The evidence is crystal clear: There's no pill with as many positive effects as a dose of the outdoors.
People who regularly get outside have lower rates of conditions ranging from diabetes to depression, and are more likely to seek treatment and follow through with it.
In this article, we’ll discuss:
The imperative for more research and hard data
Early efforts to define the outdoor industry’s role in healthcare reforms
Park prescription models whereby healthcare practitioners encourage outdoor activity
The nonpartisan nature of support for outdoor access, and the desire for equitable access
Pioneering insurers who have begun to implement outdoor programs
What’s next for our culture as it relates to healthcare and the outdoors
The Imperative for Research
"There's an inventory of 20 different health outcomes where there's evidence nature does some good," says Howard Frumkin, a professor at University of Washington in Seattle.
Frumkin has focused on the impact of the outdoors on health for much of his career. "Anecdotally and intuitively, it makes sense that time in the outdoors would be good for you," says Frumkin. "That's not good enough for somebody in my profession."
It follows that Frumkin has led a push for scientific research on the effects of nature contact for the last 20 years. His headline conclusion:
"Nature contact is good for people," says Frumkin. "Extraordinarily, unbelievably good."
It's especially important for kids. As Richard Louv wrote in his seminal book, Last Child in the Woods, "The woods were my Ritalin. Nature calmed me, focused me, and yet excited my senses."
Regardless, there's a need for rigorous clinical research. "What we don't know is a lot of granularity and detail," Frumkin says. "Do you need to be around trees or do bushes do the trick? Is it okay to view the nature out the window or do you need to be amidst it? There's a lot we don't know"
Frumkin says federal funding for the subject "is one of the in-between topics that falls between the cracks" of $30 billion in annual medical research by the National Institutes of Health and the non-medical focus of the National Science Foundation, funded to the tune of about $8 billion annually.
Regardless, the concept is especially interesting in that it's fiscally conservative. Getting people outside leads to lower costs, and that aligns with a top priority of any post-Affordable Care Act healthcare reform.
Beginning to Define the Outdoor Industry’s Role
How can the outdoor industry leverage these truths with the nation's insurers and health agencies at every level of government and get a seat at the table for healthcare reform?
As director of Sierra Club Outdoors, Stacy Bare is loudly asking just these questions. Unsurprisingly, he's a huge proponent of better integrating outdoor recreation with the nation's healthcare system.
"I still think a lot of people feel this is a little bit of a reach, which is understandable," says Bare, quoting futurist Jim Dator: "Any useful idea about the future should appear ridiculous."
But Bare thinks once perceptions are shaken out of their boxes, it's a no-brainer to embed outdoor recreation in healthcare policy. "What we're learning about time outside through research matches up with thousands of years of literature as well as our sacred texts," says Bare. "It supports health, mental health, connection to the divine."
Of the last of the three, he notes that religious icons from Jesus Christ to the Buddha had some of their most notable epiphanies in nature. "It makes sense when people say, 'My church is the outdoors, or my temple or mosque is the outdoors.’"
And as the science backs up what millennia of religion and literature has told us, "Insurers are beginning to adapt," says Bare. "Pharmaceuticals are overprescribed, and I think that's something we as a country can agree on."
"This isn't to say medicine and pharmaceuticals are bad," he continues. "There's a time and a place for pharmaceuticals. It's: 'How can we make this part of the cure?'"
A veteran of the Iraq War, Bare points to his own experiences of nature acting as a treatment for post-traumatic stress disorder (PTSD) along with research showing veterans who get outdoors have less stress and PTSD symptoms and get more sleep. "How do we make sure this is seen as a treatment for trauma?"
The big questions: If it becomes part of the framework for medical policies, asks Bare, "What does it look like and what savings does it bring? What health care costs can we save in the long run?"
He throws a few ideas at the wall: Insurers can incentivize outdoor activities with lower rates for participation, or people could use health savings accounts to buy tax-free outdoor gear. "I think there's a whole host of policy implications to this nobody should get upset about."
Crafting a Model: Park Prescriptions
One effective model that has started to develop involves doctors writing prescriptions to patients, encouraging them to spend time in the outdoors. A variety of programs integrating "park prescriptions" or “nature prescriptions” have popped up in recent years.
Inspired by Louv, Dr. Robert Zarr of Unity Health Care in Washington, D.C., started DC Park Rx in 2010 and launched the program in 2012. "Our program is a little different," he says. "It's embedded into the clinic. . . . It's part of our culture now."
To wit, the park prescriptions are included in a patient's electronic health record (EHR), and prescriptions are integrated with an easy-to-use website and mobile app. DC Park Rx includes a database of about 2,000 parks available to 300 providers and 200,000 patients in the Washington, D.C. area, and it's expanding to the Maryland and Virginia suburbs.
"We've really got it down," says Zarr. "We've got a scalable model now." He's received inquiries from practitioners all over the country and expects to launch in Michigan soon.
Zarr says it's not strictly about physical activity. "It really has to do with the interface between humans and nature," he explains. "Once they get there, they're more likely to move, but it's not all about exercise."
To have a greater impact, the broader culture needs to shift just like the clinics have. "Sitting is the new smoking," Zarr says. "It's common sense. We're just making [outdoor activity] easy to do and relevant."
And so is Charmaine Lindblad, executive director of both Prescription Trails New Mexico and New Mexico Health Care Takes on Diabetes. Type 2 diabetes "really is a lifestyle issue, [resulting from] overindulging and a lack of physical activity," explains Lindblad. It's also a costly issue: Diabetes patients have healthcare costs that are more than twice that of those who don't have the condition."
Staked with a grant from the Robert Wood Johnson Foundation, Lindblad teamed with officials from the National Park Service to identify trails for the program, which launched circa 2008. "These were outdoor folks," she says. "How do we work together? It's a hard sell."
It cuts both ways. "Getting the healthcare folks to understand that the outdoors is a resource for them is really tough," Lindblad says. "Healthcare providers need to step up to the plate, but parks and recreation folks need to understand their involvement in healthcare."
The program ranked 35 trails from one to three and offered free downloadable guides to healthcare providers. Doctors in the program can prescribe a specific trail to a patient based on multiple factors, including proximity to their home, wheelchair accessibility, and dog-friendliness.
"Not only are we saying get healthier, but we're giving them a way to do it," says Lindblad.
"It's one thing to tell people to go out and get more exercise. If you give them the tools to do it, the follow-through is much more likely."
It's a common refrain: Connect parks departments and agencies with healthcare organizations and providers and good things happen. The private sector can best support these initiatives with donations of cash or gear.
Nonpartisan Support and Equitable Access
Unlike many issues in today’s political climate, the push for funding outdoor programming tends to generate broad-based support, but they also face perpetual threats of budget cuts.
Equitable access is a priority for Jackie Ostfeld, director of the Sierra Club's Nearby Nature initiative and co-founder of the Outdoor Alliance for Kids. "Getting people outdoors is really a cross-sector, multi-sector initiative," says Ostfeld.
She points to two Obama-era initiatives, Let's Move! Outside and Every Kid in a Park, and other programs in a host of federal agencies and departments. "One of the things we really need moving forward is advocates to keep these programs active and funded in the budget," she says. "We're expecting budget cuts across the board in the next two years."
And federal programs from a host of agencies that aim to connect people to nature "are always under threat when you start hacking at the budget," she adds.
That runs counter to the support such programs receive. "It's really nonpartisan," says Ostfeld. "There's support for it on both sides of the aisle." But quantification of value remains elusive, she adds, and convincing data will be necessary to prompt serious policy shifts to further integrate outdoor recreation and healthcare, noting, "They're nonpartisan as long as it costs nothing."
Federal bloodletting aside, "There are a lot of opportunities at the local level and the state level," she adds. For example, in Los Angeles, a new parcel tax is projected to provide $100 million annually to local parks. Ostfeld also calls Oregon's Outdoor School for All, giving every 5th and 6th grader an outdoor educational experience, "a really great model."
The insurance industry's growing connection with park systems is another positive development, she adds. "I love to see individual insurers walk the walk and not wait for policy changes."
Insurers Are Breaking Trail
Increasingly, insurers have realized the value in outdoor recreation, and have helped develop park prescription programs.
Kaiser Permanente has been a leader integrating healthcare with outdoor activity. "We believe being outdoors is critically important for good health," says Dr. Jennifer Bass, a pediatrician with Kaiser in Portland, Oregon. She says Kaiser's practitioners treat "exercise as a vital sign."
But it's not just about numbers: the physical setting for exercise is key. "There are benefits of outdoor [activities] versus indoor," says Bass, noting that outdoor runners enjoy health benefits that treadmill users do not, and the former are more likely to continue with the activity in the longer term.
Launched in 2011, Kaiser's Rx Play program in Portland is "a partnership between the healthcare system and the recreation department," says Bass. The doctor writes a prescription for activity, and the patient gets a copy, as does the appropriate rec center, and an advocate places an outreach call to foster participation.
"They've had great success getting people in," says Bass. "Having a navigator to help families through the system is a critical part of the program."
Messaging and marketing are also important. "Raising awareness is the first step," says Bass. "Kaiser is in definitely in that phase."
Now focused on kids in the city, Rx Play is being revised to focus on outdoor activities in a broader geographic region, with an all-ages goal. There's a solid business case for the expansion. "We know there are cost savings," says Bass. "It's really about preventing and delaying chronic illnesses."
But it takes money to save money, she adds. "We need financial support. It doesn't cost anything to walk on the trail, but it does cost to have a navigator."
Humana has also launched a "park prescriptions" program in Park Rx. "It really started when we partnered with the National Park Service around the centennial celebration [in 2016]," says Dr. Mark Steffen, medical director for Humana. Inspired by Zarr's DC Park Rx, Steffen says Humana launched a pilot Park Rx program in 2016 at the MetCare Clinic in Plantation, Florida.
"They literally write those prescriptions in the examination room," he says. "It can be as simple as 'Get yourself outside 30 minutes a day, three days a week,' or it can be much more specific. They really tailor it to the needs of the patient."
In the pilot's first six months, doctors prescribed parks to about 400 patients, says Steffen. While it's too early to evaluate results, "Our hope is this can act as a model," he explains. "How can you do this so others can take this model and learn from it?"
Beyond insurers, the outdoor industry also has a role to play in advancing policies and programs that better connect the outdoors with healthcare. Pamela Taylor, director of strategy at the Partnership for a Healthier America (PHA), says her organization strives to "bring the private sector together" to reduce childhood obesity.
"We have a partnership with the Outdoor Industry Association," says Taylor. "They made a commitment to PHA that they will help 100,000 kids over the next year."
The goal is to get those kids -- largely from underserved rural and urban populations -- to a park in 2017. PHA's strategy of engaging the private sector opens doors for companies to get involved, and the organization is working with The North Face on a similar initiative
Donations of gear and technical clothing are a big help to the cause. "A lot of companies have an excess of apparel," says Taylor. "That is a huge, huge benefit to nonprofit organizations working with kids."
The bigger picture involves technology. "Children are more inclined to be getting their entertainment via screen time," says Taylor. The goal: Wean them from their electronic devices and get them outside.
And the focus on underserved populations is another key. "The work the outdoor industry is doing to diversify and reach communities of color is critically important," says Taylor. "The private sector plays a critical role in not only providing people with the means to get outdoors, but also ensuring they have access to it."
What’s next? We Need a Cultural Shift.
How can some of these big ideas be institutionalized in healthcare policy? The question looms especially large with the "repeal and replace Obamacare" furor in Congress.
The Affordable Care Act has already catalyzed healthcare to integrate outdoor activities into their operations. The University of Washington's Frumkin notes that reduced numbers of uninsured people due to the ACA has led hospitals to do more work in outdoor recreation to fulfill their IRS-mandated "community benefit."
"We're seeing some hospitals and healthcare systems make investments in parks and green space," he says, pointing to Kaiser Permanente as a prime example. On the other side, "You're seeing parks brand themselves with messaging like 'Healthy parks, healthy people.'"
But it ultimately all comes down to the bottom line. "The main issue with healthcare is cost," says the Sierra Club Outdoors' Bare. As year-over-year premium hikes continue, he adds, "I think there are opportunities."
Government will play a role, especially if the concept is going to go national. "You're going to have to find a learning lab for some of these ideas at the state level," says Luis Benitez, executive director of the Colorado Office of Outdoor Recreation.
"I don't see [the 2016 presidential election] as a loss of of momentum," says Benitez. "All the right partners are at the table. We're having all the right conversations. Now we're going to have to find the right partners in the healthcare industry."
Sure, the pharmaceutical industry has a huge lobby, but the outdoor industry has a similarly large, albeit decentralized, scale.
"The hypothesis is we're bigger than pharma," Benitez notes. The big need is "champions" in the outdoor industry to compete with the oversized pharma lobby.
Once the pieces are all in place, he adds, small steps will grow to big jumps. "Then you're looking at a cultural change."
RootsRated Media, a partner in Health and Wellness
We've started to follow this trendline on the RootsRated Labs Podcast, with an early episode dedicated entirely to population health as well as an interesting discussion with Luis Benitez, who we quoted above. If you're interesed, please give it a listen and let us know what you think.
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