In recent years, a grassroots movement of physicians have begun prescribing time outdoors as the best possible treatment for a growing list of ailments, from anxiety and obesity to attention-deficit disorder and high blood pressure. Meanwhile, research institutes for nature and health are opening at major medical centers and a couple bold insurance companies are embracing the idea. For this third episode in our Nature Cure series, we sit down with science writer Aaron Reuben, who reported on this emerging trend for Outside magazine. The question now, he says, is what it will take to convince big health care that free medicine is the way of the future.
Outside Podcast Theme: From Outside Magazine and PRX, these are Dispatches, stories from our writers in the field.
Peter Frick-Wright (host): This May, Outside published a cover story titled, “Ask Your Doctor if Nature is Right for You”. And it was about the rapidly expanding grassroots movement of healthcare providers who are prescribing time outdoors as a treatment for all sorts of actual, diagnosable conditions.
Now, if you’re listening to this podcast, chances are you already get outside a lot and you know that it’s “right for you.” You probably think it’s right for everyone else, too, which is why you’re always rallying your family or friends to get off the couch and go for a hike or a ride or a surf.
Either way, what you probably don’t know is that the medical establishment is at last coming around to agreeing with you in a very serious and substantive and peer-reviewed way. And this has enormous potential for the greater health of our society.
So, for this third episode in our four-part series exploring the Nature Cure, we’re going to talk with Aaron Reuben, the scientist and journalist who wrote that Outside story, and also hear from one of his key sources, Dr. Nooshin Razani, a pediatrician who’s at the leading edge of the nature prescription movement.
Leading the conversation is Outside’s Michael Roberts, one of the editors who worked with Aaron on his story and one of the loudest voices on our staff calling for more coverage of the health benefits of time in nature. Mostly, I think, cause it helps him get his family and friends off the couch.
Michael Roberts: We work with a lot of writers at Outside, but Aaron Reuben—well, he stands out as being a bit different.
Aaron Reuben: My name is Aaron Reuben. I'm a PhD candidate in Clinical Psychology at Duke University.
Michael Roberts: That’s just the start of it. Or more like the end of it. You see, for years, Aaron had been a researcher in neuroscience labs, looking at how and why our brains decline as we age. He was particularly interested in the role environmental factors play in this process, because they aren’t well understood. This caused him to shift directions and start working on environmental policy.
Reuben: I looked at um, national air pollution policy. I interned at the White House Council on environmental quality. Um, I worked on an international project to restore forests for climate change.
Roberts: Eventually, Aaron went back to school at Duke, where his PhD thesis has him working in clinics that care for people with organic brain diseases. His research focuses on the environmental factors that influence brain health and function. And as a passionate outdoor athlete, Aaron is also an advocate for protecting the natural world. This has him on the lookout for stories that compel us to take better care of the planet—and that support his side hustle, as a journalist. A couple years ago, he was at a medical conference when this big story landed right in his lap.
Reuben: And at that conference I stumbled into a talk that a doctor was giving, a pediatrician who was named Roberts Zarr, and he was talking not about how nature is good for us, which was interesting to me, but he was talking about how he's getting his patients out in nature because he already knows it's good for us.
Roberts: Dr. Zarr, as it turned out, was a pioneer in a movement among doctors to prescribe nature to their patients suffering from a variety of problems—everything from anxiety to obesity to attention-deficit disorders.
After hearing Dr. Zarr speak, Aaron approached him to learn more about his work. Then Dr. Zarr put him in touch with other doctors writing nature prescriptions. Very quickly, Aaron realized this was a big trend and that new health programs were popping up all over to support it.
Reuben: So by the time I came into the picture, there were a number of very robust programs in existence where doctors were asking their patients to go outside, sometimes with very specific instructions, sometimes with actual transportation and guides. As soon as I started talking to them, they started putting me in touch with the people who had inspired them or the people who had turned them on to the idea in the first place. And I pulled back and realized that across the country there was a whole web of programs that were partly inspired by each other, partly new, and that no one had really been talking about in a big way. And that's when I thought, Gosh, this is a story that needs to be told right now and no one seems to be doing it, so I'm going to do it.
Roberts: As Aaron learned in the course of his reporting, the nature prescription movement had really begun around 2005, and in recent years it has been growing faster and faster.
Reuben: There are 71 distinct nature prescribing programs from health care centers in the U.S. I did some rough calculations to figure out how many patients that might be reaching. The best I could tell it's in the hundreds of thousands because across these 71 programs, some of them have 10, 15, some have 500 doctors enrolled in the program. And the average, primary care physician can have a panel of up to 2000 patients. So we have 71 programs now, we have potentially hundreds of thousands of patients who at least could be getting this kind of programming. The plan as far as I'm aware is for at least 10 new programs to open up next year. And if you were to draw a line of number of programs that had been opening over the last decade, it kind of looks exponential.
Roberts: But what does that growth really mean? Haven’t our doctors been telling us to get outside for some healthy fresh air ever since—well, ever since there were doctors?
Still, Aaron insists that there’s something very different is happening now.
Reuben: Really, if you look back across the sort of history of medicine in one way or another, doctors have been asking—sometimes pleading-- with their patients to go outside. Typically to get off the couch and move -- Hippocrates called walking man's best medicine.
What makes what we're seeing today different is first, it's a lot more widespread. In the past you've had sort of specific recommendations from the doctors in Victorian England who studied melancholy. They said, go to the countryside. We don't know why, but you'll do a little better. Or in the turn of the last century, doctors who had patients with tuberculosis would say, go and get fresh air in the mountains.Today, the kinds of doctor and nurse who will ask you to go outside as part of this new movement really spans every specialty. We have dermatologists, we have cardiologists, we have psychiatric nurse practitioners. We have pediatricians and physical therapists. It's really no longer confined to niche specialties. Also for probably the first time it is really trying to be evidenced based.
This movement has really grown out of 30 years of evidence accumulating to say that time spent in nature is going to be beneficial for blood pressure, for immune function, for ruminative thinking and mood, cognitive capacity.
Roberts: But as Aaron points out in his story, while a number of studies show that natural environments are good for us in all kinds of ways, there’s still very limited data demonstrating that these new nature prescription programs actually make a difference. That’s partly because this kind of research is just really expensive.
Reuben: There's really only one sort of common criticism that I've heard that kept coming up. And that was, this sounds cool, but I just don't think it will work. Where's your evidence that it is working? And I think that was a super valid criticism. Everyone acknowledges that we need evidence and it's now being gathered or applications are out to try and gather that evidence. And look, it's just really expensive. Robert Zarr has put in proposals to conduct randomized controlled trials of his park prescription program. The budgets that he's submitted are in the low millions.
Roberts: What this means is that a lot of doctors have had to write nature prescriptions on faith, which can make them uneasy. At least until they see the results.
Reuben: When I started talking to, particularly physicians, I always had a question for them, which was along the lines of, do you feel uncomfortable being the sort of nature doc in the room? Are you ever embarrassed or shy or what's that been like? And they all sort of to a person said, look, when I started, yes, I felt a little unsure. I wasn't, I wasn't sure how I'd be received. And every single one of them is, as soon as they got real feedback from their patients that either this was working or they were into it, every one of those physicians changed their tune and now they're all really open, they’re really excited. They're really aggressive about letting you know. I think nature is making a difference. I think it'll make a difference for you.
A good clinician in 2019 is a sort of showman. And in that sense, the folks I've met who are now what I'll call nature champions, are really good at that. They're really charismatic. They're really into owning this new idea.
Roberts:A great irony of the nature prescription movement is that the most effective tool a doctor has for delivering nature prescriptions to their patients is a phone. That’s right -- a health provider trying to get their patient to get outside and take a break from screens is likely going to provide their recommendations on a screen.
As Aaron notes, this actually makes a ton of sense. If a doctor tells patient to spend more time in nature, the conversation kind of ends there. But if a doctor and a patient pull up an app that shows green spaces near a patient’s home, and they pick a couple spots to try out based on whether they offer a trail or maybe a soccer field, and the doctor can input a prescription with a frequency and duration of visits, you have a bonafide medical tool.
The Park Rx America app, which Dr. Robert Zarr helped launch, has been adopted by providers in 17 states. Between May 2018 and May 2019, doctors used it to write some 1200 prescriptions. And there are many others apps out there like it.
Reuben: And some of the cool programs now can actually allow the patients to give feedback to their doctors when their prescription is filled. I went here at this time and this happened. And then in an ideal world that doctor and the patient will start to slowly over time refine this treatment plan so that they're running in a trail three times a week, but once a month they're doing what would be more of a meditation oriented mindfulness sort of walk. There's lots of different ways we can envision this and the movements trying to be very flexible.
Roberts: We’ll be right back
Roberts: In the course of his reporting, Aaron met a number of champions—his term for the doctors that had become such fervent believers in the healing power of nature that in addition to prescribing time outside to their patients, they were encouraging other doctors to join the movement.
Reuben: I always asked every champion that I met: What got you into this? You know, you're really an odd ball at this point in terms of, you know, mainstream medical system. And what's cool about the movement is it is mainstream providers who are embracing this. I mean really in every state pretty much. Um, these are mainstream providers, but they're still on the leading edge of things. And so always ask them what brought you into the nature arena. And they all had different stories that were interesting. And I just really think about Greg Anderson.
Roberts: Greg Anderson is a primary care physician based in Washington State. In 2018, he wrote 165 nature prescriptions.
Reuben: He started his medical career as a navy doctor on an aircraft carrier -- I believe he was stationed for several months off the coast of Pakistan. And in that capacity he would routinely see [the] ship's crew, who lived and worked below the sea level basically, who just looked like death. They would come in and they would say, doctor, I feel terrible. I'm depressed, I've gotten no energy. I must have the flu or something. And he would do some blood work. And really, maybe they were a little anemic, but nothing, they didn't have any distinct diagnosable condition. And he would ask them, when was the last time you saw the sun? And they would say, doc, I don't know, three weeks.
This really made an impression on Greg Anderson. He sort of saw the consequences of extreme nature deficit and he doesn't really connect his new interests to that, but he'll readily tell you that his intervention for these people at the very start of his career was just go and stand at the back of the ship where there's a little opening, and just get some nature exposure. And people wouldn't turn on a dime, but he said it really helped them and that really opened his eyes to the fact that maybe we need a little time outside and maybe it needs to be regular.
Roberts: One of Dr. Anderson’s patients is a professor at Eastern Washington University in his mid sixties, who, not so long ago, wasn’t very healthy. He was overweight with high blood sugar and high blood pressure, and on a track towards diabetes. So Dr. Anderson came up with a two-pronged prescription. First, the professor had to start counting calories. And second, he needed to go outside and get some movement.
Reuben: He had tried to lose weight in the past, mostly by going to gyms and logging hours on treadmills and it just had never worked for him. His lifestyle was very sedentary, [he] told me he watched a lot of TV. He sat for work, not at all an atypical American. Right. But he found that just walking in the woods was easier for him to keep up this habit than going to the gym. He just wanted to go out. But he found that each time you went out into the woods, he was staying longer and longer and eventually started walking faster and he started to jog a little and then he started to jog longer and, by the time I was talking to him, he was going out on trails more than three times a week, sometimes for an hour at a time and jogging. And across a six month window from the time he first had a conversation with his doctor about the need to lose weight and intervene on where he was headed, to the time I spoke to him, he ended up losing 60 pounds, his blood sugar went back to normal, his blood pressure went back to normal, and he actually could go off the blood pressure meds he had had to start before. If you ask him what made the difference, he says, look, the calorie counting helped. There's no question that got me going. But he says, if I didn't have a trail nearby, I never would have done what I did.
Roberts: A trail nearby—that’s the catch. A big challenge with nature prescriptions is that many of the people who would benefit most from more time outside have the hardest time getting to a park that offers a trail or even just a quiet grove of trees.
Nooshin Razani: So the question of whether nature should be a prescription, or a clinical intervention, is actually a really interesting one.
Another one of the doctors that Aaron spoke to was Nooshin Razani, a pediatrician based in Oakland, California, where she founded the The Center for Nature and Health at the UCSF Benioff Children’s Hospital. Many of her patients are low-income and live in urban communities with no immediate access to green spaces. She recently spoke at an event in the Bay Area focused on rewilding American kids that was put together by Outside and the Commonwealth Club, and her main point was that simply prescribing time in nature to people in these communities doesn’t do anything for them. We also need to provide the resources that actually help them get the medicine.
Razani: We were approached by East Bay regional parks with that idea of writing prescriptions for nature. And I have to say that I was part of a group of physicians that gave a huge pushback and I still push back when people say that because really, access to nature is a public health issue, especially in the East Bay where less than 10% of all the total tree cover is in the flatlands, which is also the area where you have the lowest life expectancy and the most chronic illness. To think that a piece of paper for me, or recommendation to go outside, will somehow tip all those imbalances was not only naive but just a little tiring as a primary care provider.
So the clinicians pushed back and we said, We're not going to write nature prescriptions. You need to make more parks where our patients live. But we were very lucky because East Bay regional parks were amazing partners and they said yes and, and they kept wanting to know more and to address whatever barrier we raised. So first we said, you need to bring nature to our patients. And so they actually decorated our entire clinic with local parks in the patient rooms. They put up these like 16 foot posters of redwood for us. And that was amazing because it allowed nature to speak for itself essentially. Then we also said what people need a ride. And if we go out into nature, you have to feed people. And we need a naturalist with us because this is a new territory for many families. And they said yes to all of those things.
Roberts: Now, five years later, Dr. Razani and her colleagues have led 73 nature outings for UCSF patients and their families. One day a month, they bring around 50 people into the Redwoods or maybe take them fishing on the San Francisco Bay. They also write nature prescriptions for their patients and provide maps identifying local parks. According to research results that Dr. Razani reported in a medical journal last year, the patients have shown small but statistically significant improvements in their physical and mental health. They are less stressed and more resilient.
Dr. Razani’s activist approach to healthcare is all the more impressive when you consider the fact that her group is actually billing for their nature visits.
Money, as is often the case, is the crux of the challenge. As Aaron Rueben explains it, no pharmaceutical company or hospital network is going to profit from nature prescriptions. So what industry is going to want to invest in these programs?
Reuben: There is someone who cares and that’s the insurance companies. Because for every person who's a little less sick, they're going to make more money and they’re going to save costs. So I think insurance is the place we should be looking for the innovations in the next few years. And my answer to the question of why insurance isn't jumping all over it yet is the chicken and egg. I think they're probably waiting for some of the evidence that we still don't quite have funding for. But some insurers are dipping their toes in the water.
One of the most exciting things I saw just at the end of 2018, one insurance company, Blue Cross Blue Shield in North Carolina. For the first time as far as I can tell anywhere had begun providing a financial incentive for clinics to participate in a regional nature prescription program. So in North Carolina as of April 2018, if you sign up to hosts a trek trails program in your clinic, which is a local nature prescription program that has a lot of trails connected and they've sort of gamified nature and they've got really great images and prescription notices, particularly oriented to kids. If your clinic signs up to host that you're going to get points in a system that brings you to potentially receive greater reimbursement for service rates.
Roberts: According Trek Trails, as soon as that incentive was put into place, demand for the program went into overdrive. They had a hard time getting all the prescription pads and brochures out to clinics that were asking for them. More than a hundred clinics had signed up for the program.
Blue Cross Blue Shield told Aaron that they were trying out Trek Trails because they saw it as an opportunity to address what are known as the “social determinants” of health.
Reuben: These are the parts of health that we know have nothing to do with your access to health care. It's your lifestyle. It's the quality of your neighborhood. It's the quality of the food you get to eat. Things that we know actually make a huge difference for health outcomes. And that's why particular people in particular plans can have gym memberships covered. I have friends who can get reimbursements for athletic equipment from their insurer. Insurers are getting it for exercise and there is some evidence that they're starting to get it for time outdoors.
Roberts: Before you get too excited, keep in mind that our health plans will likely never cover our rafting trips or lift tickets at ski mountains. But that’s ok—because those kinds of more ambitious adventures aren’t really what the nature prescription movement is all about. If you’re already running rivers and skiing powder, you’re probably getting your required doses. For Doctors like Robert Zarr and Greg Anderson and Nooshin Razani, the goal is to make this medicine commonplace for everyone.
In the conclusion to his Outside story, Aaron wrote that great advances in healthcare often come about through collective efforts for change—involving not just healthcare providers but also journalists, insurers, park agencies, and conservationists. To reconnect us with things we’ve discarded that are really good for us. Food that wasn’t developed in a lab. Face to face conversations. More time outside.
Reuben: It's hard to get really excited about something that isn't killing people right now, but might be making them sad or anxious or less likely to achieve the goals or things they want in their life. I think the onus is on all of us to sort of have a grander vision for how society in life could be different if we're spending more time in nature.
Frick-Wright: That’s Michael Roberts and Aaron Reuben talking about the nature prescription movement. You can read Aaron’s feature as well as a number of other stories exploring the intersection of nature and health at outsideonline.com/naturecure.
Thanks to the Commonwealth Club for collaborating with Outside to host “Rewilding the American Child” back in May and for sharing audio from the event. You can listen to the full conversation with Nooshin Razani, Michael Roberts, and author Florence Williams at https://commonwealthclub.org.
This episode was brought to you by Adidas. And the new Terrex Free Hiker. They’ve sponsored this whole series, which concludes in a few weeks.
The Outside Podcast is a production of Outside Integrated Media and PRX.