics of the places people inhabited – their homes. Humans play a major role in defining the built environment on health (Meade and Earickson 2005). Many health issues associated with housing can be avoided and are dependent on construction materials, architectural design, and landscape development. Today, research on the built environment encompasses much more; this topic will be dealt with in detail later.

According to Gatrell and Elliott (2009), there are five approaches to the geography of health: positivist, social interactionist, structuralist, structurationist, and post-structuralist (Figure 2.2). They note that there is no single correct philosophical perspective or type of explanation in studying the geographies of health. Different approaches may be used to conduct research on a given problem.

The positivist approach to studying health relies on accurate measurement and recording, and uses statistical methods to find strong associations between health and given variables. Traditionally, medical geographers have mapped disease data and then attempted to describe and give reasons for the spatial distribution. The end goal for positivist research is to search for laws – typically, however, the end results are classified as generalizations. With a heavy reliance on statistical methods, positivists generally sample from a wider population and attempt to use the sample to predict characteristics of the population. An effort is often made to have a large sample in order to strengthen the conclusions (Gatrell and Elliott 2009).

Figure 2.2 Approaches to geographies of health. Source: Gatrell and Elliot 2009.

From the social interactionist or social constructionist perspective, researchers seek to find individual meaning in health issues. “They are so called, because meanings are constructed out of the interactions (which may be conversations or encounters) that we have with each other in everyday life” (Gatrell and Elliot 2009, 30). The social interactionist approach tends to look at factors that are not easily measured or quantified; the subjective experience of health and illness is valued in this type of research. It is important to look at the meaning of the disease or illness from the perspective of the individual, and to figure out these meanings in order to understand why people behave the way they do. Whereas the positivist approach likes to sample from large

populations, researchers studying from the “humanist” approach prefer to look at small numbers of people such as communities and neighborhoods (Gatrell and Elliott 2009).

The structuralist approach implies that the underlying causes of disease are the result of political and economic systems. This approach does not emphasize the study of individuals; it contends that research should be conducted from a broader social context. It is assumed in the structuralist approach that health is not related to the body, but to the body politic. This is also known as the political economy perspective and has been emphasized in recent years as a key method to understanding health inequality in health/medical geography (Mayer 1996). Most of the theory for this approach can be attributed to Marxist ideas of oppression, domination, and class conflict. From this perspective, medicine is not seen in a favorable context. Medicine is seen as adding to social inequality, widening the gap between the rich and the poor and not promoting any type of agenda to reduce health inequality. Recent studies from this approach have also focused on issues of health from a gender perspective (Gatrell and Elliott 2009).

The structurationist approach emphasizes that the study of health is a duality of structure and agency. “That is to say, it acknowledges that structures shape social practices and actions, but that, in turn, such practices and actions can create and recreate social structures” (Gatrell and Elliott 2009, 40). This has typically been associated with epidemiological and time geography research. This idea has been put forth to show that exposure to an environmental problem or to social stress over a given period of time can impact health (Gatrell and Elliott 2009).

According to Gatrell and Elliott (2009), the post-structuralist, or post-modern, approach is a “catch-all” for researchers that have begun to take on other theoretical developments. Some of the work conducted from this approach centers on health “risk” and adopting healthy

lifestyles. In developed countries, the problems of infectious disease have typically been solved and the focus is now on chronic diseases like cancer.

This research focuses on chronic disease in Mobile County, Alabama, and attempts to find connections between socioeconomic status and the built environment in regards to health. The ultimate goal is to understand the underlying causes of poor health in the county. This research could potentially make a significant impact on reducing health inequality by commanding the attention of those in the environmental justice movement.

As far as perspectives on the geography of health inequality, Curtis (2007) has developed a concept that considers the landscapes of health inequality (Table 2.1). She defines five types of landscapes associated with health inequality: therapeutic landscapes, landscapes of power and resistance, landscapes of poverty and wealth, landscapes of consumption, and ecological landscapes. Curtis contends that geography is well suited to thinking holistically. Geographers study people and their interaction with the environment; health and medical geographers concentrate on the health of populations and explore the reasons why health varies between places. The idea of landscapes of inequality is based on the concept that a system of factors and processes act together to create differences between places (Curtis 2007).

Table 2.1 Landscapes of health inequality.

Theoretical Framework Landscape Focus

Theories of Sense of Place and Identity Therapeutic Landscapes Theories of Social and Political Control Landscapes of Power and Resistance Theories of Production and Structuration Landscapes of Poverty and Wealth

Theories of Consumption and Lifestyle Landscapes of Consumption Theories of Ecological Processes Ecological Landscapes

Theories of sense of place and identity are significant in studies of therapeutic landscapes. Research in this theoretical framework varies from looking at therapies of complementary and alternative medicines to considering places that are „therapeutic‟ for health and those that are harmful. Therapeutic landscapes do not require an attachment to medical spaces like hospitals or clinics; the home, natural spaces, and places associated with healing can also be therapeutic (Curtis 2007).

The theoretical perspective behind studies on the landscapes of power and resistance are similar to Gatrell and Elliott‟s (2009) structurationist approach. The agency of individual action and choice interacts with the power structure of society, resulting in health differences between social groups. The controlling of resources, territoriality, and surveillance are components of the landscapes of power. Health inequalities are created because certain groups in society do not have the power to fight for legislation that will protect them. The idea goes beyond high and low income groups and research today is investigating health inequalities between different minority and ethnic groups, as well as differences between men and women (Curtis 2007).

Landscapes of poverty and wealth consider the idea of uneven development and its relation to health inequality. In her discussion on research in this area, Curtis (2007) noted that there is much debate today on the possible limits of health gains as societies become wealthier. This is not only associated with individuals, but is particularly of interest in looking at places or communities where there are conditions of material poverty. Though many environmental issues in regards to health are related to the idea of ecological landscapes, the built environment is technically an important visual component in the landscapes of poverty and wealth.

Geographically varying patterns of health care services and other important resources for health are the primary focus in landscapes of consumption research. Curtis (2007) contended

that economic inequalities contribute to the explanation of differences in consumption, but there are other factors that are important. Political, administrative, and social structures are crucial to understanding consumption as well. Curtis also pointed out that the spatial organization of infrastructure, or the methods available for the delivery of goods and services, is a critical component to understanding why health inequalities exist. These structures change over time, and depending on geographic location, can vary as well. From this standpoint, it would benefit geographers with an interest in health inequality to study the health of a place in a given time or to consider the concept of place histories and their impact on population health over time.

One of the most studied areas of health inequality is the ecological landscape. This usually involves the study of risk factors associated with the environment, and their impact on human health. Typically, research focuses on the biological and chemical risk of medically recognized diseases – in developing countries, these are often infectious diseases, while in developed countries, the focus is usually on chronic ailments. One major direction for health inequality research within this framework is exposure. Through new GIS and modeling approaches, current studies in medical geography allow us to better visualize the patterns and distributions of disease (Curtis 2007).

There are many theoretical components to the research in this dissertation. For the most part, it would be considered to take a post-modern approach in looking at health inequality, but this research does have a strong positivist approach as well. Though most of this dissertation is highly quantitative and applied, it does take into account social interactions, particularly through questions on perception of neighborhood health, activism, and the environmental justice movement. The research does consider the ecological landscape, but brings in concepts from the landscapes of power and from ideas on poverty and wealth. Dealing heavily with the built

environment, it can be associated with the triangle of human ecology, focusing on „habitat‟ and implying that the built environment in some places can be identified as an inequity (Figure 2.1).