My left arm extends all the way up to and just barely past my elbow, tapering into a small, fleshy stump. For prosthetists, I’ve always been a weird fit—that funny little kid in the office with my arm held out like a bird with a broken wing, waiting for the plaster mold to dry. Since I do not have a forearm, a prosthesis socket must fit over my elbow to stay on, but the socket necessarily limits the range of motion and makes it harder to prevent falling off during a full day of bending and extending. My most recent prosthetist had devised their own patented method of molding a socket that better accommodates bodies like mine.
What I didn’t realize was how else they have applied this knowledge, before I even became their patient. With funding from the Defense Advanced Research Projects Agency (Darpa) to develop wearable technologies for combat soldiers, my prosthetist had designed a suit made up of black straps, metal joints, and sinewy tubing, reminiscent of an outfit for a dystopian video game character. This exoskeleton is intended to “reduce injuries and fatigue and improve soldier’s ability to efficiently perform their missions,” and could potentially make real-life soldiers more lethal. The technology that allows soldiers to jump and crouch and shoot while wearing this contraption, they say, is the same as what went into making my socket. It is the result of years of experience working with people with limb differences that make it very difficult to fit a conventional prosthesis, people like me. My body—or bodies like mine—is used to help design military technology.
Imagine if your dentist applied their years of experience working on mouths like yours to develop, say, teeth weaponry for the military. Inside American prosthetist offices, this is actually a fairly common relationship. The revolving door and entangled history between the prosthetics and orthotics industry and the military has forced patients like me into a cycle of design that creates high tech arms for American veterans on one side and death and mutilation on the other. The intention is that future soldiers wearing this technology would be better at destroying enemies— creating more disabled people who will likely never receive a prosthesis. A crucial part of this cycle is the industry’s fixation on developing new, expensive, electronic prosthetic devices for veterans, who receive them from the government at no cost. Yet the vast majority of people who experience limb loss in the United States not only never receive these devices, they aren’t veterans at all.
Prosthetic devices were once largely homemade contraptions devised by their wearer to help with domestic tasks. George Webb Derenzy, captain of the 82nd Regiment in the British Army, who lost his arm to gangrene during the Napoleonic Wars, is known for designing a number of domestic mechanical gadgets that he describes in his 1822 book, Enchiridion. (Come for the one-handed boot hooks, stay for the steel egg-holder.) These kinds of devices didn’t have a large potential market and were geared toward private use. Derenzy believed they could help disabled people rejoin society without having to “burden” others with requests for help with specific tasks.
It wasn’t until the American Civil War—during which 60,000 soldiers underwent limb amputations—that the prosthetic arm and leg became lucrative business opportunities and valued commodities. The US government propped up this new industry by passing a law that issued a prosthetic limb to every veteran amputee in need. By the late 19th century, there were a number of competing prosthetic limb manufacturers: The Salem Leg Company, A. A. Marks, and J.E. Hanger, which today, under the name Hanger Clinic, is one of the largest prosthetic limb providers in the US.
The commodification of the prosthetic limb came up against some initial reluctance to hide stumps inside wooden sockets. For many Confederate veterans, healed-over stumps were a mark of pride and resilience—a true survivor bore a stump. In time, sentiments about both limb loss and artificial limbs shifted dramatically. According to David Serlin, professor of communication at UC San Diego, the US military spent the first half of the 20th century developing various analytical methods to identify the body types of ideal military recruits. The result, in popular media and the public consciousness, was an indelible association between the military and the idealized male body: muscular, symmetrical, and lean. When these bodies returned from the World Wars with missing limbs, the military sought to convince the public that not only were these men especially masculine for putting their bodies on the line, but also that prosthetic devices would help reaffirm their masculinity, virility, and even heterosexuality.
Prosthetic devices have a deep history with patriotism and nationalistic projects. The carefully staged images of veterans using prosthetic devices in Carry On, a 1918 magazine produced by the US surgeon general, told the story of how the synthesis of man and technology could completely rehabilitate amputees. According to Beth Linker, a professor of history and sociology of science at the University of Pennsylvania, the staff at Carry On “hoped to persuade the public that rehabilitation had the power to make the wounds of war disappear.” In their marketing campaigns, prosthetic limb manufacturers similarly sought to associate the prosthesis user with a triumphant and resilient nation—painting a new image of the veteran completely remade through technology and able to return to the workforce. Today, the true survivor bears a polypropylene socket with an airbrushed bald eagle flanked by fireworks and the American flag.
Throughout the 20th and into the 21st centuries, medical advancements and improvements in body armor allowed for greater survival rates in war and a larger number of amputee veterans. Just as the Civil War standardized and commodified prosthetic devices, the Second World War sped up the development of the disciplines of rehabilitation and physical therapy in the United States. In 1945 the federal government’s Artificial Limb Program built the foundation for modern prosthetics research by producing new knowledge about ergonomics and plastic socket designs. Veterans with limb loss were fitted with the most advanced prosthetic technologies at Walter Reed Medical Center in Washington, DC, which remains a crucial purveyor of state-of-the-art prostheses. Myoelectric prosthetic hands, which feature sensors inside the socket that can detect muscle movements from the residual limb to manipulate the hand, became the crown jewel of upper limb prosthetic technologies in the latter half of the 20th century.
By the 1990s, war veterans could be seen waltzing out of Walter Reed with the German-made C-leg from Ottobock, which uses microprocessors to automatically adjust the user’s gait while walking. The Iraq War prompted another wave of investment in prosthetics from the US government. Darpa launched the Revolutionizing Prosthetics program in 2006—a grand project of techno-optimism to engineer the most sophisticated bionic hand in history. The result was the LUKE hand (yes, as in Luke Skywalker), which engineers have described as having “near-natural control.” Although the LUKE hand was developed through government financing, it is produced and distributed through a private company, MobiusBionics. Over in the world of legs, Ottobock and the US Department of Defense developed the Genium X3 in 2014, a $120,000 waterproof microprocessor prosthetic leg that Vice called “the Maserati” of prosthetics.
The DOD continues to pour millions of dollars into ever-more high tech and expensive upper-limb and lower-extremity prosthetic technologies, much of it in the form of grants for private prosthetics firms such as the one I have used, and with an overwhelming emphasis on the needs of the “war fighter” following amputation. The most sophisticated and expensive prosthetic technologies have long been completely free for veterans—and extremely expensive for anyone else.
Despite two decades engaged in the war on terror, only about 1,500 American soldiers have lost a limb in combat in Afghanistan and Iraq. Compare this to the 2,250 babies born each year with missing or partially formed limbs. The overwhelming coverage in the popular media of war veterans being fitted with advanced prosthetic limbs belies a devastating truth in the United States: 185,000 civilians undergo an amputation each year, with African Americans four times as likely to experience amputation than white Americans. The majority of these amputations are caused by vascular disease, including diabetes and peripheral arterial disease. According to the Amputee Coalition, Indigenous Americans are 70 percent more likely to experience amputation compared to non-Indigenous Americans. And while poverty is a significant risk factor, research suggests that many of these amputations performed on Black and Indigenous Americans come after failures to even attempt salvaging the limb at risk.
This is the reality of who is living with limb loss in the United States, yet prosthetic limb companies and research initiatives are still overwhelmingly focused on the vision of prosthetics laid out by the military: high tech, expensive, and primarily benefiting private companies, insurers, and veterans.
The military’s cultural influence on the state of prosthetics is profound: The primary product tester for BrainRobotics, a new multi-articulating prosthetic hand manufacturer, is an army captain who lost his arm from a car bomb in Afghanistan, despite being the least representative amputee in the US. And while BrainRobotics’ big selling point is that their myoelectric hands will cost $15,000, as opposed to $50,000 for the LUKE hand, this does not make a substantial difference to non-veteran Americans whose insurance may not cover myoelectric hands because they are deemed “medically unnecessary.”
In a 2014 study of disability in the Navajo Nation, which has one of the highest rates of limb loss in the country, assistive technology providers deemed myoelectric arms too expensive and inappropriate for the needs of the typical user, who needs to regularly chop wood because they do not have electricity in their homes. Yet the primary manufacturer of non-myoelectric upper limb prosthetic attachments, TRS, gears its offerings toward hobbyists and veterans looking for leisure activities.
Meanwhile, users of basic prosthetic legs in the Navajo Nation complained of their inability to traverse the sandy unpaved roads on the reservation. High tech legs, unlike arms, have much higher user satisfaction. Medicare and Medicaid tends to approve cheaper, mechanical knees despite evidence that newer microprocessor knees not only improve quality of life but prevent falls. Their reimbursement rates are only around $18,000, making these far more comfortable and safer bionic ankles and knees—which can run up to $50,000 or more based on their features and number of bionic joints needed—inaccessible to those who need them the most.
While some have argued that the US military’s investments into prosthetics have trickled down to civilians, the reality is that most people experiencing limb loss will never benefit from these technologies, in large part because of their prohibitive cost. More research is needed to understand why, but as it stands, two-thirds of the 2 million people living with limb loss and limb difference in the US never receive a prosthetic device of any kind. Instead of continuing to fund the development of Maserati legs and Bentley arms, where are the prosthetists and engineers who want to design inexpensive and accessible technologies that help disabled people do the things they want?
3D-printing has been touted as a solution to the exorbitant costs of prosthetic devices, but their classification as medical devices by the FDA increases their cost and reduces their accessibility. Even the ABS plastic attachments I use with my carbon-fiber activity prosthesis cost hundreds of dollars and can only be purchased through a prosthetist with approval from my primary care doctor. Others hope open-access designs will let people 3D-print their own devices at home, but I want to 3D-print my own prosthetic arm as much as I want to 3D-print myself a bike helmet.
Basic components of prosthetic devices should be mass-produced, affordable, and available without insurance approval. Some of the most high-tech innovations (with the exception of bionic knees and ankles) could be substituted with lower-cost, simpler tech for many people who do not need or want to try myoelectric arms. Sockets always need to be custom, and so there will always be a need for prosthetists—but bionic knees, multi-articulating hands, and prosthetic attachments shouldn’t be luxury items, and we need more innovation beyond these options. To achieve this, we need to demilitarize the prosthetics industry and return to the sentiments of the 1960s disability rights movement: that disabled people are their own authorities on their disability.
“Disassociating prosthetics from the military in the popular imagination,” says Serlin from UCSD, should start with critiquing the “divide between the designer and the recipient, the prosthetist and the user. Where is the space for people with diabetes to be involved in aspects of research and design?”
Over a hundred years of war, we became so obsessed with “fixing” disabled people with high-tech gadgets that we lost sight of how disability is a social condition. A justice-oriented approach to prosthetics would dispense with the medical model of disability that sees disabled bodies as profit opportunities in need of “fixing” and instead embrace the needs of prostheses users and their desires. That could mean taking the industry in a different direction by focusing on cheap, simple, task-oriented solutions that are reminiscent of Captain Derenzy’s gadgets from 1822. After seeing this demonstration of a prosthesis prototype, I’d love to just velcro some stuff to my arm!
It could also mean requiring a diverse selection of potential limb-different and amputee users—including veterans, diabetic amputees, and congenital patients of a wide array of economic backgrounds—to be at the heart of any new research project as a condition for funding. Although, historically, many amputees have joined the prosthetics profession, today it seems that extremely few practitioners are themselves disabled. Prosthetists are not innovating new designs for their poorest clients, and robotics companies aren’t getting media coverage for low-tech, affordable designs. The government ought to be funding innovations that reach the majority of prosthetic users, not throwing money at luxury arms and legs.
And for all the media hype about the military advancing prosthetic science, my fancy socket was always insecure, painful, and wobbly. It snapped this past summer. The frontier of prosthetics shouldn’t be defined by the dreams laid out by the military—it should dare to create new images of the human body and break down the barriers that prevent people from attaining them.