The Centre for the Rehabilitation of the Paralysed (CRP) was founded by a young, British physiotherapist, Valerie Taylor. Valerie came to Bangladesh (then East Pakistan) in 1969, working for VSO. As one of the first physiotherapists there, she was horrified by the lack of care for paralysed and severely handicapped people. Hospital patients were dying or being condemned to permanent immobility for lack of appropriate treatment, and disabled people were frequently rejected by their relatives.

With a group of three Bangladeshis she set about providing effective treatment for spinal cord injury (SCI) victims, helping them lead active and purposeful lives. In 1979, helped by OXFAM and other charitable donors she started CRP, initially for four patients, though this quickly increased.

Now, 25 years later, a 100-bed hospital in Savar is their headquarters. There they have numerous wards, an out-patient clinic, X-ray department, pathology laboratory, operating theatres, mother and child unit, special needs school, metal and timber workshops, special seating unit and orthotics production unit. It is still the country’s only training centre for occupational therapy students. CRP also has several sub-centres: CRP-Gonokbari, 15km from Savar, is a centre specifically aimed at providing vocational training for homeless, paralysed women; CRP-Gobindapur is a physiotherapy day-clinic for children with cerebral palsy (CP), located in scenic, forested surroundings in northern Bangladesh (near Sylhet); CRP-Mirpur is a new diagnostic, medical and therapeutic centre on the outskirts of Dhaka.

CRP staff, patients, students and volunteers all work together to realise the centre’s objective – ‘Ability not Disability’.

Bangladesh
Bangladesh is a beautiful country; a land of contrasts. It is fertile, and everywhere banana trees, bamboo, sugar canes and coconut palms line the streets. Yet frequent floods and subsequent loss of crops and property make Bangladesh one of the world’s poorest countries.

I was there for the monsoon season: 95% humidity, temperatures of 30-40ºC, hot sunshine interspersed with torrential downpours, and severe flooding. Bangladesh is at the end of the flood path, so, when the rains come, it is one of the worst affected. The people told us, “Today India has opened the flood gates. Tomorrow Sylhet will be flooded; we (in Dhaka) will be flooded by Tuesday.” Yet there was no bitterness or outrage in their voices – this is simply and quietly accepted as ‘how things are.’
Bangladesh is very flat, but people have banked up the roads (many just dirt tracks) in an attempt to stop them from being flooded. When the floods come, not even the roofs of the houses can be seen above the water. Villagers then erect small tents along the roadsides – tents from bamboo and plastic sheeting to house their families, animals and other worldly possessions. This year 60 million people were made homeless by the floods – more than the total population of the UK. Yet, hardly any mention was made in the UK press.

During the floods I visited a flood-relief programme run by CCH (the Community Centre for the Handicapped). Two hundred disabled people were given rice, money and medicines, because, as I was told, the state seems unable to provide help for disabled flood victims.

Bangladesh is highly overpopulated. Its people live in extreme poverty. Yet, untouched by television or mass-tourism, they are a wonderful people – open, welcoming, hospitable and truly generous; curious and unfamiliar of westerners. Everywhere I went, people would greet me in the street with the phrase, “Hello sister! Your country, please?” A seven-year old boy I treated, after overcoming his initial fear of meeting a white person, asked me “Why did your skin fall off?”

The less people have, the more they give. Village women would invite me into their homes – single-roomed buildings, constructed from whatever was available: corrugated iron, woven bamboo, mud, or stone. Most were without running water or electricity.

They would call together their neighbours so all could meet the ‘bideshies’ (foreigners). They would put together everything they could find, to welcome us: biscuits, jackfruit, a glass of juice, or cup of tea. All the while, one of the daughters would stand in the centre of the room, spinning a circular bamboo fan above her head, to cool us, and to keep away the flies and mosquitoes.

The towns are overcrowded, noisy and colourful. Supermarkets hardly exist, but everywhere market stall holders call “Sister, mangos?” or “sister, three-piece?” (the traditional dress for girls). Young boys approach with baskets of ‘amra’ (sour fruits, served with salt and chilli powder) or knickknacks for sale. If you want chicken for dinner, you buy it live and carry it home still flapping its wings.

It is a sensory overload: you are constantly surrounded by all the vivid colours, smells and noises. Roads are overcrowded with bicycle-rickshaws, pedestrians, baby-taxis, goats and cattle, cars, buses and lorries, all hooting or ringing their bells. Decomposing rubbish lies on the edges of the highways; power cuts lasting five or six hours are a daily occurrence; water cuts are frequent and can last for days at a stretch.

Many of the villages can only be accessed by rickshaw, but even in towns many roads are no more than dirt tracks, regularly flooded and severely potholed. Buses can be very overcrowded, and people often travel on top of them, or in their open doorways.

Manual labour is cheap and readily available. Men can be seen, squatting in the full sun, breaking bricks and stones with small hammers.
Others carry the broken stones in baskets on their heads to waiting lorries. The chippings are used to for road repairs and building foundations.

Buildings (concrete blocks of flats) are erected essentially without machines. Bamboo scaffolding and folded steel reinforcement rods are transported on water-buffalo drawn carts, or on flat-bed rickshaws. On delivery, the steel rods must be hammered straight: two men squat by the bend in the rod; one holds the rod still, while the other raises a large mallet above his head to strike it. The flow of workers unloading sand, broken stones and goods from boats or lorries looks like a stream of ants moving purposefully, in line, from the source, down a gang-plank, to the sand-heap. At the source women fill the
empty baskets and lift them onto the men’s heads. At the sand-heap, a single motion (combining a bow from the hips and a twist of the wrists) empties the basket without removing it from the head. Concrete floors are produced by covering the area in a layer of brick-chippings, spraying them with water, and then tipping the sand and cement powder onto the damp chippings.

Outside the towns you quickly reach paddy fields, where children pick rice and cattle-
feed into long, flat boats, and men use water-buffalo to plough the fields and transport their goods to market. Boys fish from little traditional fishing boats, or they man nets, lowered into the water on delicate bamboo frames. Women squat at the edge of water-hollows, washing themselves and their clothes, while young children play in the water beside them.

Disabilities
The main causes of paralysis in Bangladesh are road accidents, falls from buildings and fruit trees, and accidents whilst carrying heavy loads on the head. Disability is therefore most common amongst the poorest faction of society – those who earn their living through manual labour, or who travel frequently by bus or as pedestrians. Outside CRP a number of posters have been erected: ‘Drive on the left!’ and ‘Do not get on or off moving vehicles!’ One of the first words of Bangla I learnt was ‘Asté!’ which means ‘Slow down!’

Disabled people have few rights. They are often felt to be a burden to their families and to society. A young disabled women told me,

“I have no life, no future. I’m waiting to die. Since my accident people think I am a burden to them and to society. My mother has become ill with worry, and my father has developed diabetes since my accident. They worry what will happen to me when they die. There are no provisions or facilities for disabled people in Bangladesh.
“I live in my own room; I work, I do my own cooking and my washing. But I have no friends, and no-one will ever marry me, because they believe I will be a burden to them. They don’t give me a chance.”

The lack of provisions or facilities for severely disabled or paralysed people makes independent living essentially impossible. Most roads are impassable for wheelchairs; disabilities prevent victims from returning to their previous jobs (typically manual labour), and most have had little or no formal education. Often their best chance of employment is to become self-employed, so CRP provides training in embroidery, tailoring, electronics and shop-management.

Women, becoming disabled, are often deserted by their husbands, and without family or other means of support, many are condemned to begging. In towns beggars, many of them crippled, can be seen on every street-corner. Beggar-women with crippled children in their arms teach the children to touch you, catch your eye and cup their hands to beg even before they have learnt to speak.

It seems to be a common belief (though unfounded by any religious scriptures) that disability is a punishment from God, and therefore that disabled people should not be helped. Until such attitudes can be changed, there is little hope for the disabled Bangladeshi community at large.

In addition, in a country where so many people live on the bread-line, employers are understandably reluctant to employ disabled staff whilst able-bodied workers are readily available.

CRP
CRP provides a full rehabilitation programme for its patients. Most inpatients are SCI victims, who spend their first couple of months in traction beds. After traction, patients with arm function are transferred onto trolley-beds. They lie, face-down, supporting themselves on their elbows,
and propelling themselves around to attend their various activities. I helped running an art class for such patients while their teacher was on leave. One of my first projects at CRP was to make a bookstand for a university student, to enable him to study his textbooks whilst in traction.

Many will finally be given a wheelchair. CRP has a ‘half-way hostel,’ where patients are taught to live independently again – through classes in wheelchair skills, shop management, tailoring, electronics and gardening.

CRP-Gonokbari is a sub-centre specifically for women, where they learn tailoring, embroidery, weaving or shop management, to allow them to earn a living. Many are given special low wheelchairs so that they can continue to wash and cook at ground-level.

CRP trains physiotherapists and occupational therapists, but the country at large still does not recognise the need for these professions. While I was there, the physiotherapy students held large demonstrations and went on strike because they wanted to use the title ‘doctor.’ For westerners their arguments were difficult to comprehend, but in Bangladesh status is very important. Doctors are respected; physiotherapists are not.

CRP Orthotics Production Unit
I arrived at CRP two weeks before a Dutch prosthetist and orthotist, Bert van Koll was due to leave. Bert worked for the International Committee of the Red Cross – Special Fund for the Disabled (ICRC-SFD). He helped CRP set up their new ‘Orthotics Production Unit.’ Whilst I was there, Bert trained two of the technicians to produce ankle-foot orthoses (AFOs). The technicians were completely new to the subject, and spoke very limited English (the language of tuition), so at the end of the fortnight Bert asked me to take over running the unit – to give some theoretical training and to supervise in AFOs production.

Despite having studied the ankle in detail when I designed a total ankle replacement (my fourth-year MEng project), I felt daunted by the prospect. However, Bert had taught me a lot in my first fortnight at CRP, and the technicians were diligent in their learning. I would come back after lunch to find them copying out the posters I’d made them time and time again until they knew the work.

To produce an AFO, the first job is to assess the patient. AFOs hold the ankle rigidly at 90º. This helps if the ankle is flexible but can’t be independently flexed (‘drop-foot’), or, with limited success, to correct twist (inversion/eversion). However, if the ankle is not flexible, an AFO will be of no use.

CRP treats a large number of CP children, who characteristically walk on their little toes (‘plantar-flexed and inverted’). Although AFOs can be used for such children, production is complicated, and children quickly grow out of their devices. We therefore concentrated on stroke and SCI patients.

The first step in production is to take a plaster cast of the ankle. This ‘negative mould’ is filled with plaster-of-Paris, to produce a ‘positive mould’.
A transferable marker is used to mark key anatomical positions on the calf and foot – the heads of bones which might, if subjected to pressure, lead to pressure sores. The positive mould is modified to relieve pressure in these areas (plaster addition) and to increase pressure on soft tissue (plaster removal). The mould
is then ‘finished’ using metal gauze and sandpaper.

The AFOs are produced from polypropylene (a thermoplastic). When the mould is dry a sheet of polypropylene is heated and draped over it. We would then apply suction to the mould for a good fit. Finally the moulded polypropylene is trimmed to the desired shape. During fitting sessions it is sometimes necessary to reheat and bend the AFO to increase or decrease the pressure in localised regions. Velcro straps are then attached.

In Bangladesh most things are taught by repetition. People are very good at ‘learning-by-heart’ and following commands, but they are reluctant to take any initiative. At first I found this frustrating - you had to spell out every word – for example, during the draping phase a rectangular sheet of polypropylene is removed from the oven at 200ºC. It is draped over the mould, sealed and trimmed. To buy a little extra time, the ceiling fans are turned off (to slow the cooling process). Initially, when I asked the technicians to drape a mould I would first have to instruct them to measure the size of the polypropylene needed. Twenty minutes later they would tell me they were ready to drape the polypropylene, and would open the oven door, at which point I’d realise that they hadn’t got out their gloves, their scissors, a knife, any elastic cord, or turned off the fans!

Nevertheless, when you get used to this you begin to understand that it is simply a different way of working. The technicians are not being stupid – they are simply doing what you have asked – no more, no less. There is great respect for authority. If you ask for something to be done, criticisms or suggestions won’t be voiced – they’ll just get on with it. Thus you, their manager, are responsible for ensuring everything is done by instructing them in each and every individual task. Bangladeshi managers appear to do very little themselves, but without them nothing is done, particularly when there is a new problem to be faced.

Special Seating Unit
In addition to running the new orthotics department, I spent a significant proportion of my time working with the Special Seating Unit. There, supportive wheelchairs are produced for CP children. The boss, a rehabilitation engineer, also designs assistive devices which the metal workshop manufactures.

As an introduction to this work, I initially spent a couple of hours each morning working with CP children in the paediatric unit. I learnt how to handle them and studied the therapy equipment.

I also spent time in the metal workshop, learning how things are manufactured, and the resulting design constraints. There I produced some back-braces: I cut down strips of iron, hammered them flat, and then into curves (in-plane, i.e. by hammering along the thin edge), judging lengths and curves by eye against a previous specimen. I filed the ends into semicircles, cut the waistbands from sheet metal (by guillotine), and riveted the parts together – and all without power tools.

Coming from the UK, the lack of ‘health and safety’ was shocking! Men worked in open-toed sandals, using safety goggles only for the disk-sanders, and, despite the noise levels, I never saw the ear defenders in use. It seems that the workers simply haven’t been educated in such manners. They were very highly skilled, and accidents were rare. However, one day one particularly friendly man came to
me with a very red eye. Something had jumped into it while he was working. I gently suggested wearing his safety goggles more often, and, after that, scarcely saw him without them. By the time I left, his eye had recovered, but I wished that the other workers would do likewise: their boss hadn’t told them to, so they generally didn’t.

In addition to the things I made there myself, I watched how other devices were made – the tools, materials and methods – what was easy to do, and what would be more difficult. I used the information to design book stands for the traction beds, a cervical collar, a jig for cutting pressure-relieving cushions, a set of parallel bars (to train people to walk with AFOs) and a wheelchair ramp for the CRP ambulances.

Wheelchair Design
CRP’s wheelchairs and special seating chairs (for CP children) were designed by the British charity ‘Motivation’. Their designs were good, but eight years of use have highlighted a number of problems. The special seating chairs have to be returned to CRP every six months for adjustment as the children grow, but many families live in distant, rural villages. Transporting the chairs usually means long journeys. There is little place for a wheelchair in trains or buses – so they are often stowed on the roof. To travel with a large CP child and their wheelchair by rickshaw is a challenge for the whole family!

I was asked to try to modify the design to allow the seat to be removed, enabling the bulk of the chair to be left at home when families return for follow-up.

Rob, another British volunteer, was a mechanical engineer who uses a wheelchair himself. Consequently, he has an intimate knowledge of the technical problems involved. Together we managed to produce a prototype chair which satisfied all the requirements without significant extra cost. Particular challenges arose on discovering that most poor Bangladeshis can’t read, and don’t have access to tools to undo nuts and bolts.

The humid climate causes moving parts to rust quickly. Protective products, like grease, cost money, so are unlikely to be used (even after the need has been explained) and rust-proof materials, like aluminium, are too expensive.

Our final design for the special seating chair used a set of T-bolts to secure the seat and footplate to the frame. The backrest, headrest, and side supports could be adjusted against a lightweight inner frame, which could only be attached to the outer frame in a single position.

We also modified the general-use chair (for SCI adults) to include an adjustable back axle. As the patient becomes more
confident in their chair, they can move their centre of gravity relative to the axle. This makes wheelchair skills easier, but makes you more likely to tip out backwards.

Both the new designs used the same basic frame, to simplify production and increase productivity. When we tested the prototype chairs we were pleased to find that they were lighter, handled better, and were easier to manufacture (allowing for the added complications of an adjustable axle).

Conclusions
I would like to thank the trustees of the Arthur Shercliff and Peterhouse Travel Grants for enabling me to undertake this period of voluntary work in Bangladesh. I had a fascinating time, and benefited from the experience in more ways than I could ever have imagined. It was eye-opening to live and work in a culture so different from our own – where people have so little, but give so much.

I hope that the work I undertook will have made a real difference to the lives of some of the world’s poorest disabled people. However, I know that I have received in return more than I was able to give: I experienced the warmth and hospitality of a people who are afflicted by one disaster after another, and who know the true meaning of ‘poverty’. I watched a child who could barely walk running around playing football after I fitted him with an AFO. I saw the smiles of gratitude from my patients, and received such encouragement and
exclamations of praise from the people I worked with when we handed over the wheelchair designs. And, of course, I made many special friends.

As I was told by another volunteer, “If Bangladesh hasn’t got under your skin, you haven’t been here long enough.” And when I left, I knew exactly what she meant. It had.