Most of the earth’s surface is covered by water, and most of the human body is composed of water – two facts illustrating the critical linkages between water, health and ecosystems. – World Health Organisation (WHO), 2017.

Despite WHO’s recognition of how water environments are essential for promoting health, global evidence of disconnect from our natural surroundings is growing. The world’s ecosystems are coming under increasing threat from human pressures, in particular waterways, coasts and oceans, also known as ‘blue space’. This in turn poses human health risks from environments that are polluted and degraded. Disconnect from our natural world, and our sense of self in nature, is not unrelated to a growing social disconnect. One of the greatest crises of our time is the rise of mental health issues. Growing stress and anxiety are linked to the fact that we’ve become disconnected. By 2030, WHO predicts mental health issues will be the biggest burden on society. This has consequences not just for our human health but also for environmental health, which in turn creates a vicious loop. We risk losing the very life support system that may help restore our sense of connection, health and wellbeing. The health of our outer world mirrors and the health of our inner world, and vice versa.

I’m interested in how direct experiences with water, especially the sea, might facilitate a greater sense of connection and wellbeing. This column has begun to spotlight a number of initiatives across policy, practice and academia that are seeking to better understand the complex interdependence between ocean and human health, especially the therapeutic potential of the sea. For example, the International Surf Therapy Organisation (ISTO) was established in 2017 largely in response to a growing demand to evidence the therapeutic qualities of the sea and surfing. The NEAR-Health project in Ireland is a research initiative to qualify how important nature is for human health and wellbeing. As part of that project, I led the first global systematic review of health and wellbeing benefits of therapeutic water-based activities, a form of ‘blue care’. The review highlights the need to improve our understanding of the restorative health benefits of actively engaging with water.

Blue spaces are often overlooked and remain poorly understood. Activities and engaging with blue spaces offer very different sensory experiences, and are used in different ways with different outcomes and benefits than ‘green spaces’. Out of the 33 blue space studies included in the review of Blue Care, the majority were focused on the sea or coast, with a diverse mix of people with multiple health issues, predominantly psychological. Surfing, or ‘surf therapy’ was the most popular activity used to deliver blue care. Findings suggest that part of the health benefits are linked to the challenging nature of surfing – different coasts, winds, currents, seasons require constant adaptation, and responding to nature in the moment. Challenge can be an important factor for enjoyment and quality of life enhancement. Self-reported feelings of tiredness, cold, body aches were also considered factors that could lead to a greater sense of self-efficacy and perseverance. Challenging activities were often linked to greater sustainable wellbeing.

Although the mechanisms of how surf therapy, and other blue care activities such as diving and sail therapy, contribute to wellbeing are not yet well understood we do know it has the ability to improve our health, especially our psychological wellbeing. 

When it comes to blue care, the most commonly assessed wellbeing indicators included self-esteem, self-efficacy, social confidence, resilience, and other psychological indicators such as stress, anxiety and mood. The findings emphasise a multi-dimensional view of health, with participants experiencing positive changes to sense of self, health and wellbeing in the short-term. How long the benefits are sustained remains unknown.

Shared experiences in water matter with high potential for positive social wellbeing outcomes. Learning to surf in a group, for example, can help enhance a sense of belonging, social connection and identity through shared experiences in the surf. The connective properties of the sea may also play a key role. The body’s response to waves (movement) and skills required to surf (balance) were attributed to enhanced vestibular balance for amputees, as well as pain reduction and reduced dependency on narcotics attributed to the psychological effect of surfing. The absence of gravity in salt-water can be particularly therapeutic, altering bodily sensations and improving mobility, which improves heart and lung functioning and is an integral muscular workout, especially for those with disabilities, spinal-cord injury or amputations. Again, being immersed in water can offer a sense of freedom from earthly limits.

However, not all experiences are necessarily positive and not all outcomes are universal. A number of barriers to participation and potentially adverse effects highlight the complexity of blue care design and delivery. Social norms and class that persist around water sports and surfing can leave some people from lower income backgrounds feeling socially and culturally excluded. Another potential barrier is the funding mechanisms (e.g. charitable donations, lottery funding, etc) that these programmes typically depend upon, which limit the ability to create longer-term programmes and more sustainable, participant-driven initiatives. The ‘mood-dip’ identified by some studies can be caused by perceived discrepancies between personal experience during an activity and the social demands of daily life after ‘returning to shore’. This highlights the importance of an approach that is contextually sensitive and process-oriented – measuring more than ‘what’ worked well; but also evaluating ‘how’ and ‘why’ success or indeed failure happened. There is a need for the co-design of nature-based health programmes, especially for participants with a diverse mix of needs, as well as understanding how individual expectations measure against actual outcomes.

Blue care has the potential to improve health outcomes for diverse groups, yet there is still so much we have not yet realised. Barriers persist around water quality, safety and access to healthy environments, especially in more socially deprived communities. The sea is not only a place of healing but can represent a place of loss and tragedy. Most examples of blue care were from western nations and tended to focus on adults. Public health policy needs to consider the cultural aspect of water connection and how this might intersect with other determinants of health such as gender, age, race and ethnicity.  

This conversation on ‘ocean and human health’, must continue to tease out the complexity of the health risks and benefits. To highlight how dependent our wellbeing is on the health of our ocean, including our waterways, seas and coasts. It’s a conversation we need to take beyond the domain of marine sciences and into our communities, our work, our health care, and our governments. Reclaiming our connection with our watery origins in the ancient sea may not be the solution to all our global crises but it is an essential part of our human wellbeing and ability to flourish.