Humanitarian O&P Aid: Leaving a Gentler Footprint

When natural or man-made disasters ravage a foreign country—when people are injured and suffering as the result of a cataclysm or abject poverty—O&P professionals are often moved to offer skilled humanitarian help. [caption id="attachment_236599" align="aligncenter" width="545"] bignai/stock.adobe.com[/caption] Their hearts are in the right places; but it’s their footprints that we should consider. No one wants to leave the people of a struggling country worse off than before they arrived, yet it can happen. We asked O&P clinicians experienced in providing humanitarian aid to underserved countries to share their insights and advice on how to deliver O&P aid most appropriately, effectively, and beneficially. Sustainability Is Key Just delivering and fitting components isn’t enough, they agree unanimously. “Practitioners should ask themselves who is going to do the follow-up care and what the patient will do when the device breaks?” says Jeff Erenstone, CPO, founder of Operation Namaste. “Just bringing in components is not the answer because if the local practitioners aren’t familiar with the components they won’t be used.” [caption id="attachment_236604" align="alignright" width="300"] Namaste’s liners are manufactured locally. Photographs this page courtesy of Jeff Erenstone.[/caption] He recalls a 2016 visit to Haiti, when he saw a storage area filled with supplies donated after the 2010 earthquake. “The stuff was literally rotting. The practitioner told me they didn’t know what to do with all of it.” Because prosthetic training does not exist in 75 percent of low-income countries, Operation Namaste’s trips to Nepal focus on education, updating local clinicians in modern prosthetic care, and providing the components needed to perform this care in a sustainable way, including the organization’s locally made prosthetic liners. Dino Scanio, CO, founder of the FOOT Foundation, also points to errors, including providing gel liners in parts of the world where they are unsuited for the environment. “Six months later, liners were ripping and cracking; all they’d gotten was false hope and disappointment—because nobody wants to go back and fix it.” He points out that some “turn and burn” clinics build O&P devices for a week or two and then leave the country, doing a far greater disservice to the community—not only by providing individuals with what may or may not be durable, sustainable prostheses or orthoses, but also by preventing those patients who have money from using their funds to get care locally. [caption id="attachment_236600" align="alignright" width="296"] Erenstone demonstrates the liner and casting process to a local practitioner.[/caption] Scanio’s clinics have been serving Guatemala for 16 years by fabricating everything on-site instead of using donated braces or sockets that are adjusted to fit underserved patients. “I provide the same quality of care for them here as I would in the United States, custom fitting through casting, modifying, and fabricating.” Robert Frank, CPO(E), has been facing challenges with the rehabilitation community in Ecuador for more than 25 years.* “My strongest recommendation is for training,” he agrees. “No project can last long without training of local practitioners, and no intervention can be more than a drop in the bucket without it, leaving clients disappointed and without services within a few years. Our training has extended to workshops, talks, and internships for local physical therapists and university students, and we see good results in the treatment and referrals given by the recipients of this training.” Jason Rovig, CPO, is a founder of two humanitarian communications startups. He’s CEO of Tech Equalized, a US-based tech startup building artificial intelligence helplines and data solutions that benefit vulnerable groups and nongovernmental organizations (NGOs), and COO of Art For Impact, a humanitarian-focused media and marketing company in Colombia. These two organizations work together with governments and international NGOs to provide equitable access to information for hundreds of thousands of refugees through their first initiative, Voices Of Venezuela. [caption id="attachment_236601" align="alignright" width="203"] The local practitioner participates in the liner process.[/caption] He reflects that “in many ways this is a hard topic, with no right answer. If there’s no treatment or if there’s only one choice of treatment and it’s not the ideal treatment—what’s the alternative? None. “Underserved areas can be underserved for multiple reasons—because of extreme poverty, or if they’re extremely remote and difficult to reach. I remember fitting a patient who had travelled a full day on a horse, then all day in a canoe, to board a bus in a small town, and spend another day on the bus to reach us. So the likelihood of him ever coming back is not very high, and it’s hard to sustain care if a patient is beyond your reach.” Darin Oskison, CPO, Lawall Prosthetics & Orthotics, headquartered in Philadelphia, makes annual trips to El Salvador with a team of volunteers organized by Healing the Children (HTC), where he treats children in need of orthotic care. “Over the course of the year, I collect hundreds of outgrown orthotics from parents who are happy to pass them on for another child to use.” Modifying the braces for new wearers isn’t difficult if you have the right samples, he notes. “I’ve gone with the team for six years, so I know what I’m likely to need. Uncorrected club foot is something I see every year, so I know I’ll need more and more samples, which O&P manufacturers will sometimes donate.” “Patient compliance is good; I see repeat patients and get to know the families. I’ve seen some patients all six years—they keep coming back.” [caption id="attachment_236611" align="alignleft" width="188"] Scanio poses with a boy he fitted with AFOs in Guatemala. Photograph courtesy of Dino Scanio.[/caption] Connections Are Vital John “Mo” Kenney, CPO/L, FAAOP, Kenney Orthopedics & the Kenney Foundation, headquartered in Lexington, Kentucky, encourages potential humanitarian volunteers to seek connections with someone in the host country to help lay the groundwork, make introductions, and supply information about the culture and conditions. “I think it’s critical that that relationship is established to begin with,” he stresses, “before you even go to the country.” A veteran of 30 years in the humanitarian field, he explains, “I was fortunate because I was able to ease into this by working with other foundations and people and saw different perspectives.” Kenney’s 25-year-old foundation operates four clinics quarterly in Queretaro, Mexico, one of which he coordinates. He credits their success to the sponsorship of a prominent local orthopedic surgeon who runs interference for them with local authorities by providing letters of introduction and endorsement. Oskison similarly recognizes the value of HTC’s well-established connections in El Salvador. “The reason I think our team is so successful is that we work very closely with the Rotary Club in El Salvador. We’re able to leave the tools we bring, because we know we’re going back; we only have to replenish our supplies. “You just need good contacts in the host country. I don’t know how it would work if we just went on our own without someone knowledgeable to set everything up—people already in the country preparing for our arrival. They pick us up from the airport, drive us to the hotel, hire a military escort to keep us safe; they do everything. [caption id="attachment_236610" align="alignnone" width="717"] The fabrication lab at Prostesis Imbabura. The clinic is accepting new O&P students. Photograph courtesy of Robert Frank.[/caption] “The Rotarians even bring Junior Rotarians who are bilingual, so we always have translators there to facilitate patient communication and compliance.” Patient connections are equally essential at the Kenney Clinics, so a crew of translators serves each clinic—one for each practitioner—to facilitate more accurate and complete understanding between patient and practitioner at each stage. Frank points out that as with any O&P intervention, patient compliance is developed through building a relationship with the patient. Instructions in verbal, video, or pictorial form are often more useful than written materials. “Often patients may ask fewer questions,” he adds, “and they may not want to appear critical. Emphasize that it is not rude to complain or question but is part of the process. Home instructions must be practical, since hot water or even running water may not be available.” Rovig encourages volunteers to “over-communicate with patients. Have somebody local that has medical training create simplified instructions that explain how you take care of your device, how you take care of your skin, how you accept long-term care, etc.” Scanio likewise has all the patient-care documents at his clinics translated into Spanish. “I also provide them with shoes and socks, so I’ve knocked out a large area of concern by eliminating some of the major obstacles.” His 16-year-old son Giovanni volunteers and joins him on their Guatemala clinic trips twice a year, and in between he does a sock drive at his high school; shoe donations come from other contributors, through the FOOT Foundation. “I also use a humanitarian sliding scale,” Scanio explains. “I only see the patients that are the poorest of the poor. Those that have money that come to my clinic—I slide them to local providers that have acceptable care plans, so that money stays circulating within the community. That’s sustainability.” “You should always interface with local practitioners, doctors, user groups, and therapists,” Frank amplifies. “You’ll learn a lot about the local scene and local practices, you’ll show respect, and teaching passes both ways.” “You’re going to want to partner with your local physicians, for sure,” agrees Scanio, “but you do want to make sure that you’re not setting up a clinic a mile away from a practitioner because that’s just not cool. A friendship with your doctors means you’re both going to be able to learn things. “A lot of the doctors in developing countries typically are a few years if not several years behind in technology and treatment plans, simply because they don’t have the resources to educate them. And they can educate you on a lot of things on their community. So you definitely want to partner with them.” [caption id="attachment_236606" align="alignright" width="300"] Rovig with a patient at a Hughes International Clinic in Colombia that partnered with local nonprofit, Cirec, to increase local capacity for fitting conflict victims and to help ensure their long-term patient care. Photograph courtesy of Jason Rovig.[/caption] Rovig agrees that communication is probably one of the most underrated aspects of humanitarian outreach—both to the patient and the local caregivers and hosts. Those lines of communication may not exist at all, he warns. “If you can increase the capability of local organizations, helping to deliver a better product, most likely they’re in a better position to provide both long-term adjustments and checkups. Even if the organizations don’t have O&P care, they might have clinics set up long term—and may have access to doctors who can at least do assessments of people’s limbs and skin, if there are issues down the road.” It Takes Time “It took me probably a good solid five years before I developed a strong relationship with the first lady’s office and the minister’s office of health,” Scanio remembers. “It took trust, it took collaboration, it took developing a friendship to know that I really am there to do the best that I can for their country. My family and I consider Guatemala our second home.” Erenstone points out that there’s often a reason for some reserve from the communities. “You’ve got to realize that unfortunately, experienced clinicians and service providers in these countries have been burned before. They’ve learned to be wary. So you have to show a high level of competence before they’ll actually give you their attention. They’ve had people come in with all these promises and then don’t deliver. They’re going to want to ask a lot of questions, because they want to be sure you’ve actually thought this one through. They don’t want to waste their time anymore unless things are done right.” “Local politicians are best brought into the process early and frequently,” Frank advises. They like to be credited with helping their people; so give them a chance to do so and they will be more supportive. Relevant ministries may have regulations to know about.” Rovig, too, reminds us that countries have different regulations concerning who can treat their people. “Sometimes that’s overlooked when it comes to the aid side because a country doesn’t actively enforce it. But it’s best to be aware and prepared.” [caption id="attachment_236607" align="alignleft" width="278"] Kenney at the facility in Mexico. Photograph courtesy of John Kenney.[/caption] “Even if people have volunteered for humanitarian trips before, they may not have seen what it takes behind the scenes to make it successful, including a lot of research, challenging logistics, and local relationship building,” he adds. “Talk to people who have set up clinics in hard-to-access countries, who may have the most experience. Check on the local systems like health departments and embassies that might be able to help you and walk you through the local situation.” Know Before You Go Scanio says that in the set-up phase, “you really need to know the demographic of people you’re serving, and the geographic region. What is the weather like, what is the terrain like, what are the living conditions, and what are the financial statuses of the families? Some are not going to have shoes. Some don’t take baths regularly, some don’t have running water, so that means there’s a skin care problem.” [caption id="attachment_236605" align="alignright" width="243"] Kenney working with a patient on a humanitarian trip. Photograph courtesy of John Kenney.[/caption] “Before setting off, find out what other projects and local resources there are, and if you can work with them,” Frank advises. “Find out what the follow-up will be. Many O&P mission trips are modeled after ‘in and done’ medical missions, which isn’t ideal. Medical missions often are a one-time fix with local doctor follow-up, but O&P is continuous lifetime care. And remember that you need to teach as well as provide patient care. Working with local O&P facilities gives you this opportunity.” “All patients have to come in for follow-ups,” says Erenstone, “and if practitioners in another country aren’t familiar with the care that’s being provided and are nervous about ‘doing it wrong’ since they’ve only seen it once, they may be nervous about touching it, maybe breaking it or making it worse. “Often, too, they are so appreciative of people coming into their country to help that they don’t want to criticize or question. You can ask them if they understand it, and although they assure you absolutely, with thanks, they may be avoiding telling you that they really don’t understand. [caption id="attachment_236602" align="alignleft" width="219"] Oskison with patients in El Salvador. Photographs courtesy of Darin Oskison.[/caption] “For all those reasons—that cultural difference, supply chain issues, the lack of knowledge—just ask yourself: If you’re going to provide a device for someone in developing countries, and you haven’t thought out how this is going to be followed up with in an adequate way by the local practitioners, then you’re really 100 percent responsible to go back again and follow up with that patient. “Because supply chains are much more difficult in low-income countries, shipping costs are much higher and government bureaucracy is much more likely to slow things down,” Erenstone points out. “The best approach is to figure out local sourcing as much as possible. For example, the molds that Operation Namaste makes are 3D printed because printing has become popular enough that there are 3D companies in urban areas of most low- and middle-income countries. We don’t need to send the molds to them, instead we can email the design file and they get the molds locally printed.” Erenstone also stresses that it has taken seven years for Operation Namaste to reach its current stage of achievement—setting up a methodology to be able to treat patients on a larger scale, while also performing outcomes research studies to confirm and fine tune the program, as necessary. Know Who You’re Going With “Just make sure who you’re going down with,” Oskison cautions. “You can’t really throw this thing together last minute. This group I’m going with has been going for over 25 years and we go in September, but we start planning every detail in February.” Most of the experts we spoke with agree that it’s difficult for a foreigner to enter a new underserved area and do it the right way. They suggest working with an established organization with a good reputation. For example, HTC has helped over 307,500 children in over 100 underserved countries during its 43-year history. Also check the International Society for Prosthetics and Orthotics’ (ISPO’s) list of legitimate organizations, including those listed members of the ISPO Global Partner Exchange; look for longevity that implies successful experience, and check their website or printed materials for the ISPO seal of approval. ISPO’s Code Of Conduct for Humanitarian O&P Aid Most applaud ISPO’s Code Of Conduct, which can be accessed at usispo.org/code-of-conduct-for-humanitarian-organizations.html. It supports several of the points expressed, and Kenney credits Jonathan Batzdorff, CPO, for his efforts in establishing some of the foundational international rules through ISPO and giving it more structure, “cultivating it into something that’s really beneficial for the industry,” he says. “It’s an important document that I think people should read at least once.” Although complying with the code’s tenets is voluntary, and there are no consequences or penalties, it does provide a sort of moral compass, he notes. Scanio disagrees, however. “I think it needs to be more strict. From a public health perspective, there is more to humanity than just providing legs and braces. It needs to be updated to a stronger ethical code, a stricter criteria that providers of humanitarian aid should strive to meet, taking into account geographic regions, sustainability, financial status of the family—and examine more closely whether these organizations are charging for their services, are they trained providers? Are they board certified? For what will those charges be used?” “Those are simple questions to help identify whether the organization is doing the best that they can to deliver humanitarian care appropriately and beneficially,” he says. “Isn’t that what we all should be striving for?” Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer. *For more information about Robert Frank’s experience in El Salvador, read his Perspective article in the May 2016 issue of The O&P EDGE.

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