Human health and nature find common cause in ‘green prescribing’. What is the case for radically rethinking our approach to society’s most challenging health problems through exposure to nature?
Ancient wisdom
One of the most under-celebrated, yet encouraging achievements of public health research in recent years must be the identification of measurable improvements in human wellbeing linked to increasingly biodiverse environments (1). This effect is independently related to nature-exposure itself, and not just facilitated exercise. The finding will come as no surprise to many, although for others whose lifestyles are amongst the most problematic and whose nature-deprivation is most severe, such an intuition may be less usual. In an attempt to address this disconnect, an ambitious project entitled ‘A Dose of Nature’ (2) led by Dan Bloomfield and developed in the West of England, has successfully recruited primary care teams and environmental ‘providers’ into social or ‘green prescribing’ for health, based on promoting physical and psychological experience of nature. The health objectives are ambitious, most especially for people with high rates of inactivity, overweight, isolated, suffering with depression or addictive behaviours. These are all risk factors associated with cardiovascular disease, cancers and premature mortality.
Questions and answers
‘Green prescribing’ programmes are complex, and complexity is in part what defines their greenness. Knowing what makes most difference within initiatives such as ‘A Dose of Nature’ will define areas of common interest between health and environmental agencies, and guide funding. A report commissioned by Natural England (3) has gone so far as to suggest that nature-based social prescribing can not only complement but sometimes may even replace conventional health care. Success will undoubtedly depend on continuing to develop a shared language and agreed objectives which work both for health and the environment. As the advocates of green prescribing emphasise, silo thinking is probably the biggest threat to delivering the best outcomes.
For those not entirely satisfied with English localism, the United Nations’ sanctioned ‘Ecosystem Approach’, advocating ecological and wellbeing synergies for sustainable outcomes, offers a wider contextual background (4). The question posed by this and similar theoretical aspirations is how best to ensure that more holistic ways of viewing both human and ecological wellbeing can take root and deliver for both. Currently ‘A Dose of Nature’, working with a combination of funders and providers in Cornwall (incidentally the southern UK’s most socio-economically-deprived county), is developing networks of interest, practical experience and a steadily-expanding evidence base.
A core ‘clinical’ objective has to be working out what kind of nature exposure is most effective. For example should efforts be directed solely towards ‘biophilic’ landscapes of trees, water and herbivores? Visual and olfactory encounters with birds, insects and vegetation are core, but how important is sharing ecological knowledge in the making of connections? Some specialised nature sites offer film, exhibits, and demonstrations, so what is the role of simulated nature? Further, within green settings, opportunities for physical exertion vary from being the main focus to an incidental opportunity. When and how are these variables applicable to designing prescriptions?
Currently the evidence that such programmes work remains relatively non-specific, although investment in research has begun to show more discrete benefits, for example in treating mild-moderate depression, anger control, fatigue and attention deficit disorders (5) – all common problems which are difficult to treat in primary health care. To be most effective, prescribers need a clear understanding of how to ‘dose’ nature, how much and how often interventions need to be experienced and whether benefits are maintained. They also need to know how multiple health problems and green prescriptions will interact, and when to combine nature and pharmaceuticals,
talking therapies and help with social relationships. As with all health interventions, it would be unwise to disregard possible unwanted outcomes both for people and nature. A long list of unanticipated emergent complications might range from, for example, apparently obscure but increasingly prevalent tick-born diseases, to the damaging effects of increased human footfall in fragile environments. Finally, and in common with other health care initiatives, social inclusion is a serious challenge: attention to a variety of motivations and expectations will almost certainly suggest adjustments for differing age, gender, ethnicity and social-cultural backgrounds.
Nature on a prescription pad
From a conservation perspective, our most pressing concerns include protection, expansion and connection of more diverse and richer ecosystems, and funding linked to cultural ecosystem services in the interests of public health may well make for a timely win-win outcome. So where might this take us? Nature prescribers require local and expert nature partnerships. A diversity of health profiles mean that people are likely to need a portfolio of nature experiences varying from more challenging upland and marine settings through to much more accessible and less physically-demanding urban or near-urban reserves, gardens, parks and green patches managed for nature. An NHS prescription has to be realistic, offering discrete opportunities for people to spend time moving around and perhaps contributing to the care of more biodiverse green space, usually accompanied by others. Companions may include other people seeking help, and those who facilitate the experiences, including nature therapists with an understanding of the human and environmental sciences, able to help people whose ability to make things happen for themselves is otherwise seriously impaired.
The nature of the beast
As it may well be that green prescribing regimes have quite precise requirements, and how these succeed in spreading engagement with nature more widely is a good question. For many people, cultural preferences for trees, water, and certain charismatic animal species seems to be important and we know that helping people take part in even very basic citizen science exercises such as counting butterflies can increase broader motivation with respect to nature (6). A characteristic of experience with nature is that appreciation of complexity and curiosity are inextricably linked, generating value. Do these elements have to be predictably available rather like a pharmaceutical drug, or could this medicine embrace uncertainty? In her recently published book ‘Wilding’, (7) Isabella Tree writes beautifully of less-fettered nature playing by her own rules, flouting conventional ideas of human preference. Is it necessarily counterintuitive that health benefits might be obtained from a less managed landscape capable of surprise? Alternatively what are the implications if for some people, time in gardens full of ‘organised’ exotica works just as well?
Green prescribing appears at first sight to be largely about psychological recovery, not exclusively but increasingly pressing in circumstances of deeper social disadvantage and poverty. It is important to stress however that psychological health and physical health are inseparably linked and strongly interactive. It is also the case that the behavioural, perceptual, emotional and social components of nature are most easily accessed in circumstances of greater economic fairness. Experiencing diverse and healthy green environments should arguably be a normal part of everyone’s heritage.
A better future for people and nature?
In a liberal society, environmental organisations may still face a social and public health challenge of under-inclusion: how best to ensure that people experiencing high levels of psychological, social and physical health disadvantage can literally move their lives into a better place. Over the past century, effective publicly-funded health care has enjoyed wide support. An association between a commonly-recognised public good such as national healthcare and improved access to green space can be to the advantage both of wild nature and human health. It is likely that the results of ‘A Dose of Nature’ will attract public health and environmental strategists interested in new ways of shifting health budgets into prevention and community services, simultaneously securing benefits
for current and future generations. Green prescribing is a way of valuing nature for people, which should interest those of us committed to protecting and enhancing the scattered remnants of nature we have left.
References
1. Fuller, R. et al., (2007) ‘Psychological benefits of greenspace increase with biodiversity’ Biology Letters. 3, 390–394 DOI: 10.1098/rsbl.2007.0149 2. Bloomfield D., (2016) ‘A Dose of Nature’, https://nerc.ukri.org/planetearth/stories/1805/ (accessed 26/10/18). 3. Natural England (2017) Good practice in social prescribing for mental health, the role of nature-based interventions’. http://publications.naturalengland.org.uk/publication/5134438692814848 (accessed 27/10/18) 4. Ecosystem Approach (1998) https://www.cbd.int/doc/meetings/cop/cop-04/information/cop-04-inf-09-en.pdf (accessed 05/12/18) 5. Bowler, D. et al., (2010) ‘A systematic review of evidence for the added benefits to health of exposure to natural environments’. BMC public health, 10(1), p.456. 6. Cosquer, A. et al., (2012) ‘Observations of everyday biodiversity: a new perspective for conservation?’ Ecology and Society 17(4): 2. http://dx.doi.org/10.5751/ES-04955-170402 7. Tree I., (2018) ‘Wilding, The return of nature to a British farm’. Picador, London.
ANDREW BLEWETT
Andew Blewett is a consultant psychiatrist in Devon, and a doctoral student at the University of Wageningen in the Netherlands.
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