Prosthetics and Rehabilitation Services for People with Amputations in Haiti — A Message from the Chair of US-ISPO
Robert S. Kistenberg
MPH, CP, LP, FAAOP
As the enormity of the tragedy resulting from the earthquake in Haiti comes into focus and the monumental task of search, rescue and recovery continues, attention is being given to the immediate needs of the people amidst the chaos and destruction. As is often the case with catastrophic events, a significant number of survivors, possibly numbering in the thousands, will have sustained amputations. Even before the earthquake, the need for prostheses in Haiti far outstripped the capacity of the organizations providing prosthetic services. Now, in a momentary shift of tectonic plates, the demand for prostheses and amputee rehabilitation has grown exponentially. Furthermore the headquarters for the main group providing prosthetic care in Port au Prince, Healing Hands for Haiti (HHH) (www.healinghandsforhaiti.org), has sustained substantial damage.
As is the usual reaction to such a crisis, individuals and groups want to assist which is noble and exactly what our natural instincts guide us to do. However, when it comes to providing prosthetic rehabilitation services to amputees in developing nations, one must be mindful of how these services are being delivered as it is possible to do more harm than good. As of January 19, 2010, a team from HHH, in conjunction with other international aid agencies, has been deployed to Haiti to begin the initial coordination of rehabilitation for those with amputations and spinal cord injuries (for more information click here). It is feedback from their initial on the ground assessments that should guide our next efforts.
A systematic approach to amputee care will include identification of the affected population concurrent with establishment and restoration of prosthetic facilities with adequate equipment, materials and space to provide services. The logistics of putting a humanitarian mission team in-country are daunting at the best of times but during a crisis and subsequent recovery, a coordinated effort is absolutely essential. Once the situation has been fully evaluated, plans can be made to assemble the appropriate teams. There will be no shortage of volunteer opportunities once the infrastructure is in place.
Parachute prosthetic & orthotic (P&O) services often leave problems in their wake
Before individuals or groups begin to assemble teams for short term missions to Haiti to provide prosthetic rehabilitation care, keep in mind that people with amputations will need services for the rest of their lives. Long after basic services are restored and buildings rebuilt, the amputee population will still be living with their own personal lifelong aftermath of the tragedy. If teams fly into Haiti, find some way to deliver artificial limbs and then return home, what will happen to the patients after the team has departed? How will they receive follow up care and adjustments?
This is the challenge with what is referred to as parachute P & O care. Teams drop in, disrupt local facilities and activities, provide services and fly out leaving a group of people in their wake to effectively fend for themselves.
People in Haiti with amputations need more than artificial limbs; they need prosthetic rehabilitation including not just the prosthesis but post-fabrication adjustments, physical conditioning, emotional, psychological and post traumatic stress disorder counseling, vocational rehabilitation and social reintegration.
The challenge of gradually incorporating an artificial limb into the activities, body image and daily routine of someone with a recent amputation is just as great if not more so than is the challenge of making the prosthesis in the first place. If no one is there to provide post-fabrication adjustments or provide simple maintenance when something goes awry, the prosthesis can be rendered useless, painful or worse, unsafe.
Patient transport programs-resist this temptation
Groups may be inclined to start transporting individuals to the U.S. for services. While on the surface this may seem like a good idea and convenient for the providers as they have their full facility at their disposal and host families get the benefits of opening their homes to someone in need, in reality, this is far from ideal for a number of reasons.
First, practitioners tend to use componentry they are familiar with but which may not be appropriate for the patient's home. At a prosthetic clinic in Belize, I have worked with more than one individual who has been "locked" into their prosthesis when the shuttle mechanism on their U.S. made leg malfunctioned. In one case a 13 year old girl could not get her leg off for three days or nights. Her father, desperate to alleviate her suffering, almost tried to remove it with a hacksaw before he was referred to the clinic. In the U.S. if a component malfunctions, a prosthetist is only a phone call away. In the developing world, there may be no other options.
Second, traveling overseas to a foreign country for prosthetic care can be disorienting. Imagine you come from the poorest country in the Western Hemisphere, survived the earthquake's unimaginable devastation yet you lost an arm or a leg, and someone drops a golden ticket in your hand which will take you away to the United States, Canada or any developed country for perhaps six to eight weeks. They promise a prosthesis, housing and food. You would believe you had won the lottery.
When you arrive in country you experience a world as you have never known but maybe seen on TV. Perhaps you experience running hot and cold water for the first time and creature comforts abound.
Over a period of days and weeks, you get a new prosthesis. While not always a comfortable process, the fact that you are free from worries about basic necessities of food, shelter and clothing leaves you feeling phenomenal . . . until the time for your return home looms nearer.
Third, upon returning home, those transported for services are often left with a sense of abandonment. They are surrounded by caring people in a wonderfully sheltered environment when overseas and then they are thrust back home, alone. In some patient transport programs to the U.S, patients faced with returning home in this circumstance flee their hosts, preferring to take their chances on their status as an illegal alien rather than return home. Others, longing to return home will go to try and rebuild a life with the additional challenges that new amputees must endure.
If Haitians are going to be transported for prosthetic services where they see and experience a very different lifestyle only to be returned back to the reality of post-earthquake Haiti, what impact do you believe that will have on them? And again, when something needs adjusting or replacement on the prosthesis, who do they call? Perhaps a taste of honey is worse than none at all. In short, while host families and facilities would be denied the rewarding experience of providing prosthetic rehabilitation for a foreigner, dollars spent on flights, visas, housing and food would be better spent supporting efforts to develop prosthetic infrastructure in Haiti.
Appropriate technology is defined as "a system providing proper fit and alignment based on sound biomechanical principles which suits the needs of the individual and can be sustained by the country at the most economical and affordable price". (ISPO, 1996). Professionals who perform P&O work in developing nations have offered conclusions and recommendations for appropriate orthopedic technology in developing nations (ISPO, 2001).
Appropriate technology needs to be employed focusing on the environment in which the devices are going to be used, the availability for follow up care and maintenance, the level of training of those providing the prostheses as well as those providing follow up care and of course, costs. This way the amputee population can receive limbs, physical therapy and on-going rehabilitation care.
The International Committee of the Red Cross and other organizations have developed cost effective and user friendly technologies for the developing world. These tested techniques and technology will be the best place to start to meet the urgent need. New or recycled componentry may also have a place depending on how its applied, where it is applied and by whom.
So What Can We Do?
While the UN secretary general Ban Ki-moon describes the devastation in Haiti as "one of the worst humanitarian crises in decades", it provides the international P&O rehabilitation community an opportunity to demonstrate our innate human compassion and our capacity to help people in dire need. An event such as this brings out the best in people as is evident by the global response to this crisis. So what can you do to help to build prosthetics infrastructure in Haiti?
We need to focus not only on the short term goal of providing prosthetic rehabilitation and artificial limbs for Haitians but on the long range goal of building a sustainable system in Haiti with the capacity to meet the needs of the amputee population for decades to come. While the earthquake and its effects is truly a tragedy, it gives the global prosthetic and orthotic community the opportunity to come to the aid of Haiti and demonstrate that we can in an efficient and collaborative manner make something good and sustainable for the long term while we provide prosthetic and rehabilitation care of Haitians in the short term.
Give a man an artificial leg, he can walk for as long as it fits or lasts. Teach a man to make artificial limbs and he will have a livelihood helping his countrymen for the rest of his days.
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