Perspectives
The Lancet Volume 387, No. 10015, p220–221, 16 January 2016
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Article Info
© 2016 Elsevier Ltd. All rights reserved.
Medicinal plants have long had a role in supporting the health of human populations. Our Palaeolithic hunter-gatherer ancestors possessed extensive knowledge of the nutritional-medicinal properties of surrounding vegetation. Archaeological evidence suggests that bands of prehistoric people may have commonly reserved a role for shamans who had knowledge of the location and use of medicinal plants. The beginnings of the shift to agriculture around 12 000 years ago altered human relations with the natural landscape, reducing the biodiversity of plant species used by people. And yet, everywhere powerful civilisations arose there remained enduring interest in medicinal plants. Royal gardens containing specimens with medicinal value appeared in ancient Egypt, Mesopotamia, Crete, Mexico, and China, and written texts conveyed this knowledge across generations. Aristotle was said to have kept a herb garden for medicinal use and experimentation in the Lyceum.
After the fall of the Roman Empire, Benedictine monasteries and abbeys of the Middle Ages became places of medical knowledge across Europe, and in the 9th century physic gardens began to be cultivated in their gated grounds. In these spaces, doctors and apothecaries grew medicinal plants and prepared remedies for common disorders. The “cloistering” of physic gardens was intentional: establishing a space for the husbandry of medicinal plants within a respected institution helped legitimise the craft against the folk remedies of village herbalists.
Centuries after their appearance inside monastic walls, physic gardens spread to university campuses in Medieval and Renaissance Europe to assist the education of physicians and apothecaries. Largely instigated by members of the medical profession, the first gardens appeared in Italy at universities in Pisa (1544), Padua (1545), Florence (1545), and Bologna (1567). From here, they spread to other parts of Europe, including Zurich (1560), Paris (1570), Leyden (1577), Leipzig (1580), and Montpellier (1593). Echoing the monastic approach used by doctors and apothecaries centuries before, those involved in university physic gardens demarcated their sphere of expertise from peddlers of folk medicine. As Sir Robert Sibbald and Sir Andrew Balfour wrote, they incorporated their physic garden—founded at the University of Edinburgh in 1670—into medical education so as to “Safeguard the Practitioner against the Herbalist and to enable him to have a correct knowledge of the plants which were the source of the drugs he himself would have to compound.” In the dawning age of the Enlightenment, plant-derived medicines were to be overseen by men of science, not modern shamans. Physic gardens were slowly phased out in the 17th and 18th centuries as European colonial expansion drove the creation of modern botanical gardens displaying exotic plants from around the world.
Today, physic gardens seldom exist on hospital campuses, and yet medicinal plants continue to have a central role in caring for patients. Many modern pharmaceuticals are natural products or derived from plants; indeed, the 2015 Nobel Prize in Physiology or Medicine was shared by developers of two therapies built from natural product platforms—avermectin, an antiparasitic derived from soil bacteria, and artemisinin, an antimalarial developed from sweet wormwood. Some of our cholinesterase inhibitors (atropine, galantamine, physostigmine), analgesics (morphine), microtubule inhibitors (colchicine), and antineoplastics (podophyllin, taxol, vincristine) come from higher plants. Whereas monastery and university walls once established boundaries for the professional use of medicinal plants we now have patents, regulatory bodies, corporate branding, and global distribution networks that dictate the movement, sales, and consumption of legitimate medicinal plant-derived products distinct from the lucrative herbal supplements industry.
Just as in the Middle Ages and Renaissance, historical forces are now refiguring the role of gardens in modern medicine at a time when countries face the growing burden of chronic diseases. Some hospitals are using their soil not only for the cultivation of medicinal plants but also for community gardens—pieces of land collectively used for food production. A national study recently identified 110 community gardens affiliated with hospitals in the USA. In these spaces, employees, trainees, patients, and community members are given plots in which to grow fruits, vegetables, and herbs for personal use or donation. Some hospitals incorporate gardening directly into patients' care. For instance, occupational therapists working alongside people with dementia, stroke, or traumatic brain injury have developed garden-based exercises to support skill-building, activities of daily living, and adaptive strategies, while also taking advantage of the sensory and non-institutional aspects of green space for psychosocial benefit. This dynamic use of hospital gardens certainly evokes physic gardens of the Middle Ages but imbues the notion of medicinal plants with contemporary concerns. Research has shown that being involved in gardening can increase fruit and vegetable intake and physical activity, lower body-mass index and blood pressure, and help treat chronic diseases. Community gardens also encourage neighbourhood solidarity by fostering intergenerational and cross-cultural interaction, enabling sharing of food-production knowledge, enhancing environmental aesthetics, and mitigating feelings of loneliness and alienation.
The emergence of hospital gardens portends new opportunities for 21st-century health care. A couple of years ago, we launched a 127-plot community garden at our academic health centre in Hershey, PA, USA, and have seen several innovative projects emerge. In tribute to the physic gardens of old, a medicinal plot grows more than 30 species of plants used in folk medicine (eg, lemon balm for indigestion, valerian for insomnia), as well as plants from which purified compounds are extracted and used as prescription drugs or pharmaceutical platforms (eg, foxglove, from which digoxin used for heart failure is produced). Nearby, the hospital's eating disorders clinic keeps a plot for therapeutic use and patients help cultivate edible plants that are integrated into cooking programmes and donated to area charities. In doing so, therapists encourage broader palates in patients and work to improve their relationship with food.
The largest plot is overseen by a team of medical students in a Food as Medicine group that runs various initiatives. Students grow cruciferous vegetables naturally rich in isothiocyanates for hospital researchers who are focusing on extracting these compounds, modifying them to increase their potency, and studying their effect in treating melanoma. They have also partnered with clinicians to implement a Prescription Produce programme in which underserved patients at risk of chronic diseases receive clinical “prescriptions” from their doctor for produce that can be redeemed at the hospital's farmers' market and the Food as Medicine plot. We have noticed that children in the programme are more likely to eat vegetables they hand-pick. Students also harvest produce that is donated weekly to several charitable organisations located in so-called food deserts near the hospital. In addition to food production, the plots provide educational opportunities, and students have organised hands-on classes for nutrition to elementary school groups. Of no less importance is that cultivating the garden has afforded medical students a welcome respite from the demands of clinical training.
Presumably, as modern-day hospitals assess the needs of their populations they will identify high prevalence of obesity, diabetes, and other chronic diseases linked to nutrition across the lifespan. Thus, community gardens connected to hospitals would seem to represent valuable infrastructure that can benefit local people. Unlike other interventions that specifically target at-risk individuals or subpopulations, gardens engage whole communities and provide a humane service—access to nutritious foods.
Other forces in the 21st century could also shape the relation between hospitals and gardens. As humanity confronts the likely reality of peak petroleum in coming decades, it might affect the production and transport of foods, medicines, and medical supplies and require us to grow and develop these resources locally. Indeed, with regard to food, at every step of production—harvesting, irrigation, application of pesticides and fertilisers, packaging, long-distance trucking—petrol is an energy source. If supply decreases, food prices might rise, creating conditions for food insecurity, particularly for more impoverished communities.
The 127-plot community garden at the campus of Penn State Hershey Medical Center
Photo courtesy of Daniel R George
Hospitals would seem primed to serve as epicentres of resilient local communities, with capacity to turn patches of turf grass and rooftops into urban gardens, hoop houses, and greenhouses for the year-round cultivation of produce, and to host farmers' markets supporting small-scale producers. As has already begun happening at some institutions, hospital food services can cultivate or purchase produce that is integrated into inpatient and cafeteria menus. There are also opportunities for such produce to have a direct role in patients' care through programmes such as Prescription Produce that use fruits and vegetables as clinical interventions, or educational initiatives—for instance, sending home produce baskets or recipes with mothers of newborn babies or patients recovering from cardiac events. On a larger scale, these initiatives will help contribute to the critical mission of stabilising Earth's key life support systems and revitalising prospects for the health of human civilisations.
Abraham Lincoln once wrote, “The greatest fine art of the future will be the making of a comfortable living from a small piece of land.” Perhaps the pursuit of such a vision by hospitals at the level of community—and planetary—health thus represents the ultimate “art of medicine”.
Further reading
- Burton, A. Gardens that take care of us. Lancet. 2014; 13: 447–448
- George, DR, Kraschnewski, J, Rovniak, L, Hanson, R, and Sciamanna, C. A growing opportunity: community gardens associated with US hospitals and academic health centers. Prev Med Rep. 2015;2: 35–39
- Frumkin, H, Hess, J, and Vindigni, S. Energy and public health: the challenge of peak petroleum.Public Health Rep. 2009; 124: 5–19
- Hardy, K, Buckley, S, Collins, MJ et al. Neanderthal medics? Evidence for food, cooking, and medicinal plants entrapped in dental calculus. Naturwissenschaften. 2012; 99: 617–626
- Horton, R and Lo, S. Planetary health: a new science for exceptional action. Lancet. 2015; 386:1921–1922
- JAMA. A history of botanic gardens. JAMA. 1915; 65: 170–171
