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Saúde e Sociedade

Print version ISSN 0104-1290On-line version ISSN 1984-0470

Saude soc. vol.24 no.2 São Paulo Apr./June 2015

https://doi.org/10.1590/S0104-12902015000200005 

Part 1 - Dossier

Concepts of region and regionalization: aspects of its evolution and possible uses to health regionalization

Fabio Betioli Contel 1  

1Universidade de São Paulo. Faculdade de Filosofia Letras e Ciências Humanas. Departamento de Geografia. São Paulo, SP, Brasil. E-mail: fbcontel@usp.br


ABSTRACT

This article aims to discuss some of the main definitions of region and regionalization established in human geography throughout the twentieth century, in order to find parameters for its use in the current debate on the regionalization of health. This reinterpretation allowed the proposition of three ways to understand the interface between region/regionalization and health: 1. A critical reconsideration of some concepts linked to the man/environment geographical tradition, to understand the current phase of "epidemiological transition"; 2. Reinterpretation of the geography of "urban networks" as an element in thinking about today's health care networks and the use of the "health industrial complex" as a mechanism to improve regional development ; 3. and lastly, the use of the concepts of region and regionalization originated from Marxist tradition to emphasize the material and immaterial aspects that underlie the formation of regions in the current period of globalization. From the methodological point of view, the main resource used in this article was a review of the literature on these issues.

Key words: Region; Regionalization; Health; Human Geography

RESUMO

O presente artigo resgata algumas das principais definições dos conceitos de região e regionalização estabelecidos ao longo do século XX na geografia humana, no sentido de encontrar parâmetros para seu uso no atual debate da regionalização da saúde. Essa releitura permitiu que se propusessem três possíveis caminhos para entender a interface entre região/regionalização e a saúde: 1) o resgate crítico de conceitos ligados à tradição da relação homem/meio na atual fase da "transição epidemiológica"; 2) a releitura da geografia das "redes urbanas" como elemento para se pensar as atuais redes de atenção à saúde e para o uso do "complexo industrial da saúde" como mecanismo de desenvolvimento regional; e 3) por fim, a utilização dos conceitos de região e regionalização com origem no marxismo para enfatizar os aspectos materiais e imateriais que estão na base da formação de regiões no atual período da globalização. Do ponto de vista metodológico, o principal recurso utilizado para a consecução do artigo foi a revisão bibliográfica sobre os temas abordados.

Palavras-Chave: Região; Regionalização; Saúde; Geografia humana

Foreword

A lot of difficulties are associated with the rigorous treatment of the region and regionalization concepts, particularly in geography. The first difficulty, of a more general character, comes from the simple fact that the term region, for allowing reference to various scales, can serve to indicate and locate any kind of concrete "extension", from a "region" of the human brain to a neighborhood, a province or a group of countries (Beaujeu-Garnier, 1971).

The term also has a long tradition of interdisciplinary treatment (Claval, 1987), with common application in biology, anthropology, psychology, sociology, public administration, history and economy, each discipline proposing the same way their own definitions and meanings "appropriate" to that concept.

Within this context, this paper seeks to rebuild some approaches on the region and regionalization concepts from human geography which can bring contributions to its current use in the debate of "health regionalization". As shown by (Mello and Viana 2012), the issue of regionalization figures as a central axis of progressive thought in the health field, as also are the themes of entirety, coordination, decentralization and universality. We tried to resume the concepts of region and regionalization from three important debates that have been on the geography and health interface: 1) epidemiological studies and the "influence of the geographical environment" in the health / disease process; 2) the importance of networks towards the formation of regions and the regionalization of health services; and 3) recent definitions of region and regionalization, which may provide new contributions to the understanding of contemporary problems of health regionalization. Despite being an essential aspect of geography / health interface, the associations between the norms / laws and health regionalization were not analyzed, given the significant amount of fine studies that already exist in this field (Guimarães, 2005; Machado, 2009; Lima et al., 2012). From a methodological point of view, this paper drew on mainly the use of literature review for its achievement.

Although the regionalization theme leads us to think about the possibilities of its practical implementation, the paper has tried to focus on the more theoretical aspects that concern some qualitative definitions of the concept in the twentieth century, since these settings end up foregoing in importance, the practical dimension of the discussion on regionalization (McDonald, 1966). Operational methods for defining the regions which were not associated to a dense and qualified discussion of a more theoretical character, turn out to be challenged or outdated faster (Dumolard, 1975).

Regionalization as a result of man/environment relationship: natural regions and human regions

Before becoming the target of systematic concerns, regional studies sought, above all, to identify specificities, curiosities and descriptions of the most different parts of the globe (Claval, 1974). From the mid-eighteenth century several forms of description, classification and analysis techniques have been created without the intention to develop a more "scientific" point of view about the term region. These concerns have become more common in the early twentieth century, when the systematization of a "regional geography" began to take its first steps, both in Europe and in the United States (Whitlessey, 1954); three were the main authors who developed the first theoretical definitions on the regional phenomenon: Alfred Hettner, in Germany, Vidal de la Blache, in France, and A. J. Herbertson, in Great Britain (Duarte, 1980).

The first systematic definition of the notion of region was made by Herbertson, in an article dated 1905. With regard to its more methodological aspects, it can be said that the purpose of this author is to create a "systematic geography", and seeks to find "[...] geographical divisions orders [...] on the globe" (Herbertson, 1905, p. 301). Said text opens the concern to define regionalization as a classification process (Dickinson, 1976). It makes explicit reference to the biology classification procedures (especially with regard to the division of the hierarchy of living beings in kind and gender)9, thus demonstrating a deductive bias, based on the prior definition of the regions' demarcation criteria for then " [...] divide the world into major natural regions "(p. 302). Herbertson (1905) proposes four "classes of phenomena" for such regions, in the following order of importance: 1) configuration (mainly the elements of geology and geomorphology of earth); 2) climate (air masses, temperature and precipitation levels); 3) vegetation; and 4) population densities10.

Setting natural regions would be, in this sense, "[...] the necessary step for the final solution of the problems of geography" (Dryer, 1915, p. 121), as these definitions would allow the establishment of sound and lasting cuts on the earth's surface even to understand the economic functions which each portion of the space would fulfill, since it was believed that the productive activities had clear causal relationships with natural elements such as climate, geology, landform, vegetation and soil of each area . This true "physical regionalization" of the world at the time was followed by several similar attempts, mainly conducted by Russian geographers (Grigg, 1974). Paul (Claval 1974, p. 63) shows that in this period "[...] the region was a fact of physical geography, a fact of nature [...]", in virtually all that was written on the subject. (Gomes 1995, p. 55) also noted that "[...] the concept of natural region is born from this idea that the environment has some ownership on the orientation of the society development." Most of these definitions had a deterministic or "environmentalist" Bias.

In France, the first systematic study of the concept of "natural area" was conducted by the geographer Lucien Gallois, in his book Regions naturelles et noms de pays, 1908 (Roncayolo, 1986). According to the original definition of (Gallois [1908] 2013, p 222.):

In summary, if the consideration of climate allows distinguishing the earth's surface, only a certain number of large regions, in turn the altitude and the geological soil formation introduce differences and justify a subdivision into smaller regions, more or less well-defined, whose characteristic is more highlighted the simpler are the elements that constitute it. For such large and small units, but all of physical order, it is appropriate to reserve the name of natural regions. [...] I believe, in fact, that it is necessary to find the beginning of all geographical division in nature itself.

Concurrently to the studies of Lucien Gallois, Vidal de La Blache erected, in several works, all his explanatory building geography, seeking to unite "natural" and "human" aspects in their regional monographs for explanation of geographic phenomena. Also having a history degree, the author gives great emphasis to the long time periods required for the formation of regions, and thus decreases the emphasis which was given to the determination of natural factors in the configuration of different forms of the earth's surface. To join the physical framework, human action and history, La Blache proposed the concept of genre de vie, which would be a synthesis of the relationship between the physiographic availability of each part of the world and the active and slowly adjustments made by societies to use such availabilities. (Grigg 1974: 27) reminds one of the famous La Blache's metaphors to explain the meaning of the concept of genre de vie: man and nature "shape" each other "[...] like a snail and its shell [...] "; "[...] the two form a complicated amalgam".

So, La Blache is proposing the concept of "geographical region" to refer to those portions of the earth's surface which have certain homogeneity characteristics, derived from the combination of elements of the natural environment and human action. As shown by Meri Lourdes (Bezzi 2004: 65-66), "[...] it was not the natural area anymore - physical - the privileged object of geographical analysis [...]", but the different combinations of natural and cultural elements that were held in each geographic region. This proposed definition for geographic region, from a theoretical point of view, composed a true "system of concepts" with the notions of "genre de vie", "pays" and "landscape", and the occurrence area of a homogeneous landscape would set the limits of such regions. The homogeneity of such landscape, in turn, would be reflected both in their physiographic aspects as a uniformity of human arrangements: the styles and forms of housing, modes of transportation, the agricultural cropping systems and settlement patterns (density or rarefaction) in each portion of the space.

In the mid-twentieth century, the main systematizing of such concept of region in the French geography was certainly André (Cholley 1940, 1951). According to the author, "[...] the geographical facts are essentially complex; they respond to convergence, the combinations of factors "(1951, p. 18). The factors to be combined in the earth's surface would be threefold: 1) physical factors; 2) biotic factors; and 3) human factors. It would be a task for geography to find ways that these factors are combined in each portion of the earth's surface, and identify the existing "orders" and "units" which derive from these combinations11. With this reasoning on the regional phenomenon, Cholley opened the possibility of combined study of these three factors (physical, biotic and social), as was later developed by Jacques May in the proposal of the so-called "geogens" (i.e. the environmental factors that interfere in the diffusion of the "pathogens") which precisely divide themselves into the "physical", "organic" and "social" (Bousquat; Cohn, 2004).

This period of development for such regional concept is characterized, first, as an overrun in the region settings from the predominance of natural factors in its composition. If Herbertson allowed the construction of the first major regionalization of world space from the data of "configuration", "climate" and "vegetation" of parts of the globe, all other authors who were analyzed tried to work the regional concept from smaller scales, mainly the "mesoescales", given by space portions set within the territorial limits of countries.

In this context, Max Sorre determines one of the most important definitions of region in human geography, showing that "[...] it comes to these restricted areas individualized by the uniformity of physical conditions within its limits and a particular genre de vie, or at least the nuances of a way of life "(Sorre 1952, p. 445), and the "elementary" regions would be those in which "[...] a human group practices a consolidated genre de vie in harmony together with the geographical conditions and relatively stable" (Sorre 1952, p. 449). We also owe to Max Sorre the proposition of the concept of "pathogenic complex" in the same period, which allowed considerable explanatory improvements to the study of the spread of infectious diseases in different areas of the globe (Ferreira, 1991; Costa, Teixeira, 1999).

It should be noted that the region is, to this generation of scholars, a reality "itself", independent of the researcher. In the words of Roberto Lobato (Correa 1986, p. 28-29), "[...] the geographic region so conceived is considered a concrete, tangible entity, a fact with life, so assuming an evolution and an equilibrium stage" . To Paulo Cesar (Gomes 1995, p. 57),

The region [under this definition] is a concrete, physical reality, it exists as a frame of reference for the population living in there. As a reality, this region is independent of the researcher in its ontological status. It's the geographer work to unravel and uncover the combination of factors responsible for such configuration.

Even in its most general aspects, we can say that these conceptions of region and regionalization are guided by a geographical tradition of man-environment relationship studies, which reinforced the use of concepts such as "genre de vie", "landscape", "habitat ", "ecumene", among many others that bring geographical knowledge near to the human ecology, and give significant emphasis to the weight of the" natural" phenomena as a defining element of the terms region and regionalization.

The region and regionalization as a result of formation of urban networks

Along with the development of all these new methods and concepts for regional analysis, a number of proposals was developed in Europe after the World War II that put the formation and development of urban networks, or urban networks, into the center of the debate. The cities, accordingly, will then be considered as the "[...] centro rector de la région en donde están ubicadas" (Dickinson, 1961, p. 203).

In the genesis of such introduction of cities network in the regional thought there are the works of the German geographer Walter Christaller, especially his book Central places in Southern German (Christaller, 1966). According to the author, the "complementary regions" would be the result of systemic functioning of cities, which in turn would have their organization led by the importance of each city as offering goods and services - more or less - complex. The more complex the trade activities and services in the city center in question, the greater the "range of goods" offered by that point in the territory, and the greater the relative position of this "central place" in the city system hierarchy to which it belongs. As noted by (Bousquat 2001, p. 74), "[...] it is clear the relationship of this theory to the guidelines of regionalization and hierarchy of the clientele, as extensively used in the health sector."

Although already found in Max (Sorre 1952) the cities' consideration - and especially the metropolis - in the regionalization process, the definitive incorporation of urban networks, for understanding the formation of regions, was made by the French geography work in the late 1960's. More generally, this geography sought both to establish a more critical understanding of the regional phenomenon as to expand the geography intervention capacity in state action, through urban and regional planning.

Among other important authors of this generation (who can largely be clustered in what is conventionally called as the "active geography"), it should be noted the names of Jean Tricart, Jean Dresch, and Pierre George (together with their students Bernard Kayser, Raymond Guglielmo, Yves Lacoste, Raymond Dugrand and Michel Rochefort). These new prospects opened up in France, from a "engaged geography" (Bataillon, 2006) aiming to recover elements of geographical tradition of man / environment relationship, but also advance to identify the factors related to the influence of historical processes of state and economic organization of space to define the phenomenon of regionalization.

With regard to the evolution of the concept of region, as shown by Michel (Rochefort 1961, 1960) in his pioneering studies, cities are "pillars of life relationships" which animate the urban networks, and the cohesive set of operation of this "life relationships" (vie de relations) between the cities is what configures a "regional armature", or is simply what forms that "regional urban networks". To (Kayser 1980, p. 300), "[...] the knowledge of the urban network leads directly to the geographical understanding of the regional situation." According to Etienne (Juillard 1971, p. 23), it can be considered as well, " [...] the cities, the urban armature, are the engine of regionalization." This approach from the urban networks deters some basic ideas that shaped the lablachean geography, as the search for determinations of regional formation in " man /environment relationship " or that the region is only an " extension area of a landscape ", one of the main La Blache's definitions for regions (Correa, 1986).

Michel (Rochefort 1960) framed the concepts of "life relationships" (vie de relations) and "urban network" as the main tools to identify regions of the earth's surface. Each portion of the geographical space would have a set of cities working in cohesion, and those cities which had a more complex range of services would have a more extended "zone of influence", and would be the command center of the concerned region; i.e., it will be a "regional metropolis". The "regional armature" of each urban network presents three main components: 1) a "regional metropolis" or "regional capital"; 2) some "intermediate centers"; and 3) a wide range of "local centers" of lower economic complexity, "local centers" that are tributaries of the "intermediate centers" and the commanding of cities in such region.

It is important to note, therefore, that there is a hierarchy between urban centers, according to the type of central activity engaged, and that "[...] from there it shall not be possible to study a city alone, as a form of activity: the unit should be the 'urban network'" (Rochefort, 1961, p. 3). It still follows from his original study another concept that would be very important for understanding urban networks - and regions - in their contemporary forms. This is the concept of "rare tertiary sector" or "upper tertiary", developed in the author's text with Jean Labasse. In sum, it can be said that

By the power of decision, the rarity of services, or on its power, certain higher tertiary equipment form the basis of the polarization of regional life and its location provides the best definition of the upper level of the urban armature of a certain country (Rochefort; Labasse, 1965 p. 58).12

In the same period, in France, the studies of Bernard (Kayser 1966; 1980) are highlighted on the issues of region and regionalization. According to the author, for the effective formation of such regions, what he called "liberal" processes and "voluntary" procedures both would exist (Kayser, 1980). The first type of process is intertwined with the slow and spontaneous differentiation of areas, mainly derived from the increased complexity of urban and industrial life of the country. Five factors would interfere in this liberal process:

  1. natural factors: never considered as "early" factors - the human action / occupation always are - natural factors (such as landforms, climate, soil fertility etc.) can contribute as "brakes" and also as "catalysts" in forming regions;

  2. history factors: all those elements that relate to collective representations and identities created on specific portions of the space can be considered as "history factors" in the formation of such regions; Kayser says the "value systems", "psychological attitudes" and "collective reactions" among other phenomena that shape a certain 'regionalism', that is, collective behavior based on the historical evolution of different terms of geographical space;13

  3. the polarization: the entire region develops itself from a major urban center, and the greater the importance of industrial relevance and services of such center in relation to its surroundings, the greater its ability to "perform" the region (Kayser, 1980, p. 286); according to the author, "[...] in the contemporary era, it is not therefore the region that created its capital, it is the city that has forged its region".

  4. the communications: transport equipment (especially the road and rail networks) are sine qua non conditions for regional formation; they can both strengthen the centralization of certain cities - over others - as to make the countries regional development more "balanced";

  5. the administration: Last but not least, the achievement of institutional mechanisms for "control" of such regions, is a central element of their formation; administrative functions should represent, according to Kayser, the hierarchical division of urban life in the region in question. In addition to being essential for the good economic development of such regions, the possibility of control of political decisions at the regional level is essential to maintain internal coherence of such regions.

These are, in general, the processes by which regions are formed, and the analysis of these five elements attribute sound