Amputees in Developing Nations

Greg Bush has a vivid memory from his experience working with amputees in Haiti.

“A woman walked for three days on one leg and a crutch to get a BK prosthesis,” recalls Bush, a Canadian prosthetist. “She slept out on the road. She can’t go away and return for a follow up. We expect them not to come back.”

Bush quickly learned that the most effective way to provide prosthetic services to such an individual was to do it all in one day: assess, cast, fabricate, fit, and send them on their way. This of course was not often possible. The reality of providing rehabilitation in a country with an unpredictable social infrastructure, political instability, a history of foreign intervention, and increasing poverty became apparent soon after Bush arrived with the Canadian team working with Healing Hands for Haiti. These complications gave rise to certain attitudes toward the rehabilitation professionals providing healthcare services.

At that time (circa 2004), there was no real local prosthetics infrastructure in Port-au-Prince or Jacmel. One of the local leaders, a Haitian Vodou priest, told Bush (who was stationed at the central fabrication facility) that although assistance is appreciated, the streets were now filled with garbage from the packaging material of supplies from foreign relief efforts. They were clogging the sewers and causing them to overflow. With no garbage pickup, some of the donated healthcare equipment and parts had to be piled up and burned (after the screws, bolts, and metal pipes were salvaged).

Unused parts take up space. “If someone takes these, they can become a target of a rival group,” says Bush. “They have something that they don’t need but can sell. We had to be aware of that.”

Supply and Demand

Two local armed guards were assigned to the guesthouse Bush’s team was staying in. Some of the exterior walls were equipped with barbed wire and glass shards from bottles jutting out of the concrete to deter theft of tools and materials. Even so, the equipment eventually had to be chained down and locked. The clinic was broken into the first day.

Sometimes the material came under threat before it even got to the clinic. “One day we had to pick up a crate of supplies at the wharf—plaster, plaster bandages, hand tools,” Bush explains. “The guy running the shipping depot would hold on to your supplies until you gave him some monetary incentive, or perhaps give your supplies to another group of foreign relief workers. We just decided to bring things to Haiti in large hockey bags to avoid this problem.”

This is the reality that people in Haiti live with and live through. This is their home, and the locals are trying to live by any means necessary. Sometimes it can rub foreigners the wrong way, but the Haitians haven’t the time to care. Nor should they be asked to.

In many developing nations, the ingenuity of those in need takes visitors by surprise. A medical grade assistive device, with all the material science research behind it, means nothing to the locals if the material to build it is impossible to source. Splints made of wicker or wood, slats of bamboo wrapped with twine—if they see utility in even part of the assistive device being provided, they’ll find a way to make it work. That’s the drive of the end user.

The material suppliers in the country? Well, they’re a different story.

“Plaster was always running out, plaster for casting. Plaster supply exists locally in Haiti, but it’s expensive to access. You need to hire a car, drive a distance, and then you’ll learn that the supplier prefers to sell to larger companies and builders.”

This is expected. The local businesses want to ensure that their regular customers remain regular customers, purchasing large amounts of their goods. They don’t need temporary relief workers creating a hiccup in their supply chain.

Attitudes Toward Limb Difference and Disability

Bush says a lot of the clinical maintenance work he provided was for lower limb prostheses—put a cushioned pad in the socket, redo some straps, the basics.

“Not many people would come in for upper limb work, which was good because we didn’t have the supplies to do the repair,” Bush says. “Or I would provide a functional hook, but they wanted a hand. Another lady received a pylon and SACH foot (solid ankle cushion heel). She wanted a nicer-looking cosmetic cover; she wouldn’t leave. If the donated hand we had was far too light [to match their skin tone], they wanted a darker cosmesis. They wanted to be seen without a disability.”

But concealing the prosthesis can be tricky. Donated parts come from companies and private donors. The luxury of choice for color, size, and materials is limited at best. For upper-limb prostheses, the visibility of disability is immediate and obvious. It can’t be covered by a pant leg. However, having an upper-limb prosthesis can lead to opportunities in society as long as it doesn’t look like a prosthesis. Appearance is important, or else the negative cultural attitudes dominate.

“Employers don’t want their workforce to look disabled there,” Bush says. “There was a lot of that, views related to employment, marriage, and shame. Some felt that they would never get married and no women would want them. Others felt that an amputation was a punishment, that God was punishing them for a previous crime they did, even if it was a trauma. And some felt that other people would mistake their amputation [for] being the result of a punitive measure for a crime, instead of a road traffic accident.”

Some of the upper-limb recipients didn’t seem as bothered wearing their provided prosthesis. The individual’s profession and degree of social interaction played an integral part in whether they could function as part of society.

“The farmers didn’t care as much about it,” says Bush. “They don’t live around people; no one’s judging them. City folks, on the other hand, had the attitude of ‘No hand? Not going out. I don’t care if it does or doesn’t work, just make it look like a hand. Don’t put my weakness on display.’”

The parents and caregivers of those receiving a prosthetic device thought there was some merit in the work Bush’s team was doing.

“They had heightened expectations of what we were providing their family members, but it may have come from no real understanding of prosthetic specifics. But they seemed to think that there was a benefit in having someone agree that there was a problem. Someone was looking at them for the first time. Someone was paying attention to their kid.”

I asked if he thought he made a difference in Haiti.

“It’s hard to gauge feedback, because we’re only there for two weeks at a time,” Bush says. “You try to do follow-ups with the people you provided the devices for, but you have to do this through a member of a new team going down there. The situation keeps changing. The team keeps changing.”

Every frontline healthcare worker wants to know that their intervention made a difference. Even in the developed world, this is can be difficult: There are too many people in the urban areas, not enough healthcare workers in the rural ones. In the developing world, add the state of social infrastructure and continued poverty. These problems need to be solved first (or in tandem) before long-term improvement in healthcare can be achieved and delivered locally, by the people who live there for the people who live there.

Ali Hussaini is a Research Fellow with the University of Portsmouth. His work explores emerging medical interventions, functional assessment tools, barriers to new technologies and healthcare outcome measures for improved quality of life.

Link to the article on Amplitude Website

Statement on COVID-19 Vaccination for People Working with and Using Assistive Technology

In many countries, the COVID-19 pandemic has disrupted services for assistive technology1 (prosthetics, orthotics, wheelchairs, etc.), adversely affecting vulnerable persons with  disabilities and/or limited mobility, and the need was immense already. Over 1 billion people  need at least one form of assistive technology now and this is expected to rise to 2 billion by  2050. Meanwhile, over 90% do not have access to the assistive technology they require. 

Vaccination campaigns are starting and the first elderly people are due to be vaccinated this  month. However, national vaccination plans may not yet include all people using and supporting the provision of assistive products and services as a priority group, thereby putting  healthcare providers and recipients at risk. 

In most countries, assistive technology services are provided by a mix of public and private  sectors. Since the first phase of vaccinations typically focuses on “front-line healthcare  workers”, there is a risk of missing professionals in prosthetics, orthotics, wheelchairs, therapy,  etc. who are not employed in public hospitals. Governments should include these healthcare  professionals for early vaccination since assistive technology services are intimate, requiring  close physical contact to properly provide an appropriate device. 

Germany is providing a good example of a strategy that strengthens the role of assistive  technology service providers. A federal law was recently passed to improve health and nursing  care (GPVG), beginning in January 2021. This law underlines the considerable significance of  assistive technology provision for maintaining public health and ensuring quality of life despite  restrictions due to a disability, even during the COVID-19 pandemic. The law also includes  reimbursement of protective equipment for extra hygiene measures by the statutory health  insurance (removing a financial barrier for many elderly care and small facilities). 

Previously, in 2016, Germany passed a federal uniform regulation to define critical  infrastructure. In healthcare, this involves immediate life-sustaining medical products  (commodity manufacturing and delivery); however, assistive technology providers were not  specifically mentioned, leaving room for interpretation. Since further regulations are under the  responsibility of the 16 federated states, it was these states that supported assistive technology  providers during the pandemic with financial assistance and exemption regulations for relevant  infrastructure. The new law will redeem this ambiguous situation. 

By the end of the year, the German statutory standing vaccine commission (STIKO) will  provide recommendations on how to prioritize vulnerable groups and beneficiaries in the roll  out of COVID-19 vaccine programs. Based on this groundwork, assistive technology providers  and service users should be considered as an integral part of public health care providers. 

Globally, the important role of all people involved with assistive technology services needs to  be recognized and should lead to these healthcare professionals, whether in the public or private  sector, and people who receive their services to be included in early national vaccination plans.  Early vaccination will not only enhance professional and patient safety, but also allow facilities  to return to pre-COVID-19 treatment levels, thereby starting to meet the global service backlog  that is affecting mobility, health, and quality of life. 

Please email comments to ISPO at

1 Assistive technology (AT) is an umbrella term covering systems and services that deliver assistive products.  Assistive products’ primary purpose is to maintain or improve an individual’s functioning and independence  and to facilitate participation, including devices, equipment, instruments, and software; especially designed  and produced or generally available (e.g., wheelchairs, eyeglasses, hearing aids, prostheses, assistive digital  devices, software).

ISPO Canada Annual General Meeting

On October 24th, 2020, ISPO Canada hosted a joint educational session with the Ontario Association for Prosthetics and Orthotics (OAPO). Following the Educational Session, the ISPO Canada Executive Board held their AGM. For anyone who missed the event, the AGM is available to view below.

For any non-members interesting in learning more about becoming an ISPO member, please follow the links to check out the membership option and the benefits. As a member of ISPO, you join a worldwide network of professionals with the same patient-centric approach to care and dedication to excellence and enjoy exposure to the highest level of expertise and latest developments in the field.

Student Abstract Competition: Deadline Extended

Contribute to the cutting-edge interdisciplinary program and gain national recognition!

The ISPO Canada Subcommittee invites students to submit abstracts for their research in Prosthetics and Orthotics. Selected students will submit a 5-minute presentation to be shown during the ISPO Canada & OAPO Virtual AGM and Educational Session on October 24th, 2020.

The submission deadline has been extended to FRIDAY, SEPTEMBER 25th, 2020 at 11:59PM PST.

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Please review the Submission Instructions PDF prior to making your submission.

Submission Instructions PDF – ISPO Canada & OAPO Educational Session 2020

ISPO Online Symposium on Telehealth

ISPO has the pleasure to announce its first “Symposium on Telehealth”. Organised by the ISPO Continuing Professional Development (CPD) Committee, the symposium will be held online on 16 October 2020, from 12 (noon) to 3 PM UCT.

Freely accessible to the entire ISPO community, the symposium will aim to demonstrate how communication technology is being used in various sectors of rehabilitation services. In particular, the purpose is to:

• Introduce participants to telehealth,
• Demonstrate/discuss the importance of telehealth in light of the current pandemic,
• Provide examples/model of telehealth that have been put into practical use.

Representing the multidisciplinary and international membership of ISPO, the symposium presenters will talk about topics such as the telehealth landscape, risk analysis of telehealth versus face-to-face interventions, telehealth strategies for remote regions, and telehealth for outcomes and patient education. Sufficient time is foreseen to answer questions from the audience.

The full programme and list of speakers will be made available shortly, and registration is planned to be open between mid-September and mid-October. The recording of the event will be made available to ISPO members in good standing.

You can sign up for the online online symposium by completing this short registration form.

In case of questions please do not hesitate to contact ISPO at