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Preface
This article is the report of a graduation project for the Academy of Industrial DesignEindhoven. From November 1991 through May of 1992, I developed a leg prosthesis forCambodian land mine casualties. The first several months were spent in the Netherlandslearning the basics of development aid and prosthetics, followed by an educational tour toCambodia.I can never adequately thank the people who have helped me in the course of the past sixmonths. Their support made the realization of this project possible. I owe great gratitudeto the following persons:Mr. Ph. Vendeville, my graduation teacher. Without his vision and confidence in me I wouldnever have begun the work.Mr. Ir J.M. van de Wiel, manager Westland orthopedie bv and Mr. L. de Groot, technical manger Westland orthopedie bv. It was through their supervision and stimulating advicethat I was able to take on such a specialized project.Mrs. Brigitte Hogge and Mr. Abde Boueddhi, members of Handicap International. The entireorganization received me very hospitably, giving me everything I could possibly use tostudy the situation in Cambodia. It was almost a holiday.Inne ten Have, Rotterdam, mei 1992
Introduction to Cambodia
As a result of the civil war Cambodia is heavily mined. There is a great need for legprostheses. Western prostheses are not suitable for these patients; the situation isincomparable to Europe. Most prostheses available in Cambodia, however, are based onwestern principles. This study tries to find a solution from the Cambodian point of view. Itis a study project and was not originally expected to be realized. Reactions, however, showthat this could change. Therefore it is the intention to apply for a subsidy to develop thisproject further, so that it might be realized in the future.
History
Cambodia has been dominated by violence since the end of the sixties. Between 1974 and1979 the country was oppressed by Pol Pot. His regime has had an unimaginably greatinfluence on the standards of the Cambodian people. Only seven people survived the"Museum of Crime", the former center where the Khmer Rouge tortured their opponents.Nobody knows how many were murdered during those years.
Consequence
All major roads are destroyed. Cambodia has no infrastructure -- the consequence of theAmerican bombings during the Vietnam war. Electricity is only available in certain parts of the capital a few hours a day; petrol is transported through the country by children onbicycles with jerrycans. It's still dangerous in the country; trains ride with two emptywagons in front, so that only the empty wagons are destroyed when the train hits a mine.Traveling on these wagons is for free; naturally these are loaded. The army sits in the back.
Economy
Economically the country has been broken apart systematically. There is not any form of infrastructure left; no foundations for development. The effects of the violence in Cambodiaare obvious. Until the sixties it was a fertile country, economically based on rice and rubbercultivation and small scale craftsmanship, such as wood and metal work.
 
There is hope to return to that old level again. After opening the borders a lively trade hasbeen developed in foreign goods. Western products especially are very popular. Besidesforeign products also relief workers and UN soldiers are floodingthe country, with theobvious consequences: A Cambodian craftsman earns a few dollars a month, a UN soldier onthe contrary, about $100 a day. So begging often earns much more than having a job.Corruption thrivesand legislation doesn't seem to exist. As in the years before Pol Pot,there are enormous discrepancies between rich and poor Cambodians. Thingsare pretty badin Cambodia.
Aid
Since 1979 the Khmer Rouge has been laying mines in Cambodia; about several millions bynow. In the wet seasons the small plastic mines float throughout the country. Monthlythere are between 200 and 600 casualties; the victims generally lose lower legs. A patientneeds a good prosthesis during his whole life, and the lifetime of a leg prosthesis has beenestimated at two years. The demand for leg prostheses will only increase for the foreseeablefuture. Non-Governmental Organizations (NGOs) try to tackle this problem by handing outas many prostheses as possible. It is difficult to involve the population in this process;there is no knowledge to build on, so it remains a western matter. The leg prostheses haveoften been made of cheap plastics. The advantages of plastic over prostheses made of leather and metal, are the short production time, the durability and the modern image of the material. Next to this there are the interests of western companies. For instance, thereis an organization called "Cambodia Trust". This organization sends second choice legprostheses from England to Cambodia and hands them out to the people in the capital. Theproblem is not dealt with seriously; people are led purely by short-term interests. Someorganizations try more. Handicap International is an organization which produces leg frommaterials available in Cambodia. The prostheses are made in a simple way, in about tenworkshops spread over the country. They are one of the few organizations trying to adaptto the situation in Cambodia. Despite this appropriate technology the result has a numberof disadvantages. It still is no more than a translation in material; the patient still staysheavily dependent on the both the prosthesist, and the foreign funds.
Prostheses
This girl needs an above leg prosthesis; she has never had a prosthesis before. Theprosthesist just made a new prosthesis for her, while her amputated leg hasn't healed longenough; the stump is soft and not able to stand the pressure. After one month she will bewalking with her full weight on the small bone part already visible.One of the biggest prosthesis workshops of the International Red Cross was working formonths without even one physio-therapist. All they did was fitting the prostheses on thepatient.The people involved only think in terms of existing solutions; the Cambodian context is aperipheral consideration. Because of the Pol Pot regime, the people of Cambodia arewithout knowledge; all the educated people were killed or fled. The survivors learned neverto trust another. Their own interest is their only concern.It is not useful to import a western idea in this country. Aid workers give away prosthesesfor free while soldiers demand money from patients who want to reach the prosthesistworkshops. The next day these patients take the prosthesis apart and sell the parts on themarket. After all, the material is worth a lot and the prosthesis doesn't fit anyway. The jokeof it all is: Everyone is pleased!
 
Quality
The quality of the prosthesis is mainly in the fit. To increase the durability of the fit, thestump socket is made of relatively hard material. "Once good, always good". A skilledprosthesist can make a good socket: Special areas of the leg can be burdened with pressure,others can't.It demands a skill and precision which are lacking in Cambodia. Besides, the form of thestump can change over time. It is almost impossible for the patient to adapt the prosthesisto the changing circumstances. The present prostheses are short-term provisions instead of structurally adjustable solutions. The person involved can not master his own prosthesis.The problem is clear when broken prostheses are taken as a starting point: Then the lack of quality reveals itself.Leg prostheses last in the west for about two years. In Cambodia some have to stay in uselonger; the patient with the prosthesis in the photo was walking with his full weight onthis metal edge.
Conclusion
We need a totally different kind of prosthesis for Cambodia. The patient must be able tohelp himself because there are so few prosthesis workshops. The value of the prosthesisshould not be in the material. The patient does not have the money to buy, and is tootempted to sell.A lot of children in the third world die because of diarrhea. A doctor came up with amedicine in the form of a children's song:
 If you suffer diarrhea,drink sugar and salt,dissolved in water.
This song has probably saved more people than any program. Patients have to be able tostand on their own legs.
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