Zimbabwe Day 2: Prosthetics and Policy

My second day in Zimbabwe was spent seemingly entirely in taxis as I was ferried from one place to another in search of my appointments.  In the morning, I visited an NGO service provider, Jairos Jiri, and in the afternoon an advocate for persons with disability, the Disabled Women’s Support Organization.

The Jairos Jiri Orthopedic Workshop is one of the facilities in Zimbabwe that produces prosthetic devices for amputees.

Products of Jairos Jiri's Orthopedic Workshop

Products of Jairos Jiri’s Orthopedic Workshop

The workshop had a staff of eight on the day I visited, five technicians, a cleaner, an accountant and the director.  The technicians and the accountant are persons with disability and while the Workshop wasn’t intended as a sheltered program, that’s how it has developed.  Some of the technicians have been with Jairos Jiri for more than twenty years and produce high quality items with less than ideal resources.  For wheelchairs, they accept donated chairs and then re-furbish them, customized to the client.  For prosthetics, they conduct an initial assessment, measure, fabricate and then fit below-knee and above-knee prostheses.

Gilbert, Director of the Orthopedic Workshop, holds up a new prosthetic leg.

Gilbert, Director of the Orthopedic Workshop, holds up a new prosthetic leg.

The technicians are also able to produce orthopedic shoes and assist with adjustment of crutches.


Unfortunately, Jairos Jiri is not able to provide these items free of charge.  Because the raw materials for prosthetics need to be imported, there is some cost to the client; wheelchairs, even though they are made from donated parts may still cost US $100 (compared to $250 – 300 for new).  For some clients, medical aid is available reducing the cost, but there is still an out-of-pocket expense for clients.  Gilbert, the Director of the Workshop, estimates 10 people come to the workshop every day for consultation or assessment, but only a handful of those are able to purchase the products, even at the reduced rates offered by Jairos Jiri.

On top of the costs, the facility itself is a fair distance from the center of Harare and far from public transportation options.  When I visited at the Workshop, I saw the technician who makes the shoes arriving in a hand-cranked wheelchair. The Workshop is about 300 meters from the main road, up a fairly steep slope which is potholed and broken.  And this, for residents of Harare, is the most affordable options for prosthetics and mobility devices.


Rejoice Timire, Disabled Women’s Support Organization

In the afternoon, I met with Rejoice Timire, the head of the Disabled Women’s Support Organization (DWSO).  Our meeting took place in an internet cafe which Rejoice uses as a base of operations to keep overhead costs to a minimum.  With over 5,000 members, DWSO is an active advocacy organization for women’s rights and disability rights in Zimbabwe, working with both communities to amplify its voice. DWSO was one of the disabled people’s organizations in Zimbabwe that successfully pushed for Zimbabwe’s accession to the Convention on the Rights of Persons with Disabilities (CRPD).  Now, the DPOs must push for localization and implementation of the CRPD by the Department of Social Welfare, the focal point for the CRPD.

In the past, Rejoice and DWSO members participated in a peer support outreach program at the local hospitals.  The program focused on persons who suffered from spinal injuries and other traumatic injuries and sought to help them understand and accept their condition, to “welcome them to our world,” as Rejoice described it.  Due to funding, this worthy program has been discontinued.

Disabled Women’s Support Organization conducts awareness raising activities, one of the largest will be next month’s Disability Explore which is attended by members of Parliament and organized with assistance from the Disability Desk in the President’s office.

New Campaign for Amputees in the United States

If you live in the Washington, DC area, you may have seen this poster: 2012_PR_Poster_Walk at local bus stops.  At issue is the question of whether or not the US government (probably in the form of Medicaid, for low-income individuals, and Medicare, for the elderly) will cover the costs of “custom fabricated artificial limbs.”  Now, all prosthetic devices are custom-made for the wearers; there is no standard size that would be comfortable, functional or wearable.  Prosthetics aren’t like shoes that can be mass-produced in the same sizes and forms. 

The tag line for this campaign is “Let’s help disabled people get the prosthetics they need to lead full productive lives” and the action item is for people to got to the American Orthotic & Prosthetic Association’s website, www.AOPAnet.org for more information.  The action item is fine for the US audience, but I think the tag line is applicable globally, especially in the context of landmine victim assistance.  

I bring up this campaign to simply say, if amputees in the United States have difficulty getting the support they need, if they are “left confused and isolated;” imagine how amputees in post-conflict, landmine affected countries must feel.

Michael P. Moore, July 24, 2012

The Yawning Gulf of Victim Assistance

Victim assistance, the provision of services and supplies to survivors of landmine (and other explosive ordnance, including IEDs) injuries, can vary widely depending upon where the victims live.  American survivors have access to a range and quality of services and products unavailable to the majority of survivors who are from landmine-affected countries; landmine survivors in comic books have access to even better care than Americans.  In recent years, innovations in prosthetic technology have allowed landmine survivors in developed countries to have a greater degree of mobility than ever before.  With that mobility comes an ease of re-integration as survivors are able to engage in simple behaviors like walking and running and more complex behaviors like running for Congress.  That mobility comes with a pretty hefty price tag and the cost of the best prosthetics is prohibitive for most landmine survivors (meaning those not in the United States or other developed countries).  For landmine survivors in less-developed countries, the quality of prosthetics is very poor despite attempts at innovative responses, many of which are framed in the false language of “appropriate technology.”

I’m focusing on prosthetics in particular, but I think the differences in surgical care, physical rehabilitation and economic reintegration are similarly vast.  So while I may appear to conflate victim assistance with prosthetic technology below, I’m only using it as one specific example of the difference.  As a quick example, the doctors who volunteer with the Prosthetic Outreach Foundation of Seattle (and please don’t think I’m picking on POF; I visited their facility in Vietnam and love what they do) to provide orthopedic surgery in developing countries do so for only one or two weeks a year; the rest of the year they are available to help patients in the United States (Prosthetic Outreach Foundation).


Victim Assistance in Comics

Marvel Comics characters seem to be distressingly susceptible to landmine injuries.  Fortunately, in the world of comics, the medical treatments available to landmine survivors is far superior to that available in the real world.  For example, Nick Fury, a character in the recent hit movie, “Avengers,” stepped on a landmine in World War II, but he was then given “Infinity Formula” by a French doctor which not only saved Fury’s life, but also greatly slowed his aging.  This slowed aging allows Fury to be played by the actor Samuel L. Jackson who was not even born when World War II ended (Entertainment Weekly).  Another example is the cyborg, Coldblood, who will feature in the upcoming, “Iron Man 3.”  After Eric Savin steps on a landmine, cybernetic surgery is performed on him, saving his life but transforming him into a cyborg villain (Variety). So, for those keeping score at home, in the comic book universe, advanced biochemistry and surgical techniques are used to help landmine survivors recover.  But in developed countries, the reality isn’t too far from the fantasy.


Victim Assistance in the United States and other Developed Countries

The highest quality of victim assistance in the United States is that available to soldiers returning from combat in Iraq and Afghanistan. Improvised explosive devices (IEDs) have become more powerful in recent months leading to a greater percentage of incidents where the victims have multiple amputations (Stars and Stripes).  American soldiers treated at Walter Reed or the Bethesda Naval Medical Center have access to high technology prostheses including “’a ‘power knee,’ which is the first motor-powered prosthetic; a powered ankle-foot unit with microprocessor technology to detect changes in terrain; a microprocessor knee with artificial intelligence that recognizes and adjusts to changes in speed; and ‘cheetah feet,’ which are prostheses specially designed for sprinting and high-level competition” (US Army).  Oscar Pistorius, the South African double-amputee sprinter uses the “cheetah leg” in competition.

The Cheetah Leg and the Flex-Foot (a high-tech prosthetic for daily usage, Ossur) were both invented by Van Phillips, a American who lost his own leg in a water-skiing accident.  Phillips felt that the quality of prosthetics available when he became an amputee in the 1970s had not progressed beyond the peg leg of pirate history and he was determined to come up with something that allowed amputees to return to active lives and to no longer feel discomfort (Ossur).  His success can be seen by the fact that Pistorius has been banned from Olympic competition because the Cheetah Leg was determined to give him an unfair advantage over non-amputees (New York Times) (if you will permit me a brief rant: if Pistorius has an unfair advantage because he wears prostheses, why don’t other sprinters have their feet amputated and get fitted for Cheetah Legs?).

As Pistorius shows, the Cheetah Leg and other top-of-the-line prostheses are available to more than just US soldiers.  Two million Americans, one in every 450 persons, is an amputee and as the quality of prosthetics improves, many people who have suffered severe injury, e.g., diabetes or car accidents, are opting for amputation over efforts to preserve the damaged limb.  With modern prosthetics, a person can lead a more active life than would be possible with the damaged limb.  Limbs are more lifelike, they can have painted toenails, and many are starting to have bionics. With sensors and computerized joints, an individual wearing a prosthesis can walk with the same gait as someone who has never suffered an injury.  Such technology does not come cheap though; the best equipment costs upwards of $70,000 and most prostheses need to be replaced every few years (New York Times).

The newest prosthetics are bionic, actually wired into the human nervous system.  The technology is still in development, but Todd Kuiken at the Rehabilitation Institute of Chicago has been able to develop an arm that allows an amputee to feel with his or her prosthesis (BBC News).  Such technology is so cutting edge as to seem like science fiction; the realm of comic book victim assistance doesn’t seem so far anymore.


Victim Assistance in the Developing World

So I mentioned that prosthetists in the United States are working on a new leg that would cost $70,000 and “can sense the actions of the wearer and the terrain on which the person is walking and adjust accordingly. Its microprocessors help coordinate reflexlike responses to the user’s motions, and its robotics simulate the action of missing calf muscles and Achilles tendons.”  The article continues by saying that most US insurance companies would not cover the cost of such a prosthetic (New York Times), but then again, many in the developing world don’t even have the opportunity to have a health insurance company deny coverage, so the point is a bit moot for this discussion.  My point is that there are prosthetists working on innovative options for landmine victims in the developing world.  Van Phillips, Ossur’s inventor mentioned above, told me about an initiative he started to develop a $10 below-knee prosthesis.  This prosthesis could be built locally, from locally available materials and be widely available to landmine victims and other amputees in developing countries (personal communication).  Rob Gabourie, a prosthetist working with researchers at Queen’s University and Kingston General Hospital in Canada, developed the Niagara Foot, a cheap, durable prosthetic foot specially designed for landmine victims after calls by the International Campaign to Ban Landmines (ICBL) for innovation in victim assistance.  The Niagara Foot is made from locally available materials and has been built and tested in many locations, including Canada, Germany, El Salvador, Colombia and Mexico.  Landmine victims from Thailand and El Salvador have been given Niagara Feet and the design “won first prize for rehabilitation and assistive-technology products at the Medical Design Excellence Awards” in 2012 (Kingston Whig Standard).  A third innovation is the Low-Cost Prosthetic Knee Joint, or the LC Knee which is an above the knee prosthesis that costs all of $50.  Jan Andrysek of Holland Bloorview Kids Rehabilitation Hospital designed the LC Knee which won a $100,000 grant from Grand Challenges Canada. Andrysek plans to use the grant funds to test the LC Knee in developing countries, including Ethiopia, Colombia and Nicaragua (Toronto Star).

These innovations are very good and should be applauded; they will provide amputees in the developing world with far better quality prosthetics than most have access to now.  These innovative prostheses all fall under the definition of “appropriate technology.” The International Society for Prosthetics and Orthotics (ISPO) define appropriate technology as “a system providing proper fit and alignment based on sound biomechanical principles [that] suit the needs of the individual and can be sustained by the country at the most economical and affordable price” (Journal of Mine Action).  I get this definition and I understand why ISPO advocates for appropriate technology, but at the same time, I think that’s (forgive me) bullshit.

The only appropriate technology is the best technology, period.  It doesn’t matter if the landmine survivor is in Angola, Armenia or America; they should all have access to the best care and services possible.  I recognize that today, this is not possible, but the effort of groups like ISPO and the ICBL should be to elevate the quality of care in developing countries to that of the United States and other countries.  US amputees should not have access to $70,000 prosthetics while Angolans are left hoping to get a $50 one; it’s not just unfair, it’s completely wrong.  Yes, build the $50 prosthetic today, but let’s not be satisfied with that.  Let’s build victim assistance up to the greatest possible level instead of accepting the lowest common denominator.   Race to the top; not settle at the bottom.

Michael P. Moore; June 17, 2012 – Father’s Day, in honor of every other Father’s daughter and son.