TRUE – ECOCENTRIC TERRITORY RISK UNITS: CIRCULATORY AND RESPIRATORY DISEASES AGGRAVATION IN PORTO*

This paper contributes to understand the aggravation of circulatory and respiratory diseases from an ecocentric point of view through a territorial approach. Instead of considering natural phenomena as external to the territory as in conventional natural risk approach, the integrated analysis of social and environmental in this case thermal factors, in the very unit of analysis, reveals possible risk scenarios under which aggravation may occur.


Introduction
Respiratory and circulatory diseases are in the top of the list of causes of death in Europe. The 2012The -2016 Portuguese Health Plan reports that the circulatory (32%) and respiratory (11%) diseases, besides cancer (23%), are the main causes of death maintaining the tendency reported in the 2004-2010 Health Plan.
Wondering if it is possible to recognize these tendencies in the territory, a search of relevant factors that contribute to the progression of circulatory and respiratory diseases was carried on. These factors are diverse and largely investigated under both natural and socioeconomic points of view. In Portugal, extensive research was developed since early twentieth century, when the creation of the Assistance for Tuberculosis in Northern Portugal.
To choose the variables to work with it was taken in account its condition of being observable from a territorial point of view, besides, they have to be registered along the time, like in the census and meteorological information.
Among natural environmental factors, main concern for this study is outdoor temperature, which relationship with the referred diseases is mainly studied in the form of cold spells (Kysely et al., 2009;Díaz et al., 2005;MonteiRo et al., 2013a) and heat waves (Hajat & Haines, 2002;Rey et al., 2007;MonteiRo et al., 2013b) and its combined influence (Huynen et al., 2001;Revich & Shaposhnikov, 2008). On the other hand, the influence of socioeconomic factors (AdleR et al., 1994;RogeRs et al., 1996) has been largely studied, but even though, it continuous to be in debate, as Adler says: "there is a burgeoning literature in this area, but a number of unresolved issues remain" (AdleR & Rehkopf, 2008:235) Among the innumerous socioeconomic factors, unemployment (MaRtikainen, 1990;Bethune, 1997) and outdoor work (Kotaniemi et al., 2005); (d' Amato et al., 2001) (Tüchsen et al., 2006) seem to be relevant; family size is usually used as a mean to adjust the family income or measuring the crowding index (Kaplan & Keil, 1993:1974 (Viegi et al., 2001:10). And, definitively, it is largely demonstrated that age is a risk factor and it is strongly associated with chronic diseases like in the chronic obstructive pulmonary disease (Kaplan & Keil, 1993).
The better we understand the risks, the lesser the damage will be. It seems that focusing on the territory as a hole, not just the negative output, in this case the illness, the risk construction can be better understood. Under a territorial point of view, the characterization of a risk scenario has the advantages of: (1) considering the equilibrium of the socio-natural system; (2) the risk patterns results from the combination of both, natural phenomena and social processes; (3) the risk is contemplated as a continuous process where the disastrous events are not the core but milestones; (4) it facilitates a temporal-spatial analysis.
Then, analyzing the risk under a systemic approach the analysis focuses on the causes instead of the outputs.
Also, the approach is no longer anthropic but ecocentric: nature and men belong to the same territory and jointly generate the risks. Then, it is possible to see that the health risk is not only determined by natural phenomenon like the intensity of a heat wave. It is the result of the accumulation of multi unbalanced human and natural forces at local hot spots capable to disrupt the territory equilibrium.
The observation scale is another aspect to take in account for better understanding the risk in the territory.
The accuracy of the risk observations varies upon the researcher proximity or distance from the territory. The proximity reveals the heterogeneity of the at risk area and lets reach the hot spots where risk stockpiles. Then, local level is mandatory to understand the construction of risk processes.
These concepts were applied, through the TRUE methodology (Fernández MoReno, 2013) in Porto city in northern Portugal. The purpose of the study is to identify territorial risk patterns that contribute to circulatory and respiratory diseases aggravation during the period 2000-2007.

Background and Methodology
Then, how do we understand the risks of the territory at the local level, being so diverse and chaotic in space and time?

An ecocentric approach
Instead of approaching risks with the conventional focus, which reads the negative forces called hazards as extrinsic, and vulnerability as intrinsic forces to the subject at risk; we focus on the territory as a whole system where risk is inherent to it. Human beings and Nature are equally part of the territory with their positive and negative forces. Lovelock, in the Gaia theory (J. Lovelock, 2000) states that the biosphere -including human kindand the physical components of the Earth are closely integrated to form a complex interacting system that maintains the climatic and biogeochemical conditions on Earth in a preferred homeorhesis. Each component has positive and negative aspects or complementary forces.
This can be explained with the Chinese philosophical principle of ying-yang: the search of equilibrium between these two forces arise movement and change.
Natural phenomena and human beings contain both.
Natural phenomena are favorable for human life, but it is not its unique role. In the case of the atmosphere, under certain conditions, it guaranties human life; but heat waves and hurricanes make part of its unstable nature too. It is also applicable for human beings. Human positive forces work to guaranty the permanence of human life, but also, its negative forces are destructive for Nature, and also for its own species. It is like when we have a coin, we recognize each side of the coin, but we consider the coin as a whole and not just one side.

The territory under an ecocentric approach
Under this approach, natural phenomena and human kind are considered equal members of the territory. It is possible to identify factors of different natures that make part of the territory ( fig. 1): natural, social, socionatural, individual, etc.
The territory is the effect of multiple factors relationship (PainteR, 2010). Therefore, under an ecocentric point of view, the territory defined by power relationships (territoriality) includes all human and non-human components. In fact, we see in the territory the exercise of power of both natural phenomena and social beings, in which extreme episodes are armies in action to dominate the territory.

The ecocentric approach applied to risk
Because our focus is on risk, the analysis takes in account the negative aspects of the territory without resorting  vulnerability, or Lavell (2003) refers to socio-natural hazard, it seems that these are attempts to clarify the relation between hazards and vulnerabilities. From our point of view, the fact of being a negative aspect is enough explicative for the factor adverse contribution to the balance of the territory.
Then, the risk is a socio-natural spatiotemporal Then, it becomes clear that the fundamental dimensions for territory risk analysis are not any more hazard and vulnerability, but space and time.

Approaching to local level risk through TRUEs
The territory is a non-continuous geographical space of risk that looks like a mosaic ( fig.2) If each TRUE has its own level of risk, it seems that the risk of a territory results from the accumulation of the risk of each TRUE acting isolated or producing domino effects. Then, the territory risk variability is determined by the change of behavior of its TRUEs along the time.
This notion makes the TRUE an entity that can be used as a mean for spatiotemporal comparison for risk analysis.
Characteristics of the TRUE: • The TRUE refers to the minimum area considered as the basic resolution unit for analysis, i.e. municipality, square, plot… • The number of TRUEs in a study area depends upon the purpose and scale of the research.
• The size of the TRUE depends upon the observation scale defined by: the Subject at risk, the perception of the risk, the purpose of the study, the availability of the data, etc.
Although each TRUE is different, its structure does not change, independently of the observer's standpoint.
• Each TRUE is defined by: a territorial area, a Subject at risk, and n factors interacting to produce negative synergistic effects Subject (S): There may be several subjects at risk on the same TRUE. The risk of each TRUE will be defined by a set of factors. The factors selection will depend upon the subject at risk to work with: population, buildings, social networks, natural resources, etc. By defining the subject, it is possible to avoid antagonism among factors, because the risk for a subject can be opportunity for another (N. KRuegeR et al., 1994;A. wijkman, 1984). For example: if the TRUE is a farm, the factors for the subject "owners" will be different from those for the subject "cattle", although

R=H*V*E (1)
Since then, several expressions have been proposed to define the conceptual model of conflicting relations between hazards and vulnerabilities (A. Dauphiné, 2004;W. KRon, 2005): Under the ecocentric approach proposed it is assumed that all the factors, being part of the TRUE, have the same weight. Then, the Risk in the territory (R) can be expressed as: The risk in this approach is not considered as the probability of an outcome, but, using Aven (2011:515) words, "the vector of the state of the system". Each factor needs to be transformed to a comparable compatible measure to establish the relationships among them into the TRUE. Therefore, risk is expressed through the vector norm: Under the ecocentric approach proposed, each factor can be understood as hazard the point of view of the researcher. It is assumed that all the factors, being part of Then, the Risk in the territory (R) can be expressed as: The risk in this approach is not considered as the probability of an outcome, but, the state of the system". Each factor needs to be transformed to a comparable com relationships among them into the TRUE. Therefore, risk is expressed through the ve When conducting this type of analysis, there are as many vectors norm as hypoth resulting modeling, in other words, to identify the vector norm that better exp considered the losses as outcome of the unbalanced system.  Keatinge, 1989;S. VandentoRRen, 2003). But, the negative effect on individuals is not only due to each one of these factors, but the way how they interact among them, increasing the risk of disease. They reinforce each other.
That is the case of respiratory and circulatory diseases.
They are consequence of a large variety of variables.
In the case of Porto, to make the reconstruction of the risk scenario feasible it was selected a narrowed group of variables to characterize the territory risk that For validation, the results were confronted with hospital admissions for respiratory and circulatory diseases during the same period.

The Porto's TRUE
The parish is considered the basic territorial risk unit for

Risk Factors
Three main factors were considered to model the territory risk whose consequences could contribute to the aggravation of some circulatory and respiratory diseases: social (S), individual (I) and natural (T).
Social Factor is considered as a collective condition of risk that disables, immediately or potentially, affected groups, in meeting their welfare in a socio-historical and cultural context (L. Rygel et al., 2006). This factor is defined by the following indicators: illiterate population, unemployed population and family size.  As in the Social Factor, some of the oldest parishes together with those located at the east, upstream of the Douro River, show the worst Individual Factor ( fig. 7).  The heat severity is analyzed through the Heat Index.
The Heat Index (L. Rothfusz, 1990;R. Steadman, 1979) equation The year 2003 (Table II) (Table III) and the days with significant daily difference of minimum temperature of at least 5 0 C, from one day to the day before (Table IV).
In addition to the rankings of heat and cold years considered individually, a ranking of unified heat and  The year 2003 (Table II)

Risk scenarios
The objective of the analysis is to identify the risk scenarios that better explain the contribution of the territory for the respiratory and circulatory diseases.  Table VI presents the respiratory and circulatory diseases selected, assuming its possible relation with the factors considered in the risk scenarios.

Results
Causes that contribute to the development of respiratory and circulatory diseases At this point of the research, it is possible to confirm that: (1) the risk scenario that considers social, individual, and natural factors -defined as described before-associated R1 = f (social factor, individual factor) R2 = f (social factor, individual factor, natural factor associated to heat temperature) R3 = f (social factor, individual factor, natural factor associated to cold temperature) R4 = f (social factor, individual factor, natural factor associated to heat and cold temperature)

121
Circulatory disorders with acute myocardial infarction and major complications, discharge alive.

122
Circulatory disorders with acute myocardial infarction, without major complications, discharge alive.

127
Heart failure and shock.

Causes that contribute to the development of respiratory and circulatory diseases
At this point of the research, it is possible to confirm that: (1) the risk scenario that considers social, individual, and natural factors -defined as described before-associated to cold temperature, is able to identify potential hot points for the development of Chronic Obstructive Pulmonary Disease; (2) the risk scenario that considers social, individual, and natural factors associated to joined heat-cold temperature factors is able to identify potential hot points for the development of Heart Failure and Shock Disease (127).

Risk of
Bronchitis a nd a s thma (96+97) Hos pi ta l Admission  In the other hand, Se, São Nicolau, Victoria and Santo Idelfonso parishes, located in the center of the municipality, show the highest levels of risk for both disease groups. This zone concentrates the urban islands with hottest and coldest temperatures. In addition, these parishes register the more unbalanced aging index. A possible relation to population density was avoided when reviewed the statistics. Indeed, these parishes register large disparity of population density.
São Nicolau has 11 inhabitants per hectare, while Se has 98, being the less and the more densely populated of Porto respectively.

Discussion of Results
The outputs are satisfactory for this first approach to risk scenarios for respiratory and circulatory diseases in Porto, but obviously not enough. It seems necessary to review the list of indicators contemplated for each factor, and increase the scale of the TRUE, from parish to neighborhood level. The change to a more detailed level is expected to improve the outcomes and clarify some issues that are not possible to explain at this stage of the research, as pointed above at the Results.
The heat and cold urban islands were defined in August 4th, and January 22th, 1998. The date is not considered restrictive for this analysis. Even though, if new data is available,

Conclusions
The ecocentric risk approach applied through the TRUEs methodology shows to be useful for territorial risk