Orthotic Needs in Developing Countries
Carrie Boutwell, Orthotic Residency Research
January 18, 2003
INTRODUCTION
When looking at the possibilities presented an orthotist or prosthetist of offering his/her skills to a developing country, much focus is directed on the prosthetic needs of any potential population. The continued destruction caused by landmines lends even more worldwide attention to those needing a prosthetic device.
It is reported that out of the five to eight percent of any population with a disability, one in ten cases requires some type of O & P service (1). Poliomyelitis, Hansen's disease, paralysis and other pathologies all contribute to a surprisingly high number of those needing orthotic services. Of the .8 percent worldwide needing an orthotic or prosthetic device (1), 75-80 percent need orthotic, not prosthetic, services (2).
This paper will discuss some pathologies present in developing countries that need orthotic services, the partnership between a community-based rehabilitation program (CBR) and the O&P provider, personal stories of medical professionals who have had experience working in developing countries, methods for becoming involved with a humanitarian or governmental organization, and lastly, resources for further consideration into this subject matter.
PATHOLOGIES FOR ORTHOTIC CONSIDERATION
Poliomyelitis epidemics have diminished worldwide due to a tremendous effort by the World Health Organization (WHO), Rotary International, Centers for Disease Control (CDC) and UNICEF, all working on the Global Polio Eradication Initiative. This initiative aims to make the world polio-free by 2005 (3). Dr. R.L. Huckstep, who has done extensive research on the treatment protocol for those with polio in developing countries predicts that the number of new cases in these countries will be numbered in the thousands, rather than in the millions as seen in the 1970s and 1980s (4). However, until the virus has been completely eradicated, the deformities of polio and the effects of post-polio will need to be treated.
Hansen's disease produces neuropathic upper and lower extremities before actual limb loss occurs. Clawing of the fingers, ulcerations and foot drop are all complications of this disease that can be treated orthotically to prevent limb loss. "We need to convince health authorities that the orthotist/prosthetist is a key person to hire as part of the health team," says Linda Lehman, a specialist for the Americas and Africa for the American Leprosy Missions (5). LEPRA reports 800,000 new patients will be diagnosed with Hansen's each year and that 4 to 5 million people presently have disabilities as a result of the disease (6).
Due to the lack of prenatal care and OB/GYN services offered in developing countries, many children are born with cerebral palsy. Often, there is mental involvement as well, affecting the lifespan of these children. Many children play and sell goods near dangerous roads, where there is high incident of injury. Poor road conditions, poorly maintained vehicles and overloaded vehicles all contribute to the head and spinal injuries resulting in paralysis. Due to lack of proper nursing care and immediate rehabilitative services, paralytic patients develop contractures, subsequent bedsores and ulcers-all increasing mortality.
There are numerous other conditions that if orthotically treated, would increase lifespan, possibility of employment and the improvement quality of life for the patient and his/her family. These conditions include the following:
Talipes equinovarus, present at birth but typically not diagnosed or treated until severe contractures are evident, Congenital deformities from unregulated pesticides, chemicals used in warfare and poor prenatal care and education, Long bone fractures, which in developing countries are often cheaper to amputate than to set and treat (7), Complications from diabetes, currently on the rise in developing nations (8), Scoliosis, some cases so severe and left untreated that death from pulmonary compromise occurs, Tetanus, which can leave a person with spasticity.
Adding to this list are those patients whose orthotic devices are several years old and needing replacement. These orthoses are of little use to the patient and therefore maintain the patient's level of disability (8,9). Also adding to this list are all the pathologies treated in the O&P facility of an industrialized country. In more than half those cases, take away early prevention or any prevention at all, then take away the help of a physician, an orthopaedic surgeon and basic medication and then imagine the consequence. Adding to the obvious need for orthotic services in developing countries, the American Academy of Orthopaedic Surgeons reported in early 2002 that the burden of musculoskeletal disease in developing countries is predicted to increase during the next twenty years (10).
COMMUNITY-BASED REHABILITATION AND THE O&P PROVIDER
A vast majority of disabled people in developing countries who need rehabilitative services have no way of affording the services, nor do they have a way of traveling to a rehabilitation center, which can be as far away as a day's travel on treacherous roads. Many don't know that services even exist to help increase quality of life for their disabled family member and subsequently, the quality of the caretaker's life.
Even more unfortunate is the attitude prevalent in many developing countries that a disabled person is not a viable member of the community and therefore, no effort should be made, whether monetarily or therapeutically, to help that person achieve a better standard of life. In Tanzania, the director of a community-based rehabilitation program reports, "The difficult part is convincing them that treating a disabled person is worth selling a cow (8)." They don't understand that once rehabilitated with professional therapeutic services, many disabled people can become economically independent.
According to statistics published by the American Academy of Orthopaedic Surgeons (AAOS), 60 to 80 percent of the world's population live in areas without access to basic health care (11). Due to the high number of disabled individuals who are unable to afford or locate rehabilitative services, the World Health Organization (WHO) launched its community-based rehabilitation (CBR) program in 1976 (12). The strategy behind CBR is to reduce the need for large rehabilitation centers located far from rural communities.
There is a four-level structure to the CBR approach: community (local volunteer and part-time workers), district (primary care physicians and nurses), provincial (general physicians, some specialized physicians, therapists and O&P staff) and central or national (specialized physicians, therapists, O&P practitioners) (12).
If a CBR program is present in a community where one wishes to provide O&P services, the O&P practitioner and the CBR worker are encouraged to communicate effectively in order to work together. The International Society for Prosthetist and Orthotist's (ISPO) approach to CBR is one of cooperation, not overlap-one of offering complementary services, not equal services (12). A WHO/ISPO joint statement on this topic provides guidelines to community CBR workers on how to promote and improve O&P services in developing nations:
Give priority to the early detection of disabilities, Consider the socioeconomic factors and needs of disabled patients, Assist disabled patients in locating funding sources for treatment, Act as a link between disabled patients, families and O&P providers, Explain the treatment program to disabled patients and their family, Provide information about patients' needs and expectations in referrals to the appropriate support services, Assist disabled patients during fitting preparations (13).
The benefits to having a CBR worker involved are numerous. Key is the intervention between those needing services and those organizations/individuals willing to serve. Being able to educate the community and bring a rehabilitated person out of his/her old life of exclusion is also vital. Only recently has the prejudice towards the disabled begun to change. Therefore, in those communities where prejudice towards the disabled remains, it is difficult to motivate individuals to volunteer on the community level (12). Education and incentives from governmental and non-governmental organizations, local churches and welfare organizations will help change the current attitude towards the disabled and even help to bring economic independence for the disabled community.
The CBR program not only educates the community, but also the governmental officials and politicians of a developing country who focus almost completely on acute illness. "They don't see how much of a burden chronic disease and conditions create for a country. We need to show that people left untreated are actually a much greater drain than people with acute illnesses," says Rachel Thibeault, PhD, OT (c) of her work in Sierra Leone, as quoted in O&P News, Summer 2001, "Pinpointing Progress and Problems"(13).
The use of CBR is advantageous when considering that several non-governmental organizations (NGO) often provide services to the same country or region. Under the guidance of the CBR program, with different NGOs or other governmental organizations participating together, duplicate services are reduced, collaboration is improved and the strengths of each organization are effectively used.
PERSONAL EXPERIENCES OF O&P PROFESSIONALS IN DEVELOPING COUNTRIES
This paper's author was able to locate several orthotists and medical professionals who have offered their services in developing countries. A brief overview of three practitioners' experiences will be given for the reader to glean knowledge, insight and optimism for future involvement.
Pam Lupo, CO
Pam Lupo, CO, was invited by FOCOS, an independent, non-profit group, to accompany them to Ghana, West Africa. Save the expense of the flight, FOCOS was able to pay the additional expenses she incurred, which amounted to $5000 for 12 days.
Working primarily with an orthopaedic surgical team, she assessed the needs of patients for orthotic and prosthetic devices during clinics. The time, purpose and location of the clinics had been announced by a local radio station and their local healthcare providers. During these clinics, Lupo saw a vast polio population, many children with clubfoot and many with birth defects, which she contributes to the lack of prenatal care. She saw many pediatric amputees who had lost limbs playing or selling goods near the streets.
She attended a two-day clinic in a village where she assessed surgical needs for the next FOCOS trip in February 2003. During this time, Lupo also helped with adaptive seating using the molded layback system. For one case, they simply obtained five-inch foam from the local market and put it into a donated wheelchair for a 16 year old. The child, who was 5'6", had been carried by his mother, who was 5', 100 lb., his whole life.
There are 18 million people in Ghana. Lupo was able to locate only 20 Orthotists and Prosthetists within five Ministry of Health facilities and four privately held companies. In Ghana, O&P is connected to the Ministry of Health who owns all of the main O&P labs. She estimates that the Ghanaian labs are functioning with 1950s/1960s technology. Most of the machinery, which came from Germany, was 50 years old but kept in immaculate condition. The lab Lupo worked in had an oven, a drillpress, a trautman, a sewing machine and surprisingly, a CAD carver they used for prosthetic sockets.
The most basic device Lupo saw was an AFO which had an outrigger with a spring to act as a dorsi-flexion assist. She reported that their use of plastics was primarily limited to TLSOs for body jackets. They used metal and leather on most of the polio patients. The orthopaedic technicians used heavy canvas for their corsets, foam for the soft collars and a pelite material covered in linen for semi-rigid collars. She did not see many prefabricated devices. For an economically depressed country, dead money on the shelf would be an impractical luxury.
Once gaining trust of the orthopaedic technicians from one lab, Lupo was able to recommend improvements on some of the devices she had seen. As well, she instructed them on floor-reaction AFOs and the purpose of tone-reducing modifications.
When she returns in February 2003, she will be developing a training program at the University of Ghana and setting up a lab there. During this time, Lupo will also be teaching in the Uganda clubfoot program. She wants to instruct on post-operative orthotic care for children with clubfoot using a straight last shoe with tone-reducing modifications. She will also be following up on those patients in the village that she assessed needed surgery. She has been able to obtain $200,000 of donations in materials and devices from different suppliers for this trip.
Lupo's own facility was able to spend eight months training a Ghanaian O&P technician in America, increasing his O&P technical and clinical abilities. They are also planning to train another Ghanaian to be a practitioner. Lupo started preparing their new student by sending anatomy and fabrication manuals five months in advance to his arrival in America. By training students from a developing country and sending them back to their communities, Lupo and her colleagues are equipping a region with skills to help their own disabled, to develop their own O&P clinic and to provide more O&P support for a country desperate for such services.
Lupo stressed the importance of promising local O&P labs that outside involvement from foreign practitioners or groups will bring business to the local facilities and practitioners (called orthopaedic technicians in many countries) not take business away. In order to gain trust and acceptance, she met with the local Ghanian orthopaedic technicians three times. She promised a five-year contract to educate their orthopaedic technicians, promised follow-up visits that she personally would be involved with and promised to send materials she knew they needed once she returned to America. Lupo advised sending the same orthotist on each follow-up visit to maintain trust and rapport with the local practitioners.
John French, CO
John French, CO, and instructor at the Prosthetics-Orthotics Program at UT Southwestern Medical Center, was invited by the Methodist Church to accompany them on a mission trip to Kenya. As the trip was primarily to serve the deaf population, French branched out on his own to work at a hospital in Maua.
Maua has a population of 10,000, including the outlying rural areas. This population is served by one hospital. French worked with a visiting British Occupational Therapist, a locally trained OT, who was also practicing physical therapy, and with a British physician who was filling in at the hospital for four months. Since there were little materials available, the primary reason for the trip was for assessment of the orthotic needs in the community.
French saw many children with clubfoot, many of whom would have been excellent candidates for corrective surgery. However, the visiting surgeons to this region of Kenya presently refuse to operate based solely on the lack of post-operative orthotic follow-up needed to maintain correction. Therefore, the children are rendered to a life where the eventual worsening of their lower extremities and the increase in body weight will cause them to be invalids as they will be unable to ambulate.
The local Mauaian OT was fabricating adaptive seating that sold for two US dollars. The materials used for this seat were a cardboard box, glue and shellacking to make the seat waterproof. Though seemingly simple, this device had a great impact, not only for the patient, but for the economic welfare of the family as well. This "adaptive seating" enabled patients to be able to sit on the ground, dry, without fear of insects biting them. This, in turn, allowed caretakers to be able to work bringing their children with them into the fields where they harvested.
Like Lupo, French hopes to train the local OT either in Maua or in the United States. The first skill he wants to teach is casting and fabricating a solid ankle AFO specifically for the post-operative clubfoot population. From there, French would expand the OT's skills one direction at a time, based on the next highest need for orthotic devices. Though this is a non-traditional approach to building a knowledge base and possible practice, the need for post-operative care for the clubfoot population is presently a very high priority. By providing the care necessary for a surgeon to be willing to operate on a child with clubfoot, the benefits of O&P within that region would be made known and possibly improved. For now, the residents of Maua have to travel to a town several hours away for orthotic services. Many are unable to do so since such trips, made on bus, are both expensive and arduous.
There is still such prejudice for the disabled community as disabilities are seen as an evil curse. French reported that a Samburu village north of Maua he visited had no disabled population. He suspects that the rate of infanticide for mentally and physically impaired children is quite high. Presently at remote rural clinic sites in villages near Maua, there are three basic pleas being made to families with disabled children: (1) Don't kill your children, (2) feed them the same amount as your other children, and (3) love your children.
However, there is some improvement in the decrease of prejudice towards the disabled community in Africa. Perhaps not as significant as the changes worldwide, the prejudice is gradually starting to dissipate within African nations. Employment opportunities for the disabled are gradually increasing and becoming more accepted. For instance, in Maua, there is local Disabled People's Self-Help Group. This organization, located in the town of Maua, employees the local disabled population to provide services to the greater regional disabled community. As a group, they are trying to establish their own workshop with more efficient tools and a more appropriate environment. Besides repairing shoes, they would like to start providing wheelchairs and crutches. Groups like this have a three-fold purpose. They are able to provide services for themselves, they provide employment to a group otherwise deemed non-viable and consequently, improve the economy within their community.
French, along with several other orthotists, stressed the importance of building up services within a region based on indigenous materials (10, 14, 15). As well, he advised on training the local medical professionals on basic O&P services and to save the more technological skills for a later stage of a region's O&P development.
Rob Singer, CO
Rob Singer, CO, who works with a Shriners Hospital in Oregon, has worked in Sri Lanka, Thailand, Vietnam and India as an orthotist/prosthetist and educator for the past 6 years.
In Sri Lanka, he worked for two years with Columbo Friend in Need, which is a local NGO supported by the United States government. While there, Singer instructed orthopaedic technicians for three months on vacuum-forming techniques. Up until that point, like most developing countries, the basic materials used for orthotic devices were metal and leather. Singer reported that for many years, under the socialist government, one could not import materials to Sri Lanka. Therefore, those in need of devices had two choices. One, they could put their names on a waiting list at the government hospital and wait years for an orthopaedic appliance. Two, they could supply their own materials to have their device fabricated.
Just as French reported the lifting of prejudice surrounding the disabled in Maua, Singer reported that in Sri Lanka, a handicap awareness "movement" has started. More people are aware of the potential of the disabled and more recognize the rights of the disabled (13).
For three years in Thailand, Singer worked with Handicap International, another NGO. Working with 15 French physical therapists, he worked primarily with a prosthetics lab but was able to evaluate some polio patients. He reported that within the refugee camps the Huckstep method, developed primarily for use with the polio population in African countries, was employed. Outside the refugee camps, the more conventional leather and metal was used.
Recently, Singer worked in Vietnam for two weeks as a consultant for World Concern, another American NGO. While there, he evaluated the orthotic, prosthetic and surgical needs for 140 children who presented with polio, CP, spina bifida or scoliosis. Seventy-five percent of these children presented with polio. Not having an established CBR program, the Red Cross acted as the community worker channeling those people in need to those organizations with resources. Singer reported that in more rural communities without an intermediary to contact physicians, indigent people did not have treatment modalities available to them.
Singer has also volunteered in India after being referred there by those involved with the Jaipur foot program. He was able to spend a year learning to fabricate and fit the Jaipur foot.
Singer's extensive involvement stems from his desire to help educate and upgrade the skills of O&P technicians and practitioners in developing countries. He also feels it is important to educate their community about the advantages of wearing orthotic devices to prevent the progression of deformity.
HOW TO BECOME INVOLVED
The editorial in O&P Business News, Summer 2001, "International Humanitarian P&O-Related Medical Rehabilitation Service" lists much information on how to become involved with an organization that provides orthotic and prosthetic services to developing countries. For those beginning a career in this field, the author suggests to start networking with those organizations and individuals who have knowledge of working in the international field. There are four different types of organizations that one can become involved with:
Faith based humanitarian groups-Ex: World Vision, Mercy Ships, World Hope Intl., United Methodist Church Organization for Humanitarian Relief, Professional groups-Ex: ISPO, World Orthopaedic Concern, Rehabilitation International, Philanthropic humanitarian relief organizations-Ex: ICRC, Veteran's International, Physician's Without Borders, Prosthetic Orthotic Worldwide Education and Relief (POWER), Governmental Organizations-Ex: WHO, USAID's Patrick Leahy War Victim's Fund, the German Technical Corporation (GTZ).
Also recommended is becoming a member of an ISPO national society, which will keep on file your particular interests and qualifications. This information will be available to different humanitarian associations upon request. Rob Singer, CO, suggested contacting USAID and getting a list of NGOs or private and voluntary organizations (PVO) with which to become involved. (Different organizations with potential for involvement, including USAID, are listed in this paper's USEFUL RESOURCES.)
The author advises that most will be responsible for covering their own cost of becoming involved with such organizations. However, there are possibilities for funding and support from different groups. Pam Lupo, CO, who has worked in Ghana, West Africa, was able to have her flight funded by her employer, Wright & Filippis Inc. Dino Cozzarelli, CPO, who has done mission work in Ecuador, who himself is Ecuadorian, was offered free room and board by a distant relative for his team during their time in Ecuador.
There are many cases where the need and desire to serve are present but the lack of funding prevents involvement. Brad Farrow, CPO, traveled to Guatemala every six to eight months for five years to provide prosthetic and orthotic services. Even though Farrow found with each new trip more and more people were in need of his services, he unfortunately was unable to continue to personally fund these trips. Until he is able to find a group with which to share funding, he will be unable to return to Guatemala with such frequency. This is unfortunate, as due to his extensive participation, trust and camaraderie had developed with the population he was serving. These aspects are key when considering how much more productive one's time can be when familiar with the settings, surroundings and culture of a particular foreign country.
Subsequently, the aforementioned editorial recommends becoming acquainted with the culture, customs, language, current political and historical information of the country in which one hopes to work. Knowing the O & P facilities, rehabilitation centers, medical facilities and materials available to a particular region would be helpful to both the ones wishing to provide services and the ones being provided the service. A good resource to use before traveling and preparing for a trip would be a local college history or political science professor who has knowledge of the customs and current political environment in a particular country.
Making contact with these facilities before traveling and offering a humble and dedicated attitude is pertinent to opening doors for successful involvement. If one is planning contribution without the involvement of an established humanitarian or professional group, the editorial's author strongly recommends having a personal invitation from the local O&P providers, or at least, requesting a visit to their facility prior to leaving on your trip. Going a step further, Lupo advised contacting the Ministry of Health before visiting a country. (Contact information for officials of thirteen developing countries can be found in this paper's USEFUL RESOURCES.)
Should circumstances prohibit personal involvement inside a developing country, there is also the option of donating materials and components. There are two considerations for this type of involvement.
First, several individuals with an understanding of the climate and needs for a particular region caution against sending materials without first becoming aware of what is most suitable. Plastics can melt in the tropical heat, but break in the Artic cold. Wheelchairs can be breakable in the extreme cold weather. As well, wheelchairs that are seemingly sturdy become quite loose on the rough terrain of some countries. John French, CO, went to Kenya with his son who uses a wheelchair. He reported that the wheelchair was very hard to push around, and just after one week, the wheelchair was very loose.
Secondly, Lupo strongly recommends that donated goods are tracked in countries with extreme economic hardship. The companies that donate products must be guaranteed that the materials will directly benefit those patients in need and have provided to them confirmation of proper use. Again, involvement with the local O&P provider and Ministry of Health from the beginning of your involvement is pertinent in being able to contribute most effectively to their region's needs.
USEFUL RESOURCES
Not comprehensive by any means, this section will provide the reader with contact information and literature pertaining to different aspects of becoming involved with humanitarian work.
(1) The following website lists all the companies in thirteen countries that produce and distribute assistive devices for people with disabilities. All the companies listed have contact information. Each of the following country's Minister of Welfare/Minister of Social Rehabilitation/Minister of Health is listed with accompanying contact information.
(2) ISPO's (International Society for Prosthetics and Orthotics) website is found at:
www.ispo.ws
(3) For those interested in Orthotic or Prosthetic education on the international field, ISPO lists information about certified schools and their programs for the following countries on this website:
www.ispo.ws/HTML/Orthopaedic-Schools
(4) WHO's (World Health Organization) website is found at: www.who.int/lep/
(5) USAID has several resources on its website. It lists the all private and voluntary organizations and all the governmental organizations each with accompanying contact information and mission statement. www.usaid.gov
(6) This website will give information on reports and evaluations done by the Displaced Children and Orphans Fund and Patrick J. Leahy War Victims Fund of several different countries as related to orthotic and prosthetic services being provided or funded.
www.usaid.gov/pop_health/dcofwvf/reports/evals
(7) Dr. R.L. Huckstep, who has done extensive research on supplying appliances and rehabilitation suitable for the disabled in a developing country, has a lot of information on his website. Included is a great resource, "A Simple Guide to Poliomyelitis including Appliances and Rehabilitation" for those wishing to provide appliances to a paralytic population in a developing country. www.worldortho.com
(8) The following book and author's website were recommended by several people as a valuable resource for working with the disabled in developing countries:
Disabled Village Children by David Werner, available from The Hesperian Foundation (P.O. Box 1692, Palo Alto, CA).
www.healthwrights.org/aboutus.htm
(9) Students from the University of Massachusetts Medical School have created The International Healthcare Opportunities Clearinghouse (IHOC) web site. This is designed for health-care professionals and students who are interested in volunteer work with underserved communities at home or abroad.
http://library.umassmed/edu/ihoc/viewall.cfm
(10) Dr. Ronald Garst, an orthopaedic surgeon who has served in the mission field for the past thirty years practicing and teaching in Medical Colleges, has started prosthetic and orthotic centers in the following five different countries:
India - four different cities Bangladesh - one very large department aided by volunteers from many countries. (This facility is presently in great need of assistance to start a new O&P training program). Indonesia - one center Pakistan - one center Dominican Republic - one center
Dr. Garst, has graciously allowed for his email to be printed in order that the reader might contact him for further information. rongarst@prodigy.net
(11) Upon this author's own email contact to several mission groups, Dr. David Mehne, Orthopedic Director of Medical Ministry International, replied that his organization is eager to have an orthotist or prosthetist join one of their short-term (1-2 week) projects to work with previously selected indigent patients. His email is: mmican@mmint.org
SUMMARY
There is a great need for orthotists to offer their services in developing countries. To dedicate oneself to such an undertaking includes: learning the culture, contacting the necessary local governmental officials and/or O&P facilities, complementing the rehabilitation services already provided there, working with the local O&P facilities, learning the highest O&P needs of the community, and learning the materials that would benefit each region.
There are many organizations needing orthotists to accompanying them on mission trips or humanitarian efforts. By becoming a member of an ISPO national society there would be more chance for involvement in such an arena. However, involvement on a personal note would also be quite possible should one determine to do so and there are many resources to use in order to make a trip to a developing country quite successful.
REFERENCES
Wuhan Declaration - PR China 1996. Declaration of the International Conference held 4-9 November 1996 in Wuhan, People's Republic of China. Retrieved June 23, 2002 from www.ispo.ws/HTML/page-Published-Documents.html Editorial. International Humanitarian P&O - Related Medical Rehabilitation Service. Summer 2001. Retrieved August 29, 2002, from www.oandpbiznews.com Fairley, M. Initiative Seeks Polio-Free World. O&P News. Winter 2001. Retrieved August 29, 2002. Huckstep, RL. The Challenge of the Third World. Current Orthopaedics. 2000;14: 26-33. Fairley, M. Brazil: Getting a Handle on Hansen's Disease. O&P News. Winter 2001. Retrieved August 29, 2002. Leprosy in the 21st Century. LEPRA. Retrieved August 10, 2002 from www.lepra.org.uk Green, L. O&P Community Faces Challenges in Rural and Urban Tanzania. O&P News. Summer 2002. Retrieved August 27, 2002. Global Burden of Diabetes. Press Release WHO/63, 1998. Retrieved November 10, 2002 from www.who.int/inf-pr-1998/en/pr98-63.html El Salvador after the Earthquake: P&O Aid. O&P News. Summer 2001. Retrieved August 29, 2002, from www.oandpbiznews.com Kaphingst, W. Developing Appropriate Services, Technology, and Education. O&P News, Fall 2001. Retrieved January 2, 2003 from www.oandpbiznews.com Promoting Volunteerism in Developing Nations. O&P News. Spring 2002. Retrieved August 27, 2002, from www.oandpbiznews.com Harte, C. A Dark Little Corner of Rehab. O&P News. Spring 2002. Retrieved August 27, 2002. Fairley, M. Pinpointing Progress and Problems. O&P News. Spring 2002. Retrieved August 27, 2002. Blumenthal, J. The Challenge of Knowledge and Real Opportunities in Developing Countries. Winter 2001. Retrieved August 29, 2002. Kurzman, S. Did You Step on a Mine?" Capabilities: Communicating the Science of Prosthetics and Orthotics, October 1999, retrieved August 27, 2002 from www.prosthetics-culture.org/writing/step_on_mine.html.
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