About 20 years ago we at Jaipur decide to set up a workshop for production of appliance for the handicapped our objective was primarily to cater to the needs of the neediest i.e the rural and poorer sections of society . The affluent we felt could continue to go to Poona and Bombay and procure an artificial limb or a caliper at a cost which often exceeded the annual per capital income of the rural poor.
To start with therefore our arms were two fold . The appliance should be as inexpensive as possible and a patient should not be required to travel long distance to be able to procure them Very soon however we started running into a contradiction as is customary with us we like to follow the trends in the west and the designs of our appliance were no exception these were all conceived and developed in the west. We found to our surprise that most of our polio patient were not really using the caliper and many of our amputees were reverting back to crutches . This disturbed us and so we started closely questioning our patients to understand the reason for rejection of these appliances which made them quiet unsuitable in the average Indian mileu.
I shall illustrate this with one example. The foot piece of a Western artificial limb has to be hidden and protected by a shoe. Without a shoe, the limb cannot be used. Shoes are normally not worn by| most Indians. If we want our artificial limbs to be used at home, by our women, by farmers working in their fields, and in places of worship, we have to do away with the shoe. ! This means that the foot piece should be suitable for barefoot walking. The moment the outer facade provided by the shoe is peeled away, it becomes essential that the footpiece should cosmetically simulate a natural foot. Also, its sophisticated but delicate material needs to be replaced by a waterproof durable exterior which can withstand walking on the rugged terrain of our rural landscape. Not only this, most of our countrymen squat and sit crosslegged on the floor. Squatting requires full dorsiflexion at the ankle. During cross-legged sitting, the outer border of the foot is pressed inwards, twisting the foot into inversion and internal rotation. Wearing a Western limb an amputee, cannot. work sitting ina cross-legged position because the twist of the foot piece is transmitted to,the stump causing unbearable pain Additional freedom- of (movements are, therefore necessary in a footpiece to allow our amputees to pursue a normal life-style. the Western char-sitting amputee never needed these movements and their footpiece, understandably, does not possess these attributes.
Similarly,, various problems were encountered when scrutinizing their designs of calipers for polio patients.
Different Design Criteria:
We therefore formulated a different set of design criteria and tried to work out appropriate theoretical construct when we approached our formally trained prosthetists to prepare some experimental footpieces incorporation these ideas one could see the look of dismay and protest on their faces. Their education had never prepared them to think of alternatives and they did not possess the necessary skills or the aptitude required for this work all they can do to borrow a phrase from Prof. Amulya Reddy, is to reproduce blurred Xerox copies of Western appliances.
Traditional Craftsmen Aproached:
It was at this stage that I approached our traditional craftsmen . I had seen their skills and I felt that possibly they could help us .. They quickly understood the problem and with their assistance we were able to produce develop and refine a completely different design of a footpiece which looks like a foot. Its interior contains a design which enables squatting sitting crosslegged on the floor walking barefoot on rugged terrain farming irrigation the fields, working in wet fields pulling rickshaws and climbing rocks. So good is the adaptability that even climbing trees is no problem. A design which permits these activities can be considered as an appropriate design. The element of rehabilitation is built in i.e. a farmer can go back to his village and pursue his original vocation and not migrate to a town to look out for a sedentary occupation.
These traditional craftsmen, learning at their master feet have fantastic skills and a love for working with their hands. And contrary to popular belief they have amazing ingenuity. With simple tools they are able to produce decorative objects which fill our handicraft emporia. For persons who can shape metal with I skill, making an aluminium artificial limb is child’s play. So why use expensive polyesters which are now fashionable in modern limbs. This is why we switched on to making metal limbs, which our artisans do with such speed and dexterity that visitors from abroad are taken aback when they find a trial limb being fitted in 45 minutes from the time of taking the measurements. It is this simplification which has led to an incredible rise in our work output No civilian centre in the country reaches anywhere near this number. Also the cost of such appliances is a fraction of orthodox Western limbs.
Respect for Native Skills :
Once this break through was achieved in the case of the prosthetic footpiece, we felt intellectually liberated to examine critically all the designs we have copied from the West. A whole series of new designs have emerged and are continuously emerging from our Centre. As a result of working with our local artisans, T have developed tremendous respect for their native skills and self-reliance. One often encounters amazing examples of ingenuity of design in peg legs which many of our amputees walk on, and which the village carpenter conceived without any training in prosthetics. This provides a most ingenious, airy, cool and adjustable socket using strips of bamboo. Our hot climate makes it a much more acceptable design than the biomechanically superior but unbearably hot modern total contact sockets. The concept is beautiful. It is up to us to refine such attempts. If we adopt a general policy of exhorting these artisans and learn how to communicate to them our requirements, they are "perfectly capable of rising to the occasion and could produce results with their traditional technology which is appropriate in every sense of the term. Showing an engineering drawing to them is futile. But show them a 3-dimensional model and they would replicate it in no time.
I have also become increasingly skeptical about the relevance of the formal education we are imparting to our prosthetists and orthotists. Reared in large metropolitan towns, accustomed to good living, and even though capable of talking in English with a lot of technical jargon, they lack skills, dislike soiling their hands with manual work and acquire a value-system wherein they are often scornful towards our patients and mercenaryjin their outlook, f In short, they become white-collar workers who would never willingly go to work in rural India.
To be able to study the performances of the (wo groups i.e. the formally educated professionals versus the local artisans we have, at Jaipur, developed two models of workshops in our own Department. One employs the formally educated diploma holders in rehabilitation engineering,' using high-cost Western technology, and the other is run by illiterate but highly skilled local artisans using low-cost, appropriate technology. We are convinced that, utilizing appropriate technology, the output of work is more than double with less than half the investment; the quality of products is superior’s and the patients are much more satisfied. While I would not like to raise something like the CP. Snow Leavis controversy, I think we have here another example of 4 two cultures '. I, for one,would opt for the more con viva! culture provided by our traditional craftsmen rather than an alienated group who are becoming increasingly divorced from the mainstream of our rural population.
Following the generation of appropriate technology at the micro level in one institution, (it then becomes essential to consider the problem of technology diffusion at a national, macro level to make the experiment socially meaningful. We have been working at this problem and find that several difficulties pave the way :
- Our own professional colleagues (in this case, orthopaedic surgeons), view with suspicion anything which appears to them to be unorthodox. Unless a technology is imported from the West and is expensive, it does not acquire respectability. That is why, even though field trials in over 5000 amputees and strict laboratory controls convinced us of the superiority of our limb, we had to wait till Western surgeons put their stamp of approval on our work before local resistance could be overcome to some extent.
- 2. Each profession zealously guards it s own interests and creates a mystique so that its knowledge remains exclusive. A process of demystification is frowned upon and 1 have been accused of introducing quackery by associating local artisans with what is considered to be an exclusively professional domain.
- 3. I agree entirely with Ivan lllich that we are confusing schooling with education. These are different attributes. I find my illiterate artisan limb-maker analysing a limb in an amputee, using the same kind of logic as I employ in my clinical work and I often, find that his analysis is superior to mine. When I take my car to the illiterate garage mechanic, he is again using the same kind of logic for fault finding. How can we call him uneducated?
- In the bureaucratic framework of a Government Hospital, the artisan can never get justice in the matter of 'his salary structure. I have repeatedly seen a skilled craftsman, who was earning over Rs. 1000' a month in the' market, being offered by the hospital the meager salary of a helper just because he is a non-matriculate. In a national programme, if we have to get our large reservoir of artisans to participate, new criteria for skill measurements shall have to be established. We could never draw these artisans in our work without outside assistance. This we got from the local community and we worked out an interesting but very viable model of joint participation of the surgeon, the artisan and a voluntary organisation, which not only makes up for the deficiencies of their salary structures but gives us more elbow room for innovations.
If our profession sheds its prejudices and decides to accept appropriate technology, if we can utilize the enormous reservoir of native talent which is available in every town and village, and if we can arrange to pay these artisans on a non-exploitative basis, it then comes within the realm of possibility to provide rehabilitation aids to the neediest anywhere in the country Such a strategy would lead to the satisfaction of basic human needs, generate self-reliance, demystify medical knowledge, encourage social participation and advance developmental objectives. These, after all, are the objectives of appropriate technology.