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Ecosystem Services and Human Health

Summary and Keywords

Ecosystem services refer to benefits for human societies and well-being obtained from ecosystems. Research on health effects of ecosystem services have until recently mostly focused on beneficial effects on physical and mental health from spending time in nature or having access to urban green space. However, nearly all of the different ecosystem services may have impacts on health, either directly or indirectly. Ecosystem services can be divided into provisioning services that provide food and water; regulating services that provide, for example, clean air, moderate extreme events, and regulate the local climate; supporting services that help maintain biodiversity and infectious disease control; and cultural services.

With a rapidly growing global population, the demand for food and water will increase. Knowledge about ecosystems will provide opportunities for sustainable agriculture production in both terrestrial and marine environments. Diarrheal diseases and associated childhood deaths are strongly linked to poor water quality, sanitation, and hygiene. Even though improvements are being made, nearly 750 million people still lack access to reliable water sources. Ecosystems such as forests, wetlands, and lakes capture, filter, and store water used for drinking, irrigation, and other human purposes. Wetlands also store and treat solid waste and wastewater, and such ecosystem services could become of increasing use for sustainable development.

Ecosystems contribute to local climate regulation and are of importance for climate change mitigation and adaptation. Coastal ecosystems, such as mangrove and coral reefs, act as natural barriers against storm surges and flooding. Flooding is associated with increased risk of deaths, epidemic outbreaks, and negative health impacts from destroyed infrastructure. Vegetation reduces the risk of flooding, also in cities, by increasing permeability and reducing surface runoff following precipitation events.

The urban heat island effect will increase city-center temperatures during heatwaves. The elderly, people with chronic cardiovascular and respiratory diseases, and outdoor workers in cities where temperatures soar during heatwaves are in particular vulnerable to heat. Vegetation and especially trees help in different ways to reduce temperatures by shading and evapotranspiration. Air pollution increases the mortality and morbidity risks during heatwaves. Vegetation has been shown also to contribute to improved air quality by, depending on plant species, filtering out gases and airborne particulates. Greenery also has a noise-reducing effect, thereby decreasing noise-related illnesses and annoyances. Biological control uses the knowledge of ecosystems and biodiversity to help control human and animal diseases.

Natural surroundings and urban parks and gardens have direct beneficial effects on people’s physical and mental health and well-being. Increased physical activities have well-known health benefits. Spending time in natural environments has also been linked to aesthetic benefits, life enrichments, social cohesion, and spiritual experience. Even living close to or with a view of nature has been shown to reduce stress and increase a sense of well-being.

Keywords: ecosystem services, health, urban green space, natural hazards, heatwaves, climate, air pollution, food security, water safety, noise reduction

The Importance of Ecosystem Services for Human Health and Well-Being

The term ecosystem services was originally coined in the late 1980s in order to communicate and put a value on the importance of nature for human societies and human well-being (Daily, 1997; Millennium Ecosystem Assessment, 2005). An ecosystem is a functional unit of interacting plant, animal, and microorganism communities and their physical environment. Benefits gained from ecosystems, that is, ecosystem services, include: products, such as food and water obtained from ecosystems; services provided by ecosystems through their regulating processes, for example, the regulation of air quality and local climate; supporting services of ecosystems, for example to maintain biodiversity; and cultural services, such as recreation and aesthetic considerations. The study of health benefits of ecosystem services is an emerging research field. Focus has so far primarily been on the positive effects on physical and mental health and well-being from spending time in nature or having access to urban green space (Elmqvist et al., 2013). However, nearly all of the different ecosystem services may have impacts on health, either directly or indirectly. For example, the ecosystem service “food production” contributes to better health from increased food security and positive effects on the immune system, but it also affects health indirectly by providing livelihoods. In addition, urban farming in high-income settings may contribute to mental health and well-being through social cohesion, interactions, and sense of space.

Within public health sciences and the medical sector, the concept of ecosystem services and health has up till now been rarely discussed. Negative relationships between ecosystems and human health are, however, well known in areas concerning, for example, the epidemiology of zoonosis and vector-borne diseases. Other scientific disciplines have focused on the importance of nature and vegetation for, for example, the reduction of disease drivers, such as heat and air pollutants. Furthermore, there have also been studies of the negative health effects of several conditions that ecosystem services can partly help protect against, such as extreme events, water shortage, air pollution, noise, and heat waves. By creating a framework that integrates information from various fields of knowledge, further understanding of health benefits from ecosystem services can be developed. Such information is important for local stakeholders and policymakers, for example, in areas such as sustainable urban planning and green infrastructure.

The following description of health benefits of ecosystem services is based on well-established classification frameworks of ecosystem services from the Millennium Ecosystem Assessment (2005), The Economics of Ecosystems and Biodiversity (TEEB, 2011) and the Common International Classification of Ecosystem Services (CICES).

Provisioning Services and Impacts on Food Security and Water Safety

Provisioning services include products obtained from ecosystems, in particular food and water but also medicinal plants.

Food security and adequate nutrition are of fundamental importance for people’s health and well-being. By 2015 it could be concluded that the Millennium Development goal on poverty and hunger eradication had been achieved in many countries. The percentage of chronically undernourished in the world had decreased from about 19% in 1990–1992 to about 11% in 2012–2014 according to the statistic division of the Food and Agriculture Organization of the United Nations (FAO). Still, the world is faced with a huge challenge—to eradicate current starvation and stunting as well as to feed a rapidly growing population not only in terms of calorie intake, but also providing adequate nutritious contents. More and more attention is now put on sustainable food production in both marine and terrestrial environments. In addition, with the foreseen rapid global urbanization, in particular in Asia and Africa, urban farming will become an area of increasing interest. Most cities today produce only a small share of the food consumed by their citizens. However, urban farming is important for food consumption in many cities in low-income regions. In some cities, locally grown vegetables and staple foods, such as rice, account for the majority of such foodstuff consumed, which has been shown in, for example, Tanzania and Lao People’s Democratic Republic. In addition, during economic and political crises, urban food production has been shown to play an important role for food security (Barthel, Folke, & Colding, 2010).

Water is essential for life on Earth. Water used for drinking, irrigation, and other human purposes is captured, filtered, and stored by ecosystems, such as forests, wetlands, and lakes. Vegetation cover and forests in the catchment areas influence the quantity and quality of available water. Billions of people still lack access to safe water that is reliably and continuously delivered in sufficient quantities. Improvements have been achieved and the world met the Millennium Development Goal drinking water target, with 2.3 billion people around the world gaining access to an improved drinking water source between 1990 and 2012, according to The UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water (WHO & UN-Water, 2014). During the same time, the number of children annually from diarrheal diseases was markedly reduced from 1.5 million to just over 600,000 (WHO & UNICEF, 2014). Diarrheal diseases are strongly associated with poor water, sanitation, and hygiene. However, 748 million people still lack access to an improved drinking water source, and of these almost a quarter rely on untreated surface water (WHO & UNICEF, 2014).

With a rapidly growing global population, ecosystem services and associated land areas that provide safe drinking water as well as irrigation waters for food production will become even more important to maintain and expand; for further details see the section “Waste Treatment and Sanitation.”

Medicinal Plants

Traditional use of herbal medicine is still an integral part of many cultures. Some medicinal plants have well-known medical properties, whereas others are less well documented. In 2003, the World Health Organization published an evaluation on medicinal plants with guidelines on good agricultural and collection practices, and a focus also on sustainable use and cultivation for the protection of medicinal plant species (WHO, 2003). Protection of forest ecosystem diversity, in particular in subtropical and tropical regions of the world, is important for the continued collection of medicinal plants. Ecosystem protection is important not only to avoid the risk of extinction of known medicinal plants, but also to protect plant species that have healing properties still unknown to the global society, and which could be of great value in the future.

Regulating Services and Impacts on Health

Regulating services encompass benefits obtained from regulation of ecosystem processes, and include a range of ecosystems services of direct or indirect interest for human health and well-being, such as moderation of extreme events, runoff mitigation, waste treatment, local and global climate regulation, air purification, and noise reduction.

Climate Regulation

Climate change will have numerous impacts on human health and well-being depending on local conditions and vulnerabilities. Directly, heat waves and other extreme climate-related events, such as floods and storms, may cause deaths, injuries, and exacerbate diseases, such as cardiovascular and respiratory diseases. Indirectly, the effects of climate change on ecosystems, infrastructure, and societal services will contribute to a range of negative impacts on people’s health, livelihoods and well-being: for example, changes in the geographical distribution of vector-borne diseases (such as dengue fever and Lyme disease), epidemic outbreaks of water- and food-borne diseases, the emergence of new diseases, stunting and disorders related to undernutrition, mental diseases, and increases in morbidity of chronic diseases (IPCC, 2014).

Terrestrial and marine ecosystems play an important role in regulating climate. They currently absorb roughly half of human-made carbon emissions. For example, trees act as sinks of carbon dioxide, CO2, by storing excess carbon as biomass. Biodiversity and ecosystem services are important to reduce vulnerability and increase resilience, but can also be used to adapt to and mitigate climate change, thereby reducing negative impacts of climate change on health, both at present and in the future.

Moderation of Extremes Will Become Increasingly Important in Disaster-Prone Areas

Many densely populated areas around the world are located in coastal regions, which put their inhabitants at risk from extreme hazards like storms, floods, and tsunamis. In addition, climate change will increase the frequency and intensity of climate-related extremes in many disaster-prone areas, thus further increasing the risk of deaths and other health hazards, both in immediate relation to an extreme event and in the aftermath. Floods are by far the most commonly occurring natural disaster worldwide, followed by storms. However, during the period 2004–2013 storms killed more people, followed by extreme temperatures and flood events, according to disaster statistics collected by the Centre for Research on the Epidemiology of Disasters, CRED (Guha-Sapir, Hoyois, & Below, 2014). Single events may lead to devastating effects and a large number of deaths, like the Indian Ocean tsunami in 2004, with 226,408 fatalities, and the cyclone Nargis in Myanmar in 2008 that caused 138,366 deaths.

Sustainable disaster risk management and vulnerability reduction in disaster-prone areas, in particular in coastal regions, should be based on a combination of built infrastructure (e.g., breakwaters and dykes) and solutions benefiting from the protective capacities of natural ecosystems (Costanza, Mitsch, & Day, 2006; Depietri, Renaud, & Kallis, 2012). Coastal ecosystems such as wetlands, mangroves, deltas, and coral reefs act as natural barriers buffering storm surges and flooding. Restoring or replanting wetlands and mangrove close to coastal settlements can, for example, markedly reduce the risk for deaths, negative health impacts, and material damage caused by extreme events (e.g., Danielsen et al., 2005).

Runoff Mitigation and Decreased Risk of Flooding

Vegetation cover is important prevention against flooding, landslides, and soil erosion. In forests, only about 13% of rainwater is lost to surface runoff, whereas in cities with a large part of the surface being impermeable, excessive rainwater can cause severe flooding if the stormwater collection system is underdimensioned. Climate change may further increase the risk of flooding in many vulnerable urban as well as rural areas. Flooding may cause drowning and injuries; shortage of food and safe drinking water with increased risk of water- and food-borne outbreaks; and increase the risk of outbreaks of malaria and dengue fever in endemic areas from stagnant water that facilitates insect breeding, in combination with destroyed homes that leave people more exposed to mosquito bites. Flooding may also have a range of health impacts from damaged infrastructure, nonfunctional societal services, and impaired livelihoods.

Vegetation stabilizes the soil and reduces surface runoff following precipitation events. The risk of landslides, as well as the pressure on drainage systems around human settlements, is thereby reduced. By increasing vegetation cover and reducing the impermeable surface area in built environments, the volumes of surface stormwater runoff can decrease, thus decreasing the vulnerability to flooding. Increased urban green space will thus increase permeability and water runoff mitigation, as well as decrease flood risk by intercepting rainwater.

Waste Treatment and Sanitation

Access to sanitation is, together with access to safe drinking water, the most effective prevention against diarrheal diseases and associated childhood deaths in low-income regions. Currently more than one-third of the world’s population live without basic sanitation facilities, and one billion people, of whom 90% live in rural areas, practice open defecation. It is estimated that 1.8 billion people use drinking water sources that are contaminated with fecal matters (WHO & UN-Water, 2014). Ecosystems store and treat solid waste and wastewater. Solid waste is treated by natural storage capacities and bacterial decomposition. Wetlands and aquatic ecosystems filter out and decompose organic matters in wastewaters through dilution, assimilation, and chemical recomposition (TEEB, 2011). In some areas, wetlands may create breeding sites for disease-transmitting insects. In particular, the Anopheles mosquito species that transmits malaria and the Culex species that is responsible for the transmission cycle of West Nile virus between bird reservoir species and humans require areas of stagnant waters for breeding. This will, in some areas, create a trade-off that has to be considered when planning for new wetlands for waste-water treatments.

Counteracting Heatwaves and Saving Lives

Heat and heatwaves are predominantly hazardous for people with chronic respiratory and cardiovascular diseases, the elderly, and vulnerable people who for several reasons will have difficulties implementing heat-reducing actions during a heatwave (IPCC, 2014; Kovats & Hajat, 2008). Heat waves and cities are a particularly risky combination since temperatures in certain parts of a city can become several degrees higher than in surrounding periurban and rural areas, due to the so-called urban heat island effect. It has been shown that the risk both of death and of acute episodes of chronic illnesses, such as acute respiratory illness, heart attacks, and stroke, increases markedly in relation to heatwave events (Michelozzi et al., 2009). It is well known that air pollution increases the risks associated with heat, and vice versa. This has been shown, for example, for several European cities during recent heat-wave events. Increases in mortality and morbidity in respiratory and cardiovascular diseases were also observed during the event in Russia in summer 2010 when a severe drought causing wildfires with smoke blanketing the region occurred simultaneously with a prolonged heat wave (Shaposhnikov et al., 2014). In parts of the world where ambient temperatures may soar during heat waves, outdoor workers, in particular in cities, will also be at risk (IPCC, 2014).

Urban green areas and waters, such as city gardens and ponds, and nearby forests, lakes, and sea, have strong capacity to locally buffer heat extremes (Hardin & Jensen, 2007). In summertime, ambient high temperatures are absorbed by water areas. Urban green areas and vegetation also help in reducing heat stress. Greenery, in particular trees, reflects solar radiation and lower temperatures locally through evapotranspiration and shading (Bowler, Buyung-Ali, Knight, & Pullin, 2010). By increasing urban vegetation through planting of trees, creating parklands, green rooftops, green walls, and so on, local temperatures in cities will be better regulated and maintained.

Air Purification for Better Health

Air pollution from transport, industry, domestic heating, and waste incineration is a major, well-known problem for human health. Air pollution may also originate from large-scale land-use changes that cause removal of vegetation and exposure of the soil, thus contributing to dust and sand storms that are also linked to severe health problems, such as the dust storms regularly blanketing the Beijing area, for example. Exposures to air pollution increase the risk of asthma, chronic obstructive pulmonary disease, heart disease, and stroke. Ambient air pollution also increases the risk of premature deaths from respiratory and cardiovascular diseases, and is responsible for 6.7% of all deaths worldwide each year, according to the Global Health Observatory database at the World Health Organization (WHO).

Vegetation and, in particular, certain tree species contribute to improved air quality by filtering out gases and airborne particulates through their leaves, especially for pollutants such as ozone (O3), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and above all particulate matter smaller than 10µm (PM10) (Bowler et al., 2010). Air pollution removal capacity varies between plant species and follows daily variation—at night the plant stomata are closed and do not absorb pollutants—as well as monthly variations due to changes in light hours and the shedding of the leaves (Bowler et al., 2010). However, there is a tradeoff to be considered. Even if a plant species is effective in reducing air pollutants, it has to be balanced against how allergenic its pollen is.

Noise Reduction

Noise pollution has several adverse health effects, associated with conditions such as disturbed sleep patterns, psychophysiological consequences, reduced performance and annoyance responses and changes in social behavior, and cardiovascular symptoms (WHO, 2011).

Vegetation helps in reducing noise pollution. Plant barriers can decrease noise pollution, from traffic and other human activities, through absorption, deviation, reflection, and refraction of sound. Sound is absorbed by all parts of a plant, with trees and bushes having many branches and thick, fleshy leaves being the most effective (Fang & Ling, 2003). Noise barriers may cause noise to be bounced away, and sometimes to be reflected back toward the source. A common way to refract noise is by planting clinging vegetation on walls and onto nonvegetation noise barriers and by laying out lawns. Multiple rows of trees are more effective for noise reduction than a single tree layer, preferably with smaller evergreen shrubs, plants, and grass underneath.

Biological Control

Ecosystems are important for regulating plant, animal, and human diseases spread through microorganisms, insects, arthropods, rodents, and larger animals. Predators and parasites, such as larger predator animals, birds, bats, wasps, frogs, and fungi all contribute to a natural control. By using an understanding of ecosystem structure and function, biological control can be used for both natural and managed ecosystems in order to take care of or prevent disease outbreaks.

Traditionally, in some cultures, biological control has been used to control diseases such as malaria by adding insect larvae predators to stagnant waters. Small mosquito-eating fish are in some regions added also to smaller water pots and ponds in cities and near human settlements to control the container-breeding Aedes species that transmits dengue fever and chikungunya fever, in particular, in urban and periurban environments. Biological control is now being adopted in many places during the periods of the year when outbreaks of insect-transmitting diseases may occur.

Supporting and Cultural Ecosystem Services

Ecosystems provide habitat for different plant and animal species, contribute to maintaining biodiversity, and support the different ecosystem services. Human interference in ecosystems, both through local activities and through changes in global systems such as the climate system, may cause changes in biodiversity. This may in turn affect species composition and contribute to the emergence of new diseases (i.e., a negative impact on health) and in some cases to the disappearance of disease (i.e., a beneficial health effect).

Cultural services could be described as nonmaterial benefits obtained from ecosystems, and include recreation, tourism, aesthetic benefits, spiritual experience, sense of place, and social cohesion. Spending time in nature is proven important, and has many health benefits associated with recreational, aesthetic, and spiritual aspects.

Recreation, and Physical and Mental Health

Using nature for recreational purposes and for physical activities has many verified positive effects on health. Beneficial effects of physical activities are well documented. Regular physical activity helps control weight; keeps bones, joints, and muscles healthy; decreases the risk of cardiovascular diseases, such as heart disease and stroke; and reduces the risk of type-2 diabetes. Physical activity performed on a regular basis has also been shown to provide better sleep, and help maintain thinking, learning, and judgment skills at older age, and it has been suggested that it reduces the risk of depression.

Spending time in the natural environment or human-made gardens is not only of importance for physical recreation and stress reduction, but has benefits that are less easy to measure, such as a sense of peacefulness and tranquility. In urban environments access to parks and green space has been shown to contribute to mental balancing and peacefulness, as well as to a sense of place and social cohesion and interaction (Maas, van Dillen, Verheij, & Groenewegen, 2009). The importance of urban parks and gardens for recreation varies and depends on several criteria, including accessibility, penetrability, privacy, comfort, and safety, but also on sensory disturbing factors such as noise pollution and heavy littering.

Aesthetic Benefits, Life Enrichments, Social Cohesion, and Spiritual Experience

Nature plays an important role as a provider of aesthetic and psychological benefits that enrich human life with meanings and emotions (Chiesura, 2004). Aesthetic benefits from urban green spaces have been associated with reduced stress and with increased physical and mental health (van den Berg, Maas, Verheij, & Groenewegen, 2010). Even living close to or with a view of nature has been shown to be linked to fewer stress-related health problems and better restoration (Stigsdotter et al., 2010). Studies have found that a view through a window onto green spaces could accelerate recovery from surgery, and that the proximity of an individual’s home to green spaces is correlated with fewer stress-related health problems and a perception of well-being (Ulrich, 1984; van den Berg et al., 2010). The use of urban green space, such as urban community gardens and other activities that enhance a sense of place, social interactions, and the strengthening of neighborhood participation, has been shown to have beneficial mental health effects (Elmqvist et al., 2013).

In many cultures, features such as specific trees, forests, caves, and mountains are considered sacred. Nature is deeply embedded in many religions and customs, and thus contributes to a sense of belonging as well as spiritual experience.


The concept of ecosystem services was originally used by ecologists and economists to illustrate the value of natural capital and processes for human societies and human well-being. A new way of thinking was developed. If an environment was changed for human needs, for example clearing of land for human settlements or for industrial purposes, what natural services were then lost? What infrastructure and what human-made processes were needed in order to gain the same services and products that terrestrial and marine ecosystems naturally provide? What would be the cost for society when human structures and services had to be constructed or initiated in order to gain the same ecosystem services outcomes previously provided by a piece of land, a forest, a wetland, a sea, a river, or a lake? This was a revolutionary way of thinking back in the early 1980s. Before that, natural environments were thought to mainly be of use to human societies if they were transformed and changed for specific purposes, except perhaps for recreational activities, such as hiking, mountain climbing, canoeing, swimming, and so on.

Nature and ecosystem services affect not only human societies and well-being but also human health. This is a research area that needs to be further explored. Understanding how ecosystems services are linked to human health could help to lower the burden of disease and subsequent costs for both society and the individual through protection of ecosystems, building of resilience, and creating sustainable solutions.

Even though there is a growing evidence base of the many positive interactions between ecosystem services and human health, many research gaps still need to be addressed. It is neither possible nor of interest in this context to provide a long list of research areas that need to be further explored. However, some general areas for future research have been identified to support the need for a better understanding of the importance of ecosystem services for improved health and well-being, and to decrease the global burden of disease and associated costs.

Interdisciplinary Research

In addition to basic research on specific relationships and processes, interdisciplinary research is often needed to provide a better understanding of how different ecosystem services may impact human health. A diversity of different research areas needs to be covered depending on which ecosystem service is under study, which human health impact or which potential solution is being considered. Interdisciplinary research on such topics will include collaborations—often with local stakeholder involvement—for example, between disciplines as different as climatology, ecology, botany, hydrology, disease epidemiology, entomology, psychology, social and political sciences, economics, architecture, and agriculture sciences.

Cross-Sectoral, Sustainable Ecosystem-Based Solutions with Health in Focus

The global population is projected to reach more than nine billion by 2050, and with more people together with improved socio-economic conditions in many parts of the world, the global demand on food, water, and natural resources will increase. Large-scale population movements are also expected and a rapid urbanization is anticipated, particularly in many low- and middle-income countries in Asia and Africa. Sustainable development and ecosystem based solutions will, thus, become more and more important. The UN Sustainable Development Goals that were adopted by the world’s countries on September 25, 2015 point toward the importance of using ecosystem services as a way to develop sustainable solutions in many areas. By further exploring the potential use of ecosystem services for health benefits and disease prevention, global health and well-being for both present and coming generations could, thus, be sustainably maintained and improved.

Sustainable solutions and preventive measures for global public health can be developed based on the knowledge about possible linkages between ecosystem services and health. Risk, adaptation, and mitigation assessments with a focus on ecosystem-based solutions for both improved health and disease prevention should use scientific and best-practice knowledge from different academic disciplines and societal sectors with early stakeholder involvement. Cross-sectoral collaborations will most often be needed for the implementation of ecosystem-based solutions, and civic engagement is often desirable. Such collaborations could involve sectors at the local level focusing on different topics such as public health, natural resources management, urban planning, architecture, disaster risk management, sustainable agriculture practices, sustainable water and wastewater management, knowledge about plants species for different purposes, and zoological and entomological knowledge for the use of biological control and infectious disease prevention, and so on.

In conclusion, improved knowledge on the direct and indirect linkages between ecosystem services and human health, and the use of such knowledge together with examples of best practices will become important tools for the development of sustainable solutions for public health worldwide in a not too distant future.


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