In this writing, I will explore how the hospital wheelchair (HWC) has evolved to having the trifecta of being (1) the most difficult manual wheelchair in the world to self-propel, and (2) the most commonly used manual wheelchair in the world, and (3) the most inexpensive manual wheelchair in the world to manufacture. In my opinion, (1) and (2) are a direct result of (3).
For a detailed look at (1), see Part I.
The hospital style wheelchair has been around for many decades and its basic design has not changed.
The photo on the left is Marlon Brando in the film “The Men” in 1950. The photo in the middle is modern stock photography. The one on the right was recently taken in Nigeria. As you can see, the wheelchair design is exactly the same.
How is it that this design has been so durable? It has lasted for decades and remains the most widely used wheelchair in the world. Typically, if a design is ineffective, it doesn’t last. It is replaced with more effective design. This is the power of evolution. It is rare to have a design work so well that it is not improved upon. For example, the fork, sliced bread, or the standard bicycle, theses designs have survived for decades with minimal improvement because they work so well.
Note. Specialty applications are not what I am referring to. A mountain bike is not an improvement of the basic design of a bicycle. It is a variation of the design for a specific purpose.
Wheelchairs are not disposable items. They are intended to last for years. They are critical to providing personal mobility. Imagine that you can't walk. In order to get around, you would need a wheelchair. Wheelchair are critical for both individuals and society as a whole.
How can it be that the design of HWC has not been improved upon if it is really as bad as I am claiming? Could there be other factors at play? Maybe, the HWC actually is the “sliced bread of wheelchairs”. What if it is a design that it so cheap to manufacture, and so useful for its purpose that it can’t be improved upon. What if the purpose of the HWC is primarily, not to meet the mobility and independence needs of the user, but actually for the convenience of the expected able-bodied attendant/caregiver?
On other worlds, from the standpoint of the non-wheelchair using attendant/family member/caregiver, the cheapest wheelchair to purchase that can be efficiently pushed, for the greatest variety of body shapes (universal fit), and easily folded and transported in a vehicle is really “the best”. If you are not the one whose personal mobility depends upon being able to self-propel a wheelchair, then you have a different set of priorities.
In my opinion, HWCs are designed to make it as easy as possible for the attendant to deal with the wheelchair and its occupant. For this reason, it typically has the following features:
• High positioned push handles for the attendant to comfortably hold while pushing.
• Rear wheels that are well behind the center of gravity for providing wheelchair stability for the attendant to lean on while pushing.
• Removable footrests that don’t interfere with attendant assisted front transfers.
• High armrests that discourage the wheelchair user from grabbing the wheels and self-propelling and thereby interfering with attendant movement control.
• High backrests that encourage the wheelchair user to lean backwards for stability while being transported.
• Large front casters for rolling over unseen bumpy sidewalks and cracks while the wheelchair is being propelled by the attendant.
• Footrests that extend far forward in order to accommodate clearance of the large caster wheels.
• A folding frame for the attendant to store the wheelchair in a car trunk for traveling.
• Solid tires for the least amount of maintenance.
• A frame made of steel for low manufacturing cost.
• No frame adjustability for low maintenance and low manufacturing cost.
• A large size to universally fit the maximum amount of body types.
In a nutshell, the design of the HWC is not made for optimizing the mobility of the user, but for the (assumed) attendant.
Many versions of the HWCs can be produced very cheaply in China. I have seen prices as low as $35 per unit when purchased in bulk. Around the world, people who depend upon wheelchairs for their primary mobility are using mobility devices that cost as much to manufacture as the cheap shopping carts found in grocery and department stores. In developing countries, these typically are the only wheelchairs available.
The widespread use of the HWC is analogous to the no-frills standard bicycle that can be found all over the world. From the standpoint of the attendant, the HWC is an extremely cheap and effective means to transport a low or non-ambulatory person from place to place. I think the design of the HWC has not changed in decades because it works exactly as it was intended to do.
The human problem is that the many of the people using a HWC should actually be using an ultralight/sports wheelchair to enable their mobility and independence. The implicit assumption behind the use of a HWC is that the person being transported is not a productive or independent member of society due to age/infirmity/disability. Therefore, the overriding societal priority seems to be for keeping the cost of the wheelchair as low as possible as long as it is still suitable for facilitating the needs of the attendant to transport the occupant. Think about airports and their use of wheelchairs and attendants for transportation as a clear example.
The majority of wheelchair users in the developing world have minimal personal mobility and independence due to not only architectural inaccessibility, but also from having to use a HWC for mobility. This situation results in a very high level of unemployment and limited access to much of the benefits of society. There is minimal societal investment in their personal mobility and independence.
Given the low expectations that society has of wheelchair users, a poor level of personal mobility and lack of independence is considered to be the typical and the expected outcome. Therefore, there is little incentive for change. The HWC is seen as “the wheelchair”, any other type of wheelchair is viewed as luxury item or only for the very few involved in competitive sports. The normalization of the use of the ill-fitting HWC is reinforced by wealthy countries where this type of wheelchair is also the standard representation of “the wheelchair” in mainstream media and popular culture.
Fortunately, in wealthy countries, most wheelchair users who require an ultralight manual or power wheelchair, are able to obtain one with the help of insurance. Unfortunately, these wheelchairs are seen as highly specialized medical equipment and cost from fifty to well over one hundred times as much as a HWC. Little wonder that the developing world would default to use of the HWC.
Unlike the standard bicycle, the HWC is very low functioning for the independent user. People in developing countries don’t accept poorly functioning bicycles for personal use. They may not be able to afford specialized racing or mountain bikes, but they expect their bicycle to work as intended, or they will not buy it for any price. Wheelchair users in developing countries have no other option. There is no minimum standard for self-propelled wheelchair functionality. The cheapest wheelchair will have desperate buyers regardless of its poor functionality.
The world doesn’t manufacture poorly functioning bicycles because nobody would buy them. The world does manufacturers inexpensive bicycles made of cheaper components that still provide an acceptable level of mobility ($50). Bicycles are made for able-bodied people who have standards and expectations. Wheelchairs are manufactured for people with disabilities who have no choice.
Millions of wheelchair users around the world are using inappropriate and independence inhibiting wheelchairs because they are inexpensively mass produced. Now imagine the difference in the quality of life of millions of people with mobility disabilities… if they could obtain, for a reasonable price, a wheelchair that was primarily designed to meet their mobility needs as the top priority.