How participatory budgeting can transform community engagement – An interview with Amir Campos

For most municipalities, participatory budgeting is a relatively new approach to include their citizens directly in the decision making for new investments and developments in their community. Fundación Civio is a civic tech organisation based in Madrid, Spain that develops tools for citizens that both reveal the civic value of data and promote transparency. The organisation has developed an online platform for participatory budgeting processes, both for voting and monitoring incoming proposals, that is currently being tested in three Spanish municipalities.

Diana Krebs (Project Manager for Fiscal Projects at OKI) talked with Amir Campos, project officer at Fundación Civio, on how tech solutions can help to make participatory budgeting a sustainable process in communities and what is needed beyond from a non-tech point of view.

Amir Campos, Project officer at Fundación Civio

Participatory budgeting (PB) is a relatively new form for municipalities to engage with their citizens. You developed an online platform to help to make the participatory process easier. How can this help in order to turn PB in an integrative part of community life?

Participatory budgets are born with the desire to democratize power at a local level, to “municipalize the State”, with a clear objective, that these actions at local level serve as an example at a regional and national level and foster change in State participation and investment policies. This aim for the democratization of power also represents a struggle for a better distribution of wealth, giving voice to the citizens, taking them out of political anonymity every year, making local investment’s needs visible much faster than any traditional electoral process. Participatory budgeting is a tough citizen’s marking of their local representatives.

The tool we have designed is powerful but easy to use because we have avoided the development of a tool that only technical people would use. Users are able to upload their own data (submitting or voting proposals, comments, feedback, etc. in order to generate discussions, voting processes, announcements, visualizations, etc.) It has a more visual approach that clearly differentiates our solution from existing solutions and gives further value to it. Our tool is targeted at administrators, users and policy makers without advanced technical skills and it is online, presented as Software as a Service (SaaS), avoiding the need for users to download or install any special software.

All in all, our tool will bring the experience of taking part in a process of participatory budgeting closer to all citizens. Once registered, its user-friendliness and visual features will keep users connected, not only to vote on proposals but also to monitor and share them, while exercising effective decision-making actions and redistributing available resources in their municipality. Along with off-line participatory processes, this platform gives voice to citizens’ vote and also gives them the possibility of making their public representatives more accountable through its monitoring capabilities. The final aim is to enable real participatory experiences, providing solutions that are easy to implement by all stakeholders involved, thus strengthening the democratic process.

Do you think that participatory budgeting is a concept that will be more successful in small communities, where the daily business is less ruled by political parties’ interest and more by consent of what the community needs (like new playgrounds or sports parks)? Or can it work in bigger communities such as Madrid as well?

Of course! The smaller the community, the better the decision-making process, not only at the PB level but at all levels. Wherever there is a “feeling” of a community it is much easier to generate agreements oriented towards the common good. That is why in large cities there is always more than one PB process at the same time, one at the neighborhood level, and another at the municipal level, to engage people at the neighborhood level and push them to vote at the city level. Examples such as Paris or Madrid, which use on-line and off-line platforms use that division, instead, small town halls, such as Torrelodones, open just a single process for the whole municipality. All processes need municipal representatives commitment and citizens engagement, connected to a culture of participation, for harvesting successful outcomes.

Do you see a chance that PB might increase fiscal data literacy if communities are more involved in deciding on what the community should spend tax money on?

Well, I am not sure about an improvement of fiscal data literacy, but I am absolutely convinced that citizens will better understand the budget cycle, concepts and the overall approval process. Currently, in most cases, budget preparation and approval has been a closed-door process within administrations. Municipal PB implementations will act as enabling processes for citizens to influence budget decisions, becoming actual stakeholders of the decision-making process, auditing budget compromises vs. actual spending and giving feedback to the administrations.

Furthermore, projects implemented thanks to a PB will last longer since citizens will take on a commitment to the project implemented, and their representatives and their peers with whom individuals will have to agree once and will easily renew this agreement.

The educational resources available for citizens in the platform will help also to improve the degree of literacy. They provide online materials to better understand the budget period, terms used, and how to influence and monitor the budget.

What non-tech measures and commitments do a municipal council or parliament need to take so that participatory budgeting will become a long-term integrative part of citizens’ engagement?

They will have to agree as a government. One of the key steps to maintain a Participatory Budgets initiative over time is to legislate on this so that, regardless of the party that governs the municipality, the Participatory Budgeting processes keep running and a long-lasting prevalence is achieved. Porto Alegre (Brazil) is a very good example of this; they have been redistributing their resources at the municipal level for the last 25 years.

Fundación Civio is part of the EU H2020 project, where it collaborates with 8 other partners around topics of fiscal transparency.

Source: Open Knowledge Foundation

Sunday Comics

Logic is Futile – Liz Silverman

Mary Death – Matthew Tarpley


Eggmen – Richard Barker


Architexts – Maverick & Joker

Schemantics – Michael Yu

Khartoon! – Khalid Albaih

Bad Pudding – Ollie Hayes

Life in Aggro – Cecilia Vasquez & Fei Hsiao


Poorly Drawn Lines – Reza Farazmand

Clockworks – Shawn Gaston


The Realist – Asaf Hanuka


Abstruse Goose


Mr. Lovenstein – J.L. Westover


Bonus Panel

Cat and Girl – Dorothy Gambrell

Ampersand – Barry Deutsch

Art – John Ohannesian

Sandra & Woo – Powree & Oliver Knörzer


Agonizing Trifles – Erik Jagger


In Search of Basho – Mark Fittock & Ross Findlay

Black Tea Comics – Rembrand Le Compte

nothing on

Iverly – Jeffrey Rowland

Irregular – David Morgan-Mar

Sephko – Gojko Franulic


Socks and Puppets – David Birch

Diesel Sweeties – Richard Stevens


IM Bry – Bry Onglatco

The Daily Snooze – Jacob Samuels

Bro, Don’t Like That, La, Bro – Ernest Ng

Trader Lydia – Ted Bishop

Channel Draw – Gianluca Constantini

Interesting Times – Nathan Fehr

Crimes Against Hugh’s Manatees – Hugh Crawford

xkcd – Randall Munroe

Climax! – The Phony

Free Thing of the Week: Japanese Wood Prints from the LOC

We return to distracting you with art. If you’re a fan of ukiyo-e style of wood block prints, or the less renowned but equally exquisite Yokohama-e prints, then dig into the latest from the Library of Congress: a cache of 2,500 wood block prints

Together with Nichibunken (International Research Center for Japanese Studies) who helped scan 1,100 of the prints, the Library of Congress released this outstanding collection into the public domain just this week. The original prints come from many collections, including those of Oliver Wendell Holmes and William Howard Taft, and 180 Yokohama-e prints from the private collection of Emily Crane Chadbourne.

There are some very early prints, as early as 1615, but for the most part this collection concentrates on the 19th Century, particularly the late Tokugawa period. Much of this collection was organized by the esteemed publisher of the erstwhile Washington Evening Star, Crosby Stuart Noyes, including about 1,300 prints, drawings, and illustrated books, but virtually none of it had been digitized and released to the public in an easily accessible form.

The Yokohama-e prints are especially fascinating as they show the strange, often bizarre interaction of Western figures with the Japanese tradition. According to the LOC, “Bewhiskered men and crinoline-clad women are shown striding through the city of Yokohama, clambering on and off ships, riding horses, enjoying local entertainments, and interacting with an endless array of objects from goblets to locomotives.” But the prints are more peculiar than that sentence suggests. A print of John James Audubon, for instance, shows his work being dragged away and eaten by a rat. Thomas Carlyle is pictured in a tizzy after a cat tips over a lamp on his latest novel.

More surprises await, but it’s best to see for yourself.

Check out the Library of Congress Collection, “Fine Prints: Japanese, pre-1915” here.

Harris Fellows to Help Us Shine a Light on What Works in Cities

[This article by Ed Finkel was originally published on the University of Chicago’s Harris School of Public Policy’s website.]

Cities with policies geared toward open data implementation tend to do a more thorough and consistent job of being transparent with citizenry when it comes to quantitative measures. More than half of cities have such policies (55 percent), and they’re more effective when they are stricter and more actionable, have been in place for a longer period of time, and when the city assigns a senior staff person to oversee implementation.

These were the key findings of two students, Joyce Xie and Wenjia Xie (who are unrelated), from the University of Chicago Harris School of Public Policy who participated last summer as fellows in the research of the Washington-based Sunlight Foundation, a nonprofit dedicated to government accountability and transparency. The Harris Public Policy fellows worked as part of the What Works Cities initiative, a national project around the use of data to improve services in midsized cities, launched in 2015 by Bloomberg Philanthropies, of which Sunlight Foundation is a partner organization.

“Sunlight Foundation has a set of guidelines instructing the cities in what kind of data should be published, and how to publish the data,” says Wenjia Xie, who worked with Joyce Xie to extract data from the U.S. City Open Data Census in carrying out their research. “They’re also interested in knowing whether their guidelines have an impact on policy implementation.”

“We tried to find data on the political structure, the demographics and the economic structure in those cities,” adds Joyce Xie. “Sunlight Foundation’s guidelines on open data policies were really useful in helping with the implementation.”

The summer experience of the two Xies and a third student, Rajab Ghazzaoui, represented the kickoff to a three-year memorandum of understanding between the Harris School and Sunlight Foundation covering the 2016-18 school years. The partnership will resume this summer with three new fellows: Andrew Yaspan and Faraz Ahmed, both students in Harris’ Master of Science in Computational Analysis and Public Policy (MSCAPP) program, as well as Saeb Ashan, a Harris MPP student and Pearson Fellow.

There will be up to four fellows again in 2018, whom Sunlight has again agreed to provide with substantive work projects aimed at exploring public policy issues and providing shadowing opportunities that will expand the fellows’ knowledge and skills. All have been or will be working on the What Works Initiative, working with dozens of cities to improve open data policies, disclosures and positive outcomes from sharing public information with its citizens.

In partnering with Harris, the Sunlight Foundation believes it has found a good match because the school is so oriented toward the use of data in public policy, says Stephen Larrick, director of the Open Cities program.

“There was a lot of overlap between our mission and our approach to public policy,” he says. “Only a few graduate programs in the country have this connection between computational methods and data, and public policy. We live in this intersection as well. In order for government to be accountable, it has to be empirical.”

“There was a lot of overlap between our mission and our approach to public policy. Only a few graduate programs in the country have this connection between computational methods and data, and public policy. We live in this intersection as well. In order for government to be accountable, it has to be empirical.”

– Stephen Larrick, director of the Open Cities program

The Harris MSCAPP program seemed especially well aligned, Larrick says. “We saw our work with cities, and the kind of research and empirical stance we take, and we thought that would be something of interest to Harris students, and that Harris students would bring skills relevant to our approach,” he says.

While Sunlight had spent years rigorously developing the best practices for cities to use in open data, they hadn’t empirically tested how those best practices impacted implementation of policies, Larrick says. “Before, we were able to say to a city, think about it, it’s important to have someone in charge,” he says. “Now, we’ve actually run the numbers on this.”

The findings have been communicated in everything from short reports to blog posts, and Sunlight has been careful to note that they can’t claim to have 100 percent proof given that data can be messy. “We were careful in terms of the way we talked about it, to make clear that these were interesting findings, and we didn’t want to go overboard,” says Greg Jordan-Detamore, Open Cities technologist. “Another real-world thing that [the students] got a taste of is that a big use for this material has been for our team, internally. A lot of useful analysis may not always be seen by the public.”

Joyce Xie says the project gave her the opportunity to put the data analysis skills she learned during her first year at Harris into practice. “The internship experience showed me how complicated the reality is, when you’re trying to do an analysis and find your way out of dirty data,” she says. “It also helped me to choose my classes during my second year. I realized, I thought we already learned a lot during first year, but I realized there was a lot to learn for me.”

Wenjia Xie sounds similar notes to her fellowship partner, noting that the summer experience drew from skills like econometrics, financial modeling and regression analyses. They also learned how best to communicate such findings, she notes. “You want blog posts to be accessible to everyone,” she says. “You don’t want to make it full of lots of jargon and terminology.”

Sunlight is open to working with Harris students during the school year, too, Larrick says, and they’re looking forward to this summer and the next. “One of the things [last summer’s experience] led to was a lot of ideas about how we could continue this approach,” he says. “We could dive deep on a focused project.”

Jordan-Detamore says Sunlight is considering a few different possibilities, including an exploration of popular open data sets. They’re also working on encouraging cities to be transparent about their transparency by posting open data policies online and allowing public feedback. And they might have projects involving the visualizing or displaying of open data. “We’re proponents of cities trying to publish popular data sets according to standards shared among many different cities,” he says.

Pelting Stones

Are you afraid to pelt stones?
‘We are not afraid of death,’ says Javed.
Silence ricochets in the small room
While stoic faces stare back at me.
Half-embroidered pashmina shawls lie crushed in a corner
Wallowing in the dust like all Kashmir is today.

‘Pelting stones is a lark,’ says Javed,
Stretching out his prosthetic leg on a thin carpet,
As thin as the veneer of promises made to Kashmir
By smiling Buddhas in a faraway city.

‘I ran with the mob when I was fourteen.
This leg was shot off by the police.
But you need hands to throw stones
And those I have.’
‘Yes, he is not afraid,’ Mother corroborates.
‘My sister was shot sitting by her window.
She was no stone pelter.’

‘What is there to be afraid of?’ His sisters echo.
‘To breathe freely, to make choices, to be safe:
Those are the messages on our stones.
Why must we be afraid to speak up?’

Javed glares and spits it out.
‘Every stone we throw is to shoo off
Ravenous dogs fighting over a prize.
Satanic flesh-eaters bloodying this paradise.
Ripping apart our fragile Kashmir.’

Mother has a distant look in her eyes.
She sees things that I cannot.
I can hardly hear when she whispers.
‘The first word Javed lisped was ‘Azaadi’,
‘No. My son is not afraid.’

‘Pelting stones is not a sport.
‘I’m afraid, Javed,’ I say, ‘this is not a stunt’.
However, I’m evasive and don’t deign to ask,
‘Javed, what’s the matter? What is it that your people want?’
Because I am afraid, just like the rest of you
To be shot with a chilling riposte.
In one voice, Kashmir will shout, you see
‘I don’t need any of you!
‘Will you bloody just keep off me?’

How to Fall to Your Death and Live to Tell the Tale

Alcides Moreno and his brother Edgar were window washers in New York City. The two Ecuadorian immigrants worked for City Wide Window Cleaning, suspended high above the congested streets, dragging wet squeegees across the acres of glass that make up the skyline of Manhattan.

On 7 December 2007, the brothers took an elevator to the roof of Solow Tower, a 47-storey apartment building on the Upper East Side. They stepped onto the 16-foot-long, three-foot-wide aluminium scaffolding designed to slowly lower them down the black glass of the building.

But the anchors holding the 1,250-pound platform instead gave way, plunging it and them 472 feet to the alley below. The fall lasted six seconds.

Edgar, at 30 the younger brother, tumbled off the scaffolding, hit the top of a wooden fence and was killed instantly. Part of his body was later discovered under the tangle of crushed aluminium in the alley next to the building.

‘Fall 1 – Journal of Falls’ © Dave Imms

But rescuers found Alcides alive, sitting up amid the wreckage, breathing and conscious when paramedics performed a “scoop and run” – a tactic used when a hospital is near and injuries so severe that any field treatment isn’t worth the time required to do it. Alcides was rushed to New York-Presbyterian Hospital/Weill Cornell Medical Center, four blocks away.


Falls are one of life’s great overlooked perils. We fear terror attacks, shark bites, Ebola outbreaks and other minutely remote dangers, yet over 420,000 people die worldwide each year after falling. Falls are the second leading cause of death by injury, after car accidents. In the United States, falls cause 32,000 fatalities a year (more than four times the number caused by drowning or fires combined). Nearly three times as many people die in the US after falling as are murdered by firearms.

Falls are even more significant as a cause of injury. More patients go to emergency rooms in the US after falling than from any other form of mishap, according to the Centers for Disease Control and Prevention (CDC), nearly triple the number injured by car accidents. The cost is enormous. As well as taking up more than a third of ER budgets, fall-related injuries often lead to expensive personal injury claims. In one case in an Irish supermarket, a woman was awarded 1.4 million euros compensation when she slipped on grapes inside the store.

It makes sense that falls dwarf most other hazards. To be shot or get in a car accident, you first need to be in the vicinity of a gun or a car. But falls can happen anywhere at any time to anyone.

Spectacular falls from great heights outdoors like the plunge of the Moreno brothers are extremely rare. The most dangerous spots for falls are not rooftops or cliffs, but the low-level, interior settings of everyday life: shower stalls, supermarket aisles and stairways. Despite illusions otherwise, we have become an overwhelmingly indoor species: Americans spend less than 7 per cent of the day outside but 87 per cent inside buildings (the other 6 per cent is spent sitting in cars and other vehicles). Any fall, even a tumble out of bed, can change life profoundly, taking someone from robust health to grave disability in less than one second.

Falling can cause bone fractures and, occasionally, injuries to internal organs, the brain and spinal cord. “Anybody can fall,” says Elliot J Roth, medical director of the patient recovery unit at the Shirley Ryan AbilityLab in Chicago. “And most of the traumatic brain injury patients and spinal cord injury patients we see had no previous disability.”

‘Fall 2 – Journal of Falls’ © Dave Imms

There is no Journal of Falls, though research into falling, gait and balance has increased tremendously over the past two decades. Advances in technology improve our understanding of how and why people fall, offer possibilities to mitigate the severity of falls, and improve medicine’s ability to treat those who have hurt themselves falling.

Scientists are now encouraging people to learn how to fall to minimise injury – to view falling not so much as an unexpected hazard to be avoided as an inevitability to be prepared for. Training may even have been a factor determining the outcome of the Moreno brothers’ fall to earth nearly ten years ago.


Doctors at NewYork-Presbyterian did not want to risk moving Alcides Moreno from the emergency room into a surgical theatre for fear that the slightest additional bump might kill him. They started surgery in the ER. He had two broken legs, a broken arm, a broken foot, several broken ribs, and a crushed vertebra that could have paralysed him, as well as two collapsed lungs, a swollen brain, plus several other ruptured organs. Alcides was given 24 pints of blood and 19 pints of plasma before the bleeding could be stopped.

Doctors marvelled that he was alive at all, reaching for an explanation not often used in medical literature: “miracle”.

By 100 feet or more, falls are almost always fatal, apart from freak accidents. People have fallen miles from planes and lived, due to tumbling down snowy hillsides, the way extreme skier Devin Stratton did when he accidentally skied off a 150-foot Utah mountain cliff in January 2017 and escaped unharmed, his fall arrested by branches and cushioned by deep snow. He was wearing a helmet, which cracked even as its camera recorded his plunge.

“It’s not the fall that gets you,” the skydiving joke goes. “It’s the sudden stop at the bottom.” Deceleration is the key to surviving falls and reducing injuries − it isn’t the length of fall that’s relevant, but what happens as you reach the ground. This was dramatically demonstrated in the summer of 2016 by professional skydiver and safety expert Luke Aikens. He jumped from a plane without a parachute at an altitude of 25,000 feet, or 4.7 miles, hitting a 100-by-100-foot net positioned in the southern California desert and emerging without a scratch.

One theory was that Alcides lived because, when the scaffolding gave way, he lay flat and clung to the platform, as professional window washers are trained to do. The scaffold fell not in the open street but in a narrow alley – air resistance may have built up against the platform, slowing it. The platform also may have scraped against the building and its neighbour, reducing its rate of fall. The aluminium crushed on impact, and landed on a pile of cables, both of which absorbed some of the impact, forming a cushioned barrier.

Survival from heights prompted the first medical writing about falls. Hippocrates, in his treatise on head injuries, observes, sensibly, that “he who falls from a very high place upon a very hard and blunt object is in most danger of sustaining a fracture… whereas he that falls upon more level ground, and upon a softer object, is likely to suffer less injury”. The first modern medical paper on a fall was Philip Turner’s ‘A fall from a cliff 320 feet high without fatal injuries’, published in the Guy’s Hospital Gazette in 1919. It examined the case of a Canadian Army private who stumbled over a chalk cliff on the coast of France in 1916 and lived.

In 1917, an American air cadet named Hugh DeHaven was flying in a Curtiss JN-4 “Jenny” when it collided with another biplane 700 feet above an airfield in Texas. Among the four men aboard the two planes, DeHaven alone survived the plunge. He spent the rest of his career trying to figure out why, culminating in his pioneering 1942 paper, ‘Mechanical analysis of survival in falls from heights of fifty to one hundred and fifty feet’.

In it, he examined eight cases of people surviving long falls – ignoring his own, but including the lucky Canadian private from 1916 – and found that those who landed on newly tilled gardens could walk away surprisingly intact, noting: “It is, of course, obvious that speed or height of fall, is not in itself injurious.” That might sound like the first half of the skydiving joke, but his research led him to design and patent the combined seatbelt and shoulder harness worn in every car today.

Up to the 1960s and 1970s, scientific papers on falls focused on forensics – their subjects tended to be dead, the medical questions centring on what had happened to them. This was important, for instance, when assessing trauma to children – could this child have fallen and suffered these injuries, as the caregiver claimed, or is it abuse? Falls as a separate, chronic, survivable medical problem began to get attention only in the past quarter-century. The journal Movement Disorders was begun in 1986, but the bulk of papers examining the interplay of balance, gait and falls at ground level appear after 2000.


You can trip or slip when walking, but someone standing stock still can fall too – because of a loss of consciousness, vertigo or, as the Moreno brothers remind us, something supposedly solid giving way. However it happens, gravity takes hold and a brief, violent drama begins. And like any drama, every fall has a beginning, middle and end.

“We can think of falls as having three stages: initiation, descent and impact,” says Stephen Robinovitch, a professor in the School of Engineering Science and the Department of Biomedical Physiology and Kinesiology at Simon Fraser University in British Columbia, Canada. “Most research in the area of falls relates to ‘balance maintenance’ – how we perform activities such as standing, walking and transferring without losing balance.”

By “transferring”, he means changing from one state to another: from walking to stopping, from lying in a bed to standing, or from standing to sitting in a chair. “We have found that falls among older adults in long-term care are just as likely to occur during standing and transferring as during walking,” says Robinovitch, who installed cameras in a pair of Canadian nursing homes and closely analysed 227 falls over three years.

‘Fall 3 – Journal of Falls’ © Dave Imms

Only 3 per cent were due to slips and 21 per cent due to trips, compared to 41 per cent caused by incorrect weight shifting – excessive sway during standing, or missteps during walking. For instance, an elderly woman with a walker turns her upper body and it moves forward while her feet remain planted. She topples over, due to “freezing”, a common symptom of Parkinson’s, experienced regularly by about half of those with the disease.

In general, elderly people are particularly prone to falls because they are more likely to have illnesses that affect their cognition, coordination, agility and strength. “Almost anything that goes wrong with your brain or your muscles or joints is going to affect your balance,” says Fay Horak, professor of neurology at Oregon Health & Science University.

Fall injuries are the leading cause of death by injury in people over 60, says Horak. Every year, about 30 per cent of those 65 and older living in senior residences have a fall, and when they get older than 80, that number rises to 50 per cent. A third of those falls lead to injury, according to the CDC, with 5 per cent resulting in serious injury. It gets expensive. In 2012, the average hospitalisation cost after a fall was $34,000.

How you prepare for the possibility of falling, what you do when falling, what you hit after falling – all determine whether and how severely you are hurt. And what condition you are in is key. A Yale School of Medicine study of 754 over-70s, published in the Journal of the American Medical Association in 2013, found that the more serious a disability you have beforehand, the more likely you will be severely hurt by a fall. Even what you eat is a factor: a study of 6,000 elderly French people in 2015 found a connection between poor nutrition, falling and being hurt in falls.


‘Fall 4 – Journal of Falls’ © Dave Imms

Alcides Moreno underwent 15 more surgeries and was in a coma for weeks. He was visited by his three children: Michael, 14, Moriah, 8, and Andrew, 6. His wife, Rosario, stayed at his bedside, talking to him. She repeatedly took his hand and guided it to stroke her face and hair, hoping that the touch of her skin would help bring him around. Then, on Christmas Day, Alcides reached out and stroked not his wife’s face but the face of one of his nurses.

“You’re not supposed to do that,” Rosario chided him. “I’m your wife. You touch your wife.”

“What did I do?” he asked. It was the first time he had spoken since the accident, 18 days earlier. His doctors predicted he might walk again, after lengthy rehabilitation, though the challenges proved to be not only physical but also mental. People who fall suffer the expected physical injuries, but accidental falling also carries a heavy psychological burden that can make recovery more difficult and can, counter-intuitively, set the stage for future falls.


Children begin to walk, with help, at about a year old. By 14 months they are typically walking unaided. Those first baby steps are guided by three key bodily systems. First, proprioception – input from the nerves in the muscles, a sense of where limbs are relative to each other and what they’re doing. People whose limbs are numb have difficulty walking even if their musculature is completely functional.

The second sense is vision, not just to see where you are going, but to help process information from your other senses. “Most people who walk into a dark room will sway more than if they can see – about 20 per cent more,” says Horak, an expert in how neurological disorders affect balance and gait.

And third is your vestibular system, canals of fluid in the inner ear that work in a way not very different from a carpenter’s spirit level. The system takes measurements in three dimensions, and your body uses the data to orient itself.

With these various systems doing their jobs, you can step forward and begin to walk, a feat that performance artist Laurie Anderson once described in a song with succinct scientific accuracy: “You’re walking, and you don’t always realise it/But you’re always falling/With each step, you fall forward slightly/And then catch yourself from falling/Over and over.”

Or don’t catch yourself. We fall when the smooth, almost automatic process of walking goes awry. Perhaps it is something as crude as your step being blocked by an obstacle: you trip, over a prankster’s outstretched foot perhaps. Or the traction of your foot against the floor is lost because of a slippery substance – the classic banana peel of silent movie fame, what researchers call “perturbation”.

Christine Bowers is 18. She hails from upstate New York, and is a student at the Moody Bible Institute in Chicago. One day she hopes to teach English abroad. In January 2016 she had a cavernous malformation – a tangle of blood vessels deep within her brain – removed.

“It paralysed my left side,” she says, as her physical therapist straps her into a complex harness in a large room filled with equipment at the Shirley Ryan AbilityLab. “I’m working on preventing a fall.”

Under the supervision of Ashley Bobich the therapist, Bowers is walking on the KineAssist MX, a computerised treadmill with a robotic arm and harness device at the back. The metal arm allows patients freedom of motion but catches them if they fall. This version of the device is quite new – the AbilityLab only got it at the end of 2016 and Bowers is the second patient of Bobich’s to try it. Previously, those in danger of falling would be tethered to overhead gate tracks, a far cruder system, which still can be seen in the ceilings above.

Being a student, Bowers often finds herself in crowded academic hallways, and says she values her cane as much to alert those around her that she has mobility problems as for support. Seeing the cane, she says, her classmates tend to give her a bit of room as they hurry through the corridors.

Still, she has fallen several times, and those falls made her very skittish about walking, a serious problem in the rehabilitation of those who have fallen. “It’s huge,” says Bobich. “Fear of falling puts you at risk for falling.”

Elliot Roth agrees. “Falls often cause fear of falling, and fear of falling often causes fear of walking, and fear of walking often causes abnormal or inadequate walking,” he says. A challenge of rehabilitation is to not only increase physical capacity, but also build patient confidence.

“We’ve been doing what’s called ‘perturbation training’, where I pick a change in the treadmill speed,” says Bobich. “She’s walking along, I hit the button, and the treadmill speeds up on her and she has to react… Her biggest fear was slipping on ice, so I said, ‘You know what? I have a really great way for us to train that.'”

The treadmill hums while Bobich speeds it up and slows it down, and Bowers, her right hand clasping her paralysed left, struggles to maintain her balance.

“You’re getting better at this,” says Bobich. “You’re getting way better.”


The KineAssist is an example of how technology that was once used to study ailments is now used to help patients. Advanced brain scanning, having identified the regions responsible for balance, now diagnoses damage that affects them. Accelerometers attached to people’s ankles and wrists have been used in experiments, plotting induced falls directly into a computer for study, and are now being used to diagnose balance problems – or to detect when someone living alone has fallen and summon help.

“Over one-half of older adults who fall are unable to rise independently, and are at risk for a ‘long lie’ after a fall, especially if they live alone, which can greatly increase the clinical consequences of the falls,” says Stephen Robinovitch. He and his colleagues are working to develop wearable sensor systems that detect falls with high accuracy, as well as providing information on their causes, and on near-falls.

Researchers at the Massachusetts Institute of Technology took the “wearable” out of the equation by developing a radio wave system that detects when someone has fallen and automatically summons help. The Emerald system was shown off at the White House in 2015 but is still finding its way to a market chock-full of devices that detect falls, invariably pendants.

Not that a device needs to be high-tech to mitigate falls. Wrestlers use mats because they expect to fall; American football running backs wear pads. Given that a person over 70 is three times as likely to fall as someone younger, why don’t elderly people generally use either?

The potential benefit of cushioning is certainly there. The CDC estimates that $31 billion a year is spent on medical care for over-65s injured in falls – $10 billion for hip fractures alone (90 per cent of which are due to falls). Studies show that such pads reduce the harmful effects of falling.

‘Fall 5 – Journal of Falls’ © Dave Imms

But older people have all the vanity, inhibition, forgetfulness, wishful thinking and lack of caution that younger people have, and won’t wear pads. More are carrying canes and using walkers than before, but many more who could benefit shun them because, to them, canes and walkers imply infirmity, a fate worse than death (80 per cent of elderly women told researchers in one study that they would rather die than have to live with a debilitating hip fracture). This sets up another vicious cycle related to falling: fearing the appearance of disability, some elderly people refuse to use canes, thereby increasing their chances of falling and becoming disabled.

Padded floors would seem ideal, since they require none of the diligence of body pads or canes. But padding environments is both expensive and a technical challenge. If a flooring material has too much give, wheelchairs can’t roll and footing is compromised. That’s why nursing homes tend not to be thickly carpeted. People pick up their feet less high as they age, and so have a tendency to trip on carpets.

There are materials designed to reduce injuries from falls. Kradal is a thin honeycombed flooring from New Zealand that transmits the energy of a fall away from whatever strikes it, reducing the force. A study of the flooring in Swedish nursing homes found that while it did reduce the number of injuries when residents fell on it, they fell more frequently when walking on it, leading to a dilemma: the flooring might be causing some falls even as it reduced the severity of resulting injuries.

One unexpected piece of anti-fall technology is the hearing aid. While the inner ear’s vestibular system is maintaining balance, sound itself also seems to have a role.

“We definitely found that individuals with hearing loss had more difficulty with balance and gait, and showed significant improvement when they had a hearing aid,” says Linda Thibodeau, a professor at the University of Texas at Dallas’s Advanced Hearing Research Center, summarising a recent pilot study. “Most people don’t know about this.”

Horak agrees, saying that people who have cochlear implants to give them hearing also find their balance improves. Hearing is not as critical for balance as proprioception, vision and the vestibular system, she says, “But hearing may also contribute and we don’t understand how. We think you can use your hearing to orient yourself.”

Thibodeau says one reason it’s important to establish this link is that insurance companies don’t typically cover hearing aids, because they are seen as improving lifestyle more than sustaining basic health. Hearing aids can be expensive – up to $6,000 – but a broken hip, which insurance companies do cover, can cost five or ten times that figure, or more, and lead to profound disability or death.

More than half of people in their 70s have hearing loss, but typically wait ten to 20 years beyond the time when they could first benefit before they seek treatment. If the connection to balance and falls were better known, that delay might be reduced.

The role of hearing reminds us that, while walking is considered almost automatic, balance is at some level a cognitive act, achieved by processing a cloud of information. Pile demands on our attention and that itself can cause falls, particularly among people who are already compromised physically or cognitively.

Thibodeau once led a group of people with hearing impairments to the Dallas World Aquarium to test out wireless microphone technology in the real world. “There’s a stairway going by an enormous fish tank,” she says. “I had a participant fall on the stairs, and someone at the aquarium told me, ‘A lot of people fall going down those stairs, looking at the aquarium.'” (Asked to comment whether this indeed is a common problem there, the Dallas World Aquarium director did not reply, a reminder perhaps that the legal aspects of falls can inhibit dissemination of information about them).


Given the tremendous cost of falls to individuals and society, and the increasing knowledge of how and why falls occur, what can you do to prevent them? And can you do anything to lessen harm in the split second after you start to fall?

1. Prepare your environment

Secure loose rugs or get rid of them. Make sure the tops and bottoms of stairs are lit. Clean up spills immediately. Install safety bars in showers and put down traction strips, and treat slick surfaces such as smooth marble floors with anti-slip coatings. If there’s ice outside your home, clear it and put down salt.

2. Fall-proof your routine

Watch where you are going. Don’t walk while reading or using your phone. Always hold handrails − most people using stairways do not. Don’t have your hands in your pockets, as this reduces your ability to regain your balance when you stumble. Remember that your balance can be thrown off by a heavy suitcase, backpack or bag.

Roth asks most of his patients who have fallen to describe in detail what happened. “Sometimes people are not paying attention. Multi-tasking is a myth, and people should try very hard to avoid multi-tasking. No texting while walking.”

The more problems you have controlling your balance, the more attention is required, says Horak. “If you’re carrying a big backpack on a slippery log, you don’t want somebody to ask you what’s for dinner.”

3. Improve your gear

Wear good shoes with treads. On ice, wear cleats – you can buy inexpensive soles with metal studs that slip over your shoes. Do not wear high heels, or at least have a second pair of flat shoes for walking between locations. Get a hearing aid if you need one. Wear a helmet when bicycling, skiing and skateboarding. Use a cane or walker if required. Hike with a walking stick.

4. Prepare your body

Lower body strength is important for recovering from slips, upper body strength for surviving falls. Martial arts training can help you learn how to fall. Drugs and alcohol are obviously a factor in falls – more than half of adult falls are associated with alcohol use – as is sleep apnea. Get a balanced diet to support bone density and muscle strength. If you feel lightheaded or faint, sit down immediately. Don’t worry about the social graces, you can get back up once you’ve established you are not going to lose consciousness.

Understandably, some elderly people fear falling so much that they don’t even want to contemplate it. “People should know they could improve their balance with practice, even if they have a neurological problem,” says Horak.

5. Fall the right way

What happens once you are falling? Scientists studying falling are developing “safe landing responses” to help limit the damage from falls. If you are falling, first protect your head – 37 per cent of falls by elderly people in a study by Robinovitch and colleagues involved hitting their heads, particularly during falls forward. Fight trainers and parachute jump coaches encourage people to try not to fall straight forward or backward. The key is to roll, and try to let the fleshy side parts of your body absorb the impact.

“You want to reach back for the floor with your hands,” says Chuck Coyle, fight director at the Lyric Opera of Chicago, describing how he tells actors to fall on stage. “Distribute the weight on the calf, thigh, into the glutes, rolling on the outside of your leg as opposed to falling straight back.”

Young people break their wrists because they shoot their hands out quickly when falling. Older people break their hips because they don’t get their hands out quickly enough. You’d much rather break a wrist than a hip.


Alcides Moreno underwent a long regimen of physical and occupational therapy at the Kessler Institute for Rehabilitation in New Jersey, working to strengthen his legs, restore his balance, and walk. Occupational therapy was necessary, as well as counselling, as he had grown depressed over the loss of his brother, Edgar.

He is unable to return to work but received a multimillion-dollar settlement in his lawsuit against the scaffolding company, Tractel, after a Manhattan court found that it had installed the platform negligently. The sum wasn’t revealed, but a source said it was more than the $2.5 million that Edgar’s family received.

Alcides and his family moved to Arizona, and live outside Phoenix. “This weather is good for my bones,” he told the New York Post. He keeps busy, driving his kids to school and to sporting events, and likes to work out in the gym.

Last year he and his wife had a fourth child, a son.

“I keep asking myself why I lived,” he told the BBC this year. “I have a new baby – he must be the reason, to raise this kid and tell him my history.”

‘Fall 6 – Journal of Falls’ © Dave Imms

This article first appeared on Mosaic and is republished here under a Creative Commons license.