Demystifying Medical Technology for the Poor

By Dr. Therdchai Jivacate
Secretary-general, Prostheses Foundation
Chiang Mai, Thailand

Presented at the 2008 Magsaysay Awardees' Lecture Series,
Magsaysay Center, Manila, 2 September 2008

My training in Orthopedic surgery Medicine began in 1966-1968. As an Orthopedic Resident at the Faculty of Medicine, Chaing Mai University, I cut off patients' legs as per medical directives at that time, in order to keep the patient alive. Patients did not have prosthetic legs, so they used axiliary crutches to assist in walking. Some used wood or bamboo, depending on what was available or what they found near their homes, to make their prosthetic legs. The only factory that specialized in making prosthetic legs was in Bangkok which is 700 km away.

I ask permission from the Head of the Department of Orthopedic Surgery to go to Bangkok to study how to make prosthetic legs for 3 months, with the intention when I came back to start up a small factory. The resultant factory of the Department of Orthopedic Surgery Faculty of Medicine, Chiang Mai University was the first factory to make prosthetic legs outside Bangkok.

Later I went for further studies in Physical Medicine and Rehabilitation (PM&R) at North Western University, working to help the cerebral palsy and poliomyelitis children. In 1972 I returned to Chaing Mai and began working full time on making prosthetic legs, but at that time we had to use very expensive parts ($250), mostly imported from the USA. So I began making prostheses using local materials in order to cut the cost. Eventually the cost came down to $150, but that was still too expensive for the poor.

In 1991 we started using recycled plastic waste, obtained from 'yogurt drink bottles' melted in thinner. The procedure starts with soaking cotton in the melted solution and placing it on the plaster stump mold and wrapping it all over with gauze bandage. As the thinner evaporates then a firm plastic leg is formed, and with use of cotton as a frame and combine with aluminum pipe we brought the price for our prosthetic leg down to be about $25. I started making this type of prosthetic leg for the poor with my personal funds.

The Princess Mother (Her Royal Highness Somdet Phra Srinagarindra Boromrajajonnani) heard that our team could make a good prosthetic leg at a very low cost. She then set up "The Prostheses Foundation of H.R.H the Princess Mother" on August 17, 1992 and appointed me to serve as Secretary General of the Foundation. The Foundation was established to make free prosthetic legs for the poor, independent of where they came from, their nationality or religion. The Princess Mother herself had seen all the difficulties that poor patients without prosthetic legs had when she visited the people in rural area.

Thailand has totally about 40,000 patients with missing legs. And most of the patients are poor farmers who live in rural areas and have no money to travel to a center in Chiang Mai to receive services from the Foundation. So we set up a Mobile Prosthetic Unit which went out and provided services for patients in rural areas. The Foundation also does research and development to improve the production process and to produce equipment to make prosthetic using local materials. Since 1992 the mobile unit has made 101 trips to 52 provinces in Thailand and six trips to nearby countries - Malaysia (three trips), Laos (two trips) and Myanmar (one trip). The mobile unit has provided service to 14,130 patients, made 17,251 new prosthetic legs, repaired 2,336 legs for a total 19,587 prosthetic legs. And in our Main office/ laboratory/workshop in Chaing Mai we have made 2,123 legs. Hence, we have made a total of 21,710 legs in 16 years.

Even though the Foundation sends mobile units to provide service for patients in the rural areas, still some patients did not get the service as they are in very remote areas where the mobile unit can not reach, or the patients can not get to the mobile unit when it comes, or they can not leave their family. Therefore, the Foundation has set up small prosthetic workshops in villages and district hospitals run by two amputees who live in that area, and who have received training in basic anatomy, mechanics, and biomechanics. After four months of training and practice making prosthetics legs, the Foundation then provides the trainees with a small building, equipment and parts costing about $30,500. The trained amputees can then make/fix prosthetic legs for other patients in the area. This small workshop can give very efficient services. Now we have 11 workshops and the Foundation plans to set up five new workshops per year. I believe that in near future all Thai poor patients will have prosthetic legs and a better quality of life.

I invented and developed the process and techniques to ensure that the mobile units and all the volunteer technicians, with different skills and knowledge, can all make high quality good prosthetic legs. By making good inexpensive equipment from local parts, our mobile unit trips of 5 days can services 150-300 patients. Examples of the equipment we use are -

1. Plaster socket forming apparatus, using a vacuum which helps the technician to make plaster socket for a positive stump model; this equipment helps shorten the time and makes it easier to make a prostheses for about $1,000.

2. Infrared oven to bake and soften polypropylene co-polymer used in making a prosthetic leg. This infrared oven (cost=$3,000), using vibration of plastic molecules can speed up the softening process compare to a conventional oven (cost=$21,000) and it also consumes less electricity.

3. Bubble Plastic Socket forming machine which we have designed to move the positive stump mold toward the soft plastic sheet and to attach the vacuum plastic sheet to the mold. Our production cost for this apparatus is $2,575, compare to import at $10,000.

4. A special Farmer/Agricultural Prosthetic Leg has been fabricated so that poor farmers can go back to their work using this very sturdy leg, even in muddy rice fields.

Lately, the Foundation has introduced a simple but most efficient technique called sand casting to make prosthetic legs. With this technique, the Foundation can make a good prosthetic leg for below the knee amputee within 4 hours instead of 8 hours.

In addition to make prosthetic legs for human being, the Foundation has used this simple new technique to make a prosthetic leg for a young elephant aged 2 years and 7 months. She is landmine victim when she was 7 months old she followed her mother to work in Myanmar and stepped on a landmine. Her right foot was blown below off. The wound healed two years later. I met her at the elephant hospital and decided to make her a right prosthetic leg immediately because her left elbow started to deforme and her spine started to deviate. Now she can walk and run happily as a baby elephant should enjoy.