One Step at a Time

It is judgment day in the shoemaking master class taught by renowned Hungarian cobbler Marcell Mrsan at the Savannah College of Art and Design. As he has once a week for months, Jon Kuniholm has left his wife, Michele Quinn, and 12-year-old son, Sam, in Durham, North Carolina, hopped in his grandmothers 1979 Honda Civic and endured the five-hour drive down Interstate 95 to the brick design building in the heart of the Georgia city's downtown. Under the tutelage of Mrsan, Kuniholm has labored through the painstaking process of crafting a single pair of men's size-11 dress shoes. For months he has gingerly shaved through layers of leather on one of the workshops gleaming steel skives. He has stretched and shaped the hide over a last—a plastic mold that gives a shoe its form. He has forged a special tool in the design school's metal shop that has helped him drive and bend nails into the heel. Now, Kuniholm takes a seat on one of the stools around a butcher-block worktable in Mrsan's studio. Other students, most of them in their early 20s, gather around. Some are still fumbling over the tiniest details on stylized pumps, brightly colored wedges and high-fashion mens wingtips that serve as their final projects for the class. The smell of glue wafts over the table as they set their just-completed projects down for Mrsan to examine and grade. Most had joined the class with dreams of finding a coveted spot in the lucrative fashion industry. As they wait for Mrsan to begin the final class, their conversation focuses less on technique than on the previous nights parties. Kuniholm, 40, is not like his classmates. He does not harbor visions of a career in shoemaking. For him, completing a pair of caramel leather dress shoes would provide a momentary sense of personal pride, but he hopes it will also serve as one step along a longer path that might one day help others. He cradles the shoes in his one good hand, then settles them on the table using the metal hook of his prosthetic right arm. "Okay now," Mrsan calls out with a thick Hungarian accent. "Please, lets see what you have done. Who wants to begin?" MORE THAN SEVEN YEARS now separate Kuniholm from the baking heat of the high desert in Haditha, Iraq, where he spent the last evening of 2004 gamely plucking a guitar for his fellow Marines as they tried to keep their minds off their daunting circumstances. An engineer officer for 1st Battalion, 23rd Marines, Kuniholm had been engaged in a push to flush the forces of Al Qaeda in Iraq out of the Western Euphrates River Valley. It was asymmetric warfare in more ways than one. The American forces in the dusty central province of Iraq numbered no more than 600. Their mission involved patrolling a region larger than the San Francisco Bay Area—a place where more than 1.4 million Iraqis lived in clusters along the river. Their enemy fought back in small bands. Their weapon of choice: the improvised explosive device, or IED. On New Years Day Kuniholms morning was interrupted by reports of an attack on an American patrol boat. He was dispatched to respond, first by boat, then on foot along the riverbank. Kuniholm has written about the jarring reality of the next moments for an engineering magazine and on Microsoft's accessibility website: Before he was even aware there had been an explosion, he was already splayed on the ground. The blast snapped his M4 carbine in two and nearly severed his right arm. Shrapnel from the explosive killed Lance Cpl. Brian Parrello, who was standing nearby. About 40 minutes later, as a Blackhawk helicopter prepared to evacuate Kuniholm, he told the executive officer, "I guess my guitar-playing days are over." IN APRIL 2009, 60 Minutes featured a 13-minute report on what appeared to be miraculous advances in the design of the prosthetic arm. Anchor Scott Pelley called it "a remarkable leap in technology" spearheaded by the Defense Advanced Research Projects Agency (DARPA). He marveled when a lab volunteer who had lost both arms decades before showed him a prototype robotic hand with 25 circuit boards and 10 motors that was able to snap a green grape off a vine. When the 60 Minutes piece aired, one of the scores of researchers working on new arm technology was Kuniholm. He even turned up in the televised report to help illustrate the concept, sensors attached to the stump of his right arm. In the few moments he is on screen he appears to be a hearty advocate for the scientific advances. "Imagine closing your hand for me," Pelley tells him. We hear the whir of a motor, and then we see a mechanical hand with flesh-colored rubber fingers close its grip. It was one of Kuniholm's highest profile moments, but one he now looks on with dismay. The gee-whiz technological breakthrough he was sharing with an enormous television audience was, in fact, many years old and had yet to be adopted into regular use. Unfortunately, Kuniholm says while strolling along a cobblestone boulevard in downtown Savannah, work on designing a better prosthetic arm does not look nearly as promising to him as has been portrayed on television. The most common prosthetic arm in use today, he says, is the one he wears on a daily basis. It has a metal hook at the end, is controlled by a cable that runs the length of his arm and can be retracted by moving his shoulder. The first patent for the design was filed in 1912. There was a headline in The New York Times in 1965 that declared something along the lines of, "New Prosthesis to Allow Amputee to Control Limb by Thought, Still a Few Years Away From Practical Use," Kuniholm says. "That remains true. Nobody has one. Nobody. If people spent half as much time figuring out how to make this happen instead of talking about it, wed be there already." IN THE YEARS BEFORE Kuniholm was airlifted from an Iraqi battlefield with his right arm shredded, he had already cobbled together an odd mix of studies and hobbies that, through some form of serendipity, had set him on a perfect trajectory to invent a better prosthetic arm. Kuniholm came to Dartmouth from a magnet school for science in North Carolina and took full advantage of the liberal arts education, majoring in English. He also took classes in math and science and pursued his interest in economics. He played intramural hockey and skipped his sophomore summer to work with the Harvard Institute of International Development to improve tax policy in Malawi. He loved the internship, but says he eventually soured on economics because he felt the field lacked any sense of certainty. As he explains it: "You could have two Nobel Prize-winning economists in the same room asserting two completely opposite things, and you still couldn't get a consensus on which one is right." Back in Hanover he took a part-time job working for a local law firm, including, he recalls, taking on a case "for a guy who got his leg taken off by a screw conveyer at an ice plant." In the midst of his career as a paralegal, he became an obsessive fan of a Discovery Network TV show called The Secret Life ofMachines. Realizing he loved understanding what makes things work, Kuniholm went to see Dartmouth engineering professor Ted Cooley. After speaking with him, Kuniholm decided on a career as an engineer and enrolled at North Carolina State. Longing for yet another challenge, in 1997 he joined the Marine Corps. Pushing himself is what he does: This is a man, after all, who has earned a pilots license and made an attempt to climb Denali. After officer training and requisite active duty, Kuniholm returned to N.C. State as a reservist. Within two years he completed not only a B.S. but also two graduate degrees. In 2005, while working on a biomedical engineering Ph.D. at Duke, which he has since nearly completed, Kuniholm was called to active duty. Bruce Kuniholm '64, now dean of Dukes Sanford School for public policy, says he supported his son's decision to interrupt his studies to serve in the military. Formerly an infantry officer in Vietnam, Bruce tried to instill in his son the value of public service. He says he also warned his son that joining a reserve unit would all but guarantee he would be summoned to war, which is exactly what happened. Still, Bruce was reassured. "I guess someone had a cell phone there and Jonathan must have asked the doctor to call me," he says. "I am eternally grateful that he did. My mind was eased somewhat because I knew he wouldn't lose his life." When Kuniholm returned home to begin his recovery at Walter Reed, he says, a new sense of purpose crystallized for him, based on something his father had always repeated: "My dad likes to say wherever someone ends up in their career, they usually have a convincing justification for everything they did along the way, even if they didn't mean it at the time. Apply it to where I am right now, and you can see it. I'm absolutely suited to what I'm tiying to do." WHEN KUNIHOLM JOINED the Marine Corps he was attempting to fulfill a yearning for national service that was passed down from his father and his grandfather, a graduate ofWest Point who worked as a physicist on the Manhattan Project. Upon his return from Iraq, though, Kuniholm had a new drive. He wanted to debunk what he believes are myths about advances in upper-body prosthetics, and in doing so, light the way for real and realistic progress in a field he believes has been orphaned for many years. It started for him during his recoveiy at Walter Reed. The clinic notes from his hospital stay are filled with references to Kuniholm making inquiries about prosthetic technologies and requests to his doctors for details about the DARPA research project. The moment he began to grow frustrated, he says, came when he returned to Duke, where he had been doing engineering research before Iraq, and met with Glenn Hostetter, a prosthetist at the university's medical center. Kuniholm recalls boasting to Hostetter that he was going to be the recipient of one of the most advanced new arms in the military s arsenal: "He says to me, have you ever seen one of those? And he showed me a little demonstrator of a child's myoelectric hand," Kuniholm says. "All it could do is this, and that," he says, demonstrating the motions by rotating his good wrist and opening and closing his fingers. "Two degrees of freedom. I said, 'Really? That's it?' I just couldn't believe it. That is the most frustrating thing about all of this. It's not that I can't type or write or tie a shoe. It's that because of the way this is presented in the media, everyone thinks I should." The misperceptions of the public on the topic has turned into a fixture of the lectures and speeches Kuniholm now works into his crammed schedule. Pacing the stage last year at an ideas seminar in Chapel Hill, North Carolina, his hair still sporting a military cut, wearing 1960s-style specs and a relaxed orange dress shirt, he put the question to a packed auditorium as he held up his prosthetic arm: How many microcontrollers and sensors would you guess are in this arm? The consensus in the audience was six—though about half of the crowd believed the number could be higher. The correct answer? Zero. 'Apparently from your answer to that question...[your] thoughts about prosthetics were mostly formed by science fiction and not science itself," Kuniholm told them. He then proceeded to lay out what he sees as the reasons better technology is not readily available. He believes it boils down to money. The first impediment to getting improved prosthetics to amputees is that there aren't enough amputees to make it profitable, and the notion that the recent wars have rekindled a demand for advanced prosthetics, Kuniholm says, is laughable. Although counts lag behind daily events, the Armed Forces Health Surveillance Center reports that 2,037 members of the armed services suffered "major amputations" between 2000 and the end of 2001—12 percent of whom suffered the loss of multiple limbs. Kuniholm believes that among the amputees, fewer than 300 veterans lost arms in Iraq and Afghanistan. "Venture-capitalist hearts do not go pitter-patter over numbers like that," he says. Then there are the technological hurdles. Douglas Van Citters, a professor at the Thayer Engineering School, says the hand, from an engineering perspective, is almost impossible to replicate. "It has a lot of degrees of freedom, but your skin allows you to feel things and apply precisely the amount of force [needed to perform a task]. To re-create that in a laboratory environment has proven very difficult." Although some of the latest advances look good on 60Minutes, Kuniholm says they are less enthralling when tested in real-world settings. He cites as an example a robot programmed to throw darts. "It picks the dart up off the table, throws it and gets a bull's eye every time, right? But change the weight of those darts, and it doesn't get the bull's eye," Kuniholm says. "Change the location of the dart, it can't even pick it up." The arm in the 60Minutes segment could be manipulated to pluck a grape from a vine, he says, but it is nowhere near being capable of reaching into a pocket to pick out a set of car keys. Not eveiyone shares Kuniholm's pessimistic views about the ability of prosthetics to advance in spite of these obstacles. At Geisel School of Medicine Dr. Joseph Rosen has followed the advances in technology surrounding prosthetic arms and believes they are promising. "Both the private sector and the military are putting out new arms that are really impressive," Rosen says. "There has been significant advancement, especially on five-finger hands." Rosen, who teaches a class on biomedical engineering to undergraduates at Dartmouth, recently had a student conduct research on prosthetic arm advances. He found a variety of different arms coming out of Europe—including ones controlled by brain signals. "They brought some of these hands into my class, and it was amazing how quickly the students could use them," he says. DARPA also touts the progress of its efforts. Officials there would not grant an interview, but the DARPA website reports that, after six years of work, the agency has completed development of two prosthetic arm systems that "offer increased range of motion, dexterity and control options." Kamens DEKA Integrated Solutions Corp. has filed with the FDA to market one of the systems. Kuniholm does not dispute that progress is being made, but says it has yet to be felt by the vast majority of amputees who need the arms. That is a source of great frustration to Kuniholm, who decided a couple years ago to launch an open forum online—openprosthetics.org—for other frustrated engineers and inventors to submit their ideas for improvements to the metal hook. Amputees have also used the forum to discuss medical procedures and personal concerns. When he was in the Marines, Kuniholm says, a colonel he worked for gave him a problem-solving approach that goes by the acronym BAMCIS. (Begin the planning, Arrange for reconnaissance, Make reconnaissance, Complete the planning, Issue the Order, Supervise). Kuniholm's colonel had a seventh step that he called BAMCIS-D. "The D was 'Do it yourself,' " Kuniholm says. "When everything else fails, just do it yourself. I'm on step seven." SO, WHY MAKE SHOES? Kuniholms boyish face squints in the sun that speckles through the Spanish moss hanging in thick strands from the oaks and hickory trees in downtown Savannah. He's been making his weekly journey, he says, to see if Mrsan can teach him something about shoemaking that will translate to prosthetics. The Savannah College of Art and Design identifies Mrsan as the only master shoemaker teaching his craft in the country. Initially, the descendant of six generations of leather artisans from Budapest had no idea how he could help a man trying to develop a better prosthetic arm. Now the professor says that once he pulled out books and started looking at prosthetic designs, it started to make some sense. "A buckle is a buckle, leather is leather," he says of the ways in which both shoes and prostheses connect to their wearers. If Kuniholm can't find a way to prod faster development of improved prosthetic arms, he thinks at least he can make the existing technology lighter, easier to wear and operate, and more comfortable. Kuniholm believes there are more similarities between shoes and prosthetics—even arms—than the casual observer might see. Both are used to connect parts of the human body to the outside world: At that point of contact they need to fit snugly, breathe, be comfortable, lightweight and yet strong and durable. Moreover, the techniques used in crafting a shoe are similar to those needed to build a comfortable prosthetic. The task requires cutting and shaping leather or other more advanced fabrics to fit over a stump, and fasteners to make it stay in place. While Mrsan's other students were looking to bring a fashion edge to their designs, Kuniholm was dividing his time between the shoe workshop and the metal shop, where he was designing the special tool he needed to do the work with only one good hand. This meant learning not only how to fit the leather over a cast of a foot and attach it to the shoe's sole, but how to design a mechanism that would help him accomplish that. Kuniholm says he would eventually like to advance beyond leather and construct an arm that is more akin to a running shoe, with multiple layers of leather and mesh sewn and glued to make an upper. With help from a friend, he made a cast of his stump that he hopes will allow him to custom-make a new arm for him-self within the year. The moment has come for the shoemaking students to present their finished shoes to Mrsan for his expert review. Kuniholm's pair isn't finished. Nails still protrude from the underside of one shoe. The professors critique is gentle: "I think it's amazing you could finish it up to this point," Mrsan says, examining the cut leather and smooth sole. "You proved it is possible. And the stitches are better than some of my students who don't have disabilities." Kuniholm smiles, but that last line stings, just a little. "What I'm after," Kuniholm tells the class, "is not to have Marcell qualify his compliment by saying given the circumstances it is great." By now the class has come to know well that Mrsan is stingy with compliments, and that there is a high bar for faint praise. Kuniholm tells his classmates he will be back one day to show off the results of his efforts, not on his feet, but on his arm. And he envisions for them the reaction he hopes to get from Mrsan: "Where he'll say in the good old Hungarian fashion, 'That's not bad.' And we'll all know what he means is, 'It's awesome.' " "When all else fails, just do it yourself," says Kuniholm of his frustrations with prosthetics technology He is shown wearing a neurally controlled prototype being developed through a Department of Defense initiative. "What we've done in the last 100 years in prosthetics hasn't worked," says Kuniholm, here in a Duke engineering lab wearing a split-hook device that was originally patented in 1912. "That's why I'm wearing this."