What follows is an incomplete, United States centric, look at the evolution of manual wheelchairs.
The first US parent for a manual wheelchair was given to A.P. Blunt in 1865. The wheelchairs in the photographs are from around this era. Note that the United States Civil war ended in 1865. It is easy to imagine a number of young men with amputated/injured legs from the war who need a wheelchair while in the hospital or recovering prior to using crutches or a prosthesis. Such men were likely to have strong upper bodies.
From the photographs, you can see that the rear wheels are positioned to optimize body mechanics for wheel propulsion by having the rear wheels positioned in a more forward manner. The caster wheel(s) is placed in the rear. This reverse tricycle configuration works well for self-propelling pushing power and maneuverability.
Notice that there are no attendant push handles. I am assuming that these wheelchairs were used primarily inside on interior hardwood floors by war injured young men who could wheel themselves around. These wheelchairs seem to be primarily designed to provide mobility for the user while in hospital settings and inside the home.
But it is not easy for an attendant push such a wheelchair. There are no push handles. The rear caster wheels(s) interfere with the moving feet of the pusher/attendant. The rear wheels also prevent the tilted back wheelie position which is useful in the outside environment for dealing with obstacles such as curbs, potholes, cobblestones, and rough terrain. Therefore, the reverse tricycle (or dual reverse caster) wheelchair has significant drawbacks from the perspective of an attendant.
The US patent pictured above by S.A. Potter in 1894 illustrates a revolutionary design change – dual front casters. The rear caster wheels have been switched to the front, and an attendant push bar has been added. In order to maintain rearward stability (prevent falling over backward), the rear wheels are positioned backwards such that the axle is inline with the back of the seat.
The wheelchair is now much improved from the standpoint of a pushing attendant. But from the wheelchair user’s perspective, it is now less maneuverable and harder to self-propel. The result is less user independence creating greater dependency on the attendant for mobility.
In 1937, Everest & Jennings gets a patent for a foldable dual front caster wheelchair made out of steel. The transformation of the wheelchair is now complete with the birth of the mass produced hospital style wheelchair (HWC). This wheelchair is easy to for an attendant to push. It has rearward stability. It has universal fit. It can be folded and transported. And most importantly, it is inexpensive to manufacturer/sell/purchase. From the attendant point of view, this is the "best" wheelchair ever! From the user’s perspective, not so much.
For much of the world, the manual wheelchair of 1937, is also the wheelchair of 2023. The HPC has not seen any significant design changes over this time.
But wait! What about the carbon fiber one that I am sitting in as I write? What about the titanium one that I use when I go out? These designs and lightweight materials are a significant improvement over the HWC.
My wheelchairs shown below provide me a huge amount of personal mobility. They are lighter, faster, stronger, more maneuverable, and can be independently transported as compared to a HWC.
What makes my wheelchairs so much different than the HWC is the result of economics. The majority of the cost my medical equipment is paid for my insurance. As a result, my wheelchairs cost between 50-100 times more than a HWC. Therefore, the evolution of the design of my wheelchair differs from that of the HWC.
In 1979, Marilyn Hamilton and some other athletic wheelchair users created a lightweight wheelchair designed primarily for the mobility of the user called the Quickie. In 1984, I started using the folding Quickie. Two years later, I also got a yellow Quickie II rigid (non-folding) wheelchair, both are shown in the photo below from 1986.
The Quickie was a vast improvement over the HWC in terms of having an adjustable rear axle position. They were also lighter with a more streamlined front end. They could be customized according to the size of the user’s body. As a result of the changes, they were also more difficult for an attendant to push.
After about a one hundred year gap, for the fortunate few who could afford one (or had insurance to pay for it) The design of the wheelchair was once again, user centric. Thereby, enabling a much higher level of personal mobility for active ultralight wheelchair users.
Since then, the wheelchair industry has realized that they can sell all manner of expensive categories of wheelchairs and costly wheelchair accessories to people with medical insurance or who are wealthy. Both manual and power wheelchairs now come in all sorts of varieties and price points above the minimum threshold of several thousand dollars.
The Sunrise Medical Q700 UPM pictured above sells lists for $45,610.
For a visual, if we collected all the manual wheelchairs in the world and placed them in a giant heap with the cheapest on the bottom and the most expensive on the top, the vast majority of the pile would be HWCs. Then at the very top would sit the ultralights. Yet the cost of these relatively few ultralights would equal or exceed the cost of all the HWCs combined. What would be missing from this pile is the middle range. There are very cheap and very expensive wheelchairs, but there are little in between.
Bicycles prices are determined by the free market and create a bell curve (Normal Distribution). On a wide scale, few are very cheap, few are very expensive, most are somewhere in the middle. The price of wheelchairs, on the other hand, has been distorted by insurance and government regulations and doesn’t follow the bell curve.
Most of the world must pay cash to purchase a wheelchair. Therefore, the market incentive is to manufacturer them as cheaply as possible. Since there is no standard for self-propelling user functionality to be met, the HWC (or some derivative of it) has become the primary wheelchair available to purchase in developing countries.
In other parts of the world, for those lucky few (wealthy) customers who have insurance (or government involvement), the most profitable industry strategy is to sell them the most expensive wheelchair with the greatest number of accessories.
People in less resourced countries can’t afford mid-price range user centric wheelchairs. Insured people in wealthy countries want high-end wheelchairs. Therefore, mid-priced wheelchairs don’t get manufactured. Industry profits are made by selling costly highly customized wheelchairs and accessories to the limited market of people who can pay for them.
As an analogy, imagine an hypothetical airplane. There are the very expensive first class tickets for the wealthy. The majority of passengers buy super cheap tickets and stand up in the cargo hold (steerage). Economy class doesn’t exist. This airplane was built without economy class seating.
Creating incentives for manufacturing and distributing user centric and economical wheelchairs for active manual wheelchair users in less resourced countries is not a simple problem to solve. But in order to solve a problem, you first need to be aware of its existence.