First Do No Harm: Unpacking Complexities and Solutions in International O&P Care

Providing care in less resourced areas offers O&P practitioners a unique opportunity to make a profound impact on the lives of individuals who might otherwise go without essential care. It’s a chance to merge expertise with compassion, fostering personal and professional growth through the experience. As rewarding as it may be, however, delivering care internationally presents challenges, including cultural differences, different environments, logistical hurdles, socioeconomic realities, and sustainability of post-care resources. Navigating these complexities requires thoughtful preparation, collaboration, and a commitment to ethical practices. We spoke with seasoned O&P professionals to uncover the insights, strategies, and lessons they’ve learned from their global experiences. Their stories paint a picture of the delicate balance required to make a meaningful difference while avoiding unintended harm. Ethics, Cultural Sensitivity, and Environmental Awareness Robert Kistenberg, MPH, CP, with over 30 years of experience, began his international efforts in Belize in 1996. Inspired by an encounter with an amputee, he realized there was a significant lack of clinical resources. “I was introduced to a man without legs and was asked if I could make legs for him and mail them to him,” he recalls. “I wanted to do something about it.” This led to the establishment of Prosthetic Hope International, which has been providing consistent care in Belize since then. Kistenberg started the organization and committed to two-week missions once a year. As the program expanded, it eventually secured a building with support from grants and cooperation with the Belize Ministry of Health. Kistenberg also engaged with the International Society of Prosthetics and Orthotics (ISPO), where he gained more insight into international work and served as chair for a year. Prosthetic Hope International has now grown to include quarterly missions, year-round staff, and technicians who help address patient needs between visits. Reflecting on his work, Kistenberg stresses commitment and collaboration. “First, do no harm,” he says. “Get educated, learn from others, and understand your level of commitment because the early years are tough. But when you see someone stand up on a new leg, it’s worth every sacrifice.” He often references the ISPO Code of Conduct, to which Jon Batzdorff, CPO, FAAOP, significantly contributed. Despite these successes, providing sustainable care in resource-limited settings is not without its challenges. Kistenberg emphasizes ethical practices. “The first thing to do is visit the country—don’t assume you know what they need without understanding the environment.” He also learned from failures, including unethical collaborations and fundraising complexities he’s encountered along the way. Additionally, Kistenberg implemented culturally sensitive and practical approaches to care. For instance, his team prioritizes the use of durable, low-maintenance components suited to Belize’s hot climate and limited follow-up options. “We do a lot of foam because it’s softer, more durable, easier to clean, and lasts longer in this environment,” he explains. Patient independence is another critical focus, which includes training locals to provide peer and technical support. “To the extent that I can keep the clinic operational and keep people employed there, I feel like I’m making a real impact.” John Brinkmann, MA, CPO/L, FAAOP(D), associate professor, Northwestern University’s Prosthetics-Orthotics Center, who has been in the O&P field for more than 30 years, says his time spent engaging in nonmedical, faith-based charitable work has shaped his understanding of the complexities and challenges that can arise from well-intentioned efforts to help others. Reflecting on his experience, Brinkmann says he believes that there is still not enough discussion about the potential to do more harm than good. “It’s good that we have an impulse to help others,” he says. “But I became aware of the challenges and unintended consequences, like disempowerment or dependence, that can arise when aid is misdirected or poorly planned.” This understanding informs his teaching, and he encourages others to explore the negative impacts of poorly planned foreign aid. Often, he says, humanitarian trips are approached from the perspective of the aid providers and fail to address the true needs of the population being served. “Coming in without understanding the local context can do more harm than good,” he says. This happens when medical missions fail to coordinate with local structures, resulting in mismatched solutions. He recalls hearing a presentation by a prosthetist who participated in a medical service trip and provided prosthetic services without considering the resources available in that area and without any plan for long-term follow-up. For example, gel liners were provided in an area without consistent access to clean water. Success is not merely the number of procedures performed or resources delivered but the lasting outcomes, he says. “The harder but necessary questions we need to ask are: Did the effort empower individuals? Were the solutions sustainable? Did they align with the broader context of the living conditions of the patients?” Brinkmann outlines four key principles for effective and ethical involvement in medical missions and charitable efforts. First, he says, evaluate your motives. “A feel-good impulse isn’t inherently bad, but it shouldn’t be the primary driver.” Next, he says, get informed. He encourages others to learn about the communities they are going into, their needs, and what systems are already in place. Then, he advises coordinating and partnering with local organizations with the goal of supporting their efforts rather than imposing outside solutions. Finally, he emphasizes a focus on meaningful outcomes. “The world is better because people want to help,” Brinkmann says. “We also need to ensure these impulses are guided by responsible action.” He also suggests that in some situations, financial contributions or remote support may be more effective than physically traveling to conduct on-the-ground aid. “If I am spending significant money just to go on a mission, much of that is funding my trip rather than directly supporting the people in need. That’s worth considering.” But he says he also recognizes the value of personal insight gained from these experiences. The balance between service and learning is essential, but it must not overshadow the importance of deliberate, well-researched decisions to maximize positive impact. Ultimately, Brinkmann would like to see a paradigm shift in how we approach medical missions and global aid. “The impulse to help is good,” he concludes. “But we must be willing to pause, reflect, and think deeply about how we give of our time, energy, and resources.” Cody McDonald, PhD, MPH, CPO/L, assistant professor, University of Washington, worked and volunteered as a prosthetist and orthotist in locations such as Laos, Haiti, and Ecuador after earning a doctorate in rehabilitation science, then pivoted toward research and teaching. “I was a bit disenchanted with donor-funded global work, but I really enjoyed the teaching,” she says. Now, her efforts focus on capacity building. That includes developing infrastructure, training local clinicians, and conducting research in underserved regions. She emphasizes long-term partnerships and cautions that power dynamics between donor organizations and recipient groups can make it challenging to have true partnerships. It is important to research organizations and ask questions about the codes of conduct they adhere to, and she says it is a red flag if they’re unwilling to talk about those things. “You have to have partners that are invested and not just serving their own needs,” she says. “Building trust takes so much effort.” Ethics and addressing implicit biases are critical. “We don’t do enough reflection on the biases we all bring to our work,” she says. “It’s not just about helping one individual, but we also need to be creating sustainable systems and avoiding unintended harm.” Working in Laos, for example, McDonald said, the care or treatment she felt was appropriate was often in conflict with how things were done there. “That all goes back to establishing the trust and relationship with local community members who are experts in their culture and can serve as a bridge between partners,” she says. “Especially in Laos, it was hard to get that frankness because of cultural differences. Colleagues might disagree with us and choose to do something else but not tell us they were going to do that. So it’s about building trust, relationships, and reflecting on our cultural biases that often serve as barriers to true partnerships.” Now it is her mission to expose US students to that side of international care. “It’s not just the feel-good stuff, helping individual people,” she says. “With students, it’s about getting them firsthand exposure to the many ethical challenges that exist in global health and prompting them to reflect on their motivations and positionality. Well-supported and mentored trips are a great way to train students and get them thinking about global health in a more reflective way. These trips may or may not include direct patient care.” For those looking to engage in global healthcare, she advises careful research of organizations coupled with plenty of self-reflection. “Nonprofits are businesses, too—and they’re not entirely altruistic; they have to make money to keep their doors open. The more we unwind that myth, the more critical and thoughtful we can be in supporting this work.” She also cautions against stepping outside of professional roles. “We are often tempted to speculate on things outside of our scope of practice because we think that’s better than nothing,” she says. “But the best organizations I’ve worked with have resources available to you, even if it’s just a phone call to a US physician to get an answer so you don’t have to speak outside of your scope.” Evaluating the lasting impact of this type of work should not be based on the number of devices delivered, because that doesn’t paint an accurate picture, and it tells you nothing about the quality of the care for patient outcomes. Best practice, McDonald says, is to try to put some pre- and post-treatment measures in place to quantitatively and qualitatively assess patient change over time. “Global health work falls on a continuum, but ideally, we need to have well-trained locals that have the necessary resources and get paid enough to survive providing high-quality care,” she says. “The goal is to work ourselves out of a job. When we leave a country, we want the national government and local providers to be in a place where we’re no longer needed.” Like others we spoke with, Chad Duncan, CPO, Drexel University, reinforces the need to understand cultural norms. “For example, with female patients, there may need to be another woman present, and a male practitioner may not be permitted to provide direct care. These cultural nuances matter deeply when it comes to delivering respectful and effective care.” Resource limitations in under-served regions with uncertain follow-up often demand creative problem-solving, especially with pediatric care. “If follow-up might not occur for six months or longer, we try to develop solutions, like designing adjustable prosthetics,” he says. Educating caregivers on device maintenance is also key to delivering long-term benefit. In ensuring the care is appropriate to the environmental conditions, you have to be diligent in asking the right questions, he says. “You need to understand what their living situation is and what their environment is like. What does their week and month look like? What does the rainy season look like for them? Understanding that helps ensure you select the device that can withstand the environment.” He frequently reaches out to others to ask them what worked and what didn’t in a region like Costa Rica, for example. “Sometimes you see patterns, such as a certain type of foot doesn’t work well when exposed to certain environmental factors,” he adds. Local Education and Sustainable Care Batzdorff’s nonprofit organization, ProsthetiKa, focuses on training O&P practitioners in underserved regions. “We combine clinical care with training,” he says. “It’s about creating something sustainable.” ProsthetiKa works in various countries, emphasizing long-term impact through local partnerships. “We don’t go in, treat patients, and then leave,” Batzdorff says. “It’s important to work with local practitioners—those who will be there for follow-up care.” This avoids creating dependency. In Haiti, for example, ProsthetiKa provided training supported by long-term mentors. In addition to training local providers, ProsthetiKa advocated for change in Ukraine within the government to create a sustainable component supply chain. Batzdorff has navigated his share of ethical dilemmas, too, such as corruption and talent drain, often focusing on in-country training. “You have to understand how the local system operates and ensure fairness and clarity in everything you do,” he says. Jeff Erenstone, CPO, has over a decade of experience in global O&P care, starting unexpectedly in Nepal in 2015 just before a devastating earthquake. “I was already interested in providing care there, and then that happened—and sometime became today.” He focuses on technological advancement and local capacity building. In 2019 he sold Create O&P, a 3D printing company, and now practices at Mountain O&P Services, New York, focusing on sustainable global solutions. Erenstone learned early that solutions must empower local providers. “It pained me to see people in need of prosthetic care, knowing there would be no follow-up,” he says. His focus shifted to improving local skills and resources, particularly prosthetic liners. “Liners are the difference between limping on a leg and being able to actually use it.” He and his team also developed a method for local liner manufacturing using accessible materials. “It wouldn’t solve the problem to just give them money to buy liners,” he says. “We had to enable them to manufacture and service them themselves.” Much of this work has been centered in Nepal, with additional efforts expanding to Ecuador, Rwanda, and Myanmar. Education is a cornerstone of Erenstone’s initiatives. He says local O&P providers often do not have advanced training. Due to a lack of resources, providers are often functioning as O&P assistants while managing broader care. “Is it ideal? Of course not, but it’s a solution,” Erenstone says. Supporting these caregivers is key, he says. “We can offer tech expertise, but they know their areas and challenges better than we do.” A trip to Rwanda highlighted the potential for local collaboration. “We went in with zero expectations, just to listen and learn,” he recalls. His team discovered that Rwanda’s entrepreneurial culture and medical ambitions were well aligned with their efforts. This inspired plans to support local universities and provide vocational training, empowering practitioners to produce and maintain prosthetic components independently. Eddy Fuentes, CPO, owns Centro Bionico, Guatemala. His O&P career spans more than four decades. After doing some World Health Organization-sponsored work in his home country of Guatemala, Fuentes’ dedication to the field quickly expanded. In 1986, he came to the United States as a volunteer for Heal the Children in Kentucky. “We took about 20 kids to the US for medical treatment, and that inspired me to apply as a candidate to become a prosthetist and orthotist,” he says. His passion led him to become certified by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC). He subsequently took roles at the Shriners Hospital, St. Louis, and later at Ottobock in Latin America, where he became an instructor. He now works between Guatemala and Puerto Rico, focusing on high-tech prosthetics, orthotics, spinal braces, cranial remolding helmets, and diabetic foot care. Like Erenstone, Fuentes focuses on empowering local communities through education and capacity-building. He is committed to training prosthetists around the world. “We train in places including Latin America, Ukraine, and the Caribbean, teaching them to use cost-effective technologies that are timely to fabricate,” Fuentes says. “We focus on education. This isn’t about making prosthetics for free; it’s about leaving something behind that lasts.” Fuentes has welcomed students from the United States and many other countries to his facility in Guatemala to provide hands-on learning aligned with ABC standards. He emphasizes the importance of doing what is right for patients and the profession. “When we do things with good ethics, we help people in the best possible way, and that’s what drives me.” While Fuentes recognizes the good intentions of nonprofit organizations entering under-served regions, he acknowledges the challenges they often bring. “Lots of organizations parachute in, do good service temporarily, and leave,” he says. “But when they leave, they create gaps for patients.” The lack of continuity in patient care frequently brings individuals to Fuentes’ clinic seeking follow-up treatment they cannot otherwise access. He advocates for better collaboration and accountability from organizations working in similar spaces. “If they would partner with us, or even just talk to us beforehand, we could better align resources and expertise to serve people more effectively.” Fuentes also highlights the imbalance between nonprofit and for-profit systems. “Nonprofits get free components and financial resources for their missions, but as a for-profit entity, we don’t have access to that kind of support—even though we also donate services. It makes it harder to sustain what we do.” Despite challenges, Fuentes is passionate about his work. “This profession is in my heart, and I will keep doing this as long as I live.” For him, it’s about equipping others. “When I look back at my decisions, like moving to Guatemala, it hasn’t always been easy. But I’ve been able to care for hundreds of patients, and that makes it all worth it,” he says. “This is my life’s work—and I love what I do.” Educating Future Practitioners Aarti Deshpande, MS-HCA, CPO, FAAOP, is a colleague of Batzdorff’s, and it was him that first approached her about international outreach and global healthcare in 2018. That led to a trip to Belize through the US division of ISPO (US ISPO). Originally from India, Deshpande earned a bachelor’s degree in O&P and worked there for six years when O&P technology was still in its infancy. “Working with limited resources taught me to innovate and adapt,” she says. After moving to the United States, she expanded her experience across various organizations, ultimately finding her place at the University of California, San Francisco. Her passion for global outreach is deeply rooted in her personal and professional background. “Having grown up and worked in such a different environment than I do now, I’ve seen dis-parities in healthcare—both as a consumer and a professional,” she says. This motivated Deshpande to advocate for healthcare equity and devote her efforts to bridging gaps in access and quality of care. For over a decade, she has returned to India annually to provide free consultations. “Every time I go back, it reminds me how important long-term care and sustainable healthcare models are.” Deshpande integrates clinical work, patient fittings, and education in her outreach trips with students. She prioritizes service learning and exposing her students to diverse cultural and resource settings. From mentorship in Colombia to fostering partnerships with local clinics in Mexico, her focus remains on sustainable collaboration with local partners. Her goal is “to empower, educate, and inspire through service and innovation.” Deshpande highlights a clinic she works with in Mexico with good leadership, funding for support staff, and a local, trained prosthetist. “The clinic has great leadership and the capacity and funding to hire a physical therapist, nutritionist, and social worker,” she says. Reliable documentation is also key. “They use patient charts to track how many times a patient has been seen, how long it takes them to go from amputation to a functional prosthesis, and how many times they come back for follow-up,” she explains. Deshpande is working on gathering data on O&P-related service-learning trips. “There isn’t much literature out there on O&P-related service-learning trips—different models, benefits, challenges, etc.,” she says. “No one has analyzed this information and reviewed this data.” Deshpande also notes challenges of working with donated components like liners and prosthetic feet, which require careful quality verification. Many prosthetic feet have categories based on patient weight and activity level to ensure a good fit. “When the components are donated, we don’t know the category they are in, so there is a high chance it will not be appropriate for the patient, and being aware of these challenges reduces the chance of making too many errors. We teach our students about considerations like that.” Deshpande’s advice to students is to listen to the needs of the people they’re there to help. “We always tell them to prepare and make a list because there are a lot of things that need to be done in addition to patient care,” she says. “We tell them to do a good retrospective assessment after the trip of what went well, what did not, and what they learned. Even after so many trips, I still learn something new every time.” Duncan understands the challenges of navigating a complex landscape of cultural, ethical, and logistical issues. “I associate myself with companies or nonprofits that have connections in different countries,” he says. “I act as a mentor to students, guiding them to ensure they don’t exceed their knowledge and capabilities.” Duncan highlights the value of collaboration and teamwork, involving faculty members and organizations to deliver care effectively. “We focus on evaluation, assessment, and helping students develop their hands-on skills while ensuring that the care we provide meets the needs of the people we serve.” His advice to international caregivers is simple, but vital: Always put the patient first. That patient-centered mindset makes collaboration essential. “Don’t let your hubris get in the way of the goal for that individual,” he says. “Having a group of people thinking about how to solve or approach delivery of care is very important. Internationally you often see more of a team approach than in the US—no one is the best and everyone is working for the common good.” He says it is important when going into another country as a caregiver that you are there to represent the organization you’ve partnered with. He adds, “You are there to serve them, not to undermine their health system or question it.” Duncan also encourages students to align with organizations that focus on sustainable solutions. Organizations with in-country support systems are typically better positioned to offer long-term care, he notes. Technology can also play a role in sustaining connections. “Tools like WhatsApp are incredibly helpful for maintaining communication and offering guidance after we leave,” he says. “But it’s important to know your limits. Ongoing outreach can be overwhelming, especially when managing your own caseload at home.” Ultimately, Duncan stresses the importance of the principle of nonmalfeasance and equity. “Our standards of care should be consistent globally, regardless of resources,” he says. Respecting individuals, their culture, and their dignity is paramount. Through mentorship, cultural awareness, and teamwork, Duncan and his colleagues demonstrate how ethical and effective O&P care can positively impact lives worldwide. Tara McMeekin is a writer and editor based in Colorado. Image credit In order 1-6: ASphotostudio/envato.com; Watercolor_Concept/stock.adobe.com; tridsanu/envato.com; alexis-rodriguez/unsplash.com; Seventyfour/stock.adobe.com; aniket-das/unsplash.com

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