The 1981 Ramon Magsaysay Award for Community Leadership

BIOGRAPHY of Pramod Karan Sethi

PRAMOD KARAN SETHI, the sixth of the eight children of Dr. Nihal Karan Sethi and Maina Jain, was born November 28, 1927 in the holy city of Benares (Varanasi), Uttar Pradesh, India. His father was a professor of physics at Benares Hindu University and had been associated with the institution since its founding in 1916. Benares University was formally recognized by the British Government of India but was mainly supported by voluntary public contributions. It had a strong nationalist orientation and drew its faculty from Indian intellectuals eager to teach there on meager salaries for the emotional compensation of participating in an institution attempting to generate a value system encouraging scholarship, simplicity, sacrifice and service to the nation.

SETHI feels that his father exercised the greatest influence over the formation of his character. His mother was extremely devoted to his father, SETHI says, "and had completely imbibed his firm principles on a code of conduct, social reforms, and simple living." Mahatma Gandhi was a "major influence in our family," he adds.

Although the elder Sethi had been raised in the rich tradition of a landed Jain family and had a brilliant scholastic record which pointed him toward advanced research in physics, he chose to dedicate himself to teaching, seeking to make modern science available to Indian students at an undergraduate level. He wrote the first physics textbook in Hindi and later translated many scientific texts into Hindi from English. Raised as a Jain, he was nevertheless a rationalist who believed less in traditions and religious rituals than in doing the morally "right thing" and he imbued SETHI, his six sisters and one brother, with a strong sense of rectitude and desire for intellectual achievement. As a matter of principle he educated his daughters and refused to follow the custom of providing them with a dowry declaring: "I will spend money on the education of my daughters; that is their dowry." SETHI's eldest sister was the first Jain girl to pass the matriculation examination; his next sister became a doctor.

In 1930 SETHI's father transferred from Benares to Agra College, Agra, as professor of physics and later principal. SETHI received his education in Agra, attending St. John's School (1932-33), Balwant Rajput Intermediate College (1934-42) and Agra College (1942-44).

SETHI describes his decision to embark upon a medical career as a matter of chance. He was interested in science from his earliest school days but doubted his aptitude for mathematics, preferring instead the study of biology. Under the educational system then practiced in India, SETHI explains, boys who opted for science studies in college had two choices: "If they were good in mathematics, they became engineers. If they were shaky in mathematics, they took biology. And if they took biology, they went into medicine. That was the route I took."

SETHI graduated from Sarojini Naidu Medical College in Agra in 1949 with bachelor degrees in medicine and surgery, and with honors in surgery and six other subjects. In 1952 he received his Masters in Surgery from the same institution. This degree was not recognized by the British Medical Council and in order to pursue a career at a medical college, he had to become a Fellow of the Royal College of Surgeons (F.R.C.S.). He applied to the Royal College of Surgeons in Edinburgh, Scotland, and was allowed to enter on the basis: of his outstanding record without repeating his undergraduate examinations as was customary. He received his F.R.C.S. from Edinburgh in 1954.

Upon his return to India in December SETHI applied for and obtained the position of Lecturer in Surgery at the government's Sawai Man Singh (S.M.S.) Hospital (a teaching hospital) and Medical College in Jaipur, the institution with which he is still associated.

In 1958, in order to comply with government regulations, the hospital instituted an orthopedic department which SETHI was asked to start and head. Although SETHI did not have orthopedic training the principal of the college, one of his former teachers, prevailed upon him to take the job. His first two years were spent in organizing the department and learning the technical aspects of the work. "I learned it the hard way," he says. "If I had had formal training at some center abroad my mind would already have been made up on a number of issues. This can result in easy sailing in some respects, but it also prevents one from thinking of alternatives."

There were no rehabilitative services at S.M.S. when SETHI began his work, and he recognized the immediate need for physiotherapy. The only therapist on the hospital staff was being used solely as a masseuse; his equipment consisted of one case of talcum powder issued to him monthly. The hospital had no apparatus and no money to provide it.

Making use of the Indian tradition by which grateful patients present gifts to their doctors, SETHI ruled that doctors in his department could not accept money, insisting that only a gift of something useful to the hospital should be accepted. When patients tried to press money on him, SETHI asked for equipment for his new physiotherapy section. As there were no sources of ready-made equipment he requested and was given raw material components like wood and pipes. One patient donated the wages of a carpenter and SETHI himself set out to find craftsmen who could build parallel bars and similar paraphernalia.

Physical therapy apparatus soon began to overflow from the small massage room into the corridors of the hospital, with the result that SETHI was allowed the use of an open courtyard for an exercise area and an asbestos-roofed shed was thrown up to keep his equipment dry when it was not in use. Now liberated from the massage room, the hospital physiotherapist became enthused about his new activities and other members of the staff asked to be trained as therapists. More and more patients were treated as the section's activities expanded.

SETHI also focused on changing the character of the occupational therapy practiced at that time, which emphasized training patients in simple vocational skills such as weaving and knitting. He wanted to set up a workshop in which patients could use materials designed to improve motor and coordination skills while doing meaningful work. No space was available in the hospital, but the opportunity to establish a work area arose when the lease expired on a small tea shop on the hospital grounds. The shop had gained a somewhat disreputable reputation as a "hangout for shady characters from the town," and the hospital administrator was eager to put the building to other use. He offered SETHI the space. Overnight SETHI set up his workshop in the teahouse and moved in his staff. When the lease holder protested the new arrangement, SETHI pointed out that the shop was being used for treating patients: "How can you turn them out?" he asked.

SETHI was determined to use occupational therapy as a means of increasing a patient's dexterity through participation in an engrossing activity; this led him to use nonconventional techniques and equipment. Pedal-operated saws gave patients the opportunity to exercise their legs while creating a decorative object. Dice and card games were used to encourage hand and mind coordination for stroke patients, and activities were designed to increase hand and finger dexterity for the partially paralyzed. As with the physiotherapy section the organization of this section was a response to the recognition of specific needs, using the small staff and simple facilities available.

During this formative period as head of the Orthopedic Department of Sawai Man Singh Hospital, SETHI became increasingly concerned with the problems of providing appropriate and inexpensive appliances for polio patients and amputees. The nearest sources of rehabilitative devices were over a thousand miles away (in Bombay and Poona); only his wealthier patients could afford the trip to obtain them. SETHI began to look for a way to set up a workshop to create at least some of these appliances at the hospital.

SETHI noticed a male nurse, Mohammad Khan, who, while working in a room where plaster casts were made, showed an active interest in mechanical and technical matters. Khan came from a family of craftsmen; to test his skills SETHI asked him to make splints and other simple aids. Recognizing Khan's potential, SETHI seized an opportunity to send him to the Bombay All-India Institute of Physical Medicine and Rehabilitation Workshop for a two-year training program in the construction of appliances for the handicapped. In six months Khan returned, having learned everything the institute could teach him. SETHI thereupon set up a workshop for him in the old tea shop to which an affluent patient had added two extra rooms, making it possible for both Khan's shop and the occupational therapy workshop to be housed under one roof.

Khan's workshop became known as the Fabrication Unit and its first products were calipers (braces) for polio victims. Polio in India is a disease widespread among children; most Indians are exposed to it early in life and by the time they are adults, have either contracted it or become immune. Surgical intervention can straighten some of the deformities caused by polio, but a child needs a caliper to support a paralyzed limb to enable him to walk again. Calipers are fairly simple devices to make and the Fabrication Unit became proficient in their production.

SETHI's growing confidence in the unit's capabilities led him to consider the production of artificial limbs. The simplest limbs to reproduce were those for amputees whose legs had been taken off below the knee, so in 1965 the Fabrication Unit started making limbs based on Western models using the "Solid Ankle Cushioned Heel" (SACH) footpiece.

The SACH foot was designed to be worn with a shoe which disguised its artificiality and protected it. Its rockered sole provided ease for walking, but its rigid wooden keel—from ankle to instep—made it difficult for the wearer to walk over rough ground and impossible to squat or sit cross-legged. It was, however, a great improvement over the peg leg which medical wisdom had decreed was the prosthesis to be provided to the poor. "While it is true that a peg leg is simple and inexpensive," SETHI has written, "even the rural amputee of today would reject it on cosmetic grounds." Its appearance is a constant reminder of the maiming of the wearer. It was the SACH foot, then, that the workshop made and which was fitted to SETHI's patients.

During the first two years that these limbs were being made SETHI became aware that the limbs were often discarded after their novelty wore off. Investigation proved that the limbs had been constructed and fitted properly, but that the wearers found them inappropriate to their needs. The shoe presented most of the problems. It was superfluous for Indians who customarily went barefoot in the fields, at home, at work and at places of worship. It was expensive and deteriorated rapidly when exposed to water or mud. In addition it severely limited postural flexibility.

Recognizing the defects of the prosthesis SETHI drew up criteria for an ideal footpiece. He described his needs to the workmen in Khan's shop. The foot should not require a shoe, therefore, it must look like a bare foot. It should be waterproof and durable. It should be flexible enough to allow for ease of walking over uneven ground and for its wearer to squat and sit cross-legged. Finally, it should be made of inexpensive, readily available materials.

The workshop technicians had enough formal training to lack the ability to be innovative, SETHI comments wryly. While they were wrestling with the problem another member of the hospital staff, a craft instructor, who had been hired to teach vocational skills to paraplegics housed at the hospital, became involved. Ram Chandra, whom SETHI affectionately refers to as "Masterji" (great master), was a master craftsman and the son of a master craftsman. As a boy he had been apprenticed to artisans working for the Maharajah of Jaipur and had learned both decorative and craft skills. Princely patronage waned after independence and Ram Chandra was employed by the government as a teacher at a school of arts and crafts. When school attendance declined the decision was made to send him out as a village schoolmaster, even though he was lacking in formal education. SETHI, who knew of Masterji's talents, arranged for his transfer to S.M.S. Hospital.

Masterji observed the experiments taking place in the workshop where Khan and his helpers were struggling with the design criteria outlined by SETHI. He began making suggestions. When a patient donated some simple hand tools to him, he set up his own workshop in the kitchenette attached to a building converted by SETHI from servants' quarters to a dormitory for paraplegics.

Among Masterji's many skills were metalwork and die-making. SETHI had a simple furnace constructed in the courtyard. Using a plaster of parts model of SETHI’s foot and an ancient sand-casting method for making statues, Ram Chandra produced an aluminum die—the first breakthrough in making the prosthesis which would later become known as the Jaipur Foot.

SETHI drawing on the experience in Sri Lanka of surgeon G. M. Muller who had designed a rubber foot-like covering for peg legs worn by Sri Lankan rice farmers, decided to pack the die with rubber. Knowing "next to nothing about rubber," he asked tire manufacturers for help with vulcanizing the foot, but received no assistance until he went to Chuga Bhai, owner of a one-man tire retreading shop near the hospital. Bhai not only vulcanized the foot but became so interested in the project that he refused payment.

The first rubber foot produced, although beautifully natural in form, was heavy, stiff and the color of automobile tires. SETHI was so discouraged that he put the project aside for almost a year. Mulling it over in his mind, he decided to reduce the foot's weight by implanting the mechanism of the SACH footpiece into the mold, displacing some of the heavy rubber. The product was considerably lighter but no more useful for squatting or sitting cross-legged than the Western model.

The doctor and the craftsman produced modification after modification. Sections of the solid wooden keel of the SACH foot were successively removed until a large area at the back of the foot was vacated. The space was filled with glued layers of sponge rubber encased in a hard vulcanized rubber covering. The foot became even lighter and more versatile, but it was not completely adapted to squatting or sitting cross-legged. Finally, the SACH foot assembly was eliminated completely and different components were used. A carriage bolt anchored in a laminated wood block furnished strength at the ankle. The sponge rubber heel section of the foot then acted as a universal joint, permitting freedom of movement in all directions and allowing the flexibility necessary for the amputee to sit in his normal manner. A single wooden block, later supplanted by layered rubber, "provided rigidity to the forefoot essential for efficient takeoff." Both components were wrapped in a rubber casing reinforced with a rayon cord lining commonly used in automobile tires. The life-like foot shell of vulcanized rubber— about two millimeters thick—gave the components a durable and waterproof covering. The flat sole of the foot was constructed from the rubber compound used for tire treads and provided traction much like that of a tennis shoe.

The appearance of the foot was improved when an amputee's brother provided colored rubber from his factory and the foot could then be made in a choice of three shades—light, medium or dark brown— to correspond with the wearer's skin color. The first feet produced were all the same size but later different dies were made. The solid unseparated rubber toes, which had a discouraging habit of getting knocked off during hard wear, were improved by hollowing them out and packing them with light sponge rubber. A slit could be made between the great and second toes to permit the amputee to wear a sandal.

Trials of the Jaipur Foot demonstrated its durability and comfort. An unexpected bonus was the discovery that the broad flat walking surface gave a feeling of security to the wearer which was not experienced when the SACH foot was worn; the gait of lower limb amputees was very natural and they were able to walk on uneven ground with remarkable ease. The tough rubber shell provided "virtual immunity from breakdown" and most repairs to its surface could be made in the same manner that bicycle tires are patched. The versatile Jaipur Foot could also be inserted into an oxford by the shoe-wearing urban middle class, and the adaptability of the footpiece to walking on rough terrain could not be matched by the Western design. The most ringing endorsement of the foot came from its wearers who found satisfaction with its appearance, its comfort, and its adaptability to their needs.

Masterji's shop became the center of production of the Jaipur Foot and of light aluminum limbs which his skill as a metal worker made an inexpensive alternative to the plastic and wooden limbs specified by current Western design. SETHI dubbed the workshop his "Research and Development Department" as modifications and improvements to the foot and limbs were being made continually.

SETHI presented his first scholarly paper on the Jaipur Foot at the Association of Surgeons of India's annual conference held in Bangalore in 1970. The following year he presented a paper on a modification for amputees whose feet had been taken off at the ankle (Symes amputation), an adaptation made possible by constructing the foot with a boot top which could be laced on the leg. That same year he reported on the foot at a meeting of the British Orthopedic Association at Oxford, England. The Western India Orthopedic Society presented SETHI with a Gold Medal in 1973. In 1974 international attention was again called to the foot when SETHI was asked to give the lead talk at the First World Congress on Prosthetics and Orthotics held in Montreux, Switzerland.

In 1975 Arjun Aggarwal, a wealthy former patient from Bihar who had followed and supported SETHI's experimental work, donated a large sum of money toward the construction of a five-story rehabilitation center on the hospital grounds. A matching grant of money from the State of Rajasthan and donations of equipment and furnishings from other ax-patients allowed SETHI by 1976 to consolidate his scattered departments into the handsome new building. The Rehabilitation Center housed a modern workshop for Mohammed Khan and a staff of formally trained technicians, and rooms for physiotherapy, occupational therapy, classes and seminars, and a library which SETHI enthusiastically stocked with professional publications.

Although Masterji Ram Chandra and his growing band of artisans retained their workshop near the old courtyard where amputees awaited the construction of their artificial limbs, it was Masterji who added the final touch to the splendid structure. His gift was the poignant statue which he made from hammered aluminum and placed at the new building's entrance. It portrays an Indian peasant, cruelly maimed by accident or disease. The face is thin and careworn, the body emaciated, the left leg long and muscular, the right leg is missing. The figure, clad only in a tightly wrapped dhoti, leans forward, supported by crutches. The statue is not a symbol of despair, however, but of hope, for treatment lies within.

The same year in which construction of the new Rehabilitation Center began marked the 2,500th anniversary of the attainment of nirvana by Lord Mahavir, the "great hero" and spiritual leader of the Jains. Committees of Jains were established to organize various activities appropriate to celebrate this occasion, among them a committee headed by D.R. Mehta, a respected member of the prosperous Jain community in Jaipur. Mehta's group formed itself into the Mahavir Society for the Physically Handicapped (Bhagwan Mahaveer Viklang Sahayata Samiti), and raised a large sum of money which it planned to use to establish a rehabilitation center. Mehta, who had been SETHI's patient after a severe automobile accident, sought the doctor's advice on how to go about it.

Contrary to the expectations and desires of the committee, SETHI advised against creation of a new institution, arguing that the S.M.S. Hospital was already building such a facility and that in any case construction of a center would deplete the society's capital, leaving very little money to assist the poor directly. SETHI suggested instead that the Mahavir Society work with the hospital—which was often inhibited by government restrictions and regulations—to supplement its treatment of the handicapped. Society money could be invested and the interest used to pay the costs of services; the untouched capital would insure continuation of the work. Mehta joined SETHI in convincing the other committee members of the soundness of the plan and in March 1975 the fruitful association of the Rehabilitation Center and the Mahavir Society began.

Although established by Jains, the Society's membership was open to all regardless of "sex, caste, religion or region." The cost of memberships ranged from a modest two rupees (less than 25 U.S. cents) a year, to life memberships of Rs.l,OOO for patrons. Donations were welcomed but not solicited. The society's broad objective of helping the physically handicapped was narrowed to that of providing free lower limbs and other rehabilitative aids and services. SETHI became head of the three member Technical Committee which was responsible for overseeing the work at the Rehabilitation Center. Some society members volunteered to work with amputees at the center, others were instructed to seek out the legless and send them to Jaipur. The enthusiastic members, some of them amputees themselves, spread the news so effectively that by the second year the number of people helped by the society jumped sevenfold.

The Mahavir Society became an integral part of the Rehabilitation Center, relieving the professional staff of routine work, short-cutting bureaucratic restrictions and providing a hospitable reception for the amputees who arrived every day. Additional artisans were hired for Masterji's shop to provide for the increased demand for limbs, and society money was used for the purchase of raw materials.

The construction of the Rehabilitation Center released hospital space in old buildings surrounding the courtyard. The servants' quarters, previously converted to SETHI's paraplegic ward, were reconverted, when the paraplegics were moved into hospital wards, into two small offices and a large workshop for Masterji's artisans and apprentices. Small storerooms in a building which was originally a warehouse provided free lodging for the large number of male amputees; women were housed separately. If their numbers exceeded the space provided, amputees were sheltered under the asbestos-roofed shed which formerly protected SETHI's physical therapy equipment. When the weather was fine they could sleep in the open courtyard, where they could also cook if the food provided by the hospital was not to their taste. The courtyard well provided water for drinking and bathing.

Although most amputees arrive at the center without prior notice, often accompanied by relatives, no one has yet been turned away. During the first interview with the social worker the amputee is asked to write a message home to inform relatives or friends that he has

arrived safely and is awaiting treatment. The social worker tries to find out if he is eligible for government pension because of his disability and helps him with the application if he is qualified. The center does not charge for food or care; S.M.S. is a government hospital and both are free. A simple kit containing toilet articles, a plate, a mug and a towel is given to the amputee. Thus equipped, he enters the unique ambience of the courtyard.

The courtyard is alive with activity as amputees attend to their daily needs. The atmosphere is convivial and relaxed. SETHI seeks to maintain the village atmosphere and the human scale in this part of the hospital. Most of the amputees are quite healthy and would feel imprisoned if placed in the sterile confines of a traditional hospital ward. However, Mahavir Society volunteers move easily through the group engaging amputees in conversation and making notes of their general physical condition so that if medical treatment is necessary the hospital staff can be informed. While here the amputee is encouraged to be selfreliant and care for himself. He is at home with his peers who understand him and respect his individuality and the communal experience helps build his confidence and self-esteem. Unless there are urgent reasons for his limb to be made ahead of others, the amputee settles down to wait his turn.

The process of making and fitting the new limb is described by

"The amputee comes and sits on a chair. The workman comes with a tape measure. He is like a tailor. He makes no plaster cast, he just measures the limb. He quickly notes the measurements down in a small notebook and then takes an aluminum sheet. He draws a center line then quickly draws the measurements and makes a pattern. He cuts it with shears. The sheet is put on an anvil and the workman turns it into a tube. This is welded, then the tube is shaped with a mallet. The workman looks at the patient—is he a fat man, a lean man? He gives the leg the appropriate shape right away. Then the workman fits the limb and

the patient says, 'It's a little tight here.' So, with a stroke of the mallet, the correction is made. Now he says, 'It seems to be all right.' Then the Jaipur Foot is inserted into the limb and the workman asks the patient to stand . . . . the whole process from the measuring to the time the patient stands on the limb is usually about 45 minutes. Then the man sets out to walk and, if he finds the limb is not properly aligned, the aluminum is cut or bent until he is satisfied."

The amputee's delight as he tries out his limb is an emotional experience for everyone present. Other amputees crowd around him and shout out suggestions as with growing confidence he takes his first steps. He is supported and encouraged by them. "Here group therapy is being unselfconsciously applied with great effectiveness," an observer has noted. All share in the joy and renewed hope of the man whose limb has been restored.

The amputee's length of stay at the Rehabilitation Center depends on the number of patients awaiting limbs and, in some cases, on the difficulties presented by the need for complicated fittings. A few have stayed for several months, but the average stay is about three weeks. During the time spent waiting the amputee may attend literacy classes, study a craft or a trade, obtain additional medical treatment at the hospital or socialize companionably with other patients who share his handicap.

The foundation of true rehabilitation has been laid with the provision of limbs which are so life-like that the casual observer finds it difficult to determine their artificiality, and so versatile that no longer does the legless farmer have to go to the city to seek a sedentary occupation or beg for his living. He is now able to perform the work he did before. The Mahavir Society's final service to the amputee is the gift of a railway ticket to his home; the hospital provides a packet of food to eat enroute. He is sent away prepared to blend back into his community both physically and functionally.

Before the Mahavir Society began to spread out through India to locate amputees, most of the patients treated were from the area surrounding Jaipur in Rajasthan. Since 1977 the majority of the patients have come from other Indian states. The number of amputees fitted with limbs or other aids has grown to over 2,000 in 1980, compared with 59 in 1975.

SETHI is aware of the problems created by the increasing number of amputees seeking out the center. His hope is that the Jaipur model of uniting the skills and services of doctors, craftsmen and volunteers can be duplicated throughout India so that the handicapped can be served closer to their homes. The Jaipur Rehabilitation Center, he feels, should shift from being a service center to being a training center for artisans and doctors. SETHI believes there is a danger, however, in trying to set up centers on the Jaipur model too hastily, diffusing the "low technology" concepts of providing services to the handicapped without a proper understanding of the value system which has insured the success of the program in Jaipur. He prefers that centers be established only in areas where responsible people are available to take on the work: dedicated medical personnel, motivated craftsmen and a responsible group of volunteers.

A rehabilitation center has been organized on that basis at Jodhpur's Mahatma Gandhi Memorial Hospital where a chapter of the Mahavir Society has associated itself with a doctor trained by SETHI, the "committed kind" who SETHI feels is essential to marshal community support. Two workmen trained in Ram Chandra's workshop have been sent to Jodhpur to establish a workshop there. Other hospitals have used the Jaipur Foot and have sought technical advice and information concerning the center's work which SETHI freely shares.

SETHI has begun work on simple instruction manuals which will provide step-by-step illustrations of the construction of rehabilitative devices which local artisans could make from materials available in almost any village. "Every village in our country has a cobbler, a carpenter and a blacksmith," he writes. "If this group can make agricultural tools, bullock carts or saddles for horses, why can't they make appliances for the handicapped?"

SETHI’s faith in the native intelligence and ingenuity of Indian artisans has been justified by the stream of innovations from Masterji's workshop. The design for the orthosis (aid) for polio victims has been improved by replacing the shoe, to which the conventional caliper is attached, by a wooden-soled, ankle-strapped sandal which is cooler, less expensive and more in harmony with the wearer's life style. SETHI took the idea from the Huckstep clog, originated by a British surgeon in Uganda to simplify calipers for polio children, and made modifications based on a clog design for lepers. Many structural failures were encountered which called for continuous monitoring and refining of the caliper. It took almost 10 years of experimentation in Masterji's workshop to arrive at the present design. A bicycle axle, easily obtained in the markets of Jaipur, has been adapted as a kneejoint mechanism, replacing the complicated and expensive component for an above-the knee prosthesis specified by Western design. The appearance of the aluminum leg was vastly improved when Masterji discovered that the cotton stockinette cover of the limb, necessary for insulation from heat and cold, could be given an extremely durable finish and a natural color by the application of a coat of common carpenters' glue mixed with dye. The problem of the artificial limb of an upper leg amputee slipping off the stump when the wearer sat cross-legged, was solved by replacement of the leather strap by an elastic one. With his usual generosity, SETHI has commented that he finds an "illiterate artisan limb maker analyzing a limb on an amputee using the same kind of logic I employ in my clinical work and I often find that his analysis is superior to mine."

The existence of two workshops at the Rehabilitation Center has led SETHI to compare the quantity and quality of their services. The workshop of the formally trained rehabilitation engineers started by Mohammed Khan caters to patients of the urbanized middle class, producing appliances of conventional Western design. Masterji's workshop, which SETHI refers to as the "indigenous technology workshop," serves primarily the poor, producing appliances adapted to their needs. SETHI has found that the output from the indigenous workshop is "more than double with less than half the investment; the quality of products is superior and . . . patients are much more satisfied." SETHI’s son Harsh, who has written a case study of the center has noted: "There is a qualitative difference between a craftsman who has learned his work as an art, a tradition, almost a philosophy, and a formally trained technician. Both may be working with the same machines to produce the same items, but their attitudes toward their work are strikingly different. For the technician, the work is a job and nothing more. He does not think twice before asking a patient to report to him a fortnight later. This would be a sacrilege for a craftsman who is emotionally involved in his work."

The artisan's pride and personal concern have produced enormous bursts of energetic work. In order to provide limbs for 80 patients waiting at the center before Diwali, the great Hindu Festival of Lights, the craftsmen worked unpaid through the night so "that every single patient could celebrate the festival at home."

It is unrealistic, however, to expect that such enthusiasm can be maintained consistently and the problem of arranging an appropriate salary scale for the craftsmen has arisen. Without formal education or other credentials, an Indian craftsman does not qualify for anything other than the lowest wages under government job descriptions, wages which cannot match the artisan's earnings when independently employed. SETHI has partially solved this problem by arranging for the Mahavir Society to pay the full salaries of one third of the artisans employed in Masterji's workshop, and to supplement the wages of the others. A government sponsored training program for 10 apprentices resulted in a new government classification of "metal limb worker" which granted a reasonable wage to the graduates; however, the program has not been renewed since its beginning year and the wage problem is still an issue.

As the work load has increased with larger numbers of amputees seeking limbs each year, the problem of quality control has been exacerbated. In their eagerness to provide appliances as soon as possible, some artisans have produced ones that were hastily and imperfectly made. SETHI has had to coax Masterji out of retiring several times when he had lost patience with apprentices who found it difficult to maintain the standards of the brilliant but tyrannical master. SETHI believes this problem can be solved with the employment of a workshop director who can provide managerial and organizational skills which the craftsmen may not possess. "The pride of a master craftsman in his work has to be supported," SETHI writes, but "a very close supervision of the work will have to be exercised by the medical profession. If this is not done and ill-fitting limbs are produced, the entire scheme shall lose its credibility."

To work meaningfully with the artisans SETHI believes that doctors must free themselves of professional arrogance and share their knowledge with the craftsman. "The Jaipur experience," he has written, "demonstrates that the major difficulty resides in persuading the medical profession to demystify its knowledge and participate in the program with conviction and enthusiasm." He adds, "If we adopt a general policy of exhorting artisans and learn how to communicate to them our requirements they are perfectly capable of rising to the occasion and producing results with their traditional technologies which are appropriate in every sense of the term."

SETHI’s trust in the abilities of his unlettered craftsmen led to controversy with the Artificial Limb Manufacturing Corporation (ALIMCO), a public sector enterprise established by the Indian government in 1971. ALIMCO was set up to mass produce the various components of Western-style artificial limbs, and the Rehabilitation Center at Jaipur was selected as one of the five regional centers for dissemination of these components. SETHI found that the limbs received were "ill-suited to Indian conditions," having been produced to British or American specifications and usually too large and inflexible for the Indian amputee. Furthermore, not all components were delivered together, resulting in long waits before a complete unit could be assembled. The cost of the ALIMCO limbs was five to six times the cost of those being manufactured in SETHI’s workshops. SETHI therefore stored the unusable components and continued supplying limbs from his own workshops. ALIMCO criticized the Jaipur Center for being "uninterested in providing better technology to its patients" and cut off its money grants. SETHI has recently been appointed to ALIMCO's Board of Directors and foresees an opportunity to obtain a hearing for his own concepts.

SETHI is also disillusioned with medical and technical training which he feels "confuses schooling with education" and trains personnel according to the advanced medical practices of Western society, ignoring many of the realities of the culture in which the training will be applied. In the field of physiotherapy, for instance, SETHI has become convinced that the Western emphasis on "increasing use of instrumentation and the treatment of more complex problems related to old age, rheumatoid arthritis, spastics, spinal bifida, etc.," does not relate to the disease and disablement patterns in India where diseases like leprosy and polio are still major disablers. Western training more often than not, turns out therapists who want to work in the few affluent institutions which possess the facilities their training demands. "It is the rich who get served," SETHI says, "the poor remain where they were."

The answer, he believes, lies in using alternative training strategies which emphasize "education and motivation of patients, handling larger numbers with group exercises, increasing self-reliance so that revisits are reduced and involving family members who can supervise and participate in home treatment." Also needed is radical revision of physiotherapy techniques, development of communication skills and awareness of the importance of cost-effectiveness. A small group of therapists who would receive longer and more intensive training could constitute a resource and supervisory group. SETHI denies that he is advocating a lowering of standards. "Quite the contrary," he says, "I want a therapist . . . . who knows what is important and what is not."

SETHI’s clear sense of values and priorities in his work with the disabled continues to draw others into this service. Young doctors, trained by him, have imbibed his philosophy of "indigenizing and demystifying" the delivery of services to the handicapped and have helped spread his ideas. Jaipur tradesmen contribute much of the raw material used by the center's artisans. Private and public donations to the Mahavir Society have increased its capital tenfold during the six years of its existence.

The work of the Rehabilitation Center has received increased popular attention in newspapers and magazines. Government officials and medical professionals who have seen the work have left the center's visitors' book studded with compliments. SETHI’s contribution has been recognized by his receipt in 1978 of the B.C. Roy Award as "Eminent Medical Teacher," and of the Padma Shri (Exalted Jewel) honor from the Indian government in 1981.

SETHI’s strenuous schedule has left no mark on him physically. He is a trim man who looks younger than his years, despite the horn rimmed spectacles which give him the look of a scholar. He is soft spoken but eloquent; his conversation is serious but with an occasional turn of phrase or inflection of voice which demonstrates a quiet sense of humor. He lives simply; his recreation consists of omnivorous reading and listening to classical Indian ragas and a melange of Western jazz, early rock and folk music. He belongs to no social clubs and takes no vacations, preferring to spend his leisure at home with his family.

SETHI’s wife, the former Sulochana Patni, married him in 1951 while he was a medical student and has devoted herself to rearing their three daughters and one son—Lata, 29;Harsh, 28;Nita, 25and Amrita, 19. She has accepted SETHI’s lack of social life without complaint; he considers her understanding attitude a contribution toward his work. She is a frequent visitor to the center where she has developed a warm rapport with workmen and amputees who often share with her their complaints and problems. She has become a fast friend of Masterji, spending several days at his home when the craftsman's wife needed help in arranging a daughter's wedding.

SETHI’s work at the Rehabilitation Center includes a rigorous routine of surgery and teaching which consumes 70 percent of his time. The remaining hours are spent working with the amputees. His mandatory retirement from government service in 1982 will free him from these responsibilities, but his association with the center will continue through his position on the Technical Committee of the Mahavir Society. He plans to start a small private practice; "otherwise I will starve," he remarks half humorously.

The doctor can take satisfaction from his 27 years of work with the Sawai Man Singh Hospital and Rehabilitation Center. He has demonstrated new approaches to the problems of rehabilitation by proposing alternatives which proceed from the needs of the handicapped rather than dictated by formal training. He has encouraged the production of models of rehabilitative appliances—especially adapted for the poorest Indian—which can be constructed from readily available materials. He has inspired and drawn together into a supportive association three diverse elements of Indian society—medical professionals, laymen from the community and traditional craftsmen; each sector has gained increased respect for the others in their work and shared devotion to their countrymen's needs.

With customary modesty, SETHI gives himself little credit for what he has done, referring to himself as "more of a technician—less of a leader than a catalyst." Evident in him, however, is the quality he admires in others: he is a "man who knows what is important and what is not."

October 1981
Manila

REFERENCES:

"Bhagwan Mahaveer Vikland Sahayata Samiti," Jaipur: Rehabilitation Center Sawai Man Singh Hospital. N.d.

"He Designed Limbs to Suit Indians," Indian Express. Delhi. August 3, 1981.

"Jaipur Body Develops New Artificial Limbs," Financial Express. Bombay. January 1, 1981.

"Jaipur Foot Helps Disabled to Cycle," Indian Express. Delhi. January 8, 1981.

Khandekar, Sreekant, "Best Foot Forward," India Today. Delhi. August 16-31, 1981.

"Normal Life with Aids," Indian Express. Delhi. January 8, 1981.

"Rehabilitating the Disabled at Jaipur," Patriot. Delhi. January 11, 1981.

Roy, Bunker. "Rehabilitation with a Difference," Lok Kalyan, Official Journal of the Ministry of Social Welfare. Delhi: Government of India. April, 1980.

Sethi, Harsh. The Rehabilitation Research Centre; Jaipur. Alternatives in Development Case Studies, No. 1, Kothrud, Pune: Indian Institute of Education. 1980.

Sethi, Pramod Karan. "The Foot and Footwear," Prosthetics and Orthotics International. Copenhagen: International Society for Prosthetics and Orthotics. 1977.

______."The Physiotherapy Situation-a Plea for Alternative Strategies," paper delivered at Annual Meeting of Physical Therapists, Jaipur. 1981. (Typewritten.)

______."The Use of Appropriate Technology in Rehabilitation Aids," paper read before the I.C.M.R. Conference on Appropriate Technology in Primary Health Care. April 23-26, 1981.

______."Utilization of Traditional Craftsmen in Production of Rehabilitation Aids." (Typewritten.)

______, M. P. Udawat, S. C. Kasliwal, and R. Chandra. "Vulcanized Rubber Foot for Lower Limb Amputees," Prosthetics and Orthotics International. Copenhagen: International Society for Prosthetics and Orthotics. Vol. 2, 1978, p. 125-136.

Interviews with Dr. P. K. Sethi and with persons acquainted with his work. Visit to S. M. S. Rehabilitation Center.