The military–medical complex is looking at environmental approaches to treating trauma.

By Jeff Link 

This past summer, Fred Foote met me in front of Naval Support Activity Bethesda, the home of Walter Reed National Military Medical Center, in a Maryland suburb of Washington, D.C. We set out for an early look at the Green Road, a half-mile path and a 1.7-acre woodland garden being built along the banks of a stream that winds through the sprawling campus.

Foote is a retired navy neurologist who is an adjunct assistant professor at the Uniformed Services University of the Health Sciences (USUHS). He also has the title of scholar at an outfit in Baltimore called the Institute for Integrative Health. During the 2003 invasion of Iraq, he served as a physician on the hospital ship Comfort. When the military decided in 2005 to move Walter Reed National Military Medical Center onto the naval campus to consolidate hospital operations, navy leadership recruited Foote, off duty at the time, to advise on new hospital construction. Part of the charge, which Foote took on under the banner of what he calls the Epidaurus Project, was to identify the best ways to deliver patient-centered design and care.

The Green Road Project, an initiative of the Institute for Integrative Health, is an attempt to marry holistic, or alternative, medicine with a traditional approach to treat traumatic brain injury, post-traumatic stress disorder (PTSD), and other psychological conditions. It signals an opening by the military to environmental therapies, for which hard science can be lacking, to address problems that medical science has shown to be stubborn to treat.

The Green Road, which opened in September, comprises a wooded garden and path meant as places of respite for service members and their families who live in the approximately 400 long-term housing units on the base. Between its two entry portals, the Green Road will trace a trail, accessible by wheelchair, through a woodland. But it is also a site from which researchers plan to gather data on the effects of a natural setting on brain health.

A longer trail follows Stoney Creek diagonally from the southwest to the northeastern border of the campus, linking residential units at the Fisher Houses and Sanctuary Hall. It is central to the navy’s physical plan for the campus, which aims to improve walkability, make the grounds more accessible for people on the base, and allow Walter Reed National Military Medical Center and the USUHS to consolidate overlapping operations.

At the gatehouse, an armed guard waved us through. We parked at the southwest entrance to the Green Road and went down a modest grade into a canopy of beech, sycamore, hickory, and American holly. Within a few hundred feet, the woods gave way to a sunlit glade looking onto Stoney Creek. Along the shoreline, willow and dogwood saplings rose from coarse jute. Boulders, together with the root systems of the densely gridded plantings, are helping to redraw and stabilize the water’s edge. “There is something about the rocks and water together,” Foote said, as we paused at the shoreline to listen and observe.

You can already see the young sprouts of serviceberries, redbuds, American cranberries, and river birches coming up in shadier areas. The built works—a seven-foot-wide paved path, dry-laid stone pavilions, and a wooden bridge—sit humbly within the natural environment.

“We have reason to believe, and have evidence to support, that if you bring a sick or injured person into a natural environment it lowers stress and speeds up healing, and this is especially true of the invisible wounds of war brain injury and PTSD,” Foote said. “This major research project, with advanced math that we have developed, will demonstrate healing effects of nature, mathematically, for probably the first time.”

It’s a bold claim. Studies have found that people who live near parks or green space have lower incidence of psychological illness than do city dwellers with limited access to green space. Yet, for the most part, says Esther Sternberg, the director of research at the Arizona Center for Integrative Medicine (AzCIM) at the University of Arizona College of Medicine (and a co-investigator on the Green Road Project), such research has focused on isolated biomarkers, such as levels of the hormone cortisol in the blood, and favored self-reported subjective assessments over biological, quantitative ones. “Health benefits are generally not determined through hard biological measures. Most is done by surveys,” Sternberg says. “Questionnaires are useful but less accurate and reliable than biological measures; they rely on individuals and memories. Our goal is to measure those, also, but to use quantitative measures of health outcomes.”

Sternberg’s published work focuses on the relationship between sweat biomarkers, such as cortisol and the neurotransmitter Neuropeptide Y, and the status of the immune and stress response systems. The Nano-Bio Manufacturing Consortium, a program of the U.S. Air Force Research Laboratory in Dayton, Ohio, recently awarded AzCIM $200,000 for a project to assess different sweat collection methods and integrate these into real-time wearable devices (imagine military-grade Fitbits and Apple Watches) for measuring stress biomarkers. “This kind of work is not easy. It requires enormous teams of engineers and chemists to process big data analytic systems,” Sternberg says.

And biomarker analysis is expensive. A lack of funding has hampered earlier studies of nature’s potential healing effects, Foote says. “If you want to make a new drug, it’s easy to get money for research. If you want to measure the effects of nature, the money that flows into these types of research is much less.”

The projected $4 million cost of the Green Road Project is funded in part by $1.5 million from the private sector and a $1 million award from the TKF Foundation, a nonprofit run by the philanthropists Tom and Kitty Stoner that funds urban green space. The project assembled a research team from the National Institutes of Health (NIH), the USUHS, and the University of Arizona. One team member, Patricia Deuster, is the principal investigator and director of the Department of Defense’s Consortium for Health and Military Performance. Deuster says that initial investigations will compare the responses of 50 participants to traveling on two different routes across the military base: one through a high-traffic roadway, and the other along the Green Road.

Herbert Benson, a director emeritus of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital and Mind Body Medicine Professor of Medicine at Harvard Medical School, plans to oversee the project’s studies related to gene expression. Benson says that PTSD can alter the “on” or “off” signals of a person’s genes in a way that exposure to nature might correct. “When the relaxation response is elicited, there is a decrease in the inflammatory response, leading to the stabilization of the immune system, stabilization of the energy metabolism of the body, and changes in insulin secretion,” he says.

The effects that natural settings may have on PTSD and traumatic brain injury are not well understood. A brief from the Institute of Medicine titled Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations defines PTSD as “a combination of mental health symptoms—such as reliving a traumatic event, avoiding trauma-associated stimuli, and experiencing mood swings and hyperarousal—that persist for at least 1 month and impair normal functioning.” Traumatic brain injury is also broad in its diagnostic picture, with symptoms including headaches, weakness in extremities, sleep disturbance, memory loss, inability to concentrate, depression, and suicidal thoughts.

The prevalence of PTSD, which affects an estimated 8 percent of current and former service members deployed to Iraq and Afghanistan, according to the Institute of Medicine brief, has increased significantly since the start of the two wars. Though the Department of Defense and the Department of Veterans Affairs invested some $3.3 billion in PTSD care for service members and veterans in 2012, the agencies lack clear standards and evaluation methods, and are only beginning to understand ways to treat it effectively.

“We need to determine what are the clumps of patients that constitute different biological subgroups for PTSD and traumatic brain injury,” Foote says. “We need big data, a supercomputer that can analyze a big field of data that to a human looks random. Until we know the specific biological subtypes, it will be hard to say if nature helps.”

But that’s a long way off. For now, Foote says, research will focus on providing a whole body assessment of the stress response system using psycho-social-spiritual questionnaires, qualitative interviews, and regression analysis of stress biomarkers, such as hormone levels and autonomic nervous system activity.

The designs, Foote says, will include contributions from Kim Drake, ASLA, a project manager at CDM Smith in Boston; Jack Sullivan, FASLA, an associate professor in the Department of Plant Science and Landscape Architecture at the University of Maryland in College Park; David Kamp, FASLA, the president of the firm Dirtworks in New York; and Paul Alt, a principal at Alt Architecture + Research Associates in Chicago. They intend to leave the space largely rustic and undisturbed.

By contrast, another project, the Warrior and Family Support Center Therapeutic Garden at the Brooke Army Medical Center in San Antonio, is more active. The 20,000-square-foot garden, designed by Brian Bainnson, ASLA, of Quatrefoil, Inc., in Portland, Oregon, features a parcourse, an amphitheater, a children’s playground, and a butterfly garden. Its constructed elements were created for both therapeutic and recreational purposes.

“The Green Road is deliberately the opposite,” Foote says. “We’re not building this garden to promote any special agenda of medical therapy. The only healing influence is the natural elements themselves. We want to bring pure nature to bear on PTSD, not in a highly constructed landscape of medical treatment, but a deliberately blank canvas.”

The Green Road’s design was developed after planning meetings with wounded veteran focus groups, NIH physicians, and Naval Facilities Engineering Command members. “You want to make sure anyone who enters the space also sees a way out,” Sullivan says. “You don’t want to get the sense that you can’t turn and walk away.”

I got a better sense of what Sullivan meant as I stood on the flat, still-earthen platform of the commemorative structure (which would be paved in precast concrete), looking down at the stream and bridge. The structure was primitive: There were no doors, no enclosures. As Foote observed, running his palms over the stacked stone, there is always “a wall at your back and clear lines of sight.”

The communal pavilion will have restrooms and a table that seats 10 people. The grading of the path carves out gently sloping access routes to the water, laid with crushed stone and chipped wood.

“These guys have been sitting in hospital beds,” Drake says. “I remember, in one of our focus groups, a double amputee with racing gloves and a wheelchair with mountain bike tires, saying, ‘I want to get out and mow the lawn.’ These guys don’t want to be on an accessible path all the time. They want to learn to get back to themselves, not be prisoners to their disabilities.”

The project’s aspiration, to measure scientifically the healing effects of nature on PTSD and traumatic brain injury, faces obstacles. Of the three metrics Foote has identified for research—biomarkers of the stress response, analysis of stories and journals using natural language processing, and advanced genomics—only the first is fully funded. Foote says he is looking for another $1 million for further research.

Then there’s the question of what can be demonstrated from an isolated study. A 2015 Stanford study, published in the Proceedings of the National Academy of Science, found that people who walked for 90 minutes in a natural area of Stanford’s campus, rather than next to a multilane highway in Palo Alto, had less blood flow to the subgenual prefrontal cortex, a region of the brain associated with depression. But, as one researcher, Gregory Bratman, noted in the Stanford News, the result is far from conclusive. “This finding is exciting because it demonstrates the impact of nature experience on an aspect of emotion regulation—something that may help explain how nature makes us feel better,” Bratman said.

Although data-driven science is at the center of the project, what is striking at the Green Road site is how much the landscape seems to point toward something beyond pure empiricism. And, to Foote at least, intuition is a powerful guide. “When we get veterans into natural environments, they turn happy,” he says. “We bring different volunteer groups out to the woodland garden, clearing brush, taking vines off trees, and the veterans immediately perk up and start to sparkle. They’re having a happy day, and the suffering of PTSD gets put aside.”

Jeff Link is a graduate of the Iowa Writers’ Workshop. His work has appeared in Fast Co.Exist, Keep Growing, Newcity, and other publications.

Correction: This article originally stated that the Green Road Project is an Epidaurus Project initiative. In fact, it is an initiative of the Institute for Integrative Health. The text has been updated.