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Assisting Landmine Accident Survivors in the Thai-Burmese Border Region

Updated Wednesday, 18-Sep-2013 09:17:48 EDT

Clear Path International is working with Prosthetic Research Study of Seattle to help Burmese landmine survivors obtain prostheses from afar by using a new fitting process.

Mordecai has a problem. Or, better stated, the landmine accident survivors his small organization is trying to assist have a problem.

The survivors live in the mountainous Karen state, partly controlled by Burmese troops and partly by the separatist Karen National Union. Most of the amputees cannot or will not escape east to Thailand to get access to physical mobility devices from international aid groups there. Neither can they cross the military front to the west to seek support from the limited medical services available in Burma. To make matters worse, many of the Karen mine survivors are homeless, displaced by the fighting or the presence of landmines in their villages, which are often considered rebel support bases by government troops.

So how is Mordecai, head of the Karen Handicap Welfare Association and himself a mine amputee, going to get his beneficiaries the mobility- and hope-restoring prostheses they need?


Maw Kel, director of the Mae Tao Prosthetics Department, puts together components of the Transtibial Alignment System developed by Prosthetics Research Study.
© Brian Hafner, Prosthetics Research Study

At Clear Path International, we have been talking to Prosthetic Research Study of Seattle about a portable device that could solve Mordecaiís problem. Our effort to help PRS finalize its device and get Mordecaiís group trained on it in the field provides some insight into this troubled and heavily mine-contaminated part of Asia that gets very little media attention. It also shows the value of supporting local groups with portable tools that help reach landmine amputees in one of the worldís many remote or troubled regions.

If successful, the device and the model for working with local groups can be of interest to other mine action groups or relief agencies facing the same public relations challenge elsewhere in the world.

It has always been a mystery why Burmaís political problems are largely ignored by Western reporters. During the past 10 years, an estimated two million (mostly ethnic) refugees have fled from Burma to Thailand—a large-scale humanitarian catastrophe that would get plenty of attention in most other parts of the world. They escape the constant fighting between the military government in Rangoon and the forces of several ethnic states whose history of fighting for independence dates back to before the period of British colonization.


A Burmese landmine amputee lies on the canvas grid of the human body, part of the Transtibial Alignment System. This system helps ensure the artificial limb is produced in proper alignment with the entire body and also makes it possible to produce prostheses in another location.
© Brian Hafner, Prosthetics Research Study

The Thai-Burmese border is one of the conflict areas untouched by the worldís growing embrace of the Ottawa Convention.1 Rangoon hasnít signed it, and neither have the rebels or the drug traffickers or the illegal timber barons.2 All parties make or buy cheap and often crude mines or anti-personnel devices to achieve their respective objectives: deprive the enemy of its support base, slow enemy advances, secure poppy fields or drug routes, protect forest stands, etc. Sometimes, one group uses anti-personnel devices for multiple purposes.

The result is a random use of explosives and a very high rate of contamination in the disputed areas. Accident or casualty data are hard to come by. The lands along the border are so dangerous and inaccessible that no one keeps accurate records. The Karen state alone has hundreds, if not thousands, of landmine amputees, Mordecai estimates. Another reason it is difficult to track statistics is due to the amputeesí transient existence. Many are among the large groups of displaced Burmese who live in makeshift jungle communities away from the fighting.


A technician at the Mae Tao Prosthetics Department finishes a positive cast of a landmine amputee's residual limb. The cast will be used to drape-mould a thermoplastic sheet that becomes the patient's prosthetic socket.
© Brian Hafner, Prosthetics Research Study

Those amputees who make it across the border into Thailand are lucky, at least to some extent. If they obtain temporary refugee status (which is increasingly difficult because of tightening Thai immigration policies), they may end up in one of the seven camps that sprawl along the mountainous border of the Karen state. The largest of these camps is Mae La, set up by the United Nations High Commissioner for Refugees at the base of the forested cliffs that separate Thailand and Burma. The waving pattern of its straw roofs nestled against the rolling foothills is an impressive site, continuing for several miles along a quiet back road. This is home for more than 50,000 Burmese refugees.

The camp houses 900 people with disabilities who made it out of Burma. Many are landmine accident survivors. In the camp, they get prostheses and other assistance from Handicap International. Clear Path supports Mordecaiís Care Villa at this camp. It is a full-time "nursing home" for 15 dependent landmine survivors who lost their hands, legs, eyesight, hearing or, sadly in most cases, some combination thereof.


A Burmese landmine amputee stands inside the vertical measurement tool in the Transtibial Alignment System. Here, as on the horizontal tool, technicians use the alignment rods to mark the patient's plaster cast where the socket will meet the shaft connecting it to the rubber foot after the prosthesis has been fabricated.
© Brian Hafner, Prosthetics Research Study

Many amputees who flee Burma and cross the border avoid the Thai authorities and the refugee camps, from which they cannot leave once accepted inside. They end up getting their prostheses from the prosthetics department at the Mae Tao Clinic, an unofficial medical facility started by Dr. Cynthia Maung. Maung is an ethnic Karen doctor who fled Burma after the 1988 pro-democracy student uprising and has been nominated for the Nobel Peace Prize for her tireless work on behalf of Karen refugees, whom her clinic sees by the hundreds each day.

Clear Path has been supporting the clinicís prosthetics department since 2001 with funding for materials, equipment, training, technical assistance and the construction of a new fabrication shop. The departmentís director, Maw Kel, himself an amputee who worked as a master prosthetics technician for Handicap International in the camps for many years, introduced Clear Path to Mordecai and his dilemma. That was the inspiration for helping PRS in Seattle with the completion of its Transtibial Alignment System (TTAS).

This system was the closest thing to a silver bullet we could find to address the need of a transition amputee population in an active conflict zone. PRS, the brainchild of the late Dr. Ernest Burgess, is known for a number of innovations in prosthetics and has done extensive development research for the United States Veterans Affairs Administration.


Maw Kel (right), director of the Mae Tao Prosthetics Department, and two technicians drape-mould a sheet of heated plastic over a positive cast of the amputee. A vacuum method is used to fit the plastic tightly around the cast for a form fit. The positive cast is connected to a mandril so the plastic sheet can extend, forming a stem down to the point where it will be bolted to a rubber foot so the entire "Monolimb" (socket and stem) is a single unit.
© Brian Hafner, Prosthetics Research Study

PRS developed TTAS with its own resources and substantial funding from Physicians Against Landmines and the Center for International Rehabilitation. It needed just a bit more support to get the prototype across the finish line. Clear Path and one of its sponsors, the Rotary Club of Bainbridge Island, saw its potential and paid for its completion.

To understand this potential, it is important to realize how challenging it is to measure and fit amputees for prostheses without having them available to a technician in the fabrication shop. The challenge is capturing the prospective position of a yet-to-be-made artificial leg in a vacant three-dimensional space underneath the residual limb and ensuring that the final product is in proper alignment with the rest of the patientís body.

A trained and seasoned technician can do a lot through intuition and experience acquired over many years, using simple plumb methods.3 Sadly, those skills are rare on the Thai-Burmese border. TTAS takes the guesswork out of this challenge, allowing minimally trained medics to cast and capture the residual limb in alignment with the patientís skeleton. One of its components consists of a canvas grid of the human body on which the amputee lies. After a plaster cast is made of the residual limb, transparent frames are placed over the hips and the heels (the base of which is aligned with the remaining foot).

The braces are connected above the lower body by two metal shafts along which the technician can make intersecting pencil marks on the plaster cast. This will become the center of the shaft connecting the prosthesisí socket to the rubber foot. A corresponding jig set up at the fabrication shop allows the technicians there to recreate the same customized skeletal alignment without the patient present.


Technicians at the Mae Tao Prosthetics Department pour liquid plaster into the landmine amputee's cast to make a positive mold. The mold is used to drape mould a thermoplastic sheet that becomes the patient's prosthetic socket.
© Brian Hafner, Prosthetics Research Study

The third TTAS component, a standup version of the skeletal alignment device, allows a measurement to be taken while the patient is in an upright position. PRS is still experimenting with the best patient orientation during measurement, but trials in Thailand show the technicians there are inclined to use the horizontal measurement device.

Last fall, a biomedical engineer and prosthetic and orthotic professional from PRS traveled to the Mae Tao Clinic to introduce the first TTAS and thermoplastic limb production at Maw Kelís prosthetics department. More than a dozen technicians from three fabrication shops supported by Clear Path along the Thai-Burmese border participated in the training, including Mordecaiís team.

On a visit to the Mae Tao Clinic this spring, Mordecai presented a plan to put TTAS to the test inside Burma, and Clear Path agreed to support it. Mordecai is putting together a team of six backpackers who will travel to the villages in the portion of the Pa An district controlled by the Karen National Union. They will go 50 kilometers (31 miles) into Burma, survey each of the districtís five townships for landmine amputees, and measure and cast the ones they encounter.


A technician at the Mae Tao Prosthetics Department makes adjustments to a cured plastic limb by cutting excess material from around the area that will become the socket opening.
© Brian Hafner, Prosthetics Research Study

Authorities in Thailand have an agreement with the regime in Rangoon to curb cross-border activities wherever possible, even humanitarian endeavors like Mordecaiís. However, his outreach program will give all the partners a chance to see how TTAS works in the setting for which it was designed.

Clear Path has three programs in southeast Asia: in Vietnam, Cambodia and along the Thai-Burmese border. Vietnam and Cambodia offer stable survivor assistance environments with beneficiaries who stay put. In those countries, we are already dealing with a fairly remote rural target population, and victim outreach can only be successful if we take an assertive approach to lowering the barriers between the recipients and the services they need. For instance, a significant portion of Clear Path Internationalís program costs go towards transportation and logistics, often an insurmountable hurdle for marginalized survivor families. As a result, the organization either visits the survivors at home or arranges their travel to medical and social services providers. Often, it does both.

In the Thai-Burmese border region, Clear Path takes this outreach approach a step further with our support of Mordecaiís backpacking team and their experimentation with TTAS. It will give us a chance to see how we can build a program that allows local groups such as Mordecaiís to reach out to landmine survivors in politically unstable or remote areas.

Biography

Imbert Matthee is president of Clear Path International, where he focuses on victim assistance programs, fundraising and public relations. He previously worked as a journalist for 15 years and was a reporter for the Seattle Post-Intelligencer, ABC News, the Los Angeles Times, the Seattle Times and the Everett Herald. He was also a frequent contributor to the New York Times News Service.

Endnotes

  1. Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-personnel Mines and on Their Destruction. Ottawa, Canada. Sept. 18, 1997. http://www.un.org/Depts/mine/UNDocs/ban_trty.htm. Accessed Nov. 2, 2005.
  2. While only governments can sign the Convention, non-state actors can sign the Deed of Commitment for Adherence to a Total Ban on Anti-personnel Mines and for Cooperation in Mine Action through an organization called Geneva Call. Geneva Call engages NSAs to respect and adhere to humanitarian norms, starting with the anti-personnel mine ban. For more information, see http://www.genevacall.org/home.htm. Accessed Nov. 2, 2005.
  3. Simple plumb methods use a plumb line, which is a reference line guided by a string or cord weighted at the end with a large weight known as a plumb bob. It is used to create a reference line for creating vertical lines.  

Contact Information

Imbert Matthee
Clear Path International
321 High School Rd. NE, #574
Bainbridge Island, WA 98110
USA
Tel: +1 206-780-5964
E-mail: Imbert@cpi.org
Web site: http://www.cpi.org