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War and Medicine

Summary

The challenges of reporting restrictions and patient confidentiality meant that journalists and historians had not been able to gain unrestricted access to the contemporary British military casualty chain. Through negotiated access David Cotterrell, professor in fine art, was able to view the militarised healthcare pathway from point of wounding to domestic rehabilitation. Cotterrell provided the first public exposure of this complex and sensitive subject to British audiences.

Through his written and photographic accounts, Cotterrell informed the development of new training materials for personnel going into combat zones to ensure early awareness of the care pathway, and new NHS materials to inform the public of the extended healthcare pathway. Through Cotterrell's subsequent exhibitions, publications, lectures, articles and interviews the work has also provided a catalyst for greater public debate regarding the human cost of war.

This is a darkened room in which video reproduces the sensation of being a sedated wounded soldier taken to a hospital inside the hold of an RAF Hercules - the combination of haze and noise make this quite terrifying.
Rupert Christiansen, Telegraph

Our research

The research made clear that soldiers recovering from life-changing injuries had limited means of reconstructing the narrative of their transformative experiences. From the time of wounding through to secondary operations in the UK, many soldiers remained sedated or unconscious for a period of up to five days. The radical physical transformation that had occurred during this period was not adequately reconciled through medical notes, and the embargo on photographic documentation of incident and subsequent medical procedures served further to obscure this period of lost memory.

A culture of secrecy meant that medical professionals were unable to access documentation of the expanded care pathway with which they, and their colleagues, were engaged. This fragmentation of experience and understanding within the process of evacuation, treatment and rehabilitation meant that the assessment of the contradictions and disorientation experienced by casualties and medical practitioners was denied to front-line staff.

Family members, colleagues and members of the public outside the immediate environment of the military were unable to visualise or understand the transformative effects of conflict on directly affected civilians and soldiers. Partly as a result, the scope for public debate to engage meaningfully with the longer term societal cost of contemporary conflict was limited.

The impact

Two debriefings took place on return to the UK in December 2007: one with Ministry of Defence officials in Whitehall; the other with Wellcome curatorial staff. This testimony precipitated a substantial re-evaluation of the War and Medicine exhibition design and its development.

Cotterrell was subsequently invited to share his observations with individuals, organisations and government agencies in order to support greater contextualisation of their experiences and agendas.

In Afghanistan (April 2008), Cotterrell presented to the ISAF joint chiefs of staff at the British Embassy and to NGO and embassy representatives from Canada, the UK, the US and other nations at the Turquoise Mountain Foundation in Kabul. In the UK, he delivered presentations to the Critical Care Air Support Team (RAF Intensive Care evacuation team) at RAF Lyneham (Sept 2008) and to the Royal Army Medical Corps (201 Field Hospital Regiment, 2009 and 208 Field Hospital Regiment, 2012).

Recognition that the extensive and potentially indefinite care pathway could not fully be understood by any one professional participant led the Department of Health to commission Cotterrell to access UK civilian and military medical facilities in order to build the first contemporary record of the extended healthcare pathway.

Between February and July 2009, Cotterrell observed and documented CCAST handovers at Birmingham International Airport/Queen Elizabeth Hospital, secondary operations and trauma care at the Royal Centre for Defence Medicine (RCDM), Selly Oak, and physical occupational therapy at Defence Medical Rehabilitation Centre (DMRC), Headley Court.

This record is used by the NHS to inform the general public through its NHS Choices website, viewed by over 38,000 individuals between July 2009 and June 2012. It has been championed by the Surgeon General, and is being used by the DoH and MoD to demonstrate ongoing integration. Cotterrell's comprehensive documentation was used in February 2010, at the request of the Chief of the General Staff (CGS), to modify RSOI (Reception, Staging and Onward Integration) in-deployment briefings for soldiers, medics and civilians to incorporate for the first time comprehensive documentation of the post-injury casualty pathway.

Two public exhibitions were realised in London of new time-based installations, photographic series and video works (War and Medicine, Wellcome Galleries, December 2008, and Aesthetic Distance, Danielle Arnaud contemporary art, January 2009). Accompanying and contextualising the exhibitions, extracts from Cotterrell's diary, and selected photographs were published in books by Black Dog Publishing and Wallstein Press (English/German translation).

Selected press outlets were allowed access to elements of this documentary material, with The Guardian printing a selection as a four-page feature. In November 2008, Cotterrell's work was discussed on BBC Radio 4's Front Row, Start the Week and Today programmes and BBC online and broadcast programmes. Subsequently (between November 2008 and January 2009), diary extracts, photographs and exhibition documentation were reprinted and discussed internationally in the Lancet, BMJ, Health Service Journal, Art Review, Frieze, Creative Review, Museums Journal, RSA Journal, Soldier, RUSI Journal, in national and international newspapers (Times, Telegraph, Guardian, Financial Times, Wall Street Journal) and in online contexts including service personnel discussion groups, anti-war websites, and cultural and news forums. Interviews and documentation were also broadcast on the CNN, BBC and Sky news channels.

War and Medicine attracted over 100,000 visitors, offering a heightened awareness of an under-represented aspect of conflict. The exhibition toured to the Deutsches Hygiene Museum in Dresden, 2009 and finally to the Canadian War Museum, in Ottawa, 2011. Extensive press coverage and public debate occurred at each venue and total visitor numbers for the touring exhibition exceeded 250,000. Individual works were subsequently included in Afghanistan (Wolverhampton Art Gallery, 2010), Dislocations (MoCA, Zagreb, 2011), ISEA/Istanbul Biennial (Sirket-i Hayriye Art Gallery, 2011), Medicine on the Frontline (Imperial War Museum, North, 2012-13) and Engines of War (Gasser Grunert Gallery, New York, 2013).

While the focus of the project when undertaking the commission to work with the Wellcome Trust in 2007 had been to provide a catalyst for greater public debate regarding the human cost of war, it became clear that the research had the potential to offer insights to individuals and organisations involved in military medicine. From February to November 2009, Cotterrell visited each soldier who he had witnessed being seriously injured during his short time in Helmand. In consultation with their clinicians, he provided individuals with documentation of the medical procedures, which had occurred during their time in the field hospital, evacuation and subsequent treatment in the UK. These meetings with recovering soldiers allowed individuals to reconstruct a lost narrative, providing a bridge between the radically altered sense of personal identities experienced prior to, and post-injury.

The understanding of the value of this more open approach was shared by clinical staff and patients, and precipitated the development of improved patient diaries offering a visual and textual record of their treatment. Cotterrell presented his findings to the clinical teams at Queen Elizabeth and Selly Oak Hospitals and to the wider medical community through a keynote lecture at Tate St Ives for the Association of Medical Humanities annual conference, July, 2010 and a paper at the Royal College of Physicians and Surgeons of Glasgow 2nd Triennial Conference

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