**5. Examples of linking ecosystem services to well-being and public health**

Ecosystem goods and services (EGS) are the result of processes that can contribute to social welfare [82]. Social welfare can easily be translated into elements of human well-being as defined by Summers et al. [19, 20]; particularly, health, social cohesion and cultural fulfillment. Over 50 recent reviews relating human health and ecosystem services [83] showcase the focus of connecting ecosystem goods and services (EGS) with this aspect of well-being. However, fewer studies exist directly linking physical or mental health to natural systems via ecosystem goods and services, tracing the full pathways from ecosystem structure and function to EGS to health [83]. One recent review uses causal criteria analysis (CCA) to link health and EGS [1, 84].

Causal criteria analysis was developed in epidemiology to support health decision making often based on weak but independent information [85, 86]. One study [84] conducted a CCA focusing on the effects of EGS provided by greenspaces on human disease (**Figure 6**). Green spaces included any vegetation with an environment dominated by humans [87] – urban trees, wetlands, and green roofs. The health endpoints included gastro-intestinal disease, respiratory illness, cardiovascular disease, and heat morbidity. Simply put, green spaces can abate floods and storm surge hazards by reducing runoff through natural percolation or physically limiting the influence of waves and storm surge [88]. This type of mitigation can lower human exposure to contaminated flood waters potentially reducing gastrointestinal diseases and reducing conditions that can lead to asthma through mold growth [89]. Green spaces potentially remove toxicants, reduce the prevalence of gastrointestinal disease, trap contaminants and mitigate extreme temperatures [90–94]. CCA results showed sufficient evidence for causality for all tested greenspace-EGS pairings (heat hazard mitigation, clean air, water hazard mitigation and clean water), three of six EGS-health pairings (heat hazard-heat morbidities, water hazard mitigation-gastrointestinal disease and clean water-gastrointestinal disease) and two of four direct greenspace-health pairings (heat morbidities and cardiovascular disease). This work indicates that most current literature supports intermediate pathway connections between ecosystems and ecosystem goods and services as well as ecosystem goods and services and health. However, very few studies support a direct connection between the presence of ecosystems and health outcomes. Of those studies that exist, few simultaneously measure the mediation by ecosystem goods and services (**Figure 6**).

As a specific example, ongoing studies in the San Juan Bay Estuary, Puerto Rico are evaluating the role of wetlands on Dengue fever by means of ecosystem services (e.g., biological control, clean water, and heat hazard mitigation) [95] (**Figure 7**). Ecosystem goods and services associated with heat hazard mitigation may help reduce mosquito biting, oviposition rate, and viral load. Clean surface water provides habitat for wildlife and healthier ecosystems, favoring bio-control of mosquitoes [96–99]. Preliminary findings suggest that wetlands and wetland services are negatively associated with Dengue cases even after controlling for potentially confounding variables (**Figure 8**). Wetlands and wetland services were also found to help reduce temperature which is an environmental driver of Dengue transmission [98]. These findings help support a connection between an important ecosystem in the San Juan Bay area,

Similarly, Fulford et al. [81] used a keyword-based approach to determine common terminology used by 97 counties in three regions of the U.S. (Gulf of Mexico, western Great Lakes and Northwest) to refer to community fundamental objectives closely aligned with the domains of HWBI. They analyzed strategic planning documents using the eight domains of human wellbeing described by Summers et al. [19] and listed in **Table 2**. Living Standards and Safety and Security were the most common well-being domains referred to in community strategic plans. Health and Cultural Fulfillment were the least commonly addressed domains in these documents. Major community type (same typology as used in Fulford et al. [62] differences were largely between urban and rural areas with urban community types focusing on Living Standards and Education while rural communities tended toward Leisure Time and Social Cohesion.

and manufacturing, 6 = Rural dependence on natural resources, 7 = Older suburban, 8 = Suburban industrial.

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**Figure 5.** Map showing example of Gulf of Mexico coastal counties separated into eight classification types and bar chart indicating differences in unweighted HWBI composite scores average (SE) by classification group. See [62] for more information on HWBI calculations and group delineations. Community types are represented by 1 = Urban/Suburban, 2 = Rural manufacturing, 3 = Rural farms, 4 = Rural high ethnic diversity, 5 = Rural balance of natural resource dependence

**Figure 6.** Proposed linkages between green spaces, the ecosystem services provided by green spaces and human health conditions (from [84]). EGS = Ecosystem goods and services, CVD = Cardiovascular disease, GI = Gastrointestinal, A = Intermediate steps linking green space and EGS, B = Evidence linking green space directly to human health outcomes.

> and an ecosystem service that directly influences human health. In the future, this and other eco-health research may help inform predictive models to estimate changes in health benefits

> **Figure 8.** Predicted relationship between two wetland types ((A) grassy and (B) woody) and dengue cases in San Juan,

The Role of Ecosystem Services in Community Well-Being

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Many obstacles exist in developing useful and informative relationships between ecosystem services and community well-being including cultural differences in the perception of ecosystem services and well-being, lack of consistently available data to demonstrate a causal connection between services and well-being. This is often the case when combining natural sciences and social sciences data, approaches and interpretations. Even within these disciplines, the integration of data representing indicators to create indices or demonstrate connections is highly contentious. Some policy makers suggest that summary tools (e.g., models, indices, statistical assessments) lack meaningful interpretation and have little value in the real world [100, 101]. Others argue that the time is ripe for pushing these concepts into public policy – that the real world is a complex interaction of social, economic, and environmental activities where focus on

under different decision scenarios.

Puerto Rico (Figure adapted from [95]).

**6. Conclusions**

**Figure 7.** Hypothesized conceptual model of wetlands and Dengue fever occurrence through wetland ecosystem services (adapted from [95]).

**Figure 8.** Predicted relationship between two wetland types ((A) grassy and (B) woody) and dengue cases in San Juan, Puerto Rico (Figure adapted from [95]).

and an ecosystem service that directly influences human health. In the future, this and other eco-health research may help inform predictive models to estimate changes in health benefits under different decision scenarios.
