Meeting the Challenge of P&O in Latin America

Photos courtesy of Alberto E. Castillo Moreno, OP. Latin America can be divided into three large parts: Mexico, which borders the United States; Central America; and South America. Throughout Latin America two different types of services exist for amputees: private laboratories and factories, and laboratories that are controlled through the state or federal government. Similarly, patients can be divided into three large groups: Patients who are financially independent who, in general, obtain private services from private prosthetic and orthotic laboratories, or others who travel abroad for their treatment. A large group of middle-class patients and workers who are covered by social security institutions and who receive help from their families. They are sent to laboratories financed by the government for their treatment. This type of assistance is provided in the majority of Latin American countries. In some hospitals or rehabilitation centers, where the social security services are provided, medical practitioners write the prescriptions for prosthetic and orthotic devices and send the patients to P&O laboratories, taking into account a list of private and government facilities. The final revision of the device is made in the hospital or rehabilitation center, generally without the participation of an orthotic or prosthetic practitioner. The large majority of patients are in a low-income group, and they generally utilize the prosthetic and orthotic labs supported by the federal government through the Secretary of Health of each country. Low-Income Patients Face Difficulties Many of the patients in the third group fail to give their residual limbs adequate care, due to not being given sufficient instruction and information on how to care for their amputations by the hospital when they are discharged. When they go to a rehabilitation center, frequently their residual limbs are in poor condition with contractures, redundant subcutaneous tissue, neuromas, etc. Consequently, they may need additional prosthetic treatment or a surgical revision. However, indigent patients cannot provide the financial means to maintain a long treatment period, since their income is very low and their families very large. As a result, the patient insists on a very rapid fitting of the prosthesis, thus returning home and assuming his role as the household provider. Many of these patients return to the rehabilitation center due to volume changes in the residual limb and complain that the prosthesis was fit inappropriately and insist on receiving a new prosthesis. This situation is common in some Latin American countries and results in much wasted time and materials. In some Latin American countries, prosthetic components are being produced within the country. These low-cost prostheses can be the answer to the problem of low budgets allocated to the rehabilitation of amputees, and can help alleviate the problem of importing components and materials that are too sophisticated to appropriately meet the needs of the country's amputees. In some extreme cases, patients are unable to pay for their prostheses. Those who live in rural areas usually have to travel a long distance to specialty clinics, which are generally located in the capital cities, and don't have enough money to pay for food and lodging while they are undergoing treatment. When their funds run out, they have to abandon their treatment and return home, many times without prostheses. In order to resolve these problems, some governments have assigned annual budgets to rehabilitation centers, including the prosthetic and orthotic departments. However, due to small budgets and the failure to provide the centers with regular supplies of components and materials, it is difficult for many amputees to obtain a customized prosthesis. Another obstacle amputees also face is the difficulty of finding a productive job. Needed: Recognition as O&P Professionals Another problem, which requires the attention of health authorities, is that the orthotic and prosthetic practitioner is not recognized as a professional by the clinical team. His opinions and recommendations in respect to writing the prescription and prosthetic management are not accepted or recognized. Through my experience of more than 40 years in the profession, I know that there are highly qualified colleagues who have a passion for our profession. Unfortunately, the administrative authorities are still unwilling to recognize them as professionals, in spite of the fact that in many Latin American countries there are permanent schools for allied health professionals as part of the rehabilitation team. These schools are recognized by the Secretaries of Health and Higher Education. Many practitioners' problems begin when they graduate from these schools. The Administrative Personnel Department classifies them as technicians, since they are employed in workshops. Although the government invests great sums of money training prosthetists, they classify them erroneously, and thus their salaries are smaller. Consequently, they just leave their jobs in favor of a better position, and prosthetic and orthotic services are undermined. In some Latin American countries, prosthetic and orthotic treatment is limited to only what is needed to satisfy the most urgent necessities. In rural areas and other places with limited access to services, simple devices are being created within the community with local materials. Progress Despite Obstacles It is worth mentioning that, despite the difficulties and obstacles that confront us, we are obtaining good results in certain aspects of prosthetic and orthotic service. The progress is related to the improvement of teaching and continuing education. Some of these educational opportunities are directed to practitioners, who with an adequate, minimum experience of five years, can enter the distance Graduate in Orthotics and Prosthetics program, graduating as a Category II technologist of the International Society for Prosthetics & Orthotics (ISPO). This program was instituted by the University Don Bosco and the cooperative German group GTZ in El Salvador, Central America, approximately three years ago. Other programs of continuing education and certification are being promoted by professional orthotic and prosthetic societies and associations in various Spanish-speaking countries. Promoting Education However, new schools should be founded, and existing schools should be promoted so that they operate each year, filled with new, young practitioners. An urgent need exists for the federal and state governments to focus economic funds on the education and high-level training of orthotists and prosthetists. Standards of Care Personally, I believe that the rehabilitation of the patient who requires orthotic and prosthetic assistance should adhere to similar standards, no matter in what part of the world the treatment takes place. This goal requires a movement toward uniformity of the educational and training norms and standards and resulting practitioner qualifications. Our idea is that all the orthotic and prosthetic practitioners in Latin America should obtain the same qualification as professionals. That's the way it should be.

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