The awareness of what we can do is the major issue

Fred Holtkamp holds a masters degree in rehabilitation engineering and is associate lector at Fontys University in Eindhoven at the Institute for Allied Health Professions and holds a position as visiting professor at the University of Labour and Social Affairs (ULSA) in Hanoi, Vietnam.
He was involved in a program in Vietnam where students are educated in making and adapting shoes for patients with foot disorders. Now he is researching the possibilities of establishing a similar program also in Africa. In the interview he talks about the difficulties while setting up a program like this and why these programs are so important for spreading the knowledge about professional footcare.

Mr. Holtkamp, you were part of a succesful training program in orthopedic shoemaking in Vietnam. Now there are plans to set up a similar project in Africa. Who transferred the concept from continent to continent?

The idea of starting a project like the one in  Vietnam originated one and a half years ago in the Dutch Leprosy Relief Foundation, Liliane foundation and Fontys  University, which already had supported the project in Vietnam. In their mind, it would have been a missed opportunity if this program were only available in Vietnam and not in other parts of the world. This foundation does a lot of work in Africa and we were discussing whether and how it should be possible to develop and run a program like the one in Vietnam also in Africa.

How did you come up with Tanzania as the country for this training program?

Africa is rather big. Therefore Jan Robijn, the program manager located in Vietnam and I started a desk research what kind of city or country or institution could offer a fundament from which we could start. First we started with an inventory of all kinds of countries. We already had some information from the foundation, because they have people working all over the world. We also used the know–ledge of ISPO to find out about already existing programs.

What we learned from Vietnam and others projects: It is extremely helpful for new programs, if there are already some facilities available and if you can work with people who have already experience in working with assistive devices when you start. If you don’t have to start from scratch it is much easier to take major steps with the program.

What other aspects were important for you?

We also looked at safety in the countries concerned. The teaching staff but also the students who come from other African countries need a safe environment for their education and training.  Although there is the need for help in a lot of countries in Africa, a number of countries are not really safe to work due to political and other circumstances.

Of course, we could not asses the safety situation in all countries ourselves, therefore  we talked to many people who work or used to work in different countries in Africa to find out about their experiences.

What made Tanzania your first choice?

After that first assessment, a few countries remained. Tanzania is one of the countries which is rather safe, has some infrastructure and has an awareness in prosthetics and orthotics and already offers programs in that field, like the ISPO CAT I level program affiliated with a  University. That was in our view by far the best country to start a project like this.

We paid them a visit in an  orientation mission in order to determine  what the most feasible location for the project is, which partner(s) should be involved (institution to base the program, etc.), what a project should look like and how we should locate funds. We were given the opportunity to see all the facilities of the Tanzania Training Centre for Orthopaedic Technologists  (TATCOT) affiliated to the Kilimanjaro Christian Medical University College and located on the foot of the Kilimanjaro.

It was a good program and they have very nice facilities for students and patients. We talked to the people and visited also some companies and organizations like rehab-centers as the Comprehensive Community Based Rehabilitation Tanzania and the USA River Rehabilitation and vocational centre in Arusha where we are able to arrange internships for the students. It was all there!

What were the next steps?

Our main conclusion after our visit to Tanzania was the confirmation that there are a lot of people with foot-problems. And there is a tremendous need for good information about how to deal with foot problems, what you can do with shoes and also about wound care. When we came back to the Netherlands, we presented our plans to the Dutch Leprosy Relief Foundation, explained what we need and what the people in Africa would like to have. The committee of the foundations agreed to all the suggestions we made.

So when do you start?

As soon as we have the money. We are now working on finding the financial resources for the project. That means our major work right now is writing and telling people about this. The program in Vietnam was made possible by the Dutch Postcode Lottery. They funded not only the development of the educational program itself.

Setting up the workshops, buying all kinds or machinery, making it possible for students to come over to Vietnam and be supported in respect of travel expenses and the cost of daily living and the tuition fees for the students was all part of the project funding.

Is the Dutch Postcode Lottery an option for this project?

That is what we thought first. The project in Vietnam was successful and had fine results. But through the Dutch Leprosy Relief Foundation we understood that the Postcode Lottery normally does not fund the same program twice. It is now our challenge to make it possible with other partners.

Which other institutions could support the project?

We talked to the people of the European Union in their office in Zanzibar as well as to the Dutch embassy and some other organisations. They are all willing to help us to find funding for the project. But they don’t have money themselves in Africa. The European Union has funds for projects like ours. But you have to go through a heavy elaboration process which will also cost money.

In 2017 a pedorthic training program for people from South East Asia was succesfully completed. The picture shows a part of the first cohort students after their final project presentations together with a part of the exam jury. Fred Holtkamp (extreme left) is now working to get funding for a similar project in Africa

Are there any institutions in Africa who could fund the project?

What makes it difficult in Africa for projects like ours is a lack of awareness for the problem and the possibilities to help. In European countries there is an awareness of governments as well as of social and political bodies that every person must be enabled to contribute to society. Africa is still in the process of developing this awareness. In many countries people with handicaps are still being stigmatized. In some cases they are regarded as a shame for the family. They are hidden at home and are not a part of social life. They don’t exist. In Asia people are already more involved in this process.

Therefore you first have to work on the awareness of the policy makers, the people in health care organizations and of course of the families that people with some kind of disability are still able to lead their own life and support themselves. It is not just about fitting someone with a prosthesis or an orthopedic shoe. It is also about making people aware that those people are valuable and can contribute to society. This is a secondary goal of our project. This process is ongoing. A number of initiatives worldwide help to address this topic.

Isn’t this a process that may take years or even decades?

That is why we are extremely happy with the GATE-initiative of the World Health Organization (WHO). The vision of this initiative is a world where everyone in need has access to high-quality, affordable assistive products to lead a healthy, productive and dignified life. The fact that assistive technology is now a human right does not mean that this is already accepted everywhere. But the GATE-initiative really has helped worldwide to make people in the healthcare business more aware of what the benefits of assistive technologies are.

Working on the awareness seems to be the hardest part.

Always! This is something that should be worked on with the policy makers. One of our students of the program in Vietnam made orthopedic shoes for a lorry-driver with clubfeet. By doing this, the lorry driver  was not only able to keep his job and earn his income but also to support his family.

These are the cases with which we can show that our work is able to make a difference for people and for the society. Everybody should be able to earn his own income, to live his own life and support himself independently. When a person works, from the perspective of meaning-making, he or she contributes to society and saves the society a lot of money because he or she does not have to be supported by the government. Our profession helps people overcome their deficiencies in mobility. We need more cases like this and we have to tell the policy makers about the results.

Wheras Prosthetics and Orthotics (P&O) is already established in many countries as a profession, pedorthics (orthopedic shoemaking) still struggles to be recognized as a possible treatment of foot problems. Why is that so?

In Europe there is already a long history in helping people with foot problems without surgery. But still: Foot problems are often treated with surgery even if there are orthopedic appliances like orthopedic shoes that offer a solution for the problem that is quite as good or even better. One of the handicaps we have is that the profession of orthopedic shoemaking is from a historical point of view a craftsmanship-profession. The people in the field are really good in knowing what they are doing and knowing what will help and what not.

But they are not equipped to write down what they are doing and how the patient will benefit from their work. If we are not capable to express clearly what we can do with shoes and what their benefit is, then due to lack of knowledge, existing methods like surgical interventions will prevail. We, as a profession and its professionals,  have to do more research. We have to publish more about what we do, how we do it and what the benefit of our work is. That is the task for the people who are already in the field. Our profession knows its own capabilities and limits. But also medical doctors, orthopedic surgeons, other medical professions and policy-makers should know about how patients can benefit from our work.

This is even more important where our profession is not yet known at all. We are important partners and we have to let people know about this. Therefore, there is a huge challenge for organizations like the IVO to make people more aware of this profession. In Africa you will find quite a few children with clubfeet which have not been treated the way they would be treated in industrialized countries. Clubfeet can be treated by a specialized team.  Custom made orthopedic shoes are an important part of the therapy.

But only in a few places you will find the knowledge and the capability to help these children to be able to walk on their own feet properly. In Tanzania we saw a lot of patients and a very nicely equipped P&O workshop in collaboration with the TATCOT at the Kilimanjaro Christian Medical University College. Even 3D-printers were available to print assistive devices. The technology is already there. But orthopedic shoes are not part of the therapeutic interventions.

How are foot problems treated if a specialized profession for the foot is missing?

The problem is: If people don’t know what they are missing, they won’t miss it. Once you know about the benefits of shoe adaptations or custom made orthopaedic shoes and orthotics for people with mobility-problems then you can move forward in helping those people. That is what we pointed out very clearly when we wrote the application for the Dutch Postcode Lottery. We made clear how many people suffer from foot problems and what the consequences are for society. Introducing knowledge and skills to local people to enable them to help their people was one major reason why the funding was granted.

From which regions in the world comes the biggest demand for training programs?

When I look at my own experience from travelling to many countries and visiting facilities all over the world, the conclusion is  that there is a lack of knowledge how you can help people with orthopedic shoes or shoe adaptions in many countries, even in Europe. But it is difficult to point out exactly where the biggest demand is.
When you set up a training program, one question always is, how long you have to train people to enable them to work independently after their graduation. In retrospect: Was the time of 18 month long enough to enable the graduates in Vietnam to work in the field or set up their own business?

If the question is: Can you teach them all the things you like to teach them in 18 month, the answer is no. On the other hand, if the question is: Could you teach everything in two, three or even four years? Then the answer should also be no. Even in Europe where people are trained for three or four years, they have to gain a lot of practical experience over the years when they are practicing their profession. Some of my colleagues in the Netherlands tell me that even 20 years are not enough to learn everything.

What we do is building a fundament for what you can do in patient assessment, in measuring and in manufacturing and adapting shoes. But we also teach the students when they have to stop and refer the patient to another specialist like an orthopedic surgeon. We also teach them how to do research themselves to enable them to find new solutions on their own by using databases like Pubmed and others. And they learn to transfer their knowledge and their experiences from one field to another. That way they can use the experience they gathered in diabetes for example also for treatments in rheumatology.

The students learn to cope with the situation and help themselves. And they help each other. Our graduates have set up a Facebook-group through which they communicate and offer help if someone has a question. On top of this all, also an important part in the educational program is the entrepreneurial skills. How to set up and run your own business.

What happened to the graduates from the program in Vietnam? Did they all find jobs?

Yes! Most of them had been sent to us for the training by rehab-centers or NGO’s where they already were working before the training or where they had a connection to. All the students are back. Some have already even set up their own business. Some of them are doing really well. That is exactly what we had intended when we started the project.

What advice would you give people who would like to set up a training program in their own country?

My advice would be to make this a major topic at an IVO- or ISPO-congress. You could set up a round table discussion to gather ideas, to exchange experiences and to bring together those people who are willing to commit themselves to this issue. You should make some kind of inventory where the people come from and what they would like to achieve. Then you have to nail down an approach how you can deal with those challenges.

We have to start with our own professionals. At the moment there is only a small group in our profession that has committed itself to the goal of spreading the knowledge in pedorthics all over the world. This group should be expanded. We also have to learn to cooperate and exchange ideas, experiences and students who will learn how things are done in other parts of the world. Collaborations are already much more part of our professional life than years ago. In a profession like ours we should be more aware of that.

Of course you cannot just copy one training program from one country to another. You will always have to adapt existing programs to the context of the specific country. But I really think that these initiatives can make a difference for many people. And I honestly believe this is the only way to move forward.

Interview: Wolfgang Best