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Background Several recent studies have identified a relationship between the natural environment and improved health outcomes. However, for practical reasons, most have been observational, cross-sectional studies. Purpose A natural experiment, which provides stronger evidence of causality, was used to test whether a major change to the natural environment?the loss of 100 million trees to the emerald ash borer, an invasive forest pest?has influenced mortality related to cardiovascular and lower-respiratory diseases. Methods Two fixed-effects regression models were used to estimate the relationship between emerald ash borer presence and county-level mortality from 1990 to 2007 in 15 U.S. states, while controlling for a wide range of demographic covariates. Data were collected from 1990 to 2007, and the analyses were conducted in 2011 and 2012. Results There was an increase in mortality related to cardiovascular and lower-respiratory-tract illness in counties infested with the emerald ash borer. The magnitude of this effect was greater as infestation progressed and in counties with above-average median household income. Across the 15 states in the study area, the borer was associated with an additional 6113 deaths related to illness of the lower respiratory system, and 15,080 cardiovascular-related deaths. Conclusions Results suggest that loss of trees to the emerald ash borer increased mortality related to cardiovascular and lower-respiratory-tract illness. This finding adds to the growing evidence that the natural environment provides major public health benefits.

Background Several recent studies have identified a relationship between the natural environment and improved health outcomes. However, for practical reasons, most have been observational, cross-sectional studies. Purpose A natural experiment, which provides stronger evidence of causality, was used to test whether a major change to the natural environment?the loss of 100 million trees to the emerald ash borer, an invasive forest pest?has influenced mortality related to cardiovascular and lower-respiratory diseases. Methods Two fixed-effects regression models were used to estimate the relationship between emerald ash borer presence and county-level mortality from 1990 to 2007 in 15 U.S. states, while controlling for a wide range of demographic covariates. Data were collected from 1990 to 2007, and the analyses were conducted in 2011 and 2012. Results There was an increase in mortality related to cardiovascular and lower-respiratory-tract illness in counties infested with the emerald ash borer. The magnitude of this effect was greater as infestation progressed and in counties with above-average median household income. Across the 15 states in the study area, the borer was associated with an additional 6113 deaths related to illness of the lower respiratory system, and 15,080 cardiovascular-related deaths. Conclusions Results suggest that loss of trees to the emerald ash borer increased mortality related to cardiovascular and lower-respiratory-tract illness. This finding adds to the growing evidence that the natural environment provides major public health benefits.