25 April 2019

Africa: Why Doctors Should Consider Prescribing 'Nature' to Patients

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Photo: Inna Lazareva/Thomson Reuters Foundation
Spring onion, chard and other vegetables grow in the rooftop garden of one of Johannesburg's social housing skyscrapers, set up by social enterprise Rooftop Roots, November 15 2017.
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Imagine if Abdul in Nigeria was having severe headaches and feeling dizzy, and he went to the hospital where the doctor found his blood pressure was high. What if, in addition to antihypertensives, advice on reduced salt intake and regular blood pressure measurements, the doctor wrote "go into nature"?

While doctors in Africa aren’t prescribing nature just yet, they should be, when relevant.

In 2018, doctors in Shetland, Scotland, first began prescribing nature to patients for treatment of Non-Communicable Diseases (NCDs) such as mental illness, diabetes, cardiovascular disease, and chronic stress. Nature, as prescribed in Shetland, entails 10 or so options for outdoor activities per month from which patients can choose. One option in January, for instance is count the birds in your garden. In June, an option is to visit the Keen of Hamar National Nature Reserve and discover its rare and endemic plant species. In November, one idea is to talk to a pony.

Research shows that when people explore nature, they tend to have reduced stress response, lower blood pressure, better heart rate variability and a better mood. Further, participation in any level of physical activity can improve cardiorespiratory and muscular fitness, bone health, and reduce the risk of NCDs and depression.

The benefits of prescribing nature could help millions as NCDs are a huge problem. Ischaemic heart disease and stroke were the leading causes of deaths globally in 2016 – responsible for 15.2 million deaths globally. Sadly, Africa will witness an increase of 27% of these NCDs deaths. In Mauritius, Namibia and Seychelles, NCDs are responsible for about 50% of all reported adult deaths. In Nigeria, NCDs were responsible for 24% of all deaths based on 2014 estimates – this amounted to 2,083,000 deaths or approximately the population of Gabon.

Of course, a nature prescription does not mean ignoring medical advice like salt reduction and the elimination of artificial trans fats. Doctors should make the best judgement based on the clinical state of patients and other factors, but now, nature should be one item they consider.

Doctors in Africa already advise patients who have NCDs to live active lives. This should evolve to an actual prescription of nature.  With an abundance of natural reserves, Africans may likely benefit the most from nature prescription. Africa has the Serengeti National Park in Tanzania; Samburu National Reserve in Kenya; Table Mountain in South Africa and the Obudu Cattle Ranch in Nigeria.

To use nature in driving down the burden of NCDs in Africa requires interventions at individual and population levels. These interventions should be driven by governments and supported by the private sector, communities and civil society.

At the individual level, professional heath associations and regulatory agencies should include the training of health workers like doctors, nurses, physiotherapists and community health extension workers, on the benefits of nature in reducing risks of NCDs. They should receive examples of the kinds of things to suggest to patients.

Hospitals should be designed to have vegetable and flower gardens on their premises. When doctors prescribe nature to patients (both in-patients and out-patients), it could be for them to cultivate these gardens. In-patients would have time to take daily walks round the garden, tend to their plants and breathe fresh air. By the time they are discharged, other patients can take over. This would also help build a community of nature lovers who can visit the hospitals at any time to tend to their plants. Hospital kitchens can make use of produce from these gardens to prepare nutritious meals for patients.

At the population level, African governments and civil society should support tree planting to create more nature. Many African countries have hot weather and trees provide shade for people who want to take walks as prescribed by doctors. Long term, trees contribute to mitigating the negative effects of climate change.

Community gardens can be a source of fresh air to city dwellers and provide a peaceful environment for stress reduction.

Knowledge about lifestyle changes in reducing the risk of NCDs is not new. In 1948, the Framingham Heart Study (FHS) began in Boston, Massachusetts, with the objective of identifying common factors that contribute to cardiovascular disease. By 1967, the FHS found that physical activity reduces the risk of heart disease while obesity increases the risk of heart disease. The difference is that for the first time, this evidence that has been around for more than five decades can now be prescribed by doctors.

If doctors and other health workers in Africa formalise the prescription of nature and governments improve population-level interventions, we could gradually reduce the number of Africans who die prematurely from NCDs.

Dr Ifeanyi Nsofor is a medical doctor, the CEO of EpiAFRIC, Director of Policy and Advocacy for Nigeria Health Watch, current 2019 Atlantic Fellow for Health Equity at George Washington University and a 2018 New Voices Fellow at the Aspen Institute.

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