Inﬂuences of the Oceans on Human Health and Well-Being ...

1Influences of the Oceans onHuman Health andWell-BeingBenedict Wheeler1, Mathew P. White1, Lora E. Fleming1,Timothy Taylor1, Andrea Harvey1,2, and Michael H. Depledge1

1European Centre for Environment and Human Health, University of Exeter Medical School,Knowledge Spa, Royal Cornwall Hospital Trust, Truro, Cornwall, UK2Plymouth Marine Laboratory, Plymouth, Devon, UK

1.1 IntroductionOceans have attracted humans to their shores since ancient times. Over thousandsof years, they have served as a source of food, provided livelihoods, and generatedcommerce, as well as being a means of disseminating people, and later, connectingcivilizations, near and far. Their importance is reflected in many cultural practices,and is manifest in inspirational art.

Inevitably, the oceans influence our health and well-being. Damaged marineecosystems arising from natural disasters or as a result of human exploitation, leadto negative consequences for human health and well-being [1–10].

“Health” in this context is usually defined as physical and physiologic health,which is lost or damaged following the emergence of disease or after injury. Theimpact of the oceans on health is typically assessed in relation to changes inthe incidence of acute and chronic diseases. For instance, acute poisonings andinfections associated with the consumption of seafood containing harmful algalbloom (HAB) toxins and microbial organisms result in acute disease episodes, whilechronic diseases such as diabetes and cancer may occur after long-term exposureto persistent organic pollutants consumed in contaminated seafood. Drowning is,of course, also a well-recognized health threat associated with activities in or onour seas.

Oceans and Human Health: Implications for Society and Well-Being, First Edition.Edited by Robert E. Bowen, Michael H. Depledge, Cinnamon P. Carlarne, and Lora E. Fleming.© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.Companion Website: www.wiley.com/go/bowen/oceanshumanhealth

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4 CH1 INFLUENCES OF THE OCEANS ON HUMAN HEALTH AND WELL-BEING

Unlike human health, the term “human well-being” is not one with a consensusdefinition. It is a concept used in a broad-ranging set of literatures without a pre-cise, consensus definition. Rather, the term “well-being” is a concept or abstractionused to refer to whatever is assessed in an evaluation of a person’s “life situation” or“being [11].” Within the pages of this book, the term is used in the following ways:

• economic vitality built upon the foundations of ecosystem service value and sus-tainable development practices;

• social and cultural integrity;• psychological stability and strength; and/or• human happiness.

The decline of well-being associated with some of the negative effects on physical andphysiologic health noted earlier, is now widely accepted. There is also recognitionof the negative impacts on mental health arising from ocean events, ranging fromthe aftermath of extreme weather events and tsunamis to the loss of ocean-derivedlivelihoods and cultural activities in coastal communities resulting from degradationof marine ecosystems, especially in relation to the collapse of fisheries.

The best known benefits to human health and well-being arising from interactionswith the oceans are related to the consumption of seafood, rich in alpha omegafatty acids and nonterrestrial animal proteins and amino acids. Indirect benefitsto health also arise from marine-derived pharmaceuticals and vitamins. However,alongside the promotion of physical health, there is increasing recognition of thevalue of coastal seas in promoting better mental health. Individual benefits includedecreased vulnerability to depression and the fostering of broader societal “health”benefits related to employment, commerce, and even cultural and artistic activities.The importance of mental health and well-being was captured within the WorldHealth Organization (WHO)’s definition of health, namely “a state of completephysical, mental and social well-being, and not merely the absence of disease orinfirmity” [12]. Mental health and well-being also emerge as important outcomesin models of ecosystem services. The Millenium Ecosystem Assessment (2005), forinstance, identifies “good social relations” and “freedom of choice and action” askey well-being outcomes [13]. Other ecosystem service approaches include similarpsychological constructs in their definitions of well-being; for example “positiveemotions” [14] and a “sense of place” [15]. These broader positive impacts of theoceans on human well-being, physical health, and coastal communities have onlyrecently begun to be explored as part of a growing research effort exploring thesignificance of our interactions with the natural environment [16].

In this chapter, we review the growing body of evidence regarding the influence ofinteractions between humans and the oceans on health and well-being. Past researchthat has focused on risks and harms is discussed, but we especially focus on the explo-rations of the benefits of the oceans to both human health and well-being.

1.2 Interactions and routes of exposureHuman interactions with the oceans can be both direct (i.e., fishing or bathing)and indirect (i.e., human use of antibiotics resulting in the emergence of

1.3 RISKS 5

antibiotic-resistant organisms in coastal waters, seafood, and marine mammals;and the burning of fossil fuels leading to global climate change and sea-level rise).Although varying in terms of latency of exposure and effect (i.e., the time betweenexposure and observable impacts), almost all our interactions with the oceans havethe potential to come back to help or hurt humans and other animals in unexpectedways, both now and in the future.

Many researchers suggest that for there to be effects of oceans on health andwell-being, there must be exposure [15–18]. In general this is true, but it doesoverlook the fact that sometimes false perceptions or perceived threats that inreality do not exist can exert powerful influences on well-being, and ultimatelyhealth. For example, the belief that seafood might contain toxins, even when it doesnot, can still lead to anxiety, the avoidance of seafood consumption, and ultimatelyadverse health impacts.

In general, however, exposure is key, and may range from the visual and aural expe-riences of seeing and hearing the oceans to the direct physical contact with marinewaters (e.g., through swimming and other water sports), the consumption of seafoodfrom all levels of the marine food chain, and the inhalation of marine aerosols bothin coastal areas and further inland. These exposures can be acute, sub-acute, and/orchronic (e.g., direct skin contact with an oil spill, inhalation of a HAB toxin dur-ing a bloom lasting days to months, and the daily consumption over many years oflow levels of mercury-contaminated seafood, respectively). The nature of the timingand extent of exposures can lead to a wide range of acute and chronic diseases on theone hand, but paradoxically, potentially short and/or long term health and well-beingbenefits on the other. Finally, exposures and their subsequent health and well-beingconsequences also vary in relation to the underlying susceptibilities of individuals(e.g., increased vulnerabilities of the elderly, children, immunosuppressed, etc), andby the population density of people living on or near the coasts, particularly in lowand middle income nations.

1.3 RisksMany of the most important influences of the oceans on human health and well-beingare increasingly driven by global environmental change (e.g., the frequency of occur-rence of algal blooms; and human demographic change and associated discharges ofpharmaceuticals and other pollutants). Of interest, climate change may be especiallyimportant in this regard (as is discussed later and in other chapters), often to theincreasing detriment of human health and well-being. The most obvious effects of cli-mate change include increased risks of drowning and physical trauma after coastalinundation associated with extreme weather events (e.g., hurricanes or cyclones);and in the longer term, increases in exposure to infectious diseases (e.g., cholera)and harmful algal blooms (e.g., red tides), reduced food security, and adverse mentalhealth impacts [4]; all these are associated with sea-level and sea-temperature rise,and with more severe and frequent extreme weather and flooding events.

More indirect effects of global climate change that have yet to be fully explored,include ocean acidification (secondary to increasing carbon dioxide levels in theatmosphere), which adds to pressures on fisheries that are already stressed, andmay result in increased risks of malnutrition and starvation as well as mental health


impacts in fishing- and seafood-dependent communities [19]. Rising temperaturesare already associated with geographic changes in the distribution, and possiblyincreasing frequencies of occurrence, of pathogenic microbes (e.g., bacteria living inthe marine environment such as Vibrio cholera, which can cause illnesses [cholera]in humans) and harmful algal blooms (e.g., exuberant growth of algae which canproduce potent natural toxins) [20]. The distribution and bioavailability of chemicalpollutants are also changing as the climate changes. These effects are likely tobe associated with the increasing degradation of coastal resources and infrastruc-ture, prompting massive population migration of “climate-change refugees” andincreasing conflict locally and internationally [21]. With regards to climate-drivenmigration, however, some researchers remain sceptical [22]. Migrants often tendto move within their own country or region, rather than embarking on migrationsfurther afield. What is of interest here is that those forced to relocate over bothshort and long distances may be more at risk from mental and physical illnesses,while those relocated actively as part of an adaptation processes may, in some cases,derive health benefits.

Historically and currently, marine ecosystems have been a major source of employ-ment. The open-ocean and coastal wild-capture seafood industry, has been and con-tinues to be one of the most dangerous for workers from drowning, trauma, andmental-health impacts. Other ocean and coastal extractive activities, such as aqua-culture (e.g., intensive farming of fish and other seafood in ponds, coastal or evendeeper ocean water) and working within the oil and gas industry, also have their ownadverse consequences for physical health and well-being [23, 34]; merchant marine,cargo, and even cruise shipping can also provide dangerous occupations [25, 26].New marine and maritime activities have been added over the past two centuriesaround recreational use, particularly of the coastal seas. Although usually associatedwith beneficial health and well-being effects (discussed later), these occupations andactivities are not without their own (primarily) physical health risks to workers andparticipants [27].

Humans have created a wealth of new synthetic materials over the past 150 years,often purposefully designed to last and used in an enormous range of products. Dur-ing manufacture and following use and disposal, many persistent organic chemicalsend up in the oceans, joining other emerging contaminants (e.g., plastics, radionu-clides [predominantly anthropogenic and natural radioactive substances put to manyindustrial uses], and nanoparticles [predominantly anthropogenic ultrafine particlesbetween 1 and 100 nm increasingly used in a wide range of products ranging from sunscreens to fuel additives]). They accumulate both in food chains and in componentsof marine ecosystems more widely. When specific adverse biological effects can belinked to the presence of contaminants in ecosystems, they are redesignated as “pol-lutants” [28]. Other toxicological impacts owe their origins to marine mining and therelease of inorganic chemicals (e.g., metals such as mercury) and organic chemicalsassociated especially with the oil and gas industry (e.g., petroleum oils). The terres-trial use of fertilizers (e.g., phosphorus, nitrogen and urea) and pesticides may alsobe detrimental as they are washed into the sea by rain [29–32]. Finally, pharmaceuti-cally active products ranging from estrogens from female birth control to antibioticsused in medicine and veterinary medicine, and even excreted cancer chemotherapyagents found in animal and human fecal waste, are increasingly delivered to marineecosystems by rivers, with direct and indirect damaging effects [33, 34].

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Persistent organic pollutants (e.g., the pesticide DDT, and PCBs used in trans-formers) and heavy metals can directly affect the health of humans and marinemammals where toxicity is manifest as immune-suppression, the developmental andneurologic diseases, and possibly the emergence of cancer, particularly in nativecoastal human populations [18, 35]. Increasing concentrations of nutrients (e.g.,fertilizers and fecal waste from humans and animals) in marine waters are oftenassociated with increasing microbe populations, including pathogenic microbes andtoxin-producing harmful algal blooms [36]. Antibiotic-resistant organisms (e.g., thebacteria methicillin-resistant Staphylococcus aureus [MRSA]) have already beenfound in coastal environments, notably on beaches, and may give rise to virtuallyuntreatable infections [37]. The long-term effects of micro-plastics (very fine piecesof plastic generated by ocean waves and other processes on larger plastic waste),nanoparticles, and other novel compounds are just beginning to be explored. Withinaging populations, and with the obesity epidemic, increasing body burdens ofpersistent chemicals are being identified, leading potentially to heightened risks ofcancers, possibly dementia, and other chronic diseases [38].

As noted earlier, general human farming activities (including coastal aquaculture),coupled with increasing nutrient use and rising ocean temperatures, appear to beexpanding the ranges and numbers of potentially pathogenic microbes (virusesand parasites as well as bacteria) living in coastal environments [36]. These cangive rise to acute and chronic infectious diseases (including acute gastrointestinaldisease from Norwalk virus in contaminated shellfish; skin infections with MRSAbacteria; and potentially chronic liver disease, and even death, from Vibrio para-hemolyticus bacteria). Particularly vulnerable populations include young childrenand immune-suppressed individuals (such as persons undergoing chemotherapy orwith AIDS) [39–42]. These illnesses can affect not only consumers of contaminatedseafood, but also seafood-harvesting workers.

Harmful algal blooms appear to be increasing in frequency worldwide in allaquatic systems, and their geographic ranges are also changing due to climatechange and human activities (e.g., carried globally in ballast water, and in somecases triggered by increasing nutrients) [43]. Some of these phytoplankton species,so important in underpinning the marine food web, produce potent natural toxinswhich in humans cause acute and chronic neurologic illness and possibly cancer afterseafood ingestion, as well as acute and subacute respiratory illness through exposureto toxin-contaminated marine aerosols [44, 45]. At the same time, overuse of, andenvironmental contamination with, antibiotics may have major negative impacts onone large and important group of algae, the cyanobacteria (blue-green algae), whichcould have significant implications for fisheries that are already stressed [46].

Many of the world’s fisheries (both coastal and deep ocean) are dwindlingdue to exploitation, habitat degradation, and anthropogenic pollution followingthe expansion of human populations along the coastal margins. Therefore, largenumbers of people and livestock animals dependent on food derived from the seaare likely to be confronted with malnutrition and starvation (as well as the lossof the potential health benefits). Coastal communities in developing nations areespecially at risk [10].

Although an ancient agricultural practice, aquaculture is rapidly expanding in allaquatic environments, tripling in the past 15 years. It already provides seafood formany countries locally, and as an exported commodity it is predicted to account for


39% of total global seafood production by weight [47–49]. In the future, aquaculturemay also be used increasingly for diverse purposes such as biofuel production, carbonsequestration, and as a source of medical products [50]. There is growing evidence ofthe negative ecosystem impacts in all aquatic environments of intensive and increas-ingly large-scale aquaculture, particularly its microbial, chemical, and nutrient gen-eration. The impact of the growing implementation of aquaculture on wild seafoodpopulations is still being explored [51]. Furthermore, relatively little is known aboutthe long-term health effects of aquaculture on workers or consumers, particularly thehigh use of antibiotics and the genetic manipulation of marine species by aquaculture[23, 52].

1.4 BenefitsAs noted earlier, the benefits to health and well-being from the oceans have typicallyfocused on physical health, as well as societal “health,” benefits. The Fisheries andAgricultural Organization (FAO) estimates that for over one billion people world-wide, particularly in developing countries, seafood is the primary source of animalprotein [53, 54]. Furthermore, fish and shellfish are the most highly traded foodsinternationally, providing local jobs and national export earnings (over US$51 bil-lion/year) through both traditional coastal/ocean seafood harvesting and the growingreliance on aquaculture in all aquatic environments [53, 55]. A stable and consistentsource of seafood is essential therefore for the nutritional health, prosperity, andsecurity of a large segment of the world’s population [54].

As well as its utility as a basic source of protein low in polyunsaturated fats and highin micronutrients, increasing evidence links seafood with a range of human healthbenefits. These include the effects of the long-chain polyunsaturated omega-3 fattyacids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) present in highamounts in some seafood, which are linked to the prevention of stroke and cardio-vascular mortality, and some level of protection against depression, Alzheimers, andsome cancers [18, 56–58]. Western medicinal practitioners now recommend increas-ing the amount of seafood in the diet as a preventive health measure [56].

The oceans also represent an important source of pharmaceutical products (includ-ing anticancer and pain medications). Other chemicals (e.g., extracted from kelp andalgae) harvested from the oceans and along the coasts are used in a range of productswith additional health benefits [59–62].

Among emerging uses of the oceans, under the rubric “blue carbon,” marine organ-isms such as algae are likely to be actively used in the future for producing biofuelsand for carbon sequestration to mitigate global change [50]. Offshore-wind, tidal,and wave energy reduce the need for energy from traditional sources, which havesignificant health impacts through air pollution [63].

More associated with societal “health” benefits are issues such as the use in scien-tific research of marine models of humans and their diseases (e.g., Aplysia (the seahare) as a developmental neurophysiology model) [64, 65]. Marine organisms, partic-ularly marine mammals, also serve as sentinel species of the potential threats posedby interactions with the oceans: thus, sea lions have been documented as sufferingneurologic and other health effects from exposure through the food chain to a mix-ture of HAB toxins, persistent organic pollutants, and antibiotic-resistant bacteria

1.4 BENEFITS 9

[44, 66–69]. Identification of such cases can provide early warning of future humanhealth impacts.

Finally, the most complex and elaborate forecasting systems (including the Inte-grated Ocean Observing System (IOOS)) have been developed for the monitoringand prediction of weather, extreme weather events (such as hurricanes), and globalenvironmental change, as part of efforts to predict, mitigate, and prevent healththreats to humans and societies [70–72]. Other more localized and collaborativeefforts (including utilizing citizen science and stakeholder participation) have beendeveloped to predict, mitigate, and manage the health impacts of harmful algalblooms (Box 1.1), microbial pollution, and chemical pollution [73–75].

Box 1.1 Red tide risk and benefit storyAs discussed earlier, harmful algal blooms and their potent natural toxins havebeen viewed in general as an unalloyed risk rather than benefit to human health.For example, the Florida red tide organism, Karenia brevis, regularly bloomsin the Gulf of Mexico and beyond; its potential natural toxins, brevetoxins, areassociated with a range of impacts on human, societal, and animal health [45, 76].During blooms, literally millions of fish, birds, and even marine mammals sickenand die due to the neurotoxic effects of brevetoxins. Humans who consumeshellfish (and possibly fish) contaminated with brevetoxins develop an acuteand potentially fatal neurologic illness, neurotoxic shellfish poisoning (NSP).Asthmatics and other people develop acute and subacute respiratory disease(including asthma exacerbations, bronchitis, and pneumonia) associated withbreathing marine aerosols contaminated with brevetoxins.

Yet at the same time, research into Florida red tides has led to a number of dis-coveries, some of the serendipitous, which have directly and indirectly benefitedhuman health. The organism is a phytoplankton, an important component of themarine food chain as well as essential to ocean photosynthesis and potentiallycarbon sequestration. Brevetoxins are very specific toxins which have been usedto explore the mechanisms of the sodium channels of nerve cells in neurophysio-logic research, leading to a greater understanding of human physiology and moreappropriate treatments for human diseases. Research into brevetoxins has identi-fied a new compound, brevenal, also elaborated by the HAB organism. Brevenalis an antagonist to brevetoxins, and as such can be used as a specific treatmentfor brevetoxin-induced diseases and similar illnesses such as ciguatera fish poi-soning; brevenal also has been shown to increase the mucocilliary blanket in thelung, which has lead to it being patented for the treatment of the fatal inheritedlung disease, cystic fibrosis. Finally, interdisciplinary and interagency groups work-ing with communities and citizens around Florida red tide issues have developedearly warning programs, outreach and educational materials, and exposure anddisease reporting systems for affected communities and individuals, as well as pol-icy changes around nutrient use to possibly prevent future algal blooms [73, 74].

Thus, research into and exploration of ocean issues such as HABs can have bothpositive and negative effects for human health and well-being, often unknown andunpredicted. Furthermore, it is the interactions between humans and the oceansthat make these exposures and effects possible.


1.4.1 Health and well-being from ocean and coastalecosystemsAs was alluded to earlier, some of the most exciting research into the well-being(and possibly physical health) benefits of the oceans have come from explorationinto health and well-being from the natural environment.

From an ecosystem-services perspective, marine environments provide a range ofpositive benefits to health and well-being [13, 15, 77, 78]. Some, such as the provisionof seafood, with its important nutrient and nutritional content, and pharmaceuticalcompounds derived from ocean-based organisms, are already well-documented,and their economic significance has been evaluated. Other health and well-beingbenefits, especially those arising from direct exposure to the sea (e.g., throughimmersion, ingestion, and observation) have received relatively little scientificattention, despite being documented by the Sumerians, Egyptians, Greeks, andRomans [79–81]. Broadly speaking, the issue is whether (and how) “thalassother-apy” (from the Greek word for sea, thalassa) works in the sense of aiding humanhealth and well-being remains obscure and its economic significance has yet to bedetermined.

One of the earliest accounts (1750–1760) of the possible health benefits of seawaterwas provided by Richard Russell [82]. Reviewing an extensive number of case stud-ies, Russell concluded that “Sea Water” may have a range of medicinal propertiesfor “glandular” diseases such as scurvy, King’s Evil (scrofula), jaundice, and tuber-culosis. His main argument was based on seawater’s mineral content. Building on thewidespread belief that the healing properties of terrestrial thermal springs dependedon the minerals dissolved in the water (that could, it was believed, be both ingestedand absorbed through the skin), he reasoned that since “it is certain, that salts con-tribute greatly to all Cures that are performed by Medicinal Waters… [and thatsince]… all these Qualities, and some others plainly appear in Sea Water… [it]…gives us great Hopes, that the Materia Medica may soon receive some extraordinaryAddition from this Part of Nature.” (p. xii, 1760) [82].

Following the publication of his treatise, he established a practice at Brightonon the south coast of England where patients, including members of the royalfamily, engaged in sea bathing as a cure for all manner of ills. Several hospitals weresubsequently established, including the Royal Seabathing Infirmary at Margatein 1791 specifically designed to treat scrofula [83]. Similar developments occurredacross Europe with dozens of thalassotherapy resorts and treatment centers beingestablished during the nineteenth century [80]. These therapies were often providedalongside other more established “spa” treatments such as: hydrotherapy (whichuses only water), balneotherapy (which uses thermal mineral waters), and sea mudand algae treatments [80, 84].

The evidence in support of thalassotherapy was, however, largely anecdotal andoften overplayed by commercial interests [80]. The pathways by which seawater weresupposed to treat specific diseases were unclear; case studies, such as those reviewedby Russell, often featured a range of treatments, leaving it unclear whether or notseawater was the critical intervention. Perhaps unsurprisingly, therefore, the demandfor thalassotherapy declined with the introduction of antibiotics in the middle of thetwentieth century that demonstrably treated the same diseases targeted by seawatertreatments but through well understood biological pathways. Nevertheless, there is

1.4 BENEFITS 11

evidence of a recent reemergence of interest in thalassotherapy, especially amongricher clients [80], and therein perhaps lies the most obvious benefits of the oceansto health and well-being.

For over 250 years, the main focus was on the physical mechanisms by which seawa-ter could tackle disease, while the possibility that the oceans and seas could have theirlargest impact through mental health and well-being, perhaps through pain reduc-tion [85], was for many years less well researched. There is now a large and extensivebody of literature which shows that stress, anxiety, pain, and mental disorders candirectly affect physical health by reducing immune functioning and increasing therisk of physical conditions (such as cardiovascular disease, type 2 diabetes, and pre-mature mortality) [86–88]. It is therefore entirely conceivable that one of the mainbenefits of ocean and sea exposure may be in the way in which it calms the mind,rather than directly healing the body. Reviewing the evidence for “spa” treatmentsin general, for instance, Bender et al. concluded, “the placebo effect is considerable,and if it ‘pleases,’ and pain is reduced and the patient’s general well-being improves,then arguably it is of value irrespective of trial results from randomized, controlledtrials” (p. 222) [84].

So, given that all modern definitions of health (including those used by ecologists)include mental well-being, is there any evidence that the oceans and seas in partic-ular, as opposed to more general water-based therapies, are good for mental healthand well-being? The evidence comes from two separate strands of research, whichbroadly can be summarized as economic and psychological. The economic approachto measuring well-being is based on three key assumptions [89]. First, it is assumedthat individuals have different preferences, and thus objective circumstances are notnecessarily good indicators of well-being, since different individuals will react tothese circumstances differently. Second, it is assumed that people are often unwillingand/or unable to express their well-being verbally, rendering responses to surveys,etc., unreliable. Third, it is assumed, instead, that people reveal their preferencesthrough their allocation of scarce resources, such as time and money. Thus, if individ-uals voluntarily choose to visit or live near the sea, relative to alternative locations,then it is assumed that the sea is good for their well-being, because they are actingon (and paying for) their personal preferences.

From this perspective, there is an enormous amount of evidence that peoplearound the world are keen to spend time by the sea, either by choosing to live nearthe coast or to visit coastal locations, engage in sea cruises, or go diving for tourismand recreation purposes [13, 15, 77, 90–93]. Importantly, they are also willing to paya price premium to do so, as evidenced using the revealed-preference technique ofhedonic pricing [94]. For example, homes with coastal views tend to cost more thansimilar homes with noncoastal views [77, 95], and people are willing to pay more fortourist accommodation with coastal views [96]. This approach can also be used toexamine the effect that degradation of the marine environment has on well-being bylooking at the reduced willingness to visit degraded sites. For instance, “episodes ofharmful (including toxic) algal blooms in coastal waters are increasing in frequencyand intensity, harming other marine resources such as fisheries as well as humanhealth. In a particularly severe outbreak in Italy in 1989, harmful algal blooms costthe coastal aquaculture industry $10 million and the Italian tourism industry $11.4million” (p. 6) [13]. Other studies based around revealed preferences have employedthe travel-cost method and used the value of the cost of travel as a proxy for


willingness to pay for use of the site. For example, Whitehead et al. (2008) employedthis method in valuing beach access in North Carolina in the United States [97].

Where there is no obvious market for the expression of preferences (e.g., for theprotection of marine environments or species), economists use “stated preference”methods, such as contingent valuation and choice experiments to estimate the value.These ask people to make trade-offs in order to establish how much value peopleattach to these nonmarket goods. The well-being these values express may includeso-called “non-use” values such as the satisfaction one derives from helping preservea species for future generations [93]. These methods can also be used to understandthe (perceived) value of health of sea and coastal environments by asking peoplehow much they would be willing to pay for improvements in the quality of the marineenvironment. Using this approach, for instance, Machado and Mourato (2002) esti-mated the amount people in Lisbon would be willing to pay to reduce their risk ofgastroenteritis from bathing in local contaminated coastal waters [98]. Other studieshave focused on the value of algal blooms [99]. Using these studies inferences canthen be made about the well-being derived from improved marine environments.

The second main way of assessing the well-being associated with exposure to theseas and oceans is psychological, which is based on what people say about how theythink and feel about their lives and experiences [100]. One strand of research askspeople to quantify their well-being while exposed to different environments, eitherin situ or virtually (e.g., using photographs, videos, etc.). This line of research suggeststhat individuals report higher levels of positive emotions when exposed to aquaticenvironments in general [96, 101, 102], and coastal ones in particular [103, 104], evenunder inclement weather conditions [105]. In other words, by this definition, the seais good for health because people say they find it calming and revitalizing.

A second strand of psychological research examines self-reported health andwell-being of people who live near the coast, and compares this to those who livefurther inland, controlling for various potential confounders (such as income andage). Research using English census data, for instance, suggests that those wholive within 5 km of the coast report better health than those who live inland [106].Moreover, longitudinal analysis of a large dataset of individuals in England overan 18-year period suggests that self-reported general and mental health were bothhigher in years when they lived within 5 km of the coast [107]. Possible explanationsinclude a greater chance of benefiting from the stress-reducing properties of thesea [105], and a greater likelihood of engaging in physical exercise [108], welldocumented to be beneficial for health and well-being [109].

Why should exposure to the sea make people feel good? Some theorists [110–112]have argued that we may have spent an important stretch of our evolutionary his-tory in and around coastal environments where it is proposed “a branch of primitiveape-stock was forced by competition from life in the trees to feed on the sea shoresand to hunt for food, shell fish, sea-urchins, etc. in the shallow waters off the coast”(p. 642) [110]. Hardy goes on to pose the question “Does the idea perhaps explainthe satisfaction that so many people feel in going to the seaside, in bathing, and inindulging in various forms of aquatic sport?” From this contentious theory, one couldsuggest that a coastal environment could potentially be ideal for human health andwell-being since we are evolutionarily and historically adapted to it, and thus, coastalenvironments best fit our physiological and psychological development [110].

1.5 DISCUSSION 13

Other theorists have postulated more direct effects such as muscle relaxation fromimmersion in sea water, and the possibility that even for those merely viewing theocean “tiny salt particles contained in sea air (aerosols) work their way into thedeepest parts of pulmonary alveoles and settle on their walls with a probably notnegligible physiological effect.” (p. 847) [80]. Qualitative research suggests peoplevalue the open spaces and the feelings of freedom associated with coastal environ-ments, and that they may have important cultural associations and sense of place,although these possibilities are particularly hard to quantify [15]. Overall, to date,the potential for well-being improvement is significant, but current explanations forthe psychological benefits of our seas and oceans are not currently well-developed,suggesting this is an area ripe for further theorizing and future research.

1.5 DiscussionAlthough the different interactions between the oceans and human health have beenseparated primarily into either a risk or a benefit, in reality, all of these human–oceaninteractions are interconnected and involve both real and perceived risks and bene-fits. Different uses of the oceans and coastal zones lead to different risks and benefits,as summarized in Table 1.1. Some uses of the oceans lead to employment and asso-ciated and other health benefits; all uses must be examined for their short- andlong-term impacts on the coastal and ocean ecosystems. There is need for integratedstrategies to mitigate the risks and to more fully capture the benefits.

Seafood is an excellent example of how human activities and the ocean environ-ments are inextricably linked, creating both the risks and benefits. On the one hand,there is the endangerment of many of the world’s fisheries from overfishing, coastaldegradation, and other factors; at the same time, there is growing medical advice toconsume more seafood for its nutritional and other health benefits, as well as activi-ties to select and eat seafood ethically [18, 50, 52, 58, 62]. These are also very difficult“mixed messages” to communicate to stakeholders and policy makers.

In addition, in the descriptions earlier, there is a tendency to research and presentthese very complex issues of the oceans and human health as single-focused andlinear challenges. For example, there is considerable research focused on the con-sumption of harmful algal bloom toxins in shellfish leading to neurologic disease inshellfish consumers. Yet these same shellfish may also be concomitantly contami-nated with microbes such as Norwalk viruses, antibiotic-resistant organisms such asMRSA, and persistent organic pollutants, heavy metals, or even nanoparticles andmicroplastics. Therefore, the exposures and the resultant health effects may actuallybe complex and interconnected mixtures. Another example of this complexity ofhuman–ocean interactions on an even larger scale is the recent finding that anthro-pogenic particulate air pollution, primarily seen as an urban non-ocean issue, maybe increasing the intensity of extreme weather events in the oceans [113]. Thesecomplex interactions cannot be addressed by traditional “siloed” science or policyapproaches – by necessity, interdisciplinary scientists working with policy makersand stakeholders across institutions will need to explore the interconnections of thehealth of both humans and the oceans.

Another challenge is that of quantifying the global impact on health and well-beingof these ocean–human interactions. There are limited surveillance systems in place,


Table 1.1 Summary of selected health and well-being benefits and risks of activities in theoceans and coastal zones

Use of oceans Health Healthand coastal zones benefits risks

Fishing and otherharvesting fromcoasts and oceans

Economic vitality of coastalcommunity leading toreduced mortality/morbidity

Occupational health risks (e.g., riskof drowning and injury)

Consumptive benefits fromseafood (e.g., proteins,alpha omega-3 fatty acids)

Risks from consumption ofcontaminated products (e.g., HABtoxins, heavy metals, persistantorganic pollutants [POPs])

Food-security issues for coastalcommunities

Aquaculture Economic vitality of coastalcommunity leading toreduced mortality/morbidity

Occupational health risks (e.g.,infections)

Consumptive benefits fromseafood (e.g., proteins,alpha omega-3 fatty acids)

Risks associated with coastaldegradation from nutrient,pharmaceutical, and chemicalreleases associated withaquaculture

Shipping and oil sector Economic vitality of coastalcommunity leading toreduced mortality/morbidity

Risks from spills/routine releases inmarine environment, includingmortality (e.g., cancer) andmorbidity (e.g., skin irritation)


Risks from air pollution in thecoastal environment

Energy – includingwind, wave and“blue carbon” algae



Reduced mortality/morbidityfrom traditional sources ofenergy

Potential health and well-beingrisks from accidental release ofblue carbon algae

Health benefits from climatechange mitigation

Waste sink foragriculture andwaste-water sectors

Health benefits from dispersalof fecal matter and otherpollutants

Increased risk of exposure to fecal,pesticide, and fertilizer pollutionin marine environment

Increased risk of development ofantimicrobial resistance fromrelease of antibiotic-resistantorganisms and antibiotics

Nutrient inputs affectingdevelopment of harmful algalblooms and associatedhealth risks

1.5 DISCUSSION 15

Table 1.1 (Continued)

Use of oceans Health Healthand coastal zones benefits risks

Waste sink for miningand industry

Health benefits from dispersalof mining wastes and otherpollutants

Risks to health from heavy metal,POPs, plastics, radionuclides,nanoparticles and other chemicalcontamination of seas andseafood

Waste sink for Carbon Health benefits from climatechange mitigation

Ocean acidification with potentiallong term food chain disruption

Mining of naturalpharmaceuticals andother marine-derived substances


Risks to health from pharmaceuticalinteractions in naturalenvironment (e.g., antibioticsleading to increasedantimicrobial resistance)

Health benefits from use ofocean resources inproduction ofpharmaceuticals

Destruction of species and habitatsdue to mining

Medical research Health benefits from the use ofmarine models

Residential property Health benefits from use ofcoastal resources forrecreation or impact ofviews from properties

Mortality and morbidity risks fromextreme weather on coasts (e.g.,storm surge or natural hazardssuch as a tsunami)

Pressure on coastal infrastructuremay lead to increased inputs ofpollution

Tourism and recreation Economic vitality of coastalcommunity leading toreduced mortality/morbidity

Pressure on coastal infrastructuremay lead to increased inputs ofpollution

Health and well-being benefitsfrom exercise in andexposure to naturalenvironment

Occupational and recreational risks(e.g., risk of drowning and injury)

Risk of exposure to amthropogenicand natural pollutants withassociated mortality andmorbidity risks

Spa and other “healthand well-being”industry

Potential health andwell-being benefits fromthalassotherapy

Pressure on coastal infrastructuremay lead to increased inputs ofpollution and associate healthrisksEconomic vitality of coastal

community leading toreduced mortality/morbidity



particularly globally, for the potential acute and chronic diseases and other impactsfrom ocean exposures. These surveillance systems do not necessarily even collectthe exposure data that would link these health events to ocean exposures. Oneinteresting and positive example has been the development by the US Centers forDisease Control and Prevention (CDC) National Center for Environmental Health(NCEH) Harmful Algal Bloom-Related Illness Surveillance System (HABISS).Without these data, it is hard to quantify the impacts either in terms of humanhealth and well-being, or the economy. And there has been very little work tryingto quantify and link impacts on societal cohesion with human health and well-beingimpacts, both negative and positive.

Finally, with the growing acceptance of global change and other challenges, thereis an increasing appreciation of the importance of human–ocean activities withimpacts that have already changed the health of the ocean and coastal ecosystems,and which may be changing the current and future health and well-being ofhumankind [10, 15, 21, 114]. Ultimately, we can only conclude that it is in the bestinterests of humans to protect the health of the oceans if only in order to protecttheir own health and well-being.

AcknowledgmentsThis research is funded in part by: the European Social Fund (ESF) and EuropeanRegional Development Fund (ERDF) to the European Centre for Environment andHuman Health (University of Exeter Medical School); the Natural EnvironmentResearch Council (NERC) (Plymouth Marine Laboratory); and the US NationalScience Foundation and US National Institute of Environmental Health Sciences(University of Miami).

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