Green space, health, and wellbeing: considerations for South Asia
Authors: Bipin Adhikari, Shiva Raj Mishra, Kim Natasha Dirks
Journal: The Lancet Planetary Health (2020)

Urban green space is a crucial component of planetary health, yet its effect on human health remains poorly understood.1Adhikari B Pokharel S Mishra SR Shrinking urban greenspace and the rise of non-communicable diseases in South Asia: an urgent need for an advocacy.Frontiers in Sustainable Cities. 2019; 1: 5Crossref Scopus (11) Google Scholar, 2Kondo MC Fluehr JM McKeon T Branas CC Urban green space and its impact on human health.Int J Environ Res Public Health. 2018; 15: E445Crossref PubMed Scopus (277) Google Scholar A systematic review3Rojas-Rueda D Nieuwenhuijsen MJ Gascon M Perez-Leon D Mudu P Green spaces and mortality: a systematic review and meta-analysis of cohort studies.Lancet Planet Health. 2019; 3: e469-e477Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar and meta-analysis published in 2019 in The Lancet Planetary Health by David Rojas-Rueda and colleagues collated evidence on the association between green space and mortality. Although this was the first systematic review and meta-analysis to show that living in green surroundings can reduce all-cause mortality, we noted a paucity of evidence linking green space to non-communicable diseases in Asia, particularly in South Asia. Over the past decade, an increasing number of studies have reported on the low level of physical activities among South Asians, which has been attributed to the social, cultural, and ecological characteristics of the residents, as well as increasing urbanisation.4Adhikari B Mishra SR Culture and epidemiology of Diabetes in South Asia.J Glob Health. 2019; 9020301Crossref PubMed Scopus (11) Google Scholar An insufficiency of green spaces such as parks and spaces for exercise, coupled with poor motivation to exercise and awareness of the health benefits of physical activity have contributed to increasing rates of metabolic disorders such as obesity, diabetes, and hypertension.4Adhikari B Mishra SR Culture and epidemiology of Diabetes in South Asia.J Glob Health. 2019; 9020301Crossref PubMed Scopus (11) Google Scholar, 5Hills AP Arena R Khunti K et al.Epidemiology and determinants of type 2 diabetes in south Asia.Lancet Diabetes Endocrinol. 2018; 6: 966-978Summary Full Text Full Text PDF PubMed Scopus (75) Google Scholar Neighbourhood walkability and available green space enable populations to exercise, resulting in populations with reduced metabolic risks (eg, lowered body-mass index) and improved mental wellbeing through restitution and increased exposure to pleasant landscapes.6WHOUrban Green Space Interventions and Health. A review of impacts and effectiveness.http://www.euro.who.int/__data/assets/pdf_file/0010/337690/FULL-REPORT-for-LLP.pdf?ua=1Date: 2017Date accessed: June 29, 2019Google Scholar The immediate ecological benefits of green spaces are reduction in the urban heat island effect, cleaner air, and reduced noise pollution, which have been shown to improve health-related quality of life, and reduce both morbidity and mortality.7Schraufnagel DE Balmes JR Cowl CT et al.Air pollution and noncommunicable diseases: a review by the forum of international respiratory societies' environmental committee. Part 2: air pollution and organ systems.Chest. 2019; 155: 417-426Summary Full Text Full Text PDF PubMed Scopus (221) Google Scholar Expanding green space is a triple-duty action for tackling the global syndemicity of air pollution, climate change, and the prevalence of chronic diseases. Over the past 25 years, the rural regions in South Asia have doubled the area and intensity of greenness.8Gill P Tree-mendous: Community management and outmigration have helped Nepal double its forest area in 25 years.Nepali Times. Sept 13, 2019; https://www.nepalitimes.com/banner/tree-mendous/?fbclid=IwAR0UAUC0FckAbTtKXEI8yG0HYsIfFqLg9Y61IbuaF6UiOdoJgqHxQ8zncL8Date accessed: December 1, 2019Google Scholar Despite this increase, the majority of the rural population continue to die prematurely (<70 years), with higher all-cause mortality than urban residents. This higher mortality has been attributed to a high competing risk from communicable diseases and a persistent lack of universal health coverage,9Asaria M Mazumdar S Chowdhury S Mazumdar P Mukhopadhyay A Gupta I Socioeconomic inequality in life expectancy in India.BMJ Glob Health. 2019; 4e001445Crossref PubMed Scopus (17) Google Scholar and is occurring despite residents in remote regions often having greater access to green space and higher levels of incidental physical activity than their urban counterparts. The poor health statistics can be attributed to the poor access to and low quality of health services. Thus, associating green space with mortality without accounting for the mediating factors in the green space–mortality relationship severely compromises the replicability of the meta-analysis3Rojas-Rueda D Nieuwenhuijsen MJ Gascon M Perez-Leon D Mudu P Green spaces and mortality: a systematic review and meta-analysis of cohort studies.Lancet Planet Health. 2019; 3: e469-e477Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar in low-income and middle-income settings. Future research in South Asia should include characteristics of green space and the relationship of this space with the resident population, including factors affecting variability in use of the space and the effects on rural and urban residents. For example, two of the authors (BA and SRM) grew up in Nepal, where their houses were approximately 10 km from 952 km2 of dense tropical vegetation. Yet, despite the close proximity to vast expanses of greenness, neither BA nor SRM could use it for physical exercise, because of an absence of walkable trails, dense bushes, presence of wild animals, difficult terrains, and natural reserves being allotted for safaris with regulated entries. Although proximity to green space and walkability are essentially measures of the extent to which a neighbourhood is conducive to exercise and green experiences, it does not necessarily mean that living in and around these environments induces people to use them for physical activities. To encourage people to engage in physical exercise, the design of green spaces and parks need to be tailored to the local values for aesthetics, culture, and spiritual practices. For example, the spaces need to be able to accommodate walking trails and drinking water, and sanitation facilities equipped with adequate security measures, which is particularly true for South Asian women, who have high levels of risk in these areas. Although it is essential to promote and build future cities with more urban green spaces to reap the many benefits they provide, it is also crucial to explore and build evidence on both the intermediate and broader factors that affect the relationship between green space and health outcomes. For example, future research could delve more deeply into intermediate factors, such as personal motivation, and the level of physical activity among those living in proximity to green areas, as well as the broader social and cultural factors (eg, food practices), including the enablers and barriers to physical activity. We declare no competing interests.