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Dr. Robert Zarr, MD, MPH is the Founder and Medical Director of Park Rx America (PRA), a national non-profit. Dr. Zarr believes that nature-rich areas should be accessible to all and incorporated into our daily routines, and that spending time in and around nature is the single most important first step to improving both human and planetary health. PRA is committed to educating healthcare professionals and the public, and to providing the tools to meet each individual’s unique needs.
Before relocating to Ottawa, Canada in 2021 he worked for 20 years as a board-certified paediatrician at Unity Health Care in Washington, DC, where he cared for low-income and immigrant populations. He previously served as advisor to the National Park Service on park prescriptions. Dr. Zarr continues his work at Unity as a physician researcher.
PaRx Director Dr. Melissa Lem sat down with Dr. Zarr to learn about the inspiration behind his groundbreaking work on Park Rx America and as a nature therapy guide, his recent move to Canada, and his advice for fellow healthcare professionals about how to become effective nature prescribers.
I probably have the most clarity in my memory from my childhood in Austin, Texas. That was a place where I spent a lot of time outside. Austin is a very “outdoorsy” city—and it’s known as the Hill Country. When I was a kid we literally had woods right across the street. I was lucky enough to have a friend a couple doors down, and we went hiking, swimming, building forts and tree houses, playing tennis. We were outside a lot.
Even at university I remember studying outside. University of Texas at Austin has a beautiful campus, and I often studied outside the LBJ Library, which has a huge fountain and grassy knoll. We didn’t have a lot of money, so as students what you did was camp—I remember taking a trip to Big Bend National Park during Spring Break. A lot of areas near Austin are also beautiful. Pedernales Falls was a common daytrip on the weekends for us to get away for the day. Austin is accessible by foot and by bike, and there’s a hike and bike trail that runs on either side of Colorado River.
I lived in Washington, D.C. for twenty years. I spent time outside during the first ten years, but not with the kind of perspective I have now. For the first ten years I was still wowed with a lot of the things you think of with D.C.—the museums, the Smithsonian, the Capitol—all these huge iconic places and buildings and architecture. The second half of my time there was spent a lot outdoors, exploring all the nature in and right outside the city. Washington, DC is a gorgeous place to live; it’s ranked number one on the Trust for Public Land report card of cities with most accessible green space. Even some of the poorest areas have access to incredible areas, like Anacostia Park.
I have always loved kids, but when I started medical school, I didn’t know I was going to go into paediatrics. I started my clinical rotations, and the very first one was paediatrics. Then every subsequent rotation was interesting, but nothing ever came close. I did my medical education at Baylor College of Medicine. I withdrew from medical school in order to get a Masters in Public Health after the first one-and-a-half years, and when I came back into doing rotations, it just made so much sense to be talking prevention, community health, international health, when talking about kids.
When you’re trying to make a difference, it’s good to start as early as possible. Many people in Paediatrics and Public Health focus only on the first three years of life. So it just made a lot of sense to pursue a career where I could spend a lot of time with children, but at the same time feel like I was putting together my public health hat and clinical hat in a way I could reap the benefits of both.
My inspiration to create Park Rx America came at an American Academy of Paediatrics meeting at a conference in San Francisco in 2010, when I heard Richard Louv speak. I had heard of Last Child in the Woods, but hadn’t quite read it yet. I was starting to meet people at different organizations—Leyla McCurdy at the National Environment Education Foundation, Anne O’Neill through the National Park Service—so everything sort of came together. And I felt like this was probably meant to be in terms of my getting involved as a physician.
I kind of put one and one together, and thought, this is very strange and curious how spending time in nature—which should just be a common sense thing—how people are talking about turning it into a prescription, for the nature deficit, mental and other health impacts. And then I got more and more connected with conservationists and environmental stewards, and everything made sense and came together for me.
One of the things I’m proudest of is the relationships and friendships I’ve been lucky enough to develop because of this interest in nature and human health. To not just share my own experiences, but to hear what others are doing and how it’s changed their practices.
When I hear other colleagues and friends around the country—and around the world now—talk about how their practices or their lives are different now, it just feels so good to know that people can change, and share your enthusiasm.
I think that we have raised a lot of awareness through PRA, and probably more than I realize because people talk, word travels—we’ve been really blessed with a lot of media coverage as well. There’s just been a lot of attention that’s come as a result of this. And I think that’s something to be proud of.
I think also, just to be able to take what was a concept—a great concept—and put it into practice; making things easy, accessible and user-friendly—they’re not small things. So taking something that is a good idea, then to codify it and say, “This is how we’re going to do it.” Not everyone will agree with me, and even you and I take different angles on how to do this. But I am happy when people tell me, You couldn’t make it any easier. It’s gotten to the point where it’s very streamlined.
And the fact that we’re still growing every day. Every day I see a couple of people who register and join. I like seeing where they’re at, and what specialty they’re from. It’s fascinating to think there are all these doctors out there who somehow heard about us, and took the time to get registered. Doctors are super busy people, and if they take the time to do that, that says something. You’re doing something right if they’re still coming to you.
I spent almost twenty years in the same two exam rooms, in the same community health centre in Washington. Unity Health Care was one of the very first federally qualified health centres in the country, which provide accessible primary care to underserved areas. The movement started in the late 60s and early 70s, and the site that I was at was one of the very first. Most of the clinicians there are family doctors, and paediatricians are definitely a minority. But it creates a place to work that maybe is a little more like the rest of the world for us—we do some primary care, but also serve as a specialty for the family doctors, nurse practitioners and others who do see kids, but don’t see as many kids, or as sick kids.
In my own practice I see patients from a few days of life old up to their early twenties. For me, in my career, that seems like a big age range—for you it must seem like a small age range—but for me it’s a huge expanse behaviourally, cognitively, developmentally.
And I found myself prescribing nature to not just kids, but to young adults, to parents. A kid can’t really exist alone—they have to fit into some other context, and family is the most obvious one. So I found myself writing a prescription to be outdoors for a three day old, whose mother really needs as much as the baby to get some sunlight.
I start by asking a few basic questions to figure out how they spend their day. That’s the most shocking to me, when you hear the answers they give you. It’s hard to imagine any human being, much less a child, spending such an inordinate amount of time indoors, whether it be because they live indoors, their schools are indoors, they play indoors, and added onto that is the burden of all the electronic time for both work and play now.
Some of the most obvious examples of kids I prescribe nature to are those who are stressed out; chronic stress is epidemic. Kids are under a lot of pressure from school, peers, family, and now with fear of getting COVID or passing it along to their family. And because I spent twenty years working with kids who live in poverty, there were other additional stresses of food insecurity, insecurity of housing, and violence.
And so figuring out where in their lives they might be able to be alone—away from other humans but in a natural space—it’s definitely interesting to see what happens to them. How they change and grow when they realize not only is it okay for them to spend time outdoors in nature, with nature, but that their doctor is legitimizing it to them.
If you live in a city that’s known for its violence and unrest and crime, it’s not an easy ask to get a parent to say okay, that they can in a measured way be outside and be alone, or even go with friends. The issues of inactivity and overweight and obesity are all wrapped up in one, but a lot of kids in the lower age range want to play and be outdoors. And so it’s important to work with the parents to figure out what in their schedule they can tweak a little bit more to allow them to be outdoors.
Paediatrics is actually looking more and more like adult medicine. I see lipid disorders, rising A1Cs, blood pressure issues. Anxiety is a really common diagnosis, with chronic stress and depression, and kids need to learn how to manage these stresses. It’s unfortunately looking so much more and more like adult medicine. The world they’re born into isn’t a fair world.
And today still I feel like having a conversation about where and how to spend time outdoors safely is somewhat of a subversive thing. We’re expected to give patients pills and send them to specialists, but this is something you can do for yourself that doesn’t have the same potential side effects. It can make a huge difference—a giant difference.
I’m a certified Association of Nature and Forest Therapy guide. I’m happy to report it was absolutely the right decision, both personally and professionally. If you’re considering it, it’s a really amazing experience because it gives you another set of tools to promote reconnection with nature—but in a much more intimate and intense way.
It’s very different from nature prescriptions. When you’re a guide, you’re not a therapist. Nature is the therapy. You’ve got to be able to let go, and you have to be able to accept and embrace the language of invitation. I think that’s something that doctors are not generally used to; we are probably more used to giving advice, but being a guide is really about guiding. It’s about creating a space for people to feel comfortable, and where they won’t feel judged, and for them to laugh and play, and feel and sense, and have this experience in what could be the most ordinary of places. It could be your backyard, or places you’ve been to a thousand times, but that you’ve never quite experienced like this before. It’s really about creating this moment in time whereby people can experience what it’s like to develop relationship with the more-than-human world by virtue of opening up the possibilities of your senses in that moment.
One of the things I’ve realized, Melissa, is this isn’t just about patients, and this isn’t just about the planet either. A piece of this that has caught my attention is the mental and physical and spiritual health of us providers. And I don’t think we talk about it, or are comfortable talking about it, very much. Something I’ve been doing more of over the past few years is providing these guided walks to colleagues. We did several walks, with doctors, medical assistants and clerks, instead of meetings. If you work in a large centre like mine you have departmental meetings. But instead of being indoors, I was able to connect a guide with our staff to go on a two-and-a-half hour walk instead of a three-hour meeting, and it was pretty amazing to see.
The thing about a nature therapy walk is it’s not just an individual relationship that you develop with the more-than-human world. It’s also about sharing with the human group, which is very important.
A nature therapy guide provides structure. It’s not a super-rigid structure, but it nonetheless allows for this sharing to happen. And the sharing is human to human, obviously, but it’s done in a way where there is little to no judgment. Silence is another form of expression; it’s totally acceptable in a guided walk. Wearing my physician hat and guide hat together might help me to provide more guided walks for my colleagues. I’d like to do more of that. I’ve already gone on a walk here in Ottawa with Forest Therapy Ottawa, and I’m excited to see where this leads.
I gotta’ admit that when I write nature prescriptions, I will bring a little bit of nature therapy into that conversation. I think it’s appropriate. Time permitting, I’ll ask a few questions of my patients. I remember asking a kid what he was going to do for the summertime, and he said he was going to work with his dad. Doing what? I asked, and he said, Planting trees. And I just point-blank asked him, Do you ever talk to the trees? Do you think they listen to you? Just to see what his response was. He didn’t seem surprised at all by my questions.
It’s fascinating. We assume so much of this nature stuff we do is not going to be well received by our patients or by our colleagues, but I’m always surprised at how well it is received. There’s nothing more natural than to spend time outside, or talk to a tree, or sit on a stump, take a deep breath, smell a flower, or spend time with friends and family outside.
When you talk about Nature in that way it’s a no-brainer to them. And when you have the hat of a guide, the hat of a physician, a member of society who probably is still even today somewhat respected, you’ve got a podium. And it feels good to be able to promote something that you know in your heart is good for people and good for the planet. Not everybody can be Greta. We are who we are, and know what can we offer, no matter how small it is. That’s something I feel good about.
PRA is committed to educating and training fellow healthcare providers about the connections between human health and planetary health and showing them how to incorporate a brief physician intervention into a daily routine and busy clinic setting. We’re actually in the midst of revamping our platform and our website, so we’ll have more of a patient interface, so we can have more direct conversation with the public. One of my hopes is to get our patients to practically write the own prescriptions, and have their doctor legitimize it.
I’m also involved as a co-Principal Investigator (with Dr. Deb Cohen) in a clinical trial on park prescriptions. This research is funded by the National Institutes of Health in the US. It’s a very simple design-control and intervention group with control getting “care as usual,” and intervention getting “care as usual” plus a nature prescription through PRA’s nature prescribing platform. We’ll be recruiting 500 participants between six to sixteen years old. We are measuring activity using accelerometry. We are also using a survey tool to ask questions about park use, sedentary activity, electronic device use, stress, cognition and memory, as well as biometrics like body mass index, A1C, triglycerides and cholesterol.
To log your Rx as a participant you answer one to two questions depending on your age category (6 to 9 or 10 to 16). The questions are about your mood and your connectedness to nature. Because every provider has an individual account, we’re able to track the progress of participants and the continuity of their experience through the prescriptions. It’s pretty exciting.
Canada is a lovely place. My family visited Canada many times; we have friends and family here, and we always loved it. Now here we are living in Ottawa, and it’s cold compared to Washington, DC (laughs). It has four seasons! We arrived in the summer, and now it’s already Fall, but it’s absolutely breathtaking with the change of leaves. It’s heartening to see the similarities.
Within Ottawa, being close to nature was a very big part of our decision to live where we live. We live in an area now that is very nature-rich. We have access to a pond, to a lake, to the Ottawa River, and across the street is the Beechwood Cemetery, which includes Canada’s National Cemetery. We’ve seen three coyotes in there, and wild turkeys, and at the lake we have a lone gull we call Jonathan. We love to see Jonathan every time we go by. Just on the edge of the Cemetery is the Macoun Marsh, and it’s just a lovely tiny little area where the flora and the fauna are elaborately drawn in colour with their names, so there’s an educational side to it. And there’s an area that faces the west, so if you go at the right time you get a lot of sunlight.
But we still live in the time of COVID, so our exploration of the city is still quite limited. Ottawa’s not completely opened back up yet; there are still a lot of restrictions in place, and that’s wise and safe and the right thing to do.
Having access to nature is even more relevant during a time like this where your movement and your time with other humans is restricted.
We’ve still gotten to explore a little bit. We’ve gone to Mer Bleue, a bog 15 minutes away, and we’ve been to Quebec, which is literally across the river. There’s a huge park here called Gatineau Park, which is just breathtaking and expansive. So yeah, we’re very lucky. And I know that we’re always trying to wear our lens of equity when we talk about nature, because access to Nature should be a human right, but it’s not fairly distributed across all people. I feel very grateful that I have access to it.
I do find that in many places in Ottawa you’ve got pretty good access to the river, to woodsy areas, to wilderness pretty quickly. It doesn’t take long to get out of the more urban areas, and even in downtown there are some spectacular parks.
We’re adjusting to life in Canada. Canada is a lovely place. We’re here for two years. We don’t know much beyond that, but we’re excited to be here. My family and I find Canadians very welcoming people and that means a lot to me.
That’s a good question. Probably the best way for me to answer that question is to tell you that my favourite spot has more to do with its accessibility that anything else. I’ve been to amazing spots all over the world, but the ones I love are the ones I have relationships with. I’ve been to Peru, New Zealand, Australia, and they’re there in my mind, but not in my heart the same way as the places I go to more frequently.
Right now going to Beechwood Cemetery is spectacular. It’s calm, it’s peaceful, it’s easy to get around for someone in their middle age. There’s a lot of trees, and certain trees catch my attention. Right now the barrenness of the trees I find very beautiful, as well as all the conifers—that to me is spectacular. If you look out one of my windows right now you can see the pond, which is also very beautiful.
After nineteen years of not owning a car, we bought one so we could drive ten minutes to the National Arboretum. During the pandemic, we went there religiously every day for one-and-a-half hours, my wife and I, to have open space. So that’s a place that’s very dear to my heart now. If you and I are ever at the Arboretum at the same time I can take you places you’ll never find on your own (laughs).
What’s amazing is no matter where you are, it’s all constantly changing. That’s something that isn’t talked about enough. The experience you have outdoors is never the same twice—the time of day, your stress level, the level of the sun, the way the wind blows, the animals you might come in contact with, the colours of leaves, ice patches—it’s endless, the permutations of experience you can have in the exact same place.
The older I get the more I realize you don’t have to go deep, deep, into remote areas of the world to have an experience of wonder. Sometimes wonder is literally right outside my window.
I remember when I first moved here I heard this clicking sound. Is it a mechanical thing? Is it a problem? I went to find it, and do you know what it was? It was a chipmunk! There are no chipmunks where I used to live. Squirrels make a distinctly different sound.
There’s a lot of value in being in the same place and developing a profundity of relationship with nature, with the land, with everything that’s on the land, and also recognizing who’s been on this land long before we arrived.
So your favourite place is wherever you are, and to be still, to listen, and to feel, to be alive there. Sometimes, Melissa, it’s in a sterile hospital, where there’s no natural light or window. This brings me to my experience of meditation, which is realizing that you are nature, we are nature. And sometimes that’s all you have, given the fact that not everyone can go out every moment of every day. So to feel your own pulse, or to feel your heartbeat, or feel your own breath on your philtrum, to sense the tingling in your hands and body, that’s also nature.
We humans are not apart from nature—we are nature. And I don’t think it does us any good to think of nature as something over there. We’ve evolved for millions of years outdoors, and at the end of the day, we are fauna.
If you’re a Canadian physician you have to go to PaRx—that’s pretty obvious.
I also think that speaking with other physicians and hearing their experiences is important. And also integrating what we talked about earlier, which is self-reflection, and thinking about, as a physician, how you spend your day, because most of us don’t spend our days in the healthiest way possible. That’s maybe the first step, is to think about whether you have nature deficit as a physician, and how might you address that.
There’s many ways to do it. We’ve talked about nature therapy walks—that’s a time commitment, 2½ hours—but some simple things, like not eating at your desk while charting, making an effort to go outside and take a break in the middle of the day, which would include some time outdoors or near some nature-rich area, might be a first good step.
One of the terms they use in the U.S. National Park Service is One Health. I almost love it more than planetary health. I love the oneness and the interconnectedness—thinking about not just how your actions affect you, but how they affect others. Self-reflection can be painful, but hopefully it comes with some insight into how we physicians live our lives, and how we can translate our experiences to our patients to empower them to control what they can in their lives, and create better self-care, prevention and mental health practices.
For more on Dr. Zarr’s work, head to parkrxamerica.org.