The British Palawan Trust
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November 2018 NewsLetter
Angie Dadaeg was 28 years old in 2005 when Bahatala, the BPT’s unit in Palawan discovered her through its Outreach Program, a way of extending services to those in remote villages. When we first saw her Angie was weaving pandan leaves to make banig or sleeping mats in the living room of her parents’ house in a small village planted with coconuts. She was confined to that room most of the day, unable to walk or even stand; she had polio at a very young age. Their house was on stilts and as in most rural households, the toilet and washroom were downstairs in a separate hut, so that if she needed to go there she had to wait until someone was available to carry her. She did not have a wheelchair so she hardly ventured outside and looked quite pale. Her mother would sell the sleeping mats she made and in that way she contributed towards household expenses.
We found a wheelchair for Angie, and soon she was enjoying being outside in the grounds of the house. But she still needed someone to take her back up into the house with steep stairs. We suggested the idea of a permanent room
on ground level beside the house. Her mother was very supportive but not everyone in her family welcomed the idea. They resented what they regarded as Angie’s wish to be “independent”, something they thought was unnecessary. Nevertheless the project persisted. Bahatala provided the materials and Angie with her banig sales contributed to labour costs. But this also meant that Angie’s earnings were diverted from going towards household expenses.
Angie’s room was built and the family was eventually persuaded that Angie deserved her new accommodation. It had a wheelchair ramp and her own bathroom. Her health improved as she could now go outside whenever she wished. Angie continued working with pandan leaves and started making handbags out of them.
Angie had never attended school but she would look at her sister’s homework and learned how to read in Tagalog (the medium in school). She had some help from her mother but mostly she succeeded by her tenacious efforts. Eventually she wanted to learn English too and borrowed a Tagalog- English dictionary from a relative. Because she had to return the dictionary she decided to copy it entirely so that she could have her own. She longed to have books and found that newspaper
written in English used as grocery wrappings was an easy source of reading material. Then she met Susan Evangelista,
a member of the Board of Directors of Bahatala, a retired educator and English professor, who gave her books to read. She also started a correspondence wherein Susan discovered that Angie could read and write proficiently despite the fact that she had never set foot in a classroom.
Susan wrote to the Department of Education to request that Angie be permitted, even without having formally attended elementary school, to take an examination for eligibility to attend high school. Angie passed the exam and was able to enrol in the local high school. Angie’s mother pushed her in her wheelchair but it was a daily struggle for the school was on top of a small hill. She studied hard and gradually impressed the teachers with her dedication. After doing her homework she worked in the evenings weaving pandan leaves her mother had gathered into beautiful handbags to help pay for school. Angie became an outstanding student and graduated from high school with honours in 2011.
Her education did not stop there for she now set her goal of becoming a social worker. That meant moving to the city (Puerto Princesa) and enrolling at the Western Palawan University. It meant finding the funds for matriculation and a suitable boarding house where she could wheel herself to the campus. She obtained part scholarships and continued to weave her pandan bags in the evenings to make ends meet. Bahatala’s carpenter worked on her rented room to make it suitable for a wheelchair user. Her mother remained her steadfast support and moved in to help her. The university had a lesson in complying with accessibility laws by compelling it to assign Angie’s classes in ground floor classrooms.
In 2015 Angie graduated with a Bachelor of Science degree in Social Work. Sadly her mother died a year short of her graduation from a heart condition. This was a difficult time for Angie as she was preparing for her final exams. She passed her finals and took the Board Exams the same year and passed it.
When we first met Angie 10 years ago, confined to that room unable to go anywhere without help, she did not dare dream of setting foot into a school, much less into a university. With a little help and encouragement but mostly because of her determination and hard work she got to where she is now. Angie, now a certified Social Worker was hired by the local government of Roxas to look after the concerns of persons with disabilities in the municipality. It is now her turn to help others.
There are many more like Angie whose lives have been touched and hopes realized.
It is all because of you that we have been able to help people like Angie.
Summer 2017 News Letter
For many young disabled people in Palawan poverty, bad infrastructure and poor public transport hold them back from receiving the education they desire. The BPT thru its local unit (Bahatala) has been helping many of them find solutions to enable them to fulfil their dreams, and live productive lives. Ruel, for example, had difficulties getting to his school.
The youngest of 4 siblings, Ruel was born with his lower left limb missing and most fingers deformed or missing. Ruel had a pair of crutches to get around, but at home he would discard them and just hop around. He went to school and learned to write using what fingers he had.
When Ruel was thirteen his mother left. His mother’s family owned their farm land, so his father had to find work elsewhere. But Ruel and his father were allowed to remain in their house. Ruel's 3 older siblings had already married and were raising families of their own. He continued going to school using the wooden crutches his father made and did most of the household chores while his father worked in the field. After school, Ruel would clean the house, gather firewood, and start cooking. At weekends he washed their clothes. At school he was shy and had few friends.
When Ruel finished primary school, he was faced with a 3-kilometer walk to the nearest high school. Hobbling on crutches it took an hour each way to get to school. The BPT obtained a wheelchair for Ruel and he started wheeling himself to school along the main provincial highway. But the wheelchair and Ruel’s stamina soon proved no match for Palawan roads. He needed a better way to get to school.
Bahatala’s workshop was set-up to help disabled people with mobility problems (the only workshop of its kind in the whole province). There, Ruel participated in a project to come up with an appropriate vehicle that will solve his needs. Along with two other disabled persons, he helped fabricate a tricycle more suitable for Palawan’s rough roads and was able to return to school. At 17 he graduated from high school and applied for an Electronics course at the local college.
Ruel enrolled for a 2-year diploma course at the Western Palawan University (WPU), 8 kilometres from home where he had to stay in a boarding house. Bahatala found sponsors for his school and living expenses. His custom-built tricycle proved indispensable for moving around the sprawling campus.
After graduation Ruel returned home. He opened a shop, and became known for his skill at fixing electronic appliances. He repairs videoke machines (every village has one or two), televisions, radios, and gets called to do home services. After many years on the road Ruel’s tricycle had taken quite a battering. In Bahatala’s workshop Ruel now did most of the work for a new tricycle.
Like Ruel, Aljun was born with disabilities. He was born at home, the 4th of 5 siblings. Aljun’s left lower leg was missing and his right leg deformed by a constriction band and missing toes. His parents thought they could not afford specialist help and taught him to walk using home-made wooden crutches and sent him to school.
We first met Aljun in 2005 when Bahatala was conducting an Outreach Clinic in the remote village of Liminangcong, 250km northwest of Puerto Princesa. The nearest town is Taytay, a 3-hour drive by a road made rougher by the rainy season. Nuns running a private high school made us aware of a 10-year fisherman's son walking the streets with wooden crutches. They thought that maybe we could give him a better pair of crutches. Fortunately for Aljun, Bahatala’s prosthetic technician was part of the Outreach team. He was measured for an artificial leg right there and then. Financial difficulties and bad road conditions meant it took several months before he made the trip to Bahatala to fit his leg and learn to walk with it.
When Aljun graduated from elementary school, the nuns running St Ezequiel Moreno, a private high school, offered him a scholarship if he studied well. He told the school’s Principal that ever since he was a small boy he had dreamed of being a teacher but was worried about his appearance with his missing leg and crutches. The Principal encouraged him, suggesting he could one day teach in that school. When Aljun graduated from high school, he told his parents that he wanted to go to college. His parents could hardly afford college fees and living allowances, but as none of their other children had desired to pursue higher studies, they decided to support him. Fortunately, the nearest town of Taytay has a branch of the Palawan State University. Aged 17, Aljun enrolled for a 4-year course in Education.
Aljun lived frugally in a crammed student boarding house, cooking his own food, his family regularly sending him dried fish. For all his hard work and his parents’ sacrifices, he realized his dream and graduated with a degree in Education in 2016, and was offered a teaching post by the new Principal of St Ezekiel Moreno High School.
This school year (2017) Aljun started teaching Grade 10 pupils Economics (in Tagalog he proudly told us). He has also just been fitted with his fourth artificial leg.
News Letter 2016
In the last Newsletter, the Chairman wrote about the vital support we were afforded by AVID (Australian Volunteers for International development), the agency that made it possible for prosthetist specialist Udo Foerster to spend a year in our unit in Palawan.
When Udo left at the end of the year, the Workshop had gained from a major transformation. The workplace had been renovated to promote a better and safer workplace. More importantly, he introduced prosthetic technology that significantly cut production time as well as produced lighter and more modifiable prosthetics. But perhaps the most significant of Udo’s legacies were the new knowledge and skills acquired by our technicians and clinic personnel. The results of these benefits can be seen from the two-fold increase in our prosthetics production this year. Our workshop, indeed the Rehabilitation Centre, remains to be the only facility of its kind in the whole province of Palawan. It has touched and transformed numerous lives since its beginnings 15 years ago.
MJ was six year old when we first saw him in February of 2015. His family lives in a remote village inside an acacia forest. His mother had heard of our rehabilitation team visiting the nearby health centre and decided to bring him. MJ had never been seen by a medical team before, his family thinking that they could not possibly afford what the doctor would advise. He is the youngest of 8 children, the 4 oldest of whom are already married. With one missing leg and a clubfoot in the other, it meant he had never walked upright. He learned to walk on his knees instead, using a pair of rubber slippers. MJ was painfully shy and would not even look at you when spoken to. Apart from living in an isolated hamlet, his congenital handicaps did not make it easy for playing outdoors as much as other children could.
One of our first tasks was to make the family understand that MJ’s special condition involved manifold procedures and that their cooperation was vital for any success. Travelling woes in Palawan are often a major hindrance to attending treatment sessions, and in MJ’s case this was a particular issue. Travelling to the Centre commenced with a long walk under the acacia forest (sometimes aided by a carabao), followed by crossing a river over a rickety hanging bridge in order to reach the highway, and finally catching the bus to the city. MJ’s transportation costs were covered by various donors, who also covered all attendant treatment costs. The family, like most Filipinos in the rural areas, do not have the extra means to afford health and travel expenses, especially in the long term.
The first stage of his treatment required surgical removal of the bone spur of his right limb. This was performed by the visiting surgical mission team from “Interplast Germany”. While his stump was healing, treatment of his clubfoot was started by Bahatala’s (the BPT’s unit in Palawan) Ponseti Team. MJ and his mother had to attend a series of casting sessions from March to June 2015, with a total of 9 casts before his clubfoot’s ideal position was achieved and he was suitable for tenotomy, to achieve lengthening of the Achilles tendon and flexibility of the foot.
News Letter Autumn 2015
The British Palawan Trust Newsletter
BAHATALA, Abanico Road, Puerto Princesa, Palawan, Philippines 5300
In the UK: Orthopaedic Department, Ipswich Hospital, Heath Road, Ipswich, Suffolk IP4 5PD
UK Registered Charity No. 328651 www.britishpalawantrust.org.uk September 2015
It is three years since we lost Soc. The unit he founded continues and has established itself in the health care system in Palawan. The amount of work has steadily increased since the opening of the new clinic (The J A Socrates Rehabilitation Centre and Workshop) and even more since the Ponseti clubfoot-training course developed by Global Clubfoot Initiative (featured in the BPT Newsletter, February 2015) was added to the Centre’s regular programs.
When I was there in February 2015 another exciting development occurred. A visiting prosthetist/orthotist (Udo Foerster) funded by the Australian government’s international aid program, started a twelve-month posting. Udo arrived with his wife and three charming children. The first job was to find them somewhere to live and this was achieved successfully as a friend of Cecile’s was letting her house.
Udo then had to learn what we do and what our staff were capable of. Our house prosthetist, Romy, had been trained some years ago and had not had any update training. Reymon, who does all the manufacturing of assistive devices and equipment for the disabled (especially for children) had always expressed a desire to learn how to make artificial limbs, especially as he wears one (above-knee). Udo spent the next week or two getting to know everyone and see how the whole unit worked. He came on some visits to outlying villages so that he could understand the practical problems of persons with a disability, in a setting such as Palawan.
Since then Udo has trained the two men in the workshop in more modern techniques, including the introduction of modular lower components in place of the fiber-glass and resin laminates. He involved the physiotherapists from the clinic in assessment and rehabilitation of amputees. This may involve us in greater cost but we get most of the prosthetic costs from the Philippine system. I am sure that all this retraining will give the workshop a new spark of life.
Udo also identified the need to develop our brace and splint making. The local surgeons prescribe braces for many conditions and there is no facility on the island at present. The first requirement was a special oven for thermoplastic heating. Fortunately CBM (Christian Blind Mission, a German-based charity) were visiting and had some funds left over for the current year for special requests. They have given us enough for the oven and a suction machine. So we hope to have brace-making in our abilities to provide a full service for the people of Palawan.
Meanwhile the work in the clinic keeps the two physiotherapists and one nurse busy. Wednesdays are the day for clubfeet. One of the new local Orthopaedic Surgeons comes to the clinic to perform tenotomies for clubfoot and will also see any other patients that the staff are worried about. Since Steve Mannion (Global Clubfoot Initiative) taught our staff the Ponseti technique, we have become the clubfoot centre for the whole province (now about 900,000 population). In addition, post-injury patients and Cerebral Palsy, as well as Stroke patients keep the clinic full of activity. Cecile arranges with Rural Health Units to visit villages all over the province including some of the islands in the north. These trips enable us to check on old patients and make arrangements for new ones to come to the clinic for assessment, treatment or onward referral to appropriate specialists.
We are very grateful to the Australian Volunteers for International Development (AVID) as well as our generous regular donors for the assistance with our work. Please contact me if you have any questions or would like to join our mailing list for regular news letters
LOUIS DELISS BPT Chairman
Chris (not his real name), the 7th in a family of eight children had caught his leg in a farm machinery when he was only 3 years old. (see the Patients section) Dr Socrates amputated his virtually severed leg careful to preserve the already precarious length, not to cut any more closer to the knee, allowing sufficient stump length for a socket. At that time he was the youngest of our amputees and we had him jump the queue for prosthetics production. The family lived far away from the BPT workshop in Puerto Princesa, in a remote southern village in Palawan and when he went home, he walked with his first prosthetic leg.
Two years passed and we had not heard from Chris’s family (no mobile phones then) so we had him sent for using our network of social welfare agencies. The father could not afford to the leave the farm and the mother had the big family to attend to, were their excuses. But the father proudly showed how he lengthened Chris’s leg by inserting about 2 inches of wood above the Satch foot, which adjusted for Chris’s growth and allowed him to walk to school.
The photo above left shows Chris who was now 5 years old and had just been fitted with his second leg (holding his old leg beside him). He needed a new leg almost every two years as the fiberglass laminated legs that the workshop produced had to be replaced entirely when the child lengthened.
2015 and twelve years later, Chris gets his first endo-skeletal prosthetic leg. He is now 15 and has had 5 prostheses of laminated fiberglass and resin. His new leg is made of modular parts which allow for adjustability of alignments, among other benefits. Udo, our Australian volunteer has made our adoption of this technology possible. Chris now goes to school on his bike and looks forward to better mobility on his lighter leg.
Just over a year ago British orthopaedic surgeon Steve Mannion of Global Clubfoot Initiative came to our clinic in Puerto Princesa, and conducted a Ponseti workshop attended by the Staff of Bahatala (BPT’s Unit) and health workers from the government and private sector. He was joined by Dutch Physiotherapist Michiel Steenbeek. Michiel has devised a low-cost abduction brace to complement the Ponseti treatment.
As a result of that visit the BPT’s clinic was established as the leading source of clubfeet treatment in the province. A local orthopaedic surgeon who attended the workshop generously committed his services, and a regular Clubfoot Clinic using the Ponseti method was launched. Pirani scoring (a simple tool for measuring the severity of each component of a clubfoot at presentation and for monitoring progress) is strictly observed by the treatment team. Abduction braces, an important part of Ponseti treatment, are now produced regularly in the BPT workshop.
A major problem was how to get clubfeet babies to come to the clinic and return regularly for the series
of casting. Villages are highly dispersed among 23 municipalities, and repeat travels to attend treatment are an added burden to families’ already meager resources.
A large number of births still happen at home, attended only by local “hilots” (traditional birth attendants with no obstetrical training). Consequently, there is poor monitoring of clubfeet or other birth abnormalities. There is even poorer access to health and rehabilitation services. In many cases parents of children born with clubfeet would regard them as the family’s providence. Some would believe that such providence should not be interfered with.
A boost to the Ponseti program was endorsement by the Provincial Government’s Health Office. It mobilized its network of Rural Health Units to help track newborn babies with clubfeet. A poster campaign was launched to promote the availability of free treatment in the BPT clinic.
These efforts have so far resulted in reaching 31 new clubfoot cases over the last 15 months. Seventy (70) percent of these babies have come from far-flung villages, which would indicate that the campaign is working.
The goal of the program is, ultimately, to reach every newborn with clubfoot and support the families to comply with treatment. Financially burdened families are helped with travel costs with funds procured from local supporters. Without this extra help, many of these families would abandon treatment as soon as their resources are used up.
The Story of R
R’s story, like many other stories of children born with disabling conditions in difficult circumstances, is a very inspiring one. She was born at home attended only by traditional birth attendant or “hilot”.
R’s mother recalls that when she was born she looked like a “mummy” with her arms folded across her chest. Theirs is a tiny remote village at the foothills of the southern mountains, far from the capital where she was told to go for consultation, for there was something odd about the baby. But she never could find the spare money to travel.
As a baby R was alert and curious. She moved around their bamboo floor on her back, pushing herself with her buttocks. When she was 4 years old, she wanted to go to nursery school just like the other children she watched from her window. Her mother carried her to school, and there she sat in a chair for the whole day until it was time to go home.
When the BPT Outreach Team went to her village, her mother wondered if she could ask for a wheelchair. Instead of a regular wheelchair, Reymon of the BPT workshop (his story was featured in the March, 2012 issue of the BPT Newsletter, see below) constructed R a made-to-measure special chair on mountain bike wheels, complete with a foldable desk.
Now her mother wheels her to school and the same chair works as her school desk. She can also come out to play, with her school mates pushing her special chair.
R was determined to do other things her school mates do. With a bit of help from her mother she taught herself how to write. As she has no useful hands, she first tried to write using her feet, but that didn’t work. Soon she discovered that she could actually use the corners of her mouth to hold a pencil. Her proud mother tells us how most of R’s new-found abilities to write came from her own hard work and determination.
Newsletter spring 2012
The Story of Reymon
Reymon, the eldest son of nine children, was born in 1978 in the remote island of Balabac, in southern Palawan. His father was a kaingero (slash and burn farmer). When Reymon was 13 his father fell ill with a mysterious illness. He became intolerant to daylight and could only tend to his fields in the moonlight. His skin erupted in sores and he gradually became more sick and lethargic. Eventually Reymon’s father had what appeared to be a mental breakdown. Local doctors were baffled and the family could not afford to seek further medical care. They turned to local faith healers who believed he had been cursed by wicked spirits but none of their “cures” worked either. Reymon stopped schooling at Grade 6 and effectively become the family’s main breadwinner. His mother helped by washing other people’s clothes, and the older sisters worked as servants.
When Reymon was 18 another tragedy struck when he was pinned down by a giant balete (fig) tree as he was clearing a field. The journey to the main hospital in Puerto Princesa took a five-hour boat ride to the mainland and then another six hours’ travel over land. By the time he got there his right leg had to be amputated, high above the knee. The family was devastated. Not only did they face a future without their main breadwinner, but they had already spent a lot of money for travelling and hospital expenses for Reymon.
In hindsight Reymon believes it was fate that this tragedy brought him to the BPT’s Orthopaedic and Rehabilitation Centre in Puerto Princesa, Palawan, but when he arrived there the future looked bleak. After his amputation, Reymon’s mental health deteriorated. The shock of losing much of his right leg and the prospect of being disabled and unable to work, and becoming an added burden to his already struggling family was too much to bear. Reymon contemplated suicide.
With the BPT’s help, Reymon’s medical needs were met and he was fitted with his first artificial leg. Its Prosthetic Workshop technician (the sole provider of this service in Palawan) faced a big challenge as Reymon’s stump was quite high, almost reaching the hip. A special knee joint had to be ordered from Manila. While awaiting his artificial leg to be completed, Reymon begged for something to do. We wondered how he could be useful, at the same time we wanted to get Reymon’s mind off his darkening thoughts, so we decided to let him assist our carpenter who was making bookshelves at that time. Before this, Reymon had never handled any carpentry tools in his life. He was made to sand pieces of wood to start with, for this required very little skill.
Sanding wood turned out to be the start of a new and rewarding career for Reymon. Now, 20 years later, Reymon is a very skilled carpenter. He is a regular staff member of the BPT’s unit in Palawan, held in high regard by everyone in the organization. They are always proud to show visitors all the beautiful tables and shelves that he has produced for the office and clinic. His work is of high standard. But even more satisfying for Reymon is making special chairs and standing frames for disabled children. Together with the BPT’s physical therapists, he designed a special chair on wheels for very disabled children. The staff have christened it “Reymon’s Chair”.
Reymon’s skills do not stop at carpentry. He trained as a wheelchair technician in Tahanang Walang Hagdan (House Without Stairs) in Manila, a producer of wheelchairs and other aids for the disabled, all staffed by persons in wheelchairs. The results of this training can be seen in the various wheelchair adaptation projects that he has been involved in, for and by disabled people.
Reymon’s road to rehabilitation has been an inspiring one. He may walk with a slight limp but otherwise one has to look closely to notice that he has a disability. Being a disabled person himself has made Reymon more acutely aware of other disabled people’s needs.
Reymon’s father has long passed away, his mother has gone back to her hometown in the Philippine’s mainland; his other siblings now have families of their own. Reymon is married and has a 7-year old daughter who is in Grade 1. He dreams that his daughter will get the education that was denied him. But perhaps Reymon does not realize fully yet that he HAS had an education. The many skills he has acquired take a lifetime to achieve. Reymon’s skills are very precious and his presence on the BPT team is very valuable.
Newsletter Spring 2010
The British Palawan Trust’s Orthopaedic training program started 3 years ago. With a decade of orthopaedic practice behind us we began to develop a basic course designed for Palawan’s frontline health workers. The doctors are general practitioners in primary hospitals and the nurses serve village health clinics and often by necessity, assume the role of clinic doctors. Our aim in general was to provide some Orthopaedic knowledge that will be useful and relevant to frontline health providers. There was no illusion that specialist services were going to be unnecessary, but the reality was that these services are rarely available and often, there are services that non-specialists can provide.
In the Philippines, as perhaps in much of the developing world, Orthopaedics is not given a significant share of training time in medical and nursing schools. This is partly because it is presumed that such cases will be best dealt with by specialists. Yet even in the rural areas, such as most villages in Palawan, orthopaedic cases abound, trauma being the most common source. Local doctors and nurses are often at a loss when presented by even the simplest of fractures or dislocations. The specialists, mostly in private practices are far away in the city clinics and hospitals. The result is often non-treatment and neglect, or patients consulting the village quack or “hilot”, which often makes matters worse. On the other hand, the costs for orthopaedic treatment in the Philippines can be prohibitive. People would often borrow money, or would resort to pawning or selling their property, with devastating results for the family’s finances.
Doctors and nurses have separate courses, with doctors getting special training in bandaging, plastering and simple casting, The course starts with basic science and then understanding how fractures heal.
Hence participants discover that closed fractures with acceptable or reduced displacements or angulations heal naturally. They are taught how to recognize common fractures without x-rays (as there are none where they are). They are taught to recognize cases which they need not refer, or to prepare patients for transport if they need specialists’ attention. They are taught that open fractures should be properly washed and cleaned before packing them off for referral. We teach applications of splintage using banana stems (for these are abundant everywhere), the use of slings, collars and cuffs, crutches and other orthopaedic appliances.
We teach how to elevate injured limbs even during transport (ambulance services are scarce and patients are usually transported in public vehicles). We teach rehabilitation exercises that can be done at home, how to ease sore backs to save patients with non specific back pain from further aggravating travel, and so forth. Then there are misconceptions to correct. For instance families used to wait for a year or so before referring babies with clubfeet; now the health workers have been urged to send these babies to us upon birth.
The BPT has aimed to reach frontline health workers in all of Palawan’s 23 municipalities. To date we have achieved 70 % of this target, and the program continues. We could not have done this without the partnerships of local governments and health agencies, and the generosity of you donors in the UK. Indeed the BPT through its NGO in Palawan, BAHATALA, has actively worked with government institutions, to reach more health care providers and in turn more patients who need our services.
Newsletter Spring 2009
When Maria (not her real name) was born club footed, her parents decided against treatment. She was 22 years old when she approached the British Palawan Trust for help. All of her adult life, Maria was shy and insecure about her appearance. She loved to sing, but was too self conscious and ashamed of her deformity to perform in public.
She could not even wear a pair of shoes.
One in every thousand babies born worldwide suffers from Congenital Talipes Equino Varus; otherwise known as “club foot.” For parents in Palawan with very limited finances, traveling to orthopaedic services in Manila is out of the question. There would barely be enough money to feed the entire family, let alone make a journey of such great expense. So many babies in Palawan were left untreated, and grew up with their deformities, learning to walk barefooted with their club feet. There was a widespread, rather compensatory belief among rural folk that club footed babies were symbols of good fortune to their families, a blessing from God. Maria’s parents did not seek treatment for their baby believing that it was God’s will.
In 1992 the British Palawan Trust began providing orthopaedic services to Palawan. Many times we sought out clubfoot babies in their villages and homes, learning about them from hearsay. People are afraid of hospitals because of how much they may be charged for treatment. Thanks to the generosity of our donors, we offer our services for free. The many costs, from the basic materials to the surgery, and the anaesthesiologist’s professional fees, are covered by the BPT. Club foot treatment is a long-term, ongoing process. Often transportation costs have to be provided to ensure that patients are returned for their follow up appointments (which can be numerous).
With the Ponsetti method, club foot is now easy to treat if serial casting is started early. Surgery is not required except a percutaneous Achilles tenotomy in a few cases only. This is a quick out-patient procedure done with topical anaesthesia on a mildly sedated baby. Our youngest patient, therefore done without surgery, was only an hour old: that is the ideal with excellent results and after two or three weekly change of casts only.
In 1992, however, there were club feet in our clinic in virtually every age group of the local population. They presented to us; in many instances we went to them, late. So a lot of corrective surgical procedures under general anaesthesia had to be performed in the operating room, followed by serial casting.
For ambulant children, more so when older or as young teenagers, casting has to be with fibreglass because they walk full weight bearing in their casts; POP or Plaster of Paris is not strong enough. Not only is it expensive, fibreglass casting material is also not available in Palawan so this has to be procured outside (in our case from a supplier in the UK). Afterwards some of the older children and the young adults need the skills of our orthotics technician for braces and special shoes. This manufacturing service is the only one of its kind in Palawan.
These days most of our club foot patients are babies and toddlers. Maria was a rare case. During her many and necessary physiotherapy sessions Maria became friends with our clinical staff. She sang at one of our Physiotherapists’ wedding and is now regularly invited to sing at such occasions. Because of her successful treatment, Maria was able to live out her dream of sharing her beautiful singing voice with others.
J A Socrates MD FRCS Ed
Newsletter Summer 2008
Treating children with congenital anomalies is vital to our work. Our growing links with government rural health units and social welfare agencies have meant finding more of such children.
The October 2006 issue of our newsletter featured a teenage girl (Lee) born with her big toe tethered to a constriction band on the ipsilateral ankle. Her affected foot is now plantigrade and she wears normal (not special) shoes to school.
About a year ago we met Jay, a girl just under one year, with a constriction band and a badly distended foot, which I suspected was Proteus syndrome (so named for the Greek Proteus, the shape-changer who guarded Poseidon’s seal herd). This is a disorder of bone and soft tissue overgrowth which changes a part, or the whole of the body’s shape and size, to abnormal, even bizarre shapes and dimensions. In 1986 MM Cohen postulated that Elephant Man had Proteus Syndrome rather than Von Recklinghausen’s Disease.
We had not had another constriction band case that required amputation until Jay was brought to us by her mother. It was Jay’s first visit to a doctor; her mother had never seen a child with such an abnormality and she had assumed treatment for this would be more than she could afford. Jay had already started to walk using her gigantic foot quite well. But now the gradual enlargement of the foot had reached a critical point in which the blood supply was no longer sufficient for it. Jay was febrile, restless and irritable, and would not stop crying. The huge foot was swollen, cyanotic and painful if touched.
We emailed her x-rays and photographs to Mr. Deliss in Ipswich, and he agreed that the foot had to go. Thus Jay, right before her first birthday, became our youngest amputee and beneficiary of our prostheses workshop. We now expect Jay to grow up walking normally with her artificial leg. She will of course, like all our young amputees, need changes of the prostheses as she grows.
.We continue to encounter children with congenital anomalies who are appropriate candidates for prosthetics. In most cases they live in remote areas, and their parents had never hoped for anything beyond seeing their children crawl or perhaps through some lucky chance, procuring wheelchairs for them.
With your generous help we are able to make a tremendous difference in the lives of these children. Thank you very much,
Also in the summer 2008 Newsletter was this piece written by our Canadian VSO Physiotherapist.
Message from a VSO Volunteer:
A year ago I understood very little about global health concerns. Although I had certainly heard stories of limited resources, unanswered health needs, I appreciated little of the real experience. This changed over the last year as I worked at Bahatala as a volunteer Physical therapist. My assignment was to participate in daily work with the other therapists, to mentor, learn, and provide treatment. This was made easy, despite challenges of language, climate, and cultural differences, because of the genuine care and enthusiasm of the staff. After 19 years working in Canada, I felt stagnant and was no longer interested in being a physical therapist. I wanted something more rewarding. The work at Bahatala provided the environment for a renewed passion for health care, and helped define my role as a physical therapist.
Becoming part of the Bahatala team meant becoming part of the dream of Dr. Socrates to help the people of Palawan. To be part of a dream in action is very rewarding; mission statements, objectives, and goals are no longer the nice words that describe an organization; they are instead the working intentions and guidelines that bring the dream to reality. I was to work embracing the philosophy "Appropriate Orthopedics". How could I contribute to the people of Palawan so they could receive maximum care despite limited resources?
Teach, empower, reassure... these were the skills and the practice I could focus on. This is a big part of appropriate orthopedics, and it is also the key to appropriate rehabilitation in Bahatala. These skills are greatly valued by Dr. Socrates and the staff. With poor access to ongoing education, the therapists’ ability to expand on their professional knowledge is limited. This was the gap I was to work with. To gain more understanding I first focused on working with the patients. Although the therapy work itself was just an ongoing expression of the 19 years of physical therapy work I had already done, the look in patients’ eyes as they began to understand their problems and treatment was the renewing force that brought passion to what I was doing. At the same time I was learning simple and direct orthopaedic management of broken bones, dislocated elbows, club feet -- the list goes on. The body heals itself, but it needs to be assisted with good alignment, balance, and the exercise for each situation. After that we can let time and physiology be the healing forces. So with this intention I continued treating patients and mentoring the therapists.
After one year, my contract was finishing and I reflected on the blessings I had received, with the support of Voluntary Services Overseas (VSO); inspiration and encouragement from my patients as I worked to empower and treat them. The staff welcomed me into the work place with so much enthusiasm that I now feel completely a part of Bahatala. I gained added appreciation for the wonders of our bodies as I watched appropriate orthopedics in action. I am very grateful to Bahatala, and to you, the donors of the British Palawan Trust for it is with your financial support that Bahatala exists. I hope you may one day travel to Palawan and see Bahatala for yourselves. I went home rejuvenated, and inspired, and my dreams include return visits to Bahatala.
P.S. The Newsletter also had details of how to donate (See How to Help)
News Letter October 2007
In the February 2006 issue of the Newsletter we featured two very disabled men striving to improve the quality of their lives. In this issue we report on how disabled workers help to make education possible for others who would otherwise be deprived of it.
Every child in the Philippines has a constitutional right to free education; yet a disabled child who is unable to walk would invariably grow up deprived of this basic right. Since 1991 the Philippines has had a Magna Carta for the Disabled that provides the disabled child, among others, with “adequate access to quality education”.
The reality is for disabled children in the rural areas going to school are a daunting prospect; in most cases they simply are unable to reach the school premises. There are no school buses and the usual “public transportation” (these would be motorbikes with sidecars or tricycles) are scarce and costly. So it is the norm for pupils to hike several miles to school and back. For a disabled child a determined parent would have to resort to carrying the child to school. The roads in these areas are mostly unpaved and in the rainy season, full of mud pools. Wheelchairs, if possessed, are rendered short-lived under such conditions.
A solution to this situation was to manufacture pushbike tricycles in the workshop of the BRITISH PALAWAN TRUST in Puerto Princesa. Our able disabled workers, who were themselves deprived of formal education, put their skills to test to craft this mode of transport: hooded sidecars were assembled from scratch and attached to sturdy mountain bicycles. These muscle-powered vehicles are custom-built to particular requirements, are cheap to maintain and do not harm the environment.
Community Based Rehabilitation: Training Workers
A province-wide training program to equip community health workers with basic skills in appropriate orthopaedics and rehabilitation was launched at the start of 2007. Its training sessions are tailored for government health personnel in Rural Health Units or RHUs; ultimately it aims for the prevention of disabling conditions that result from ignorance and the inaccessibility of appropriate medical and rehabilitation services. Seventy one or about 1/3 of the provincial total of 240 midwives and nurses running the RHUs have now finished the 3-day training sessions conducted by Dr Socrates and the staff of BAHATALA (the Trust’s local partner in the Palawan). The program has the support of the Provincial Health Office and the local governments of 23 municipalities in Palawan. The British Embassy in the Philippines has made significant contributions to the program. Eventually, the program aims to cover all essential rural health workers.
VSO (Voluntary Services Overseas) Collaboration: In April 2007 a senior physiotherapist from the United Kingdom’s VSO Program in the Philippines, Ms. Angela Vetra, joined BAHATALA for a year’s placement. She is tasked with providing skills transfer through training and continuing professional staff development. She works directly with patients and provides regular tutorials to Bahatala’s staff – and teaches a Pilates class on her spare time!
This year the World Health Organization has honoured Dr Socrates with the 2007 Sasakawa Health Prize for “outstanding innovative work in health development”. He shares this prestigious Award with the British Palawan Trust, its Trustees and its generous donors. He believes that the achievements that have earned this prestigious Award could not have been made possible without your sustained support of the BPT for over a decade.
Thank you very much.
Dr. Jose Antonio Socrates, MD, FRCS Ed.
News Letter October 2006
In our last issue we featured 2 severely disabled men who worked together in BPT’s Bahatala Rehabilitation Workshop to convert a wheelchair into a tricycle for disabled persons. In July during the Philippines’ “Disability Week”, the Workshop organized a much-needed wheelchair maintenance course for wheelchair users and their families in Palawan. It was the first of its kind in the province and there was much appreciation for the practical knowledge gained in the training. This was entirely an affair for the disabled, with disabled people as tutors, facilitators and participants.
Milestone: training program:
One of the main goals of the British Palawan Trust (BPT) in the Philippines is to develop appropriate training programs for health workers for the care of the disabled and for the prevention of disabilities. A major step towards achieving this goal was the construction of a new training facility in Puerto Princesa outside the hospital compound, on a piece of donated land. The BPT Chairman, Louis Deliss, along with key representatives of local government and non-government agencies (including the Provincial Governor) attended its inauguration in April 2006. Since then the building which can house small groups of up to 35 participants, has hosted training courses and conferences and has become the venue for meetings of organizations of Persons With Disability (PWDs).
An unusual case of a rare anomaly:
Constriction Bands: there is no published statistical data in the Philippines, and little elsewhere in the world on this congenital anomaly. However, Louis Deliss, BPT Chairman, has observed quite a number of cases he has seen on his many visits to Palawan. A rather unusual case was that of a teenage girl, Lee, (not her real name) who was born with most of the fingers of both hands fused together (an anomaly called syndactily). Her toes were also fused, but the tip of her right big toe was fused as well to her shin. Where the toe and shin were fused, the skin was deeply furrowed all around the shin, a constriction band: an anomaly of the soft tissues. That also means that her ankle and heel had to be flexed at an extreme upward angle so the big toe could reach the shin.
Lee was born with normal bones but as she grew up, the configuration of her affected foot and ankle imposed abnormal forces on them and shaped the way they grew. So it was important that her right big toe should have been separated early on from the shin, releasing the foot and ankle to allow them to grow normally. When she was born thirteen years ago in a rural part of Palawan she was seen by a local doctor who advised that she be brought to a medical centre in the capital city, Manila. However, this was an undertaking the family simply could not afford. So Lee grew up with her bizarre condition; fortunately, it did not stop her from attending school. However as she could wear only one shoe, she walked with a limp and could not manage long distances.
What Lee needed was a very simple operation. What was done to her on April 2006, during school break, was what should have been done for her when she was just a baby. Under local anaesthesia the skin-covered tube of soft tissues tethering her big toe to her shin was divided. Then, through serial casting – with fibreglass since she is heavy and ambulant – the freed foot was slowly brought down to plantigrade. It was all so simple; Lee didn’t have to wait 13 years to have that done for her. She even sat up on the operating table to watch as I, the surgeon, used a scalpel to cut her foot free! Lee never had to stop schooling while on serial casting and now she is ready to wear a pair of shoes, custom-built in our workshop, for the first time in her life - thanks to the British Palawan Trust.
While Lee’s girls’ congenital anomaly is rare, the neglect and disabling consequences that she had to endure for a long time is not uncommon in the Philippines. Indeed we see many such patients when we go out visiting communities. Often they have opted to live with their disabling conditions fearing that a trip to the doctor or hospital could only mean expenses that they cannot possibly afford.
Your continuing generous support of our project in Palawan is ensuring that cases like Lee’s are helped.
Thank you very much,
Dr Jose Antonio Socrates FRCS Ed
Photos of Lee, her foot and her operation are in the gallery
Patient Story from Spring 2006 News Letter
Two young men are working intently on what looks like a bicycle wheel, balancing it on a paint-stained worktable cluttered with small tools and machine parts. One of the men, Fernando, discovered early on that he had real expertise in repairing, fixing, and building things, although he never studied as a child; he had polio at the age of five, and his withered legs and disfigured back made it impossible for him to go to school. But at the moment he is thinking only of the wheel he is working on, and how to attach it to the contraption he is helping the other man, Dexter, make.
Dexter lost both his legs when he was accidentally electrocuted, while attending to the downed power lines of his employer’s house.. His limbs burned beyond repair. He is young and was cut down in his prime; it was a difficult transition. He was given a wheelchair as a parting gift from his employer, which, in the tropical Philippine climate, and with no opportunity for maintenance, soon turned rusty and dilapidated. It functioned not much more than a big chair with wheels.
Fernando and Dexter met in Bahatala where they started separately as “patients”- although the word doesn’t seem to fit, as they are certainly not simply “administered to”, but take an active role in bettering their own lives. Bahatala’s workshop facilities are open for use for people like them. It is the only workshop of its kind in Palawan.
They are working here, in the well-equipped workshop, working on their own volition on a contraption that will give Dexter new mobility – for Fernando knows from his own experience that mobility and some degree of self-reliance are worth aspiring for.
Fernando built his first wheelchair, years ago, after many idle hours in his cousin’s welding shop. He lived in a remote village north of Puerto Princesa but discovered Bahatala’s workshop when one of its community-based rehabilitation workers brought him to Puerto Princesa. Shortly after that Bahatala sponsored his training in Manila’s Tahanan Walang Hagdan (or House Without Stairs, a pioneering rehabilitation workshop managed entirely by wheelchair users). Now, Fernando has become an expert in wheelchair matters and has become Bahatala’s valued adviser.
In the course of working together with Dexter, Fernando shared more than his practical skills in assembling and maintaining wheelchairs. Fernando shared with him his disabled life’s many lessons, and triumphs. For Fernando has positively risen above what many in our society see as an impediment to a productive life.
The Bahatala Rehabilitation Centre Workshop in Puerto Princesa, Palawan has enabled many disabled persons to improve the quality of their lives. The Centre has become a place where disabled people are welcome and where they come into contact with one another. Here they discover what they can do for each other.
Bahatala, its workers and patients, and its workshop, are all supported primarily by the BRITISH PALAWAN TRUST.
Thank you very much,
Jose Antonio Socrates, FRCS Ed
PS There is a photo of Dexter in the Gallery.