Summary of the impact

The research involved the first uncensored documentation of the contemporary UK military pathway and has been used internationally to raise awareness in professional participants and the general public of the ethical and practical complexities of militarised healthcare.

The impact of this research was evidenced within three distinct> territories: 1. Informing improvements in military and civilian training leading to the creation of standard briefing materials for British deployed forces, medics and civilians to ensure early awareness of the `care pathway'; 2. Establishing additional reference points within contemporary art discourse and reflecting on the role of independent observers of conflict; and 3. Aiding patient recovery and understanding by helping individuals reconcile the profound change that they have undergone through injury and by establishing precedents for a format of comprehensive patient diaries, enabling longer-term understanding of traumatic experience.

Underpinning research

This research, made possible with initial support from the Wellcome Trust, investigated the militarised and civilian contexts of Afghanistan and the United Kingdom. Research was carried out between 2007 and 2012; Cotterrell joined Sheffield Hallam University in 2005 as Senior Lecturer in Fine Art, was promoted to Professor of Fine Art in 2008, and remains in post.

The research reviewed the ethical and practical challenges of medicine within conflict environments. This was achieved by direct immersion in the environments of militarised medicine. Cotterrell examined, and reflected upon, the personal dislocation experienced by those affected by trauma. Through recorded testimony, artefacts, artworks and analyses, the major aim of this research was to identify and illuminate key historical points in the evolution of relationships between institutionalised healthcare and violence. These were first introduced to the public domain in the public exhibitions War and Medicine, (R1) Aesthetic Distance (R3) and in the publication of extracts from Cotterrell's diaries (R2).

In 2007, support from the Wellcome Trust (G1) enabled Cotterrell to visit `tier 2' British military medical facilities to observe contemporary practice and to consider methods of synthesising the primary evidence witnessed there. After two years of negotiation, the Ministry of Defence exceptionally agreed to allow access (free from traditional media handling or censorship) to operational facilities in the Helmand province of Afghanistan (S1).

Following pre-deployment training, Cotterrell travelled to join 201 Field Hospital Regiment and 5 General Support Regiment at Camp Bastion. Cotterrell spent November 2007 living amongst medics and observing evacuations, resuscitation and surgical operations conducted from point of injury to strategic aeromed. Cotterrell visited the Helmand Executive Group at Lash-Kagar and travelled to Forward Operating Base, Sangin with 40 Commando to observe the work of Combat Medical Technicians and Role 1 facilities in front-line conditions (S2).

With support from the RSA (G2), and via the UN Humanitarian Air Service, Cotterrell returned to Afghanistan in April 2008 to areas beyond British military control. Travelling on foot, or using local transport, visits were undertaken to Afghan military hospitals, NGOs and local medical facilities in Kabul, Masar-e Sharif, Balkh and the Panjshir Valley. Interviews were conducted to contextualise the experiences of militarised healthcare with representatives of ISAF forces, international and local agencies, and individual doctors, academics, soldiers and civilians (S3).

In February 2009, supported by the Department of Health (G6), Cotterrell negotiated access to the UK continuing care pathway in order to establish a more complete picture of the fragmented narrative of military trauma treatment. Over a period of six months, he photographed, interviewed and recorded testimonials from service personnel he had previously encountered in Afghanistan. In addition, he documented strategic aeromed arrivals and handovers to Queen Elizabeth and Selly Oak Hospitals, Birmingham, operations and acute treatment at the Royal Centre for Defence Medicine, and also rehabilitation and therapy at the Defence Medical Rehabilitation Unit at Headley Court (S4).

Significant insights were gained through this research. It became clear that the challenges of reporting restrictions, patient confidentiality and multiple governing agencies had meant that prior to Cotterrell's negotiated access to view the care-pathway from point of wounding to domestic rehabilitation, journalists and historians had not been able to gain unrestricted access to the contemporary British military casualty chain. Cotterrell's subsequent exhibitions, publications, lectures and interviews provided the first public exposure of this complex and sensitive subject to British audiences.

The research made clear that soldiers recovering from life-changing injuries had limited means of re-constructing 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.

The 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 research project's multimodal demonstration of the necessity to enable more public and professional engagement with the challenging subject of military medicine opened the way for subsequent documentaries by newspapers and broadcasters (such as the 2011 BBC Documentary `Frontline Medicine') and signalled a fundamental change in the way in which the reality of injury within conflict would be permissible to discuss in mainstream media. Cotterrell was the first civilian to be deployed to Afghanistan and the first observer to gain permission to document the work of the Joint Forces Medical Group engaged in the Afghanistan campaign.

References to the research

Key Outputs:

Awards and Prizes:

G1.Cotterrell, D, War Artist commission, Wellcome Trust, 2007-2008, £20,000

G2.Cotterrell, D, Arts and Ecology International Fellowship, RSA, 2008, £3,250

G3.Cotterrell, D, Arts and Business, 2008, £9,000

G4.Cotterrell, D, INTERACT International Fellowship, Arts Council England, 2008, £8,000

G5.Cotterrell, D, Managed Funds Award, Arts Council England, 2008, £5,500

G6.Cotterrell, D, Department of Health, 2009, £5,000

G7.Cotterrell, D, ArtHubAsia, 2009, £4,000

G8.Cotterrell, D, Philip Leverhulme Prize, 2010, £89,100

G9.Kneebone, R and Cotterrell, D, AHRC Network Grant, 2010, £30,000 (S5)

Details of the impact

1. Military and civilian training

The primary research in Helmand province was documented through an extensive photographic record and detailed diary. 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 (S3). 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) (S2).

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 hand-overs 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 (S4). This record is used by the NHS to inform the general public through its NHS Choices website (S7), 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.

2. Contemporary art discourse

Within the research project's proposed museum and gallery context, two public exhibitions were realised in London of new time-based installations, photographic series and video works (War and Medicine, Wellcome Galleries, December 2008 (R1), and Aesthetic Distance, Danielle Arnaud contemporary art, January 2009 (R3)) (S1, S2 & S3). 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) (S1). Selected press outlets were allowed access to elements of this documentary material, with The Guardian printing a selection as a four-page feature (24/11/08) (R2). In November 2008, Cotterrell's work was discussed on BBC Radio 4's Front Row, Start the Week and Today programmes and BBC On-line 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 on-line contexts including service personnel discussion groups, anti-war web-sites, cultural and news forums. Interviews and documentation were also broadcast on CNN, BBC and SKY news channels. (S8)

`War and Medicine' attracted over 100,000 visitors, offering a heightened awareness of an under- represented aspect of conflict (S6). The exhibition toured to the Deutsches Hygiene Museum in Dresden, 2009 (S9) and finally to the Canadian War Museum, in Ottawa, 2011 (S1). 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) (S2) and Engines of War (Gasser Grunert Gallery, New York, 2013).

A portfolio of evidence of the above is available from SHU on request.

3. Patient recovery and understanding

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 (S4) and to the wider medical community through a keynote lecture at Tate St Ives for the Association of Medical Humanities annual conference, July, 2010 (S5) and a paper at the Royal College of Physicians and Surgeons of Glasgow 2nd Triennial Conference, 2011.

Sources to corroborate the impact

S1: Head of Public Programmes, Wellcome Trust

S2: Major in a Medical Regiment, British Forces

S3: Former Head of Art, RSA

S4: Live Well Editor, NHS Choices

S5 Professor of Surgical Education, Imperial College London

Online Sources:

S6: http://www.wellcomecollection.org/whats-on/exhibitions/war-and-medicine.aspx

S7: http://www.nhs.uk/tools/pages/militaryphoto.aspx

S8: http://www.cotterrell.com/search/?q=war+and+medicine

S9: http://dhmd.de/index.php?id=1427