Rev Environ Health 2016; aop

Margot W. Parkes*

Pacific connections for health, ecosystems and
society: new approaches to the land-water-health
nexus
DOI 10.1515/reveh-2015-0067
Received November 15, 2015; accepted November 16, 2015

Introduction

Abstract: Renewed effort to understand the social-ecological context of health is drawing attention to the dynamics
of land and water resources and their combined influence
on the determinants of health. A new area of research,
education and policy is emerging that focuses on the landwater-health nexus: this orientation is applicable from
small wetlands through to large-scale watersheds or river
basins, and draws attention to the benefits of combined
land and water governance, as well as the interrelated
implications for health, ecological and societal concerns.
Informed by research precedents, imperatives and collaborations emerging in Canada and parts of Oceania,
this review profiles three integrative, applied approaches
that are bringing attention to the importance the landwater-health nexus within the Pacific Basin: wetlands
and watersheds as intersectoral settings to address landwater-health dynamics; tools to integrate health, ecological and societal dynamics at the land-water-health nexus;
and indigenous leadership that is linking health and wellbeing with land and water governance. Emphasis is given
to key characteristics of a new generation of inquiry and
action at the land-water-health nexus, as well as capacity-building, practice and policy opportunities to address
converging environmental, social and health objectives
linked to the management and governance of land and
water resources.

The need for greater understanding of how ecosystem
change influences both environmental and social determinants of health continues to demand international
attention from global to national and local scale (1, 2). A
core feature of progress in this area has been a shift from
simple representations of ecosystem and health linkages
as cause-effect relationships associated with specific
hazards, to a more nuanced and systems-based orientation to diverse pathways by which ecosystem services and
social-ecological systems can influence health and wellbeing directly and indirectly (3–5). These connections
and interrelationships are exemplified by the dynamics of
land and water resources and their combined influence on
health, ecological and social issues.
The demand for combined attention to land and water
resources in relation to the social-ecological context of
health draws on three important research insights made
over the last decade. First, the health implications of water
resources management cannot be understood in isolation
from land-use, and vice versa. These interrelationships
call for combined attention to the land-water-health nexus,
applicable at different scales, ranging from small wetlands
through to large-scale watersheds (6, 7). Wetlands are
defined by Ramsar as “areas of marsh, fen, peatland or
water, whether natural or artificial, permanent or temporary, with water that is static or flowing, fresh, brackish or
salt, including areas of marine water the depth of which at
lowtide does not exceed 6 m” (8). Watersheds (also known
as catchments and river basins) are spatially bounded biogeophysical units including their associated social actors
and institutions (9) and can be viewed as “functionally
distinct hydrologic units in which the water cycle is a key
driver of ecosystem processes [and which] come reasonably close to what might be considered an idealized ecosystem” (10, p. 319). Second, understanding land-water-health
dynamics requires attention to negative and positive influences on health and well-being, whereby the condition of
wetlands or watersheds can determine exposure to health
hazards (chemical and microbial contaminants), while

Keywords: determinants of health; indigenous; Pacific;
watersheds; wetlands.

*Corresponding author: Margot W. Parkes, Canada Research Chair
in Health, Ecosystems and Society, Associate Professor, School
of Health Sciences, Cross-appointed, Northern Medical Program,
University of Northern British Columbia, BC, Canada,
E-mail: margot.parkes@unbc.ca

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Parkes: New approaches to the land-water-health nexus

at the same time providing health benefits ranging from
the core human requirements of food and water, through
to lifestyle, livelihoods and the health benefits of biodiversity, equitable water access, and stewardship (6, 7, 11).
Third, attention to land-water-health issues demands a
shift in attention from government to governance (7, 12).
Understanding governance as “a process whereby societies or organizations make their important decisions,
determine whom they involve in the process and how they
render account” (13, p. 1) enables attention to be placed on
the range of factors, roles, responsibilities and intersectoral challenges associated with governing land and water
resources, and the implications of watershed governance
for the determinants of health.
Attention to the land-water-health nexus is considered especially important in an era of dramatic increases
in the rate and scale of social-ecological change, compounded by intensifying resource extraction and development internationally, and the overlay of climate change (1,
4, 14, 15). These changes compound and exacerbate the
complex health and well-being issues associated with the
governance of land and water resources, ranging from
safety and security of drinking water sources, to capacity
to sustain livelihoods, food security, economies, lifestyle
and cultural values, especially in resource-dependent
and climate-impacted communities (4, 7, 16–20). Such
issues have implications not only for populations living in
rapidly urbanizing societies, but also for rural, remote and
indigenous communities that remain especially sensitive
to changes in social-ecological systems which, in combination, can disrupt social determinants of health, create
environmental hazards, and disturb critical relationships
among culture, identity and well-being (21, 22).
In response to these issues, a new area of research,
education and policy is emerging that focuses on the interrelated health, ecological and societal consequences of a
combined focus on land and water governance. Informed
by research precedents, imperatives and collaborations
emerging across Canada and parts of the Oceania region
(Oceania: A general name applied to the isles of the Pacific
Ocean, including Polynesia, Melanesia, Micronesia, Australasia and sometimes the Malaysian Islands) (23), this
brief review profiles three integrative, applied approaches
that are bringing new attention to the importance the
land-water-health nexus within the Pacific Basin:
1. Wetlands and watersheds as intersectoral settings to
address land-water-health dynamics;
2. Tools to integrate health, ecological and societal
dynamics at the land-water-health nexus;
3. Indigenous leadership: linking health and well-being
with land and water governance.

Innovations at the land-waterhealth nexus
A combined focus on interrelated land, water and health
issues demands not only new knowledge generation
about these issues but also increased attention to the
actions required to address the social-ecological influences on the determinants of health. Innovative responses
to these demands are emerging from a variety of research
and policy contexts, including explicit attention to the
‘knowledge to action’ dynamics of ecosystem approaches
to health, and the complex societal challenges identified
as ‘wicked problems’ at the interface of health, ecological
and societal concerns (24–27).
In the Pacific region, opportunities to exchange
knowledge about land-water-health issues, as well as
actions to address these issues, are challenged by the jurisdictional, demographic, cultural and ecological diversity
of the region (28, 29). Even so, the types of innovations
profiled here are notable for their generic relevance and
potential for application in a range of contexts spanning
the small island states of the South Pacific to the continental-coastal dynamics of Australia and Canada.

Wetlands and watersheds: intersectoral settings to address land-water-health
dynamics
The need for attention to the role of the public health
sector in responding to complex intersectoral challenges
is growing, especially in response to the combined ecological and social impacts of climate change and resource
development on health and well-being (16, 19, 20). Calls
for a new generation of intersectoral action are arising in
contexts from global to local, ranging from a recognition
of planetary and global impacts (1) through to national
calls for new types of intersectoral action to address the
combined health implications of social and environmental change (2, 30). Within countries, the importance of
public health engagement with land and water governance processes is being highlighted in contexts ranging
from the public implications of oil and gas exploration
(16, 17, 19), through to increased interactions among
health units and watershed-based jurisdictions (31) and
growing interest in the cumulative (health, social, environmental) impacts of resource development (20, 32, 33).
Health units and authorities are finding themselves challenged by the recognition that changes to land and water
resources will provide the context for population health in

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Parkes: New approaches to the land-water-health nexus

the short, medium and long-term. Addressing ‘upstream’
determinants of health demands explicit attention be
paid to the driving forces of social and ecological change
(7, 20). Along with growing recognition that ‘upstream is
a place’, are demands for ‘integrated settings approaches’
focused on social-ecological contexts for health (34–36).
Against this backdrop, watersheds and wetlands
are increasingly being recognized as settings for health,
helping to contextualize important features and characteristics of the land-water-health nexus across a range of
scales and contexts (6, 7, 34). Both wetlands and watersheds are usefully understood as social-ecological settings, which also demonstrate the characteristics of
coupled natural–human systems (10, 37). Wetlands and
watersheds therefore offer a place-based construct within
which to understand and manage driving forces of change
in particular social-ecological systems, the interactions
between social systems, ecosystems and health, and to
identify specific actions to improve social and ecological
determinants of health within these settings. As expressions of the land-water-health nexus, wetlands and watersheds are being found to be internationally relevant, but
especially pertinent in the context of changing climate
and associated impacts on land and water resources in
the interrelated continental, island and terrestrial-marine
systems across the Pacific region (18, 38, 39).
A heuristic framework for depicting and examining
these intersectoral dynamics is presented in Figure 1. This
framework, is adapted from previous versions of the prism
framework (7, 40), to highlight the fact that these intersectoral relationships could be understood in the context of
any social-ecological system. In this example, wetlands
and watersheds are proposed as place-based settings
within which to examine the intersectoral dynamics of the
land-water-health nexus.

Tools to integrate health, ecological and
societal dynamics at the land-water-health
nexus
Tightly coupled social-ecological change and associated
shifts in the landscape of the determinants of health
highlight the need for the public health community to
move from a focus on why the social-ecological context
for health is important, to identify how the health sector
can work with others to develop research, practices and
policies appropriate to the intersectoral challenges at the
land-water-health nexus. Better understanding of the
boundary-crossing, complex intersectoral challenges of
land and water governance, has been associated with the

3

Figure 1: The prism framework for health and sustainability
adapted to the land-water-health nexus.
The framework offers a heuristic for application in any socialecological system. In this example, wetlands and watersheds are
presented as a place-based setting within which to examine the
intersectoral dynamics of the land-water-health nexus. Adapted
from Parkes et al. (7, 20). “The Prism Framework for Health and
Sustainability adapted to the Land-Water-Health Nexus” by Margot
W. Parkes is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

need for new types of tools and practices that can benefit
from multiple forms of ‘knowledge’ (local, community,
disciplinary, organizational, indigenous and holistic)
and multiple types of ‘actions’ (ranging from specific
research, education and practices to policies, legislations
and socio-political change). One response to this need
has been ongoing attention to participatory, multi-stakeholder, transdisciplinary approaches to knowledge generation and exchange, especially within the emerging field
of ecosystem approaches to health (5, 41), and which are
benefitting from development of related approaches in the
context of watershed in catchment management, across
Canada and Australasia (42–44).
Another effort to respond to the complexities of the
land-water-health nexus is arising through the revision,
development and refinement of existing decision-support
tools. Rapid development in geospatial technologies has
seen considerable shift from traditional (largely biophysically oriented) Geographic Information Systems (GIS),
through to participatory, and expert-informed GIS tools
that explicitly seek to understand the complex social-ecological values and priorities operating at the land-waterhealth nexus (45, 46). A related development has been the
design of geospatial watershed ‘portal’ tools capable of
integrating diverse forms of spatially related data, documents, audio-visual material across health, social and
ecological realms within watersheds (47).

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Parkes: New approaches to the land-water-health nexus

Indigenous leadership: linking health and
well-being with land and water governance
A notable area of development in decision-support tools
relevant to the land-water-health nexus has been innovations and targeted efforts to develop integrative tools
that value and prioritize indigenous perspectives on these
relationships (44, 48–50). Indeed, integrative indigenous
perspectives and research leadership has been providing
a range of opportunities for integration of health, ecological and social concerns, with particular relevance to
the land-water-health nexus (22, 39, 51). Many integrative
approaches to understanding indigenous health explicitly
identify land, water and environmental stewardship as
interrelated determinants of indigenous well-being and
“web of being” (22, 52–56). Given the legacies of unethical research and disproportionate health burdens impacting indigenous peoples internationally, using culturally
appropriate practices to promote health and prevent
disease at the land-water-health nexus will be imperative (57). Lessons and insights from across Canada and
Oceania echo wider issues and priorities for indigenous
peoples internationally.
Responding adequately to the diverse land-waterhealth context in the Pacific region will require a shift in
perspective from “including” indigenous knowledge, to
focusing on interrelated processes of indigenous leadership, knowledge generation and action to address
the health, ecological and socio-cultural dynamics of
land and water governance experienced by indigenous
peoples. In addition to developments in existing decision-support tools, an array of new approaches to learning and exchange are being developed, including Digital
Story-telling and related narrative approaches that
reflect well-documented connections among language,
cultural strength, histories of orality and connectivity
between land and community as drivers of indigenous
peoples’ health and well-being (57–59). A new generation
of effort in the Oceania region is prioritizing both Indigenous perspectives and an explicit focus on the landwater-health nexus (39). One indication of this was the
inaugural Oceania Ecohealth Symposium titled “Linking
Peoples, Landscapes, Health and Well-being” (December 2013) convened at the University of Melbourne which
explicitly profiled precedents of indigenous leadership
from Australia, New Zealand and the South Pacific. This
event highlighted the level of interest in fostering indigenous-oriented collaborations that profile leadership
and practices relating to land, water and health, including the potential co-design of comparative international
research. These developments are directly informed by

collaborations among indigenous and non-indigenous
researchers and practitioners in Canada and Oceania, and
offer fertile prospects for research and learning across the
Pacific Basin.

Conclusions
This brief review presents innovations and developments
focused on different aspects of the land-water-health
nexus, drawing particularly from experience and precedents in Canada and parts of Oceania. These efforts form
part of a growing body of work that links health, ecosystems and society across scales, spanning biodiversity and
health (11), wetlands and health (6, 60), watersheds and
health (7, 34) and planetary health (1). Emphasis has been
given to new areas of inquiry and action with potential
for research collaborations and comparative case-studies
across the diverse Pacific region, as well as capacity-building, practice and policy opportunities to address converging environmental, social and health objectives arising in
relation to the management and governance of land and
water resources.

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