The British Palawan Trust

News Letters

The British Palawan Trust

NEWSLETTER

BAHATALA, Ospital ng Palawan, Puerto Princesa, Palawan, Philippines  5300

In the UK: Orthopaedic Department, Ipswich Hospital, Heath Road, Ipswich, Suffolk  IP4 5PD

UK Registered Charity  No. 328651

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please send your name and address to the Chairman. See How To Help

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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.

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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

Dear Supporter,

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,

For photographs to accompany this story go to

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)

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News Letter October 2007

Dear Supporter

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.

For photographs to accompany this story go to

Other News: 

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.   

Volunteer Physiotherapist

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! 

WHO Award

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.

Yours sincerely,

Dr. Jose Antonio Socrates, MD, FRCS Ed.

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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

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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,

                        Yours sincerely,

                        Jose Antonio Socrates, FRCS Ed

PS There is a photo of Dexter in the Gallery.