17 Jul
Defiant Gardens: from Helmand to Headley Court

Posted by Kenneth Helphand in the Uncategorized archive








The art of medicine

Defiant gardens: from Helmand to Headley Court



There were gardens at Camp Bastion, so many of them that anyone ying in to the British base of operations during the UK’s involvement in the war in Afghanistan from 2001 to 2014 would have been astounded. The best way to see all these little patches of green in the dry dust of the desert behind miles and miles of barbed wire fence was from a helicopter, but if you ew or travelled in one of the Apaches or Chinooks that bumped down every hour at one of Bastion’s landing sites, you had other things to worry about. Aircraft were at their most vulnerable to enemy re as they came into land, especially in daylight. Medical sta returning to the eld hospital—the landing site there was called HLS Nightingale—were focused intensely on getting the patient they carried to the trauma bay or the operating theatre and from there, home.

Studies have supported the bene t of gardens in hospitals and caregiving settings. Patients who look at views of a garden from their hospital bed do better post- operatively than those who look at a car park. Patients with dementia can feel less agitated and distressed if they have access to gardens in their care facilities. There is a long history, predating scoping reviews and outcome studies, of gardens in medical facilities working therapeutically. So for all those reasons, hospitals today are incorporating gardens, often in extraordinary forms, into their architecture and design. This essay is not about those gardens or about the horticultural therapy practised there. It is about gardens like those at Camp Bastion, which do the same work and more, not planned, rarely expensive,

but every bit as important in the process of healing for people in the worst of circumstances.

One of the gardens had been built by a plastic surgeon who heard the bump of the medical helicopter ight as it landed at HLS Nightingale every time he was on call at Camp Bastion eld hospital. The sound meant long sessions of surgical reconstruction that often felt more like something else once the limbs he had removed were packed away into yellow plastic disposal bags and the blood cleaned o the oor of the operating theatre. Before he came to the eld hospital, he’d been based with units that did their ghting on the move in the deep desert, and it always astonished him to see owers growing there no matter how hard or dry the ground. He took photographs of them, to remember, and when he had time and space at Bastion,hegrewsomeforhimself.Hisgardenwasmarked out with wooden fencing scrounged from somewhere, and terracotta pots wedged into the dust and lled with strong little plants, all arranged in a neat scheme. He watered them diligently with a yellow hose—plenty of water at Camp Bastion from the aquifer 150 m down that drained fresh water from the snow melt of the Hindu Kush mountains—and he watched his pots ll with salads and herbs from seed, and plants from cuttings whose names he never discovered but which grew and grew despite the heat and dust.

His garden proved its worth in ways he couldn’t have imagined. He sat out in it, not in the cool of the evening but in between the long bouts of surgery, when the sun was at its brightest and hottest. The surgical theatres at Bastion were air-conditioned, sometimes a little too e ciently, and they got chilly after hours of work. Everyone, including the unconscious patient, was shivering by the end. So he went to his garden to warm up, to check on his plants, and to be comforted by things that were as far away from con ict and casualty as could possibly be imagined.

A landscape architect, Kenneth Helphand, has de ned the technical term for places like this. He calls them de ant gardens: a good name, and well deserved. De ant gardens are built in places surrounded by war and violence all over the world, from trenches on the Western Front a century ago, and in ghettos and concentration or internment camps in the century since. The surgeon at Bastion thought of his garden as just a little patch, but scale isn’t important. With de ant gardens, even a micro- restorative environment is restorative, in an unexpected multiplicity of ways. As a surgeon, he o ered restoration and the possibility of healing to his patients. His garden gave some of that back to him. De ant gardens remind their gardeners of home and hope. They give people a way




www.thelancet.com Vol 392 July 14, 2018



Alan Kay





to manage the horrors that can happen to them, and to glimpse a world beyond.

At the other end of the casualty continuum, and a world away from the desert, another de ant garden was built at Headley Court, in Surrey, UK. Headley has been the o cial Defence and National Rehabilitation Centre (DMRC) since World War 2. It was where casualties injured in Afghanistan whose survival had been ensured by the surgeons at the eld hospital were taken to begin their new lives beyond survival, through rehabilitation. In a phased handover during 2018, the rehabilitation facilities at Headley are moving to DMRC Stanford Hall in Leicestershire. The new centre will have extensive landscaped gardens and grounds. These will take their inspiration from the garden at Headley, which was conceived in 2010 by a physiotherapist because he wanted to create a space where his patients could transition between the static world of the rehabilitation gym and the jumble of the real world outside. Headley already had the remnants of a beautiful garden built in the 1900s, but the physiotherapist reframed it, added a layer to make a garden within a garden, with a path through places where patients could learn how to feel things like wet grass, gravel, edges, adverse cambers, and cracked paving stones, all through their prosthetic feet so their brains could adjust and they could walk out into their new lives with con dence and skill.

At Headley Court, it wasn’t just the physical reactions to trauma that the physiotherapists and patients dealt with, it was also the psychological reaction. At Headley between 2009 and 2014, the multidisciplinary rehabilitation teams didn’t generally use the term post-traumatic stress disorder with their complex trauma patients because it wasn’t quite the right one at that point in their recovery. Instead, they called it the trauma reaction, another well chosen name. The trauma reaction could be a good day spent hitting rehabilitation goals in the gym suddenly turning into a bad day, grieving for what has been lost—a limb, a comrade, a self.

The physiotherapist understood that a di erent kind of garden would be needed for the trauma reaction, so he asked that another layer of garden be added to those already there. It was designed by the father of a patient who understood his son’s exhilaration that he could walk once more but with the knowledge that it was on prosthetic feet that would never again feel grass between their toes. The garden he made at Headley was for his son, his friends, his family, and all the medics who had worked so they could nd comfort and restoration.

Along the paths where the patients practised new ways of walking, he laid beds full of plants that produced an abundance of blossom: petals that could be gathered up and bagged to make confetti for future weddings. There were plants whose owers and leaves smelled as good as

they looked, in the air or on the ngertips. Plants where families could give bored children a leaf to nibble on so they could nd out what herbs taste like. Something remarkable to share with other family groups gathered there for the same reasons, or with sta on their breaks. Plants that were beautiful when it rained, silver drops of water hanging from their foliage. For autumn, there were plants that made catkins, and plants with leaves that suddenly burst ery red. Plants that elegantly framed winter with frosted stems, seed heads, feathery, silvered leaves, something to look for from the windows inside, when even the boldest preferred the warmth. A garden for all seasons, on the calendar or in the soul.

Perhaps at rst glance, the little patch of garden in Afghanistan and the masterpiece that was Headley Court don’t seem to have much in common. But they are both de ant gardens, created in response to the hardest of challenges, places that provide mechanisms and evidence of human resilience in extreme circumstances. They speak to very deep, old human instinct to connect with nature, especially when we are under pressure. The nature of de ant gardens helps all of us—patient, family, friends, and caregivers of whatever kind—to evolve, rediscover who we are, and be comforted by the familiar, whether it grows in a small terracotta pot or a lush, ower- lled bed at the end of an emerald lawn.

Emily Mayhew

Historian in Residence, TRBL Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London SW7 2AZ, UK

I am Imperial Lead on the Paediatric Blast Injury Partnership, part of the Centre for Blast Injury Studies network and am Historian in Residence in the Department of Bioengineering, Imperial College London.

Further reading

Helphand K. Defiant gardens: making gardens in wartime. San Antonio, TX: Trinity University Press, 2006

Wilson EO. Biophilia. Cambridge, MA: Harvard University Press, 1984

Mayhew E. A heavy reckoning. London: Profile/Wellcome, 2017

Hickman C. Therapeutic landscapes. Manchester: Manchester University Press, 2013





www.thelancet.com Vol 392 July 14, 2018




Rupert Frere

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