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How can a healthy ocean improve human health and enhance wellbeing on a rapidly changing planet?

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3. Ocean opportunities for enhancing physical health, mental health and societal wellbeing

A growing body of evidence demonstrates that spending time in, on and by the ocean supports human physical health and mental wellbeing, and that interacting with a healthy ocean can contribute to ‘the fundamental right of every human being . . . to enjoy . . . the highest attainable standard of health’ (WHO n.d.).

Resolutions from the UN Human Rights Council in 2021 (A/HRC/RES/48/13) and the UN General Assembly in 2022 (A/RES/76/300) recognise that a clean, healthy and sustainable environment is a human right.

However, there are clearly many threats to ocean health and to the health of the people and communities who interact with the ocean. These threats need to be managed to maintain the ocean’s current benefits for human health and wellbeing and hopefully to increase them in the future.

The health benefits of a healthy ocean

The ocean benefits human health by being a place where individuals can relax and be physically active, play, be creative, spend quality time with friends and family, and satisfy the deeply held human need to feel connected to the wider natural world around us (Britton et al. 2020; White et al. 2020). A healthy ocean can offer us the opportunity to not only survive but thrive.

The Global Burden of Disease study (IHME n.d.) points out that the disease burdens in many countries are shifting from communicable, nutritional and neonatal issues to non-communicable diseases (NCDs) (e.g. cardiovascular diseases, diabetes and depression). It is in the prevention of NCDs that living near the ocean may offer important but often unrecognised human health benefits.

Coastal residents are more likely than inland dwellers to meet the recommended levels of physical activity (Pasanen et al. 2019) that reduce the risk of many NCDs. After correcting for income and other factors, longitudinal studies show that moving to the coast is associated with sustained improvements in mental health (White et al. 2023). Several multi-country studies show that because of these and other factors (e.g. generally lower levels of air pollution), people living nearer the coast report better overall health (Elliott et al. 2023; Geiger et al. 2023).

The benefits of residence near the coast appear to be particularly strong among poorer communities with high levels of environmental and socioeconomic disadvantage (Garrett et al. 2019), as well as during times of stress such as in financial downturns and the COVID-19 pandemic (Pouso et al. 2021). The disproportionate benefits of coastal residence are seen globally and are by no means restricted to the Global North (Maharja et al. 2023b) (see Case study 6).

In particular, research is beginning to show that communities living in and around MPAs and other areas designated as ‘protected’ experience diverse human health and wellbeing benefits, including decreased overall national mortality and improved child health as well as positive ecosystem impacts (Madarcos et al. 2021; Haque et al. 2023; Nowakowski et al. 2023). The research to date is also clear that collaborative and effective management of these areas with the ongoing involvement of local communities is essential to creating and sustaining these ocean and human health benefits (Ban et al. 2019; Gollan and Barclay 2020; Rasheed 2020).

For inland residents, the ocean is a key tourism destination (European Commission n.d.). Economists assume that the health and wellbeing benefits people derive from recreational visits and coastal holidays reflect the amount of time and money they invest in them (Börger et al. 2021). Thus, the $5 trillion spent annually on coastal and marine tourism (5 percent of global GDP) reflects the value visitors place on these benefits.

Many health professionals have a limited awareness of (or time to review) the mounting evidence that contact with the ocean can improve mental and physical health. Greater efforts to engage, motivate and secure buy-in from this influential group are needed (Depledge et al. 2019) (see Case study 7).

CASE STUDY 6. Thriving during the COVID-19 pandemic (Indonesia): The ocean as a source of solace in times of stress

Artisanal fishing is the predominant work in small island communities in Indonesia, and these communities rely on local coastal and marine ecosystems for their livelihoods (Maharja et al. 2023a). Emerging evidence indicates, however, that these ecosystems are important not only as a source of sustenance but also as a source of health and wellbeing.

For instance, despite their relative isolation, these communities were not immune to the stress and anxiety caused by the COVID-19 pandemic. Lockdown measures imposed during the pandemic resulted in economic loss, increased household conflict and diminished access to healthcare (Richter et al. 2021). However, engagement in ocean-based recreational activities by these communities during this challenging time, especially collective immersive interactions such as swimming and snorkelling, were shown to protect or ‘buffer’ people against adverse mental health outcomes (Maharja et al. 2023b) (Figure CS-6.1).

Put simply, the benefits of engaging in marine recreational activities for mental and social wellbeing are not restricted to affluent post-industrial societies in the Global North (Britton et al. 2020).

FIGURE CS-6.1. Ocean recreation as a buffer against the adverse mental health outcomes of COVID-19 lockdown restrictions
Photo credit:

Sainal.

CASE STUDY 7. The National Health Service and Healthcare Ocean: Positive action for ocean health

Healthcare locally and globally has significant unintentional negative impacts on ocean health. These include greenhouse gas emissions, pharmaceutical and plastic pollution, shipping and destructive land use.

Healthcare systems, both conventional and traditional, are also unique in their opportunity to support health and wellbeing within communities through place-based approaches that reduce inequalities in coastal and blue spaces. The benefits of connecting patients with nature (including the ocean) to improve physical and psychological health outcomes are becoming well established. Uniquely, the health sector can play a key role in advocating with local people and local authorities for improved blue space infrastructure and quality and for clean coastal waters that encourage physical activity and restore mental health. The health sector is also uniquely well qualified to identify those who could benefit the most from blue place activities, for example through ‘social prescribing’ programmes (‘blue prescriptions’) designed to enhance the health and wellbeing of community members.

The UK National Health Service (NHS) serves an island of over 67 million people, spending £32 billion a year with 80,000 global suppliers. It was the first global healthcare system to declare a climate emergency, aiming to be net zero by 2045 (including all supply chains). Within the first year of the Greener NHS Programme, the NHS reduced its emissions equivalent to powering 1.1 million homes annually. To date, the ambition of delivering a net zero NHS has focused predominantly on carbon (Figure CS-7.1).

Recognising that human health and wellbeing are inextricably linked to the health of both the ocean and waterways, a group of UK healthcare providers have started Healthcare Ocean (n.d.). The goal is to raise awareness of the interconnections between human and ocean health. They work with international shipping companies and NHS suppliers, as well as community and healthcare ‘blue prescription’ providers, towards sustainable, equitable and biodiverse approaches.

FIGURE CS-7.1. Scope 1, 2 and 3 emissions mapping for the UK National Health Service
Note:

CFCs = chlorofluorocarbons; CH4 = methane; CO2 = carbon dioxide; GHGP = Greenhouse Gas Protocol; HFCs = hydrofluorocarbons; N2 0 = nitrous oxide; PFCs = perfluorochemicals; SF6 = sulphur hexafluoride.

Source: NHS n.d.

Health risks of ocean degradation

Although potentially beneficial for human health and wellbeing, the ocean can also be a frightening and dangerous place for both visitors and residents of coastal communities, because of its vast size and specific threats (e.g. tsunamis, extreme weather), as well as the multiple and increasing stressors on ocean health. This is particularly true for Indigenous and traditional coastal communities at the ‘cliff face’ of the interactions between our rapidly changing climate and the ocean, as well as from pollution and socioeconomic inequalities.

Climate change and biodiversity loss

Climate change and biodiversity loss are already undermining the benefits of the ocean to human mental, physical and social wellbeing (Whitmee et al. 2015). Flooding, land erosion, rising sea levels and more frequent and violent storms pose a growing threat to the physical and mental health of coastal communities. A World Bank report on the West African countries of Benin, Côte d’Ivoire, Senegal and Togo estimates that pollution and flooding cause over 13,000 deaths a year; and that the total cost of coastal-related environmental degradation in 2017 was $3.8 billion, 5.3 percent of these countries’ GDP (Croitoru et al. 2019).

Hotter ocean temperatures resulting from global warming endanger delicate ecosystems such as coral reefs (Chaijaroen 2022). They also encourage invasive species, microbial pollution and harmful algal blooms (HABs) (Gobler 2020). For example, HABs jeopardise ocean and human health by contaminating seafood and exposing people to the natural toxins when they swim or even breathe inland air because these toxins can be aerosolised (Berdalet et al. 2016). In addition, HABs reduce recreational benefits and cause the loss of ‘cultural-ecosystem services’ by killing off iconic and locally culturally important species (Beaumont et al. 2008).

Pollution

Pollution is another great challenge confronting the ocean (Fleming et al. 2019), jeopardising both human health and ecosystems that up to 3 billion people depend on for their food and livelihoods, particularly coastal communities in the Global South. Land-derived pollutants include heavy metals, macro- and microplastics, pesticides, persistent organic pollutants, inadequately treated sewage, pharmaceuticals, antibiotics and excessive nutrients (e.g. nitrogen and phosphorus). These enter freshwater and marine systems (including contaminating food chains), mostly from urban, agricultural and industrial runoff and discharge. 

Pollution’s impacts occur far from the freshwater and marine ecosystems where pollutants are discharged, and many of these health impacts are poorly understood and underestimated. Furthermore, marginalised coastal communities already vulnerable to the impacts of climate change and socioeconomic inequality are disproportionately more likely to be exposed to pollutants from the ocean and other sources (Landrigan et al. 2020).

Known human health consequences of pollution exposure include skin and gastrointestinal infections, increased risk of some cancers, infertility and birth defects, neuro-behavioural toxicity, endocrine disruption and antimicrobial resistance (Landrigan et al. 2020). Accumulations on beaches of plastic waste (Beaumont et al. 2019) and microbial pollution can deter people from visiting the sea at all (Börger et al. 2021).

Socioeconomic challenges

Relatively poorer coastal communities may benefit most from interactions with the ocean (Garrett et al. 2019), and people living nearer the coast report better overall health (Elliott et al. 2023; Geiger et al. 2023). Nevertheless, a recent report by the United Kingdom’s chief medical officer (CMO) summarised the many challenges of coastal living, even in a relatively high-income country such as the United Kingdom. The report pointed out that compared to inland communities, coastal residents tend to have lower life expectancy and higher rates of many major diseases. In the United Kingdom, this is currently caused by, among other factors, older adults moving to the coast for retirement, difficulties in attracting medical and social care staff to peripheral communities, limited transport and only seasonal employment options (UK Chief Medical Officer 2021).

Coastal ‘gentrification’ (when more wealthy people move into seaside communities, often forcing out local populations) is another challenge to health and wellbeing. In many prime locations internationally, tourism and gentrification are pushing up property prices and rendering residential and other access to the ocean unaffordable (Freeman and Cheyne 2008). Yet in other contexts threatened by sea-level rises (e.g. the U.S. city of Miami) (Li and Grant 2022), higher-income households may be leaving coastal areas for higher ground, leaving poorer households vulnerable to potential harms from ongoing and future climate change.

Development and spatial planning

The UK CMO report highlights the medium- to long-term risks to the health and wellbeing of coastal communities resulting from economic growth that is neither environmentally nor socially sustainable. Over-development of fishing or tourism industries beyond local ‘carrying capacities’ may provide short-term economic returns but leads to significant future ocean and human health problems (Leka et al. 2022; Sun et al. 2022).

At the same time, protection measures for coastal ecosystems must ensure that the trade-offs, which can lead to inequitable benefit sharing (cf. Praptiwi et al. 2021), can be mitigated. Thus, the involvement of local coastal communities in the governance of marine areas through community participatory approaches with policymakers and scientists is required to ensure the sustainable future of both people and the ocean (Estradivari et al. 2022).

Planning policies that allow or even support richer citizens to move to, or have second homes by, the coast create further problems. They can make it increasingly difficult for local residents to afford homes in traditional coastal locations (much less access ocean benefits), leading to yearly boom-and-bust cycles of low-paid seasonal employment opportunities, in which many properties are empty for much of the year (Dykes and Walmsley 2015; Depledge et al. 2017).

The need to protect ‘high-value’ properties from coastal erosion can also lead to the construction of inappropriate coastal defences that simply shift the problem to other more vulnerable areas along the coast; or restrict public access, effectively privatising access to the coast, making it exclusively the playground of the wealthy and actively excluding local residents (Cooper and McKenna 2008; Reed 2009).

Current limitations and knowledge gaps

To date, much of the data on benefits are derived from research in the Global North, and much of this research has been short-term. There is a particular dearth of research looking at both the risks and benefits of the ocean for human physical, mental and social wellbeing in the Global South (but see Case study 6) (Rasheed 2020; Short et al. 2021).

One way to address this knowledge gap is to commission in-depth cohort studies which follow the health and wellbeing of specific ocean communities (particularly in the Global South and populations living in and around MPAs), as well as ocean health, over several years to understand how changes in local ocean conditions affect changes in community health over time. Such studies can yield valuable data, but they are expensive and can require many years to yield actionable findings.

Causal mechanisms

As with any environmental exposure, identifying causal pathways linking the ocean with human health is difficult against a background of multiple exposures, interacting mechanisms (including inter-generational impacts) and varying time from exposure to health impacts that range in time-scale from minutes to decades (Fleming et al. 2019). Mechanisms and effects must be clearly defined, plausible and testable. Clear definition requires measurement of various elements, including dose composition (i.e. the type of ocean contact), frequency (how often), duration (how long), intensity (how immersed), consistency (same dose over time) and passivity (whether participation is required).

Geographical evidence–action mismatches

Even when reasonably high-quality data exist, the geographical scales of ocean and health data may be incompatible with policy-action needs. For instance, the European Union has relatively joined-up multi-country data and policies with respect to ocean health, but human health data and policies primarily shape interventions at the member-state (country) or subnational level (H2020 SOPHIE Consortium 2020).

Ocean

Similar mismatches may existin countries where geographical units related to ocean management do not match geographical units related to health services. Marine protected areas, for instance, may reflect a relatively coherent ocean ecosystem but also include very different human communities from different countries, with very different access to healthcare services and consequently data on health outcomes.

Solutions to these problems will require more collaborative thinking among environmental scientists, health scientists, geographers, demographers, local communities and policymakers to ensure that right-scale ocean and human health data are available for the right kind of health actions and vice versa (Rasheed 2020). Co-created research with local communities (especially in the Global South) is particularly essential.

Generalisability: Scaling up and scaling out

Many studies showing health benefits of ocean interactions are small-scale, build heavily on local knowledge, experience and opportunities, and often rely on highly motivated individuals who persist in the face of numerous challenges (Britton et al. 2020).

Although they often provide useful information, it is frequently unclear how relevant these place-based results of one intervention are for other places and peoples (especially in the Global North versus the Global South) and how appropriate or feasible it is to scale up these interventions to larger populations and in different locations (see Case study 8).

Actions and opportunities

Assessing the feasibility and impact of high-level goals (e.g. to increase the amount of the ocean that is protected, or reduce depression rates within a country) is very difficult. It is often more realistic to assess the feasibility, timing and impact of specific attempts to operationalise these goals, either among specific populations and locations, or the generalisation of current good practices to other populations and locations (scaling up and scaling out).

Deliver on the Global Biodiversity Framework targets, among them to designate 30 percent of the ocean as MPAs by 2030, including working with local communities and OECMs (Gurney et al. 2021). This is critically important work for human health and wellbeing as well as for ecosystems, but timelines and mechanisms are yet to be decided. In particular, co-created longitudinal research and other activities with coastal communities living in and around MPAs and other protected areas are essential to examine and address the risks and benefits to both ocean and human health (Rasheed 2020; Madarcos et al. 2021; Haque et al. 2023; Nowakowski et al. 2023).

CASE STUDY 8. Blue health and wellbeing ‘prescriptions’: The Bay (Morecombe, United Kingdom)

Morecombe Bay is a large stretch of coastline in northwest England. Working closely with local Wildlife Trusts and the Eden Project, the Lancashire and South Cumbria National Health Service (NHS) Foundation Trust has established ‘The Bay’, an ocean-based wellbeing programme along the whole of the bay’s coastline.

Focusing on ‘blue social prescribing’, healthcare providers refer patients to programmes supported by and supporting different local coastal communities. The Bay programme offers a range of interventions, including treatment-focused specialist support for people with chronic mental health issues, through to more prevention-focused activities encouraging greater coastal use for people at risk of poor health.

Building on relationships established with referral partners, the Bay’s blue social prescribing programme is on target to support nearly 500 individuals most seriously impacted by social exclusion and isolation over the first two years of delivery.

The Bay programme’s broader ‘whole population approach’ brings together over 4,000 people every year with activities including litter picks, rockpool rambles for children and families, citizen science projects such as sea watches and monitoring reefs, and policy-focused actions including lobbying decision-makers. The health of the coastal marine environment is growing stronger as a result of the local communities’ becoming healthier and better connected (Figure CS-8.1).

Early social return on investment analyses suggests that every £1 invested in Bay activities brings £2.16 of benefit in terms of reduced costs of treating mental health-related conditions. This doubling of return is a conservative estimate: it does not consider the wider economic benefits of reducing unemployment, increasing visitors to the coastline and environmental cost savings from the positive work achieved (Wildlife Trusts 2023).

FIGURE CS-8.1. Outcomes of blue prescribing sessions
Source:

NAGHP n.d.

Use of nature-based solutions (NBS). Societal and local interventions tend to focus on making changes to the environment through urban planning or environmental management initiatives. When these involve supporting restoration or improvement of ecosystems, they are often referred to as ‘nature-based solutions’ (NBS). Individual-level nature-based actions tend to focus on supporting specific individuals with specific health-related conditions or behaviours (e.g. depression, anxiety, physical inactivity) and are often referred to as ‘nature-based therapies’ (NBTs). Many NBS are already in place to reduce stormwater coastal flooding and can be leveraged to create NBTs, such as local community engagement in mangrove-planting schemes in the Philippines, which can provide both individual and community benefits.

Reduce microbial, chemical, plastic, pharmaceutical, nutrient and other pollution at the source. An example is the European Chemicals Agency proposal to restrict production of perfluoroalkyl and polyfluoroalkyl substances to ‘essential uses’ only. Minimally identifying the sources and preventing ocean pollution from the land and the air is essential. This is also very relevant to the health sector (including the pharmaceutical industry), with its extensive chemical and carbon footprint internationally (Belkhir and Elmeligi 2019; Steenmeijer et al. 2022).

Promote ocean sustainable healthcare systems and practices. Conventional healthcare systems need to embed ocean health criteria in their climate strategies and to harness their influence with healthcare suppliers through procurement frameworks that address both climate and ocean criteria (such as pollution mitigation of plastic and pharmaceutical wastes) to protect ocean and human health (see Case study 7 and Case study 11). The health sector in the Global North can also learn from sustainable healthcare strategies in the Global South as well as from traditional and Indigenous medicine practices (Harris 2023).

Adopt a ‘human-health-in-all-policies’ approach for both local marine and terrestrial plans. As an example, the Motion for the Ocean programme is a model to help local authorities play their part in realising a clean, healthy and productive ocean and all its direct benefits for the economy, human health and societal wellbeing (LGA Coastal SIG n.d.). Ideally this ‘health-and-environment-in-all-policies’ approach would be adopted globally at all policy levels.

Ensure local community co-creation in all localised planning implicating the marine environment. An example is an interdisciplinary urban ‘blue acupuncture’ initiative to improve access to a local beach in a deprived community that was co-designed with local residents, schoolchildren, community actors and local government (Bell et al. 2020).

Upscale existing, and develop new, blue care prescription programmes. Upscale blue prescribing programmes that encourage participatory management with both individuals and local communities, prioritise underserved groups and contribute to ocean or coastal recovery (as shown in Case study 6 and Case study 8). A further benefit of these programmes is that they provide opportunities to support the health and wellbeing of marginalised groups (including people of colour), allowing them to re-engage with beaches and other high-quality blue spaces from which they have been excluded because of historical racial and other segregation or complete lack of access.

Upscale ocean literacy programmes, focusing on links between ocean and human health. Healthcare personnel interact with many people but are largely unaware of relationships between ocean and human health. Educated in ocean and human health, they could be important leaders and partners. To address the disparity of knowledge among healthcare personnel, ocean health could be integrated into professional development opportunities such as required continuing education training certification or Grand Rounds (Healthcare Ocean n.d.).

Youth are also an important target group for ocean literacy as part of their development as ocean citizens. As an example, the Australian state of New South Wales has developed educational materials for Year 10 Personal Development, Health and Physical Education (PDHPE) students titled ‘Moving Ocean’. This programme empowers individuals to support ocean health and is an excellent example of aligning personal health and ocean health curricula.

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