First, Do No Harm: The New Principles for Providing Humanitarian O&P Care in Developing Nations

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By Morgan Stanfield

Yesterday, your reimbursement was one live chicken, the equivalent of $5, and a bag of corn. The day before, you paid one of your patients instead—she'd spent her week's food money to buy her ticket for the 150-mile bus ride to your makeshift clinic, so you slipped her enough to cover a meal and a place to sleep. Today, you hope for no payment at all, except for the rush of excitement in a pair of brown eyes when their owner realizes he can walk again, work again—live again.

If you provide O&P humanitarian care in developing nations, you're likely familiar with this kind of payment. You also likely receive manifold other benefits—the satisfaction of giving your best to the people who need it most; the adventures of travel and culture shock; the challenges of solving extraordinary problems.

However, you might be able to gain even more, according to new thinking in the world of humanitarian efforts. To receive it, are you willing to look closely at your work, ask yourself fundamental questions about your methods, and perhaps even reorganize your procedures of giving?

The U.S. National Member Society of the International Society for Prosthetics and Orthotics (U.S. ISPO) is betting that you are. Your colleagues from developing nations around the world can attest to what you might receive in return—knowledge that you've contributed to your profession, provided long-term economic support to the cultures you visit, and created long-term solutions for your patients.

If you aren't, the results can be appalling—for your patients, for your colleagues, for the cultures you visit, and for your profession.

Who Gives?

Jon Batzdorff, CPO, (second from left) stands with patients at the PROJIMO rehabilitation center, Sinaloa, Mexico. Photographs courtesy of ProsthetiKa.

The Orthotics, Prosthetics & Rehabilitation Humanitarian Database, a project of the Digital Resource Foundation for the Orthotics & Prosthetics (DRFOP) Community, lists more than 40 organizations that provide humanitarian O&P care to people in and from developing nations, and their list includes just a fraction of such groups worldwide. Organization such as Rotary International, Cambodia Trust, and Shriners Hospitals for Children provide millions of dollars per year in multiple nations, while smaller groups, such as The Barr Foundation and Limbs for Life, provide anything from a few used components per year up to a few hundred thousand dollars per year. This aid pours into target cultures on six continents and dozens of nations. But what does it leave in its wake?

Crushing the Competition

Children at PROJIMO explore a locally produced wheelchair.

Eddy Leopoldo Fuentes, CPO, of Ortopedia Centroamericana, Guatemala, wrote about his experience with a problem too-often faced by O&P professionals in developing nations in the article, "The Effect of Good Missions Overseas," which appeared in the 2009 U.S. ISPO E-Highlights newsletter. After nearly ten years of working as a CPO in the United States and having served as the Central and South America prosthetist coordinator for The Barr Foundation, Fuentes and his wife decided to move back to their home country of Guatamala to join their families. He carefully assessed the local economy and the financial outlook for O&P practices.

"I invested in a small practice that my brother Julio Cesar was running, to make it the best in the region," Fuentes writes. "I evaluated the market, and I thought that I had a good chance to make it. I knew about the local prosthetists providing services at the Social Security Hospital, the Army hospital, and others who also were providing private services as well. But I never thought that my biggest competitors were going to be some [humanitarian] medical teams providing O&P services in Guatemala." He continues, "Some of these missions come to Guatemala loaded with...good heart and good intentions but with little knowledge as to who is here and which services are being provided."

As a result, Fuentes writes, some groups partner with dishonest local practitioners who accept free limbs then sell them on the black market. In other cases, humanitarian groups provide free care to patients who have a decent income and could afford private care.

"This places unsuspecting and well-meaning NGOs [nongovernmental organizations] in a position as a competitor with an unfair advantage over the local practitioners trying to make a living," Fuentes says. "We just can't compete against 'free legs.' In this fashion, legitimate businesses have almost no chance to be successful."

Parachute Prosthetists Fit and Run

Batzdorff and a PROJIMO patient enjoy her success.

Professionals aren't the only ones who can suffer from an NGO's well-meaning actions, whether the actions are missteps or due to limitations in local resources. Robert Kistenberg, MPH, CP, LP, FAAOP, is chair of U.S. ISPO and clinical director of Prosthetic Hope, (formerly Sonrie Ministries), a group that provides O&P care in Belize.

"'Parachute prosthetics,' which is what we started out doing, is when you fly in, do your business, and then fly out," he says. "It was not a sustainable model or ideal for our patients."

Such care leaves patients without adjustments, repairs, or supplies. Even if a return trip is planned, patients are left dependent on further charity.

In her book, How to be a Help Instead of a Nuisance, Karen Kissel Wegela advises caregivers in all fields, "The more open we are to really hearing how things are for the other person, the less likely we are to impose our own biases on the situation. So the first step...is to show up with an open mind and heart."

Showing up with preconceived ideas has led some well-intentioned O&P caregivers to leave behind serious problems after completing NGO work. One of America's most respected charities partners with a group that donates thousands of mass-produced wheelchairs per year in developing countries. These adult-sized wheelchairs are oftentimes provided to children who cannot push them.

Jon Batzdorff, CPO, founder of the international NGO ProsthetiKa and chair of U.S. ISPO's international outreach committee, notes, "There's an organization called Whirlwind Wheelchairs, and they train people to make really good custom wheelchairs that are low-cost and made from locally available materials, and they've created jobs that have really improved local communities throughout the world. They developed in Central America and then very quickly, their local people's chair shops were put out of business [by the wheelchair donations]. People in local shops are having trouble making a living and are so frustrated. They're asking, 'Why isn't the charity buying the wheelchairs we make? They can even get funding for having these chairs made locally, so it isn't an issue of money."

Tainted by War, Leading a Movement

Patients wait outside the PROJIMO clinic to receive O&P care.

Another problem is NGO work tainted by political motives. In 2004, Bruce Biber, deputy head of division, policy, and cooperation within the movement of the International Committee of the Red Cross (ICRC) and Red Crescent, published an article on the ICRC website titled, "The Code of Conduct: Humanitarian Principles in Practice" (www.icrc.org). He wrote, "A major challenge to ICRC operations...is the tendency of some state actors to integrate humanitarian activities into the conduct of their politico-military campaigns.... Actions presented as humanitarian are becoming suspect, perceived—rightly or wrongly—as part of a wider strategy to defeat an opponent or enemy. If clear distinctions are not made between politico-military players and their implementing agencies on the one hand, and independent humanitarian actors such as the ICRC on the other hand, then humanitarian action in general threatens to be rejected, irrespective of who is involved and the actual integrity of their motives."

In response to this threat and others, the ICRC had, in 1994, written its Code of Conduct for the ICRC Movement and Non-Governmental Organizations in Disaster Relief. In turn, the ICRC code influenced another group wanting to provide the most effective and ethical care possible: O&P professionals.

In 2007, Batzdorff was elected to the board of U.S. ISPO and was asked to chair its international outreach committee. He planned to connect with ISPO groups already providing outreach and to find out what his Latin American colleagues wanted the committee to address. Latin American clinicians volunteered a range of issues with NGOs, especially unfair competition for customers who could afford to pay, and "fit-and-run" care. Batzdorff recalls, "They weren't saying that they didn't want these people to come, but said they would like to be involved and have a chance to participate in helping their own people who were needy."

After a helpful conversation about these issues with Rosielena Jovane C. Orthotist/Prosthetist Lic. #2-1, of Becker Orthopedic, Troy, Michigan, Batzdorff started researching how other fields had handled such issues. He came across the ICRC code of conduct and developed a similar document for O&P. After several stages of feedback and revision, the U.S. ISPO Code of Conduct for Prosthetic and Orthotic Nongovernmental Humanitarian and Development Assistance was presented in the fall 2009 U.S. ISPO newsletter. Its nine principles are focused on nondiscrimination, nondependency, support for local capacity, and cooperation with locals.

A technician enjoys his work at a Monclava, Mexico, clinic.

The purpose of the entirely voluntary code, Batzdorff says, is to facilitate discussion. "There's no single perfect way to do things," he says, but cooperation, listening, and outreach are absolutely key to providing the highest quality work possible in any situation.

Prosthetic Hope (then Sonrie Ministries) was the first signatory to the code. Kistenberg explains, "I've met P&O practitioners from around the world who have recounted the detrimental effects of doing P&O the wrong way." Prosthetic Hope has also striven to put best-practices in place since its early days. For example, no local services existed in Belize when they began, so its staff hired and trained their first patient, Adrian Camarara. Camarara now staffs the Belize part-time clinic as its clinical manager and performs repairs, scheduling, and intakes. When possible, Prosthetic Hope also purchases supplies, such as resins, in Belize.

Kistenberg also notes, "We operate on donations. There is a fairly well-recognized phenomenon that if you provide services for free, the individuals who are getting them don't feel ownership, so you should always charge something. We're not going to turn anybody away because they don't have funding, but the thought is that everybody can contribute in some way." Prosthetic Hope has in fact accepted live chickens...and bags of corn.

Next Steps

Future plans for the U.S. ISPO code of conduct are still being worked out, Batzdorff says, as his committee gathers information about how it can best serve patients and the profession. In the meantime, Batzdorff encourages NGOs to read the code, accept the invitation to sign on, and to submit feedback.

"Once people have signed on, we'll develop a list of organizations that have signed on and endorsed it, and we hope that will become a badge of distinction," he says.

Just as important, the outreach committee plans to establish a hotline people can call if they feel they have been negatively impacted. The idea is for them to call before their problem becomes critical and report their situation and the way the organization has affected them. Batzdorff says, "We'll have no authority to enforce anything, but we can contact organizations we receive complaints about. We'll tell them, gently, that we've heard about these particular problems and would like their input because we're trying to improve relations among countries and maximize the assistance people are giving." The first groups Batzdorff looks forward to connecting with are wheelchair charities that could potentially work with groups like Whirlwind Wheelchairs.

Kistenberg also lists two other major humanitarian projects in the works: the Prosthetic and Orthotic Components Clearinghouse (POCC) and a humanitarian online calendar of events.

POCC, Kistenberg says, "is a collaborative activity between U.S. ISPO, Georgia Tech and a group called MedShare International, which is a medical/surgical recycling organization (MSRO). The Barr Foundation is supporting this activity through an initial donation of components and funds. Students at Georgia Tech and Emory University will provide human resources. Individuals, prosthetists and orthotists, or manufacturers can donate components to POCC, those are inventoried in a database, and if people are going somewhere and they need certain components, they can go online and order what they want and just pay shipping and a nominal warehousing fee." To be eligible to access POCC components, NGOs would need to sign on to the code of conduct, then meet guidelines related to the code.

The planned calendar of mission events, a proposed collaboration between the Orthotics, Prosthetics & Rehabilitation Humanitarian Database and oandp.com, would allow mission teams to note on an online calendar where they are going and what they plan to provide. Kistenberg says, "It's hard to have folks who are competing for limited resources to see eye to eye sometimes. This could help eliminate some redundancy of services and get people to collaborate." He added that groups or people with a calling to serve in a particular location could more easily find ways to contribute.

Kistenberg concludes that humanitarian work, done well, provides profound benefits not only to the recipient, but to the O&P professional: "Seeing how people are able to operate in the environments in which they find themselves, and how they solve problems with the materials that they use, really expands your ability to be able to do what you do. When you go to a country where they don't do any thermoplastics or still make everything out of aluminum, you get an appreciation for their hand skills, but the way that they are able to take what they have and help people is a global lesson. That just makes you a better practitioner, flat-out."

Morgan Stanfield can be reached at

For more information about the U.S. ISPO Code of Conduct or to sign on to the code, visit the U.S. ISPO website.