Saturday, July 3, 2010


This is a post I initiated in March but never finished. Now that I've gone again, I realized I need to get it out. Hope you enjoy.

I just found the coolest flickr photostream about Sierra Leone from a guy named Adam Cohn. This is more what it looks like than my very amateurish photographic attempts. I hope this link works because its captivating. Unfortunately, my camera battery died out here so I have very few photos from this leg of the trip.

For the last 6 months we've been getting reports about the excellent work being done out in Bo where three of 2009's trainees live. One of them, Musa Mansaray, is the Director of Rehab at the Bo Rehabilitation Center (BRC). Bo is Sierra Leone's second city, located about a 3-5 hour drive east and a little south of Freetown. Fortunately, the Italian government has recently built a paved road, making travel far, far easier.

Madonna is huge here. Or, at least these huge stickers of her are all over their taxis and buses.

This part of the country was very hard hit during their horrible civil war. The reason so much conflict happened here is that this is one part of Sierra Leone where Diamond mining is prevalent. Without dwelling too much on the specifics, the people of Bo suffered immeasurably during the war, leaving many with amputations and amplifying endemic polio. Therefore, the need for wheelchair services is as great in Bo as anywhere in the world.

Fortunately, the people of Bo (and the rest of Sierra Leone) have been steadfastly supported by Handicap International, one of the most effective organizations for helping people with disabilities in the world. One focus for HI in Sierra Leone has been in support of the Rehabilitative Services, strengthening and supporting the clinical programs country wide. As in Liberia, many of the clinicians here are 'mid-level therapists' or former nurses and social workers trained by European HI staff for up to 2 years. There are likely 3 or 4 Physical or Occupational Therapists in the entire country. Musa Mansaray, the director of the BRC is one of them.

We were able to work with Musa and his staff to gain an initial feel for their skill level in context of the wheelchair distribution process. So far, so good. Coming from the US and knowing what we have, I must say I was impressed by the vibe and hard work going on in their rehab center. The heat and conditions aside, it felt like any rehab gym in the states. People where working hard to improve their motor function. They have the basics and use them to get the job done as best they know how.

We assessed one of the wheelchair users, a 16 year-old refugee from Liberia. When I first viewed him in his chair, I felt something was very wrong. Either he had grown 5 inches in the last year since he had the chair, or his chair did not fit him. If a chair is too small for a user, their weight rests almost completely on their sitting bones, placing them at risk for a pressure ulcer. That said, the seat length, depth and backrest were appropriate and the chair was in good order. He uses it every day as his primary source of mobility.

As I assessed the fit of the boy in the chair, I realized that in addition to the infection they were treating he has all the symptoms and movement patterns of Duchenne's muscular dystrophy (undiagnosed). He lives in a refugee camp on the outskirts of town and had to travel several miles across a bumpy trail to get to school. With great relief, I realized the staff had trained the family how to adjust the footrests of the chair and raise the footrests so they wouldn't high-center the chair. This tells me the clinicians had measured and fit the chair appropriately and the technicians had built it correctly. Most importantly, the family had received correct instructions for adjusting and maintaining the chair. This is a very good initial case study for the BRC!

It is important to note that I was aware of my own bias coming into the situation. It would be easy to believe that, "Yes! they are doing it correctly and I'm so very happy to have gone!" However, Ike and I realized that catching a glimpse of one small part of the rehab center's week and transposing that across the entire wheelchair program in Sierra Leone would be dangerous. We had many, many long discussions about the need for an objective evaluation of the program. The need to truly analyze the skills of the clinicians and technicians we trained and the people they have since trained.

More to come about the Mobility Sierra Leone workshop soon.

Sunday, April 25, 2010


I got to go on a really great run to the top of a little mountain overlooking the city. Everyone was saying there was a very unusual haze for this time of year. Usually you can see forever out into the sea. (Double click to see detail)

One of Last year's biggest challenges was accurate measurement of the patient's body for the wheelchair. The chairs we provide are built to fit the user's hips, thigh length and lower leg height. An accurate fit might make all the difference in the wheelchair user's success or failure with the chair. We found that measurement continues to be a challenge for our clinicians.

Through a unique twist, we found that Motivation held a training at the Rehab Center the two weeks before our arrival. Nicky Seymour was a Motivation trainer who gave us excellent feedback on her training and the general situation there in Freetown. We were able to evaluate Emily and Cecil as they assessed a patient for a new wheelchair.

Here she is with her current chair

As a Physical Therapist, I can say that its always difficult to have another Clinician around to critique your work. There is an extra pressure that can make you overlook the obvious. Having two people observe and critique your work is twice as bad. That said, Emily and Cecil did very well with their patient evaluation. We had to review measurement again and hopefully practice will make perfect.

One of the issues that came out of Nicky's observation is that there had been some chairs in Freetown that were issued without proper fit. This dangerous situation came about when one of the government officials ordered the staff at the Rehab Center to build a bunch of chairs and hand them out without fitting. The politics of Sierra Leon are famously rough handed and I can't blame the staff for following orders. Fortunately, we are working with them to disallow this in the future.


One of the most exciting things about the LDS Humanitarian Service and LDS Charities is the intelligent ways in which they pursue their mission. The Wheelchair Initiative has been fortunate to partner with Motivation UK, gaining much from their long experience in providing very high quality, low cost wheelchairs AND training clinicians and technicians for prescription wheelchair service. The Worldmade philosophy and program is explained on their website and some background is in the blog I wrote last year. My respect for them continues to grow as I see the progressive way they pursue their goals. Fairly brilliant approach and execution.

One of the Hallmarks of the Motivation approach is to train Clinicians and Technicians in a prescription wheelchair service. This approach magnifies the clinical and technical skills of wheelchair providers in areas that need it most. Motivation has several levels of training and LDS Humanitarian services has worked to incorporate their training system. Obviously with an effort and need this broad, there are many diverse ways of approaching the problem.

Last year we were able to go to Liberia, where we taught teams from Liberia and Sierra Leon for the Worldmade Fit for Life program. The goal was to 'train the trainers'. The program has been largely successful in that the teams from both countries were able to extend the training by relaying their knowledge to other clinicians and technicians.

This year we wanted to follow up with the teams from Sierra Leon and evaluate their implementation. Isaac Ferguson had been to Freetown to implement a Neonatal Resuscitation Training in the fall and made a surprising discovery that the technicians from Bo had formed their own Wheelchair Production site. We were keen on visiting this site to evaluate the quality and efficacy of their program. We were also very interested in evaluating the performance of the clinicians in Freetown and Bo.

Ike Ferguson and I were sent to Sierra Leon for the first leg of our trip. We flew from SLC to JFK and then to Accra, Ghana and finally to Sierra Leon. Arriving in any 3rd world country is always a shock and this was no different. The airport is across a big bay and there are several ways to get across. On the way over, we took the 'speed boat', which was like a floating yellow sauna.

Its just amazing to leave Utah on a 60 degree spring day in March, travel across the Atlantic and end up in 95 degree heat with 100% humidity. Getting to the boat involved driving in a small bus down a half mile of dirt roads to the shore, where it was blissfully cool. Then we had to put on the lifejackets and get into the sauna.

Of course, there were more temperate alternatives:

Freetown is an amazing mountainside city by the sea that was founded by freed slaves from returning America and England. The English used it as a returning point for Africans liberated from slave ships in the 1800's and the Colonial influences are found throughout.

We found the Sierra Leonian Navy.

And the famous Cotton Tree, where freed slaves prayed under and Christened Freetown

The most exciting part of arriving in Freetown was the 15 minute drive to the Mission Offices. Aside from being in such a cool and very foreign feeling place, we saw over 11 Worldmade Wheelchairs!

This was an encouraging sign as we were hoping to be able to assess someone who previously received a chair and evaluate the appropriateness of their fit.

Sunday, April 19, 2009

Why I went to Africa

Why did I go to Africa?

The Church of Jesus Christ of Latter-Day Saints has an ongoing Wheelchair Initiative, providing wheelchairs of various complexity and function. Recently, a need was identified for wheelchairs that could be both custom fit to the user and have more specific functions – such as handling rough terrain or folding for transport in a car. So an partnership was formed with Worldmade, a wheelchair services NGO that provides not only wheelchairs but training for wheelchair services provision.

The World Health Organization recently issued a guide to Wheelchair Provision in developing countries, which is a long but fascinating read. There are several reasons that simply giving wheelchairs to users without prescripton can do great harm to a community: 1) The chair may harm the user 2) The user may not actually need a chair and often there is no filter for determining need (a rehab chair can make a great cart for hauling items) 3) The existing wheelchair service provider in the country will be put out of business when their market is suddenly flooded with free wheelchairs from abroad 4) The chairs may wear out very quickly leaving the end user in a worse position than when they started.

The worldmade model stresses training for wheelchair providers, assembly technicians and end users to ensure the best chair ends up with the appropriate user. This ensures the appropriate chair ends up with the appropriate user, the existing wheelchair services provider is strengthened through increased training and the providers have more options for wheelchairs to give.

Therefore, the LDS Church is working to provide a spectrum of wheelchair services worldwide. Sharon Eubanks has spearheaded this effort you can hear her audio clips on this project in the above link.

One day last summer I received a random email about volunteering for the wheelchair initiative. We don’t really know exactly how I ended up on their list but I’m very grateful have been found.

In October, Worldmade came to Salt Lake City and trained the Short Terms Specialists on their method of training. In January, we were informed we’d be going to Monrovia, Liberia for the training. Our team consisted of Emily Cawley and Cathy Mills on the technician training side, Dan Mills and myself on the prescription side and Issaac Ferguson as our coordinator and program facilitator. Ike is a veteran of LDS Humanitarian Services and has spend many years in Africa working to improve the living conditions for the people there. Actually, Ike is like the Forrest Gump of Humanitarian Services in that he’s been in just about every country you can imagine over many decades, working on projects like clean water, iodine provision and most recently developed the Neonatal Resuscitation Training program. More on Ike later.

At the end of March, 2009, we flew from SLC to Accra, Ghana. This was my first trip to Africa and I was amazed at the sights and sounds. Ghana is a beautiful country just above the equator in West-Central southern coast of Africa. We were there for a day and a half, waiting for the bi-weekly flight to Liberia and stayed in downtown Accra.

It was fun milling out a bit with the people there. Caution! This video clip may make you have a seizure! But it was the only way I felt I could have a camera out without offending.

They even have fruit bats in the trees…

We flew to Roberts Field, the major airport for Liberia on Kenya Airways, which was a really nice airline if you ever get the chance to fly with them. Who knew they would serve greens? I was already feeling at home.

Roberts Field is an old world war II airstrip the US built for staging their war and was an important cold war air base. It sits directly next to a million acre Firestone rubber plantation and about an hour from Monrovia, the capital.

The difference between Accra and Monrovia was amazing. There have been several cival wars and much unrest in the country for many years. There is a telling documentary called “Liberia, an Uncivil War" that explains the details of Liberian politics in far greater detail than I can. Its fairly graphic but worth watching. All of the city shots from the film are in Monrovia close to the location of JFK hospital. The UN has its largest peacekeeping mission in Liberia with 15,000 troops from many nations (but not ours). So there are hundreds of really cool Landcruisers and Nissan Patrols with just about every acronym you can imagine. NGO's from many, many countries are working to help stabilize and develop the country.

Ex-Patriots generally stay in compounds like this, with plenty of bars, high walls and razor wire. We didn't go out at night, but during the day things seemed safe enough.

Downtown Monrovia

A trip to the hardware store. Most of the businesses are owned by the Lebanese, who are good at economic development anywhere. There are also plenty of Indians and Chinese. Dan and Ike think its hot in Liberia.

The Chinese have a different emphasis on economic development than we do. They build roads and universities and infrastructure like crazy. The US is focusing on building institutions and programs to educate the people. Thing is, the roads are easier to see and often the politicians end up pocketing the money the US sends. Our reputation is getting kicked around by the differences and basically, the Chinese are taking over Africa through economic development.

This is a classic tricycle wheelchair in the third world. More on this guy later...

We had a hard time getting the shipping container with the wheelchairs out of Customs. Actually, Ike, Aaron of Handicap International and Josephine of the Monrovia Rehab Center of JFK Hospital were on the case and worked hard to get things moving. We weren't sure the container would arrive and decided to proceed with the opening ceremonies so we could at least start the training. But sure enough just as we were ending the ceremonies, this ancient chinese smoke bomb truck rolled in and we got our chairs!

It was hilarious watching the guys open the container with a pipe but apparently it can be done.

We were excited to meet the therapists and technicians who came from both Liberia and Sierra Leon for the training. Most of the Liberians were trained by Handicap International about 5 or 6 years ago and they had an amazing breadth of experience. The team from Sierra Leyon was likewise dynamic and engaging. It was apparent from the start that we had a great crew to work with.

Sometimes I feel kinda tall... Like I somehow stick out a little.

First we learned what they knew about wheelchairs and then worked on wheelchair service provision with adjustable chairs.

When you don't have chairs that are adjustable, why would you ever need to measure a wheelchair user?

Measuring has its challenges...

But in the end, we all got on the same page

Afterwards, we got the Tripple P. Pita, Peanut Butter and Plantains. Between that and the Jallah rice and chicken we ate every day... I wouldn't live long in a place like this without adding many more P's (as in pounds) to the equation.

Most NGO's and definitely the UN use some of the coolest Landcruisers I've ever seen. Everywhere you looked there were Nissan Patrols and funky trucks to be found.

But not us, we wanted to blend in a lot better. So we got ourselves a Nissan. We weren't sure which model it was, so Emily dubbed it the 'Nissan Awesome" and it stuck. 5 large Americans in that thing gave us all new definitions for 'stuck'.

Note the bulging tire - it was one of the several we had to change

Ike prepping for a 'Driveway Moment' in which he told almost always told us about an amazing experience in the far corners of the Public Health Universe. It also gave us prime opportunity to tease Ike about his excellent backing up skills.

For me, Ike's stories brought home the spirit and principles of services and Public Health. Serving others through training and systematic programs allows them to embrace principles that will help them grow into self-sustaining life. Having a systematic program allows us to evaluate if its actually working and find better ways to help them grow. This wheelchair program is a prime example and is why the WHO issued their guidelines for wheelchair provision in third world countries. We hope that we are providing chairs through the existing services delivery program to support and grow their capabilites in their countries.

Back to the course. One of the reasons I love Physical Therapy is that you get to turn book knowledge into practical use. The MRC brought some wheelchair candidates in for measuring,

Here are a few of them. During the wars, there was great difficulty in administering Polio vaccine causing s a significant outbreak in Liberia. Many of the patients we saw in clinic were either victims of these outbreaks or of rocket attacks. They were normal people who wanted to work and make their way in the world. These 3 guys were typical in that they all were either in school and/or working in the community. They needed wheelchairs to get into their schools or work.

It is fairly amazing to see the way these guys got around. But they did get around and made things happen.

Once the measurement and assessment was complete the technicians built the chair to the specific prescription. When that was completed, the patients returned for the final assessment and adjustments of the chair to fit their bodies
At times, novel adjustments had to be made to protect the users. The staff at the MRC were especially good at this component.

It was fun to see the knowledge brought together with many happy smiles. Here are a few of the cases...

Liberia is an amazing country. It was my first time in the third world but I don't think its all that different from Chicago or Houston or Atlanta. Just hotter, with no traffic lights, nicer people, and a lot more difficult living conditions. Oh, and its a lot more jiggly.

This is the Mall of Monrovia
You can buy just about anything you can imagine here. Just don't eat it.
This guy is making pots and pans with the magic ingredients of aluminum and D-cell batteries.

There were some unexpected sights and sounds
Note the American Flag shirt (made from actual flag) and construction helmet.
And the shot out buildings, which were everywhere.
They even have nice beaches. Just be careful which ones you go to
Cool weavers

Much appreciation to the hospitality and assistance of the Missionaries and families who helped us.
There is a bunch more to tell and say but this is enough for now. Hope it explains what we did and where we went and especially why.