In memoriam

Footloose with P.K. Sethi

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TO talk of man’s awards, tell us little of his achievements. To talk of a man’s achievements says little of his struggle. To talk of the man’s struggle depicts little of his presence. To talk of a presence, says little of his person. P.K. Sethi became a legend in his lifetime and we did what we do to legends. We created a biography encapsulated him as textbook copy, with a textbook life. But a life of man is a text that demands several readings where each narrative has to be a fresh story.

This essay is a resume of Sethi’s story not as a biography but as a reflection on four fundamental aspects of the man; Sethi’s biography as embodying a nationalist type, his style of innovation, his acute sense of phenomenology and his reflections on medicine.

Pramod Karan Sethi was born on 23 November 1927, the sixth of eight children. His father was a professor of physics at Benaras Hindu University. BHU marked a patriotism and nationalism of a certain kind. It created a style that was swadeshi, ascetic, and deeply devoted to scholarship, a framework that sought to acheive integrity through professionalism, a generation that offered biography as a value frame. It was a way of life and living which was immaculately correct, open and wary of orthodoxy.

Professor Nihal Kiran Sethi transferred from Benaras to Agra and it was in Agra that P.K. Sethi completed his education, attending Balwant Rajput College and Agra College. He obtained his medical degrees from Sarojini Naidu Medical College and capped it with an FRCS from Edinburgh. He then joined SMS Hospital in Jaipur as a lecturer and stayed on to become a legend.

Sometimes the bureaucratic norm as a standard or legal requirement can provide the contingency for an innovative, out-of-the box career. The SMS College, in order to comply with regulations, instituted an orthopedics department. Sethi was asked to head it through he had no formal training in orthopedics. He regarded this fact as fortunate because it saved him from encountering orthopedics with a prefabricated mind. There is a touch of humour, irony to this phase.

Sethi realized he needed a plan for rehabilitation. The first requirement was a professional physiotherapist and all Sethi had was a masseuse, equipped with a monthly allotment of talcum powder. Sethi knew that as forms of competence, the traditional and modern could be brothers under the skin, a wisdom he followed throughout his career.

The physiotherapy section grew gradually, surviving on gifts from patients. Sethi needed parallel bars and other infrastructure and he found craftsmen who constructed them. Sethi argued that physiotherapy was a ritual of competence, a system enabling the patient to recover his skills. He saw the need for occupational therapy and felt that such activities could be both creative and therapeutic. He created a whole range of activities from pedal operated saws to exercises for manual dexterity, anything for a patient to return to the citizenship of competence. Sethi sensed the need for a workshop to create such tools. A rehabilitation centre can be a craftsman’s toy shop but what one needed was a traditional craftsman trained in rehabilitation techniques.

Sethi recognized that one of his male nurses fitted the bill. He sent Mohammed Khan to Bombay for a two year training programme. Khan returned in six months and Sethi set up a workshop for him in an old tea room at the hospital. It was christened, ‘The fabrication unit’ and it began making calipers and braces. The transition from making braces and calipers to limbs is an almost natural one, but every new stage brings with it a different complexity and a different orthodoxy.

Bruno Latour, the French sociologist of science in his book, The Pasteurization of France, argued that the heroic model of science which gives agency to one man adds little to understanding. Latour’s story centred around the network where Pasteurization was a compact between microbe, peasant, technology and the scientist. In Latour’s narrative, the microbe has an agency of its own in shaping history and theory. In the history of prosthetic limbs, the SACH foot has a similar role.

SACH is an acronym which stands for Solid Ankle Cushioned Heel. As an instrument of prosthetics, a Sach foot is an ode to ethnocentricity. It was a foot piece which hid its artificiality disguised as a shoe. A great improvement over the peg leg, the Sach shoe provided an ease of walking. However, it had a rigid wooden heel from ankle to instep which made it impossible for the wearer to squat or sit cross-legged. It represented a way of life which anchored certain cultural and economic assumptions, which became ruthlessly obvious as its novelty wore off. The fabrication unit began with a Sach shoe and gradually discovered its limits.

P.K. Sethi understood the complexity of innovations. He did not merely create the Jaipur foot, he created the network of relations that made the foot a possibility. As a wag said, ‘He knew when to put the foot forward and when to put the foot down. It was a case of footwork.’ We often forget that an invention is an act of philosophy. To create a foot, you don’t just sculpt a foot; you visualize and posit a phenemonology. One of the books Sethi loved to cite was Oliver Sacks’ A Leg to Stand On. Sacks was an exceptional neurologist who wrote an essay on his own damaged foot.

A foot is not just an object, it is a presence. A foot is a theory of walking; it is, in a cultural sense, a theory of squatting. A deskwork foot and a hiking foot demands a different repertoire of actions. An amputated foot is a strange presence. Sacks in one of his essays talks of the phantom limb. When a person loses his hand or leg, it persists as a memory, an imaginary of nerves waiting to act it out. A phantom limb is a presence without corporeality. It is there and not there. Amputation as a word evokes erasure. It describes an absence. In an additive sense, a prosthetic foot completes the jigsaw called man. But a jigsaw as a puzzle is different from a symphony. A symphony is a collection of relations, a being and a becoming. A foot that lacks a phenomenology is an object without relations. Surgery, invention, care are all acts of phenomenology and this Sethi intuitively and tacitly recognized. He understood that a technologist is a philosopher and being a technologist and a doctor required both a philosophy and an anthropology. A foot is not just an embodiment of the body. It is a metonym of a culture.

A foot role-plays out a culture as a theory of walking, as a theory of dance and a prosthetic foot must simulate these aspects of culture. In that sense, technology is a set of dialects that calls for creative translation.

The Jaipur foot was such an act of adaption, invention and translation. It embodied a theory of pain as a theory of culture. A sense that recovery is an act of discovery and a sense that rehabilitation is not just an act of plumbing.

Invention as mimicry demanded a reframing. The sociological facts were simple. Ours was a society where the shoe is not an everyday fact. Villagers hardly wear shoes and, in an urban environment, women rarely wear shoes at home. As an economic fact, a shoe raises the cost of a limb and makes it more susceptible to breakdown. A stiff shoe is a miscast in a village where walking over rough terrain is essential and squatting is the first act of calisthenics. The logic was simple, why pay one-third more for additional discomfort? Could one imagine a cheaper more comfortable limb?

Poverty demands a subtle imagination. A Third World limb does not allow for a third rate science or a first world imagination. One needed to translate or virtually contextualize the shoe. Sethi made a shopping list of requirements.

The shoe had to cease being a shoe. It had to look like a bare foot and yet be cosmetically acceptable. While being waterproof and durable, it should allow for ease of walking over uneven ground and allow the wearer to squat and sit cross-legged. In a technical sense, it needed dorsiflexion for squatting, transverse rotation to allow one to be cross-legged and also allow adaptability over an uneven terrain. This much more demanding object had to look natural and remain cheap, providing a challenge to local art and artistry.

Sethi sensed that formally trained technicians disabled themselves. They were Sach’s men, who had internalized the technology and the shoe. It became a black box within which they lived. One needed sustained out of the box thinking. Re-enter the craftsman, this time one with a pedigree from another paradigm.

Sethi in his typically pragmatic, unsentimental way wanted his patients to learn a craft and possess limbs for it. Fortunately the craft instructor he found was a curious and caring man, who watched with interest the first fumbling attempts to shape a limb for paraplegics. Ramchandra, or Masterji as he was called, got involved in the exercise.

Masterji had the genealogy of a master craftsman. As a boy, he was apprenticed to artisans working with the Maharaja of Jaipur. But the world of patronage with which he grew up was dying out. The new state, as a poor substitute, appointed him a teacher of arts and crafts. When he was being sent off to a village school, Sethi arranged for his transfer.

Masterji was a crucial part of this transformative story. The jugalbandi between a creative surgeon and a master craftsman provided the frame for the rest of the story. Happily the best storyteller of these events was Sethi’s son, Harsh, a political economist who wrote major commentaries on the world of NGOs, a world where new forms of innovation were hybridizing with new ideas of institution building. The Sethi-Masterji collaboration deserves every intricacy of ethnographic detail we can muster.

Innovation begins with looking and listening. It moves to an understanding of why the old solution might be the problem. Formal training can become a rail track where the mind chugs along in old grooves. A dissent that merely derails the mind is inadequate. It must persuade it to run on different lines. For formally trained limb makers, the Sach foot was bible and imported materials, sacred substances one fetishized.

Our craftsman was not subject to such grammars. He thought environmentally in terms of local materials. But one must understand that our craftsmen are not parochial creatures. They love the gossip of the cosmopolitan and blend and experiment with it. Technology, like cooking, becomes open to new recipes.

Ramchandra set up his own workshop in a kitchenette. It, in turn was part of a building, a servant’s quarters that Sethi had converted into a dormitory for paraplegics. Masterji was also skilled in metalwork and dye making and the agile Sethi immediately improvised a furnace in the courtyard. Using a plaster of paris model and an ancient sandcasting method for making statues, Masterji produced an aluminium dye. Meanwhile Sethi, playing on the experience of the Srilankan surgeon G.M. Muller, had designed a variation of ‘the foot’. Muller while designing peg legs for Srilankan farmers had packed the die with rubber.

Ramchandra knew little about rubber. He approached the manufacturers but they were indifferent. He then approached an ordinary wayside tyre retreading shop owned by Chuga bhai near the hospital. The latter not only vulcanized the foot but also taught the workers how to do it themselves. He became one of the guardian angels of the place, deriving immense joy and satisfaction watching patients walk away from the place.

The first rubber foot was more natural to look at but it still was stiff and evoked the colour of rubber tyres. In fact, Sethi was so discouraged that he suspended work for a year. He played around displacing some of the rubber. While lighter, the shoe was still western and of little use for squatting or sitting cross-legged. The pair tinkered around trying modification after modification. They scooped out huge parts of the Sach’s foot, filling it with glued layers of sponge in a vulcanized covering.

A juggling of objects at the concrete level became a shuffling of concepts at the abstract level. The duo in thinking of the shoe were reconceptualizing the foot. A substitution of components became a resetting of relations. It was not just a substitution of imported design by indigenous design, it was an invitation to a rethinking. The checklist of changes bears out. ‘The sponge rubber heel section of the foot acted as a universal joint allowing freedom of movement to the amputee in all directions. A single wooden block, later supplanted by layered rubber, provided rigidity to the forefront essential for efficient takeoff. Both components were wrapped in a rubber casing reinforced with a rayon cord lining commonly used in automobile tyres. The flat sole of the foot was constructed from the rubber compound used for tyre treads and provided traction much like a tennis shoe.’

A new limb was born and sensitive to shades, it was in three colours. Later a slit was made between the great and second toes to facilitate the wearing of a sandal.

The Jaipur foot would have delighted an Edward De Bono as an anthropology of lateral thinking, where ‘six hats’ solved a variety of problems by posing the question in many ways. What Kuhn called normal science was not what Sethi and his group belonged to. They were conceptual trespassers, who sought answers where none existed. By not being constrained by the logic of the problematic or profession, they created a set of out of the box solutions.

The Jaipur foot is now the stuff of history. But history took time to be recognized. An invention demands not only unconventional thinking but a way of running the gauntlet of stereotypes. Our western trained doctors still hold that quality emanates from research centres and that science as expertise cannot be emulated by the untrained craftsmen and an unorthodox doctor. What people took a long time to understand was that craftsmen grasp science in their own unique way. They may be indifferent to blueprints but produce a 3-D model and they can grasp and reproduce it with uncanny precision. This is not something rare. Any owner of a foreign car desperate for parts could relate stories of the ingenuity of local mechanics. Sadly such stories remain anecdotal and are not theorized into a theory of innovation. Colonialism as a grammar was much more subversive and subservient than we think. But new contents provide new sites and the foot became a global travelling fact in a world addicted to land mines. The foot spread as an ideal solution to the amputated in a world of unrecognized wars.

Awards followed from a gold medal from the British Orthopedic Society in 1973 to the Magasaysay Award in 1981. But I feel the awards isolated Sethi and made him lonelier. He was searching for understanding not hagiography or the silly gossip that grows in response to creativity and excellence in our society. But more deeply, he was disappointed at the way medicine itself was going, and he was saddened at the decline of the doctor as the ascetic professional and the alienation of medicine from justice and healing. Sethi, as he confessed, was ‘a disillusioned man’. His essay, ‘The Doctor in the 21st Century’ (Seminar 409, September 1993), was an initial testimony to this disappointment.

PK was more than an inventor and a surgeon. He was deprecating about himself, claiming that as he was poor at maths, he took biology. A further set of accidents transformed him into a doctor. He was a self-reflexive doctor, deeply aware that medicine without the matrix of philosophy and anthropology was incomplete.

A doctor trained in the colonial era at Agra and Edinburgh, Sethi saw the dreams of western medicine go wrong. What was to be a paradigm of healing became mechanistic, commercial and iatrogenic. The healer was obsolescent and a medicine that sought efficiency discounted the human.

Recalling autobiographically, Sethi claimed that medicine like science developed within a framework of asceticism. Something about the colonial era drove a generation of professionals to excel, to be better or equal to their masters. A few wrote research papers, but their originality expressed itself in a multiplicity of ways. It was a profession that ‘oozed wisdom, scholarship, goodness, concern and humility.’

These values made sociological sense in a profession ‘that was more art that science’, where the doctor was a listener speaking the idioms of the patient. Such a medicine as a dialect lost out to medicine as science under the patronage of the state.

The latter sought a different objectivity, celebrated a different idea of measurement which sanctified laboratory indicators rather than a sensibility to pain and emotion. It was a decline of different kinds of diagnosis and storytelling. Sethi felt like Oliver Sacks who captured this lost world in his works, Migraine and A Leg to Stand On.

For Sethi, the new medicine destroyed the old contract between man and bacteria, a symbiosis that disappeared in the new politics of anxiety that targeted them. In that process we lost the wisdom of the body. It became ‘a fallible contraption in perpetual need of patching.’ Medicine based on advanced technology became a medicine of images rather than a full semiotics of the body.

Sethi was no romantic swooning over a lost past. His medicine was a lifestyle and he saw this expressed in the work of some of his colleagues, the Arole’s – Raj and Mabelle – at Jamkhed, N.H. Antia’s work on leprosy, K.S. Sanjivi’s community of doctors – The Voluntary Health Service – in Chennai. It involved one legend celebrating the everydayness of other legends. It is this that made his essay ‘The Doctor in the 21st Century’, an act of generosity, a reflection of a surgeon recognizing the wisdom of medical critiques, the power of an Ivan Illich, in particular his seminal Medical Nemeses, a Lopa Mehta and Manu Kothari and their amazing work on death and cancer, a recognition that medicine as science must dialogue with health as justice. He realized that a medicine for the poor was not a poor medicine but a theory of health that reflected on the poverty of medicine. It was an internal dialogue within western medicine which was as critical for knowledge as the traditional dialogue of different medical systems.

P.K. Sethi died in early January 2008 of a heart attack. There were obituaries worldwide, all almost identical as if following a standard sheet. Death as obituary becomes the beginning of erasure. We inaugurate burials with standardization and stereotype. What we need is a festival of storytelling, of celebration, where memory looks at such a community of reinventions. The fact that India had a Sethi, an Amulya Reddy and C.V. Seshadri is a fact for celebration. If a society is known by its dissenters, the last years of the twentieth century were blessed ones. One is grateful for that.

Shiv Visvanathan

 

* Dr. P.K. Sethi, 23 November 1927 – 6 January 2008.

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