ASME Student Project

Members of San Francisco State’s Student Section of theAmerican Society of Mechanical Engineers (ASME) are working with Whirlwind on building a hand-powered front-wheel-drive tricycle as a club project. The club has been responsible for welding, fabricating, and contributing to the iterative design process through testing. “The team of undergraduate students is learning valuable skills to help their eventual careers in engineering,” says club president Nic Celeste, “while seeing first-hand how engineering and design can help make the world a better place for those with limited mobility.” The ASME Trike Project is overseen by Whirlwind product designer Aaron Wieler. It is one of several engineering and entrepreneurship projects that we are currently working on with students at San Francisco State, where our headquarters and shop are located.

Matt McCambridge (in picture on the left), Whirlwind’s Product Development Manager, works with mechanical engineering students Craig Brinton and Nic Celeste on an innovative trike prototype.

The Importance of User Choice for Cost-Effective Wheelchair Provision in Low Income Countries

THE IMPORTANCE OF USER CHOICE FOR COST-EFFECTIVE WHEELCHAIR PROVISION IN LOW INCOME COUNTRIES (.pdf available here)
by Marc Krizack, J.D., Executive Director
Whirlwind Wheelchair International at San Francisco State University

The limited success of free market mechanisms in wheelchair provision in low income countries requires a
comprehensive, coordinated, and sustained intervention by governments, charities, and development
agencies working in close collaboration with the organized movement of people with disabilities. To be
effective, this effort must be designed to stimulate market mechanisms. Up to now, funders have usually
subsidized supply, that is, they have purchased wheelchairs that are then given to users. This system must
be turned on its head. Funders must instead subsidize demand, that is, provide funds for wheelchair users to
choose for themselves what wheelchairs they want and need.
A healthy market economy tends to correct imbalances in price, quality, and availability of goods and
services through competition among producers and feedback from consumer purchasing decisions. The
introduction of new products creates new needs and demand and thus provides opportunities for further
economic development via a continually evolving array of products and services. A healthy market economy
tends toward efficient use of investment resources as each product and service in the web of related
products and services develops apace, usually getting neither too far ahead of nor too far behind the
demand.

A DISTORTED MARKET
The market economy, however, is skewed when it comes to wheelchairs in low income countries. End users
have little money and are most often not the purchasers of the wheelchairs they use. Instead, governments,
charities and international development organizations purchase the wheelchairs and give them away. Initial
cost is the predominant consideration for these distributors; the wheelchairs provided are rarely built for the
environments in which they will be used. There is little consumer input to make manufacturers and
distributors deal with other considerations, such as quality, fitness for use, proper fit, and safety.
Furthermore, a flood of cheap or free imports has the effect of lessening competition by driving out the
small, local manufacturers who depend on local governments and charitable organizations, the users, and
the users’ families to pay for their chairs.

A STUNTED REHABILITATION INFRASTRUCTURE
The influx of very large numbers of wheelchairs into a region also outpaces the development of secondary
facilities, goods, and services, what we will call “the rehabilitation infrastructure” required for users to get
the most out of their wheelchairs. The result is that millions of dollars are wasted each year because there
are few spare parts to repair the wheelchairs when they break, few repairers trained in wheelchair repair, and few trained personnel to measure and assess users for a proper chair-to-user fit.

THE SOLUTION
The most efficient use of capital resources for wheelchair purchases requires that the number of wheelchairs
introduced into any given area not greatly exceed the capacity of the rehabilitation infrastructure to support
them. That is, in order for the chairs to be properly fitted, maintained, and repaired, it is better to apportion
resources between wheelchairs and these necessary services. A wise intervention will regularly evaluate the
capacity of the extant rehabilitation infrastructure, support a commensurate level of wheelchair production,
and build up and extend the capacity of the infrastructure to be able to increase the number of wheelchairs
that can be provided effectively.

DEMAND SUBSIDIES
In order for a system of user choice to work, donors would place their money in a managed fund. There
should be a variety of wheelchairs, readily accessible consumer information, standards for safety, strength
and durability, and trained persons who can advise the users in choosing an appropriate wheelchair. With
these elements in place, a user could receive a voucher to purchase the least expensive of the approved
wheelchairs that meet the user’s needs. If the user wanted a more expensive chair, the user would have to
pay the difference. An adequate pot of money would be attractive to manufacturers who would produce
chairs to meet the users’ requirements. The type and variety of available wheelchairs would grow, along with
related services, giving users greater and greater choice and improving a user’s chances to obtain the most
appropriate wheelchair for his or her individual needs.

CONCLUSION
Governments, donors and development agencies can learn how best to allocate resources between
wheelchairs and wheelchair services/training by participating in a collaborative effort with disabled people’s
organizations to provide wheelchair users with the opportunity to choose their own wheelchairs. The
resulting feedback will directly benefit wheelchair users and help donors to get the best results in the most
cost-effective way.

12th World Congress of the International Society for Prosthetics and Orthotics
Vancouver, Canada, July 29 –August 3, 2007

Wheelchair Riders in Control

Wheelchair Riders in Control
WWI's Model of Technology Transfer
by Peter Pfaelzer, Ph.D. and Marc Krizack, J.D.

This article describes Whirlwind’s design methodology from its beginnings in 1980 until 2005, when
Whirlwind focused on small shop manufacturing. Today we call this design methodology “User-
Originated.” Although Whirlwind now designs for larger scale manufacturing with a significant amount of
work done on the computer, much of this article retains its relevance for those interested in good,
appropriate design for people in the developing world.  (article .pdf here)

When Ralf Hotchkiss began designing wheelchairs in Latin America in 1980, there was no one else
designing state of the art wheelchairs at a low cost for active use in developing countries. Today, there
are at least four other non-profit organizations promoting wheelchair production around the world. Yet
Hotchkiss's model, since expanded and now institutionalized at Whirlwind Wheelchair International,
remains unique in its approach. For unlike other organizations, WWI ascribes to the wheelchair rider -- as
designer, trainer, mechanic, tester, and even marketer -- the central role in the technology transfer
process. This model has made the Whirlwind Network of independent wheelchair producers the highly
productive source of new ideas in wheelchair design that it is today.

Design Methodology
The most common design methodology used in modern manufacturing today is the prescriptive design
process. This methodology is characterized by a multi-step linear process of problem formulation, idea
generation, and prototype production. It presumes that most significant relevant information and resulting
solutions can be learned prior to production, and it relies on highly educated experts in every stage of a
centralized design process. The prescriptive process is employed to minimize the risk before large
amounts of capital are invested in the production of costly prototypes. The process itself requires the
expenditure of significant amounts of capital.

Prescriptive Design: The time and money spent on problem formulation and ideation prior to prototype construction may

reduce the number of prototypes necessary to produce a successful design.
WWI's design methodology is based on a method more common in small business known as the
descriptive design process. This process was the primary design process utilized prior to the turn of the
century when engineers learned their craft on the shop floor rather than at specialized technical colleges
and universities. In contrast to the modern engineering prescriptive design process which requires a
substantial amount of early work on paper or the computer, the descriptive process is characterized by
the early production of a prototype. The design is refined through repeated prototype/evaluation/prototype
cycles. The designer learns about the problem through the generation and evaluation of sequential
prototypes.

The descriptive process relies to a large extent on the craftsperson in a more decentralized design
process and may require more prototyping cycles than the prescriptive method. However, for a product
like a wheelchair, that can be prototyped quickly and inexpensively, the descriptive design process is
efficient and cost-effective. For WWI, use of the descriptive design process derives naturally from the
socio-economic situation in developing countries and from the complex nature of disability itself.
Unlike general product design, which is aimed at the population at large who within a certain range can all
be accommodated by a single design, product design for people with disabilities is difficult because it
requires multiple solutions. A wheelchair is not merely a chair with wheels. Different wheelchair riders,
even with the same nominal disability such as paraplegia, quadriplegia, multiple sclerosis, cerebral palsy,
or post polio, can have widely different ways of sitting and pushing which need to be considered in the
design process. The mobility equipment needs of disabled kids also change as they grow. One only has
to look at the wide range of wheelchairs available in industrialized countries to understand fully how
complex designing for disabilities really is.

What Difference Does the Setting Make?
The design problem is made even more complex for designers of mobility equipment in the developing
world. As a matter of course, wheelchair design must also include consideration of diverse uses and
geographical conditions. Wheelchairs can be for indoor use, outdoor use, long distance travel, urban use,
rural use, and quite often must function well in dirt, in mud, in fields, on gravel, through bomb craters, etc.
WWI's wide rubber caster, known as the "Zimbabwe Wheel," is the result of design for the most rugged
conditions.
The absence of even the most basic accessibility in the architectural infrastructure and public
transportation must be considered in the design process. As an example, the extremely narrow bathroom
and elevator doors in Russia gave rise to the Siberian wheelchair frame which can be narrowed by the
rider while sitting in the chair.
Cultural factors can also affect wheelchair design. In many countries in the Near East and Asia, for
instance, much social activity, including cooking and eating, occurs at floor level. Wheelchairs in these
settings must be designed to allow the rider to participate in these activities. The newest Whirlwind allows
some users to sit near the floor by incorporating a jump seat at the level of the footrests.
Wheelchair design must also take into consideration such factors as the type of toilet facilities available,
which can often be little more than a hole in the ground or floor. The wheelchair rider/builders in the
Whirlwind Network wish to achieve the greatest degree of independence, mobility, and social integration
possible. Thus, their wheelchair designs must be capable of responding to these multiple needs. The
prescriptive design methodology, working as it does at some distance from the wheelchair riders in
developing countries, is unlikely to produce the range of solutions necessary to answer these local needs.
Wheelchair design in developing countries is also limited by cost considerations. Because most people
who need a wheelchair cannot afford an imported one, low price is a primary design criterion. The two
main ways of keeping wheelchair prices low are through low initial capitalization of wheelchair shops and
by the use of materials readily available where the wheelchair is to be built.
All plant and equipment costs must be amortized and included in a wheelchair's retail price. When initial
capital funds are borrowed, the cost of repaying the loan must be included in the chair price as well. Low
per shop capitalization costs make it easier to raise start-up capital and establish more production
facilities. These multiple producers can form a competitive marketplace for wheelchairs keeping quality
high while forcing prices down. At the same time these producers can act cooperatively, each becoming
part of a design network. This is how the Whirlwind Network came to be.
The use of readily available materials is necessary to keep costs low and ensure that the chair will be
locally repairable. For Third World wheelchair design this often means that a single model will have
multiple design variations.
Even within a single country, political and economic factors can either limit the availability of existing
materials or create a situation where previously costly materials become available and affordable. The
placing or lifting of trade barriers to the importation of bearings, for example, has had a big impact on the
design of wheelchairs. In Africa where bearings were too expensive, WWI designed roller bearings using
steel nails or welding rod. In 1983 in Nicaragua, the price of acetylene used in welding skyrocketed as a
consequence of the Reagan administration's economic embargo. Wheelchair rider Omar Talavera
responded by designing a caster fork made from a single piece of bent steel rod that did not need to be
welded. Although only meant as a temporary innovation, it nonetheless kept the price of caster forks
affordable until the embargo ended and the cost of acetylene dropped. The lesson is that wheelchair
designers must be capable of producing rapid solutions as the local availability of component materials
changes.

Wheelchair Riders Integral to Design Solutions
Historically, these many needs have been best understood and dealt with by wheelchair riders involved in
every aspect of a continually evolving design and production process. WWI at San Francisco State
University nurtures this process by acting as the hub of a network of wheelchair builders now spanning
more than 25 countries. WWI's role is to energize and extend the network, promote and coordinate
activity, serve as the communications center, and stimulate and cross-fertilize the design process. The
WWI design teams have always included at least one wheelchair rider. Our wheelchair rider-designers
use the chairs they design during their daily activities to understand exactly how they perform in real
conditions.
Both at San Francisco State University and around the world, WWI wheelchair building courses always
include a significant number of wheelchair riders among the training participants. These participants
become active collaborators in the design process. They ensure that WWI is kept aware of all the factors
which affect their real mobility needs and often provide the design answers themselves. We term this
process "Collaborative Design."

Phillipe Mazard (Handicap International, France) discusses marketing schemes with David Mukwasa from Disacare (Zambia).

Although theoretically there is no reason why wheelchairs can't be built exclusively by non-disabled
designer/mechanics relying on information supplied by wheelchair riders, the reality is that very few nondisabled
persons fully believe and understand what people with disabilities say, even about matters which
a disabled person can be expected to know most.
Wheelchair designs, once translated into prototypes, must be tested. WWI uses inexpensive shop floor
strength tests and obstacle course performance tests to simulate real conditions. But the only way
wheelchairs can be tested under the full variety of actual conditions and for every conceivable purpose is
by wheelchair riders who use the chairs every day. Over time wheelchair riders provide the feedback
which is essential for going to the next level in the design process. They have the added benefit of a good
wheelchair during this evaluation process, and unlike the evaluation process in the prescriptive design
method, the cost of testing and evaluation is minimal and design changes can be made rapidly.
The involvement of wheelchair riders in wheelchair design and production also affects the technology
used in wheelchair building. Many of the wheelchair riders we train have only basic mechanical
experience and little formal schooling. Production methods and training techniques must be kept simple
to facilitate the training process. The practical strength tests and obstacle courses, along with the use of
full-size drawings, pictures, and similar techniques facilitate the participation of people who by and large
are without formal advanced educations. We have sometimes learned this the hard way. Ten years ago
WWI abandoned a nicely compact footrest design whose compound angles were so difficult to bend
properly that even the trainers wasted a lot of time and tubing trying to get it right.

Marketing Advocates
A critical area in which wheelchair riders can play a decisive role is wheelchair marketing. Because most
wheelchairs in developing countries are purchased by government and private charities rather than the
end user, the wheelchair rider/consumer has not had the ability to influence quality and price to the same
extent as purchasers of general consumer products. But wheelchair riders can play an effective role in
gaining increased government funding for good quality, locally built wheelchairs. In Novosibirsk, Russia,
activists from the Finist (Phoenix) Disabled Sports Club demonstrated the Whirlwind wheelchair made in
Novosibirsk to government officials in charge of wheelchair purchases. They made these officials realize
that wheelchair riders are the real experts when it comes to wheelchairs, and they educated the officials
about the Whirlwind's advantages for active use. That effort led to a government order for 500 Whirlwind
wheelchairs.
Wheelchair rider/advocates also play an important long term role in developing the wheelchair market.
The removal of architectural barriers and the increase in accessible transportation open up new
opportunities, especially for people with more significant disabilities. This will create a need for improved
wheelchairs so that, to paraphrase Star Trek, they may go where no wheelchair rider has gone before.

Conclusion
The most efficient use of development funds for promoting the design and production of wheelchairs in
developing countries is through a decentralized international network of small to medium sized production
shops, coordinated through a central hub which facilitates communication and collaborative design
through newsletters, wheelchair design congresses, technical exchange visits, web pages, and other
means. Most importantly, because someone has to be responsible for making the difficult choices
involved in balancing design features against cost, the wheelchair rider, who knows the problems best
and is most affected by the prescribed solutions, must play the leading role in wheelchair design.
 

The authors wish to thank Joan Rogin for her contributions in both the conceptual and editorial phases of this article.

It's Not About Wheelchairs

It's Not About Wheelchairs (.pdf available here)
By Marc Krizack, Whirlwind Executive Director

Building an Inclusive Development Community: A Manual on Including People with Disabilities in
International Development Programs, Heinicke-Motsch, Karen and Susan Sygall, editors, Mobility
International, USA, 2003 Chapter 4.1. 8 pages

People wanting to provide wheelchairs to those in developing countries who need them are most often
guided by their hearts. The problem, however, is vast and complex, and unfortunately, things are not
always as simple as they appear.
Many well-intentioned people donate old hospital style wheelchairs that granny used before she died to
one or another charitable organization which more likely than not merely stuffs them into a container paid
for under U.S. Humanitarian Assistance. Many, many chairs still need to be refurbished upon arrival, and
will sit collecting dust and rust in some warehouse or storage yard waiting in vain for a local volunteer to
clean them up and repair them. Those in good condition are not accompanied by instructions or spare
parts to keep them in working order, so even if they start out being usable, they soon end up collecting
dust or rusting away like the others. Providing free wheelchairs is likely to be a waste of money without
there being a system or mechanism in place (both in the U.S. and in the target country) to ensure that
only good quality wheelchairs will be sent and that they will be appropriate for each person who will use
them.
Providing wheelchairs is not about wheelchairs. It is aboutproviding people with the one thing they need
to move out into their owncommunities – to go where the action is. It is about integrating people with
disabilities into their society.
As long as wheelchair donors focus on the wheelchair and not on the end user, people with disabilities
will remain dependent and unproductive, a drain on society's resources. When the needs of the end user
are considered first, the most appropriate wheelchair (not merely the cheapest) can be provided, and with
other targeted assistance, the wheelchair rider can go to school, get a job, and become a net contributor
to society.
The underlying problem is that the usual market forces are not present in any significant way when it
comes to the purchase of wheelchairs in developing countries. The end user most often cannot afford to
pay for his or her wheelchair. The market for wheelchairs is made primarily by government agencies,
development organizations, and charitable and religious institutions. Historically, the end user has been a
mere object of charity, with unfortunate human and economic consequences. People who could be active
with the right wheelchair for their situation receive an inappropriate chair that does not provide any
significant improvement in their mobility, independence, or integration into society. A chair that is too
wide, for example, is difficult to push and may be impossible to get through doorways. Besides the human
cost, it is a waste of money.
The key player that is most often overlooked is the wheelchair rider him/herself. Or, rather, it is the local
and national self-help service and advocacy organizations of people with disabilities. These organizations
are in a position to advocate on behalf of those who need wheelchairs before the government agencies
and charitable and development organizations which purchase wheelchairs to ensure that the recipient of
a chair receives one that is appropriate for his or her situation (physical condition, age and size,
geographic setting, personal goals, etc.).
With organizational development assistance, such as training in grant writing and management, the
disability organizations can increase the local market for wheelchairs, which not only benefits a greater
number of end users, but can also provide market stability for local wheelchair manufacturers, who are
also likely to be employers of people with disabilities.

It Works in Siberia. The scenario just described has worked, and is currently working in Novosibirsk,
Siberia. In 1993, with grants from U.S.AID, a disabled sports club transformed itself into an Independent
Living Center, a service and advocacy center run by and for people with physical disabilities. At the same
time, an Aeroflot helicopter repair facility and a newly established local small private company went into
the wheelchair-building business. At the time, the government was buying wheelchairs from Russia's only
then-existing wheelchair factory located near Moscow. In fact, there was no mechanism for buying
wheelchairs anywhere else.
The activists from the disabled sports club convinced local rehabilitation administrators to make the case
with Moscow to allow them to buy wheelchairs made locally, and they were successful. The rider-activists
also convinced the local rehabilitation administrators to allow them to choose whether they wanted a chair
from the Aeroflot factory or from the private company, whose wheelchairs were better built.
Today, the Novosibirsk Regional Center for Independent Living "FINIST" (Phoenix) is a sales agent for
the private wheelchair company (the Aeroflot facility stopped building wheelchairs) and receives
commissions. When it writes grants for job training programs, for example, it makes sure to include some
amount for the purchase of appropriate wheelchairs so that each of the program participants will have a
suitable wheelchair. FINIST also is involved in the annual Novosibirsk Regional budget process. In these
ways, FINIST helps maintain a market for locally built wheelchairs.

Getting bang for your buck. Assuming no increase in available funding, spending money on the
development of an organizational infrastructure in the target country will mean less money now for
wheelchairs. In the long run, however, it will prove to be a more efficient use of resources. Wheelchairs
that are sent will be used, not left to collect dust or rust. The average life of a wheelchair will be prolonged
through proper maintenance andrepair. Wheelchair recipients will have increased mobility and
independence with all the benefits that that implies. A well-supported infrastructure can mean jobs and
income for those least likely to be employed. If all of this is integrated into a comprehensive program of
physical, social, and vocational rehabilitation, it can become sustainable.

Pooling resources and efforts with other international aid organizations. In almost every place
where there is an international aid organization, there are two or more such organizations. Often, there
are a half dozen or more. These organizations can share resources, such as a warehouse and the costs
of maintaining a repair shop. Each can also provide a separate, non-duplicative function, with one
providing wheelchairs, others training physical therapists, others providing organizational development
assistance, etc. The ideal situation would be a sharing of some resources on the one hand and the
continuation of individual activities on the other, even if these would be duplicative, in order to promote a
healthy “competition” and give wheelchair users a choice of service providers.

Finding a Partner. The first step a donor organization must take is to secure a capable and reliable
counterpart in the target country. That counterpart can either be a branch of the donating organization,
another international development agency, or it can be a purely local organization. The ideal local
organization is one that represents the interests of people who use wheelchairs. Preferably, this is an
organization run by wheelchair users themselves because no one knows the problems wheelchair riders
face better than wheelchair riders themselves. Where this is not possible, or in the case where the
international development agency chooses to partner with a non-disabled run organization, such as is the
case with many church-affiliated programs, wheelchair users and/or local disability groups that represent
wheelchair users should be actively involved to ensure that the needs of the end-user will be met.
The local partner needs to have the capacity to gather and relay accurate information to the US-based
office. It needs to be able to handle all customs paperwork, and have a place to store the wheelchairs
until they are distributed. It will need to be able to make final adjustments to the wheelchairs before they
are distributed so they will best fit the recipient. Depending on the arrangement with the US-based office,
the local group may also need to have the capacity to refurbish the donated chairs.

Assessing the Need. The second step in any wheelchair donation program is an assessment of the
actual need. It is not enough to simply send down wheelchairs with the idea that any wheelchair is better
than no wheelchair. Important information to be gathered in an assessment includes:
a) Identifying the individuals who need wheelchairs;
b) Evaluating each prospective recipient’s personal needs, including age, size, physical condition,
geographic setting (rural or urban), personal goals, etc.). This is best accomplished through the services
of a qualified physical or occupational therapist who can accurately measure and assess each
prospective recipient and make appropriate recommendations for the type of wheelchair the individual
needs. Local non-professionals, however, especially other people with disabilities, can be trained for this
purpose.
c) Determining how the wheelchair rider will get his/her wheelchair repaired. Issues include 1) the
availability of a person (usually a family member or a wheelchair or bicycle mechanic, but it could be the
wheelchair user him or herself) who is able to maintain and repair the wheelchair; 2) the availability of
spare parts, especially those parts that wear out most often, including tires, inner tubes, and bearings;
and 3) the source of adequate funds to repair the wheelchair. The life expectancy of the wheelchair
(usually between 2 and 5 years for active use) and the annual cost of wheelchair repairs must also be
estimated.
There are currently three organizations worldwide that specialize in appropriate wheelchair design for
developing countries. They are a) Whirlwind Wheelchair International, based at San Francisco State
University; b) Motivation, based in Bristol, England; and Handicap International, based in Belgium.
Depending on the target country, the assessment phase should include consultations with at least one of
these organizations.

Setting up the program. The simplest situation is one where new wheelchairs are sent to a city or region
that has a parts distributor who sells parts very cheaply. Of course, the simplest situation is rarely ever the
real one. This is because most donated wheelchairs are likely to be used wheelchairs. These chairs need
to be cleaned and often adjusted or repaired. Because of the difficulty in acquiring replacement parts in
many places around the world, it is often best to have the chairs cleaned and repaired before shipment.
(On the other hand, a big advantage to repairing the chairs once they reach the target site is the creation
of local job opportunities, and of course, it will be more cost-effective to have the chair repaired in the
target country where labor is considerably cheaper.)

Standardization is a good idea. The wide variety of wheelchairs, not only of different types but from
different manufacturers, makes the spare parts problem all the more difficult. Rather than accept any
wheelchair that is donated to it, the U.S. organization might want to concentrate on only a few types of
wheelchairs from only one or two different manufacturers. This strategy has the advantage of making it
easier to acquire spare parts. Chairs that cannot be repaired can be stripped of their parts, which can be
sent along with the shipment of complete wheelchairs. For the wheelchair users in the target country,
standardization means that a broken down old wheelchair will still be useful as a source for spare parts.
Funds raised to purchase new spare parts can also take advantage of bulk pricing. Standardization
should not be confused with the one-size-fits-all model. Here we are referring only to standardization of
types and models of chairs. Different sizes and customization remain indispensable options.

The Problem of electric wheelchairs. Extra careful attention should be paid when considering the
donation of an electric wheelchair. All of the problems discussed above are multiplied many times over
with an electric wheelchair. Parts are expensive, almost always unavailable, and special training is
usually required to diagnose and repair problems. Although an electric wheelchair can increase a
person’s range of mobility and allow for independent travel, the lack of accessible architectural features
such as curb ramps, building ramps, and elevators, not to mention kneeling buses and the like, can make
it more difficult for the rider with a heavy electric wheelchair.

Seat Cushions are indispensable. One area that is usually overlooked by wheelchair donors is the
critical need for adequate seat cushions. Far from providing new life to a previously immobile person, a
wheelchair without a proper cushion can mean death from pressure sores. Pressure sores, also known as
decubiti, are breakdowns of the skin caused by continuous pressure of the underlying bones against a
hard surface. People with full feeling in their buttocks and legs frequently and automatically adjust their
sitting, lying and standing postures in order to relieve the pain and discomfort that can be caused by
these pressures even after only a few minutes in one position. A person with a spinal cord injury,
however, does not feel pain from sitting in one position, and general discomfort may arise only after a
long time when the body's internal mechanisms try to cope with an injury that has already occurred. The
best possible cushion, correct posture, and awareness of techniques to frequently relieve pressure and
adjust weight distribution are necessary if the spinal cord injured person is to avoid pressure sores.
In a paper entitled “Coordinating Wheelchair Provision in Developing Countries, presented at the RESNA
2000 conference (Rehabilitation Engineering Society of North America – now known only by its acronym)
Matt McCambridge, MSE, discussed principles of “responsible wheelchair provision.”
“The rider must receive training in pressure ulcer management and the use and care of a wheelchair,"
writes McCambridge. "Provisions must be made to ensure that the chair can be repaired, and follow up
assessment should be done to determine whether the equipment meets the person's needs."
Three basic choices are available when providing a cushion. One is to provide a standard foam or airfilled
cushion with each donated chair. Another is to send a cushion that has been custom made for the
recipient. The third is to have cushions made in the target country using available low-cost materials. This
last alternative has been the subject of an annual international competition sponsored by RESNA
beginning in 1996. “Over the years, many innovative and successful designs have been entered into the
competition. The winning designs for each year of the competition from 1996 to 1999 were: (a) Bicycle
inner tubes tied into individual semi-inflated segments, arranged in rectangular pattern 3 layers deep; (b)
Foam rubber sheet over contoured coconut coir (scooped out under ischials and tailbone), rubberized
cloth; (c) Buckwheat hulls in a bag sewn from a T-shirt; and (d) Foam block scored in checkerboard
pattern to minimize shear, cavity under tailbone filled with coconut fibers, linen cover with zipper.” (From
RESNA 2000 Proceedings – For more information contact Beneficial Designs, Inc. Website:
http://www.beneficialdesigns.com

THE UNSEEN DANGERS OF DONATED WHEELCHAIRS
Unfair Competition. If one of the goals of international aid organizations is to develop sustainable
programs, that is, to help people to help themselves, then free imports of used wheelchairs from the U.S.
defeats that purpose in an important way: it undermines the development of local wheelchair
manufacture. If any foreign company, in any other industry, sold its products below cost in another
country, it would be accused of unfair competition and dumping, in violation of international trade
agreements. Yet we applaud the free distribution of wheelchairs that cost a lot to refurbish, ship, and
distribute, even if these costs are hidden because they are paid for through donations, volunteer labor,
and 100% subsidized shipping.
To avoid competition with an existing wheelchair manufacturer, it is not enough that a person who gets a
free wheelchair lives far from the factory, or that his or her family could not afford to buy a wheelchair
anyway. In a free market, wheelchairs, like all goods, will insinuate themselves into the marketplace.
There are many, many examples of wheelchair users with perfectly good chairs who have learned that a
quick buck is to be made by crawling in to the local church wheelchair giveaway site, or showing up in a
decrepit old wheelchair, in order to receive a free chair, which he later sells to a trader at the flea market.
And a family that lives hand to mouth will sell its donated wheelchair, trading any advantages the
wheelchair might give, so it can survive for the next few months. Is this any wonder when you consider
that in India there are beggar families that maim and disfigure their children in order to make them more
successful at begging?
Of course, for every wheelchair sold, there must be a buyer. But since the buyers of wheelchairs are
principally government agencies and charitable and development organizations, there is pressure on
these organizations to buy cheaper chairs on the open market, rather than from the local manufacturer. In
at least one case, a wheelchair manufacturer himself bought the imported, donated wheelchairs at the
flea market and included them in a batch of wheelchairs purchased by the international funding source.
The manufacturer may not have lost money, but his employees, some of whom were wheelchair riders
themselves, lost an opportunity to earn their wages.

The right tool for the right job. There are many wrong, even if well-intentioned, reasons to be involved
in providing wheelchairs to people with disabilities in developing countries. There is only one right reason:
To provide the wheelchair user with real mobility that will improve his or her opportunities to be an active,
integrated member of the local community and of society in general, by being able to leave the confines
of home or hospital in order to go to school, get a job, shop for food, and engage in all those other
activities independently mobile people do every day. The wrong wheelchair won’t help its rider do any of
that.

About the Author: Marc Krizack has 29 years of experience working on disability issues in developing
countries, Eastern Europe and Russia. He currently is managing a project for Whirlwind Wheelchair
International that is developing the wheelchair industry in Nicaragua. Since 1993 he has focused much of
his efforts on developing programs that mainstream people with disabilities in Novosibirsk, Russia.