Robert Zarr is walking from his Columbia Heights medical practice toward Meridian Hill Park, talking about what’s going on inside his head. If you could see his brain on an MRI, he says, far more extensive regions would be lighting up than if he were having this same conversation sitting at his desk.
Zarr, a pediatrician at Unity Health Care’s Upper Cardozo Health Center, has a special interest in the unseen benefits of getting outside. He is the “physician champion” of DC Parks Rx, an innovative community health program committed to combating the woes of urban living by prescribing time outdoors.
Zarr mentions obesity, diabetes and mental health disorders as he walks. “It only takes a couple of kids” with symptoms of ADHD to disrupt a classroom, he says, and teachers start recommending their parents talk to pediatricians about Ritalin or other medical interventions.
Hence the D.C. parks prescription program. Convinced by a growing body of scientific evidence that many of the chronic scourges of city life can be prevented or alleviated by reconnecting with nature, Zarr has created an online database of about 350 green spaces in the District, from grassy triangles at the intersection of roads to swaths of Rock Creek Park. Replete with the specific data about access, safety and facilities that physicians need if they are to prescribe a stroll in the park rather than a trip to the pharmacy, it is the first such tool in the country that allows providers to type a patient’s Zip code into their records and retrieve specially tailored summaries and maps. This allows park prescriptions to be integrated into doctors’ workflows and enables Zarr to collect the resulting data.
Zarr is taking on a historically intractable challenge, tackled by John F. Kennedy, who launched the President’s Council on Physical Fitness in 1963, and first lady Michelle Obama with her five-year-old “Let’s Move” campaign. The Johns Hopkins Bloomberg School of Public Health established an entire department in 2005 devoted to research into the effects of behavior on health.
“It not enough to simply suggest to someone that a particular behavior change might be beneficial to their health,” writes David Holtgrave, chair of the Hopkins department, in an e-mail. “It often involves working with individuals, their social networks and the surrounding policy environment to effect that change.” There is “robust literature” showing the benefits of changing the environment, says Keisha Pollack, an associate professor at Hopkins.
As a public health pediatrician, Zarr aims to take advantage of a physician’s power to counsel individuals and “meet people where they are.” A few decades ago, he says, doctors didn’t ask about other behaviors that affect health, such as alcohol intake or wearing a seat belt.
“I’m all about that first step,” he says.
Zarr sits down to describe his park prescription program, not on a bench but on the green, spring grass. He points out a couple of activities available here at Meridian Hill, such as climbing the sweeping Italianate staircases, and then he nods toward a young man reading a book under a tree.
His program is about more than exercise regimens, he explains. There are medical benefits to simply being outdoors. And part of his personal mission is to foster “the next generation of environmental stewards.”
That combination — of professional commitment to his patients with a save-the-planet passion — is gradually gaining traction.
The park database has been public since it was launched almost two years ago, Zarr says, making it “hard to say how many people are using it.” But at Unity Health Care, which serves 100,000 District residents, 180 providers with access to the system have made 720 prescriptions. Designed initially for children, it has recently been extended to include adults. Zarr is exploring a partnership with the Department of Parks and Recreation, and in mid-May he learned he had funding from the C&O Canal Trust to make the database more easily searchable. Unity recently gave Zarr the green light to begin the long process of mining the biometric data he is accumulating — from BMIs to blood pressure and depression.
Creators of many 19th-century urban parks — such as Frederick Law Olmsted, whom Zarr recognizes as a “forward thinker” — believed that green spaces would provide rustic relief for workers in rapidly industrializing cities. Hence Central Park, and others like it in Boston, Chicago and beyond, with outcroppings of rocks, open pastures and broad walkways, designed to tame nature’s wilderness just enough to soothe the emotional stresses of the city.
That philosophy — along with many urban parks — fell into neglect during the 20th century, and transportation allowed wealthier working people to decamp to the suburbs. The modern medical concept of using public spaces to improve community health took form about 15 years ago in Australia and gained prominence at an international summit in 2010.
The National Park Service launched a Healthy Parks Healthy People US program a year later with the premise that “parks are part of a public health structure,” says Jonathan B. Jarvis, NPS director, “and that they are under-utilized for that purpose.”
Park-prescription projects have taken off across the United States, from San Francisco to Philadelphia.
Drug ads are “all around us,” Jarvis says, but we overlook “this antidote for cancer, obesity, heart disease, depression,” the efficacy of which has been explored in academic research as well as in such popular literature as Richard Louv’s 2005 bestseller, “Last Child in the Woods.” Jarvis, who says the burgeoning movement coincides neatly with “increased interest in preventive medicine,” has begun collaborating with the Centers for Disease Control and Prevention and several health-care organizations.
Numerous environmental and public health groups help sustain the movement. Zarr has received support from the National Environmental Education Foundation, as have another District doctor and one in Baltimore. The National Recreation and Park Association, which represents 105,000 publicly funded local parks, furnished him with a $10,000 grant to create the database and conduct initial research and continues to evaluate local initiatives such as his with the goal of scaling the most successful models nationally.
Among the pilot park-
prescription projects around the United States, Jarvis says, Zarr’s stands out in that he operates out of a clinic that serves vulnerable populations — the kind of low-
income, inner-city community that is often “park-deficient,” he says. Zarr created the database with public health students from George Washington University, making it a “perfect example of how this should be done,” says Jarvis, with “solid information” tailored to satisfy the “data-
driven” medical community.
Check out Meridian Hill Park on the National Park Service Web site, and you’ll find that the 12-acre space includes the largest cascading fountain in North America, that its design was based on an Italian aristocrat’s private residence and that its stairways and other architectural features are made of concrete aggregate. A cellphone tour promises further details about its historic statues.
Check out the same park on Zarr’s online database and you discover that Meridian Hill is one of 14 parks in the 20009 Zip code, that its perimeter path is four feet wide and half a mile long, that there is a stone walkway with stairs and plenty of rest areas with benches. The restrooms are clean, the water fountains function, and trees provide shade. The path is rated “easy” for walkers; suggested activities include jogging and walking the dog.
The DC Park Rx Web site provides similarly detailed “Park Pages” in 35 Zip codes.
In Capitol Hill’s 20002, for example, Brentwood Park gets a grade of C for cleanliness and B for accessibility, but it has no restrooms or drinking fountains. West Potomac Park rates high for cleanliness and low for accessibility and has no benches or trash cans.
As extensive as his database is, Zarr sees it as only a start. “It has to be more,” he says.
He wants to create an app so users can Yelp a park to match their interests. He would like to adapt the Fitbit concept, making it easier to provide feedback to the prescribing doctor, who could then tweak an individual patient’s activities.
Most of all, he is on a mission to collect “harder data.”
Zarr’s research has already shown that if a child is prescribed a park, he or she will spend 22 more minutes a week physically active. Zarr also knows from other studies that spending time outside has a positive effect on health. But does prescribing that behavior — “pushing it,” as he puts it — bring about a desired outcome?
That’s the kind of question that needs to be answered, according to Zarnaaz Bashir of the NRPA, if a model like Zarr’s is to be scaled nationally.
The stronger the evidence base, agrees Sara Newman, director of the Office of Public Health for the National Park Service, “the more doctors are going to be convinced” to adopt the idea.
At the Upper Cardozo Health Center, one of Zarr’s colleagues, María Rueda-González, is introducing two patients to DC Parks Rx.
Ruth and Mariamawit Belaye, second- and fourth-graders at Dorothy I. Height Community Academy Public Charter School, have come in with their father for a routine physical. Once a medical assistant has taken Ruth’s vital signs, Rueda-González draws the family around her computer screen to show them the park database.
Rueda-González begins by explaining that playing outside is a benefit for everyone — and particularly for any kids who tend to be overweight, those who avoid exercise because they have asthma and for “anyone who feels sad.”
She then plugs in the girls’ home Zip code — 20011 — and, after a short wait, “Abracadabra!” she announces. “It works!” On her screen is an alphabetical list of 31 green spaces within the Zip code.
The girls don’t remember the name of the park closest to their home, so the pediatrician searches the database. She clicks first on Emery Recreation Center, noting that it gets a C for both cleanliness and accessibility. She moves on, pointing out a community garden at one park, a swimming pool at another, all the time infusing the conversation with tips on safety — the importance of wearing bike helmets, of using sunscreen and of never going into the water alone.
The session ends on a more formal note. Rueda-González turns from the computer screen to a prescription pad with the heading “Rx for Outdoor Activity”and picks up a pen. She prescribes outdoor play for an hour each day during spring break.
The doctor signs the form. The girls nod. Their father signs. With a click, the prescription becomes part of their health records.
A week later, at the recently renovated Fort Stevens Recreation Center, Ruth and Mariamawit show they have taken the doctors’ message to heart, taking turns with a blue jump rope and pink ball, before racing over to demonstrate their prowess on the jungle gym.
“It’s a good thing,” their father says, motioning toward the girls as they bound across a wobbly bridge to scramble up a sturdy network of ropes — each playful step a part of Zarr’s more purposeful mission.