How a revolutionary cure put clubfoot on the global health agenda

Last June, as my colleague and I walked through a small village in the western region of Sierra Leone, a group of children surrounded us and asked us to take their photo. We decided to appease them and stopped to take their pictures when my colleague excitedly tapped me on the shoulder, “Look at his foot! Look at his foot!”

I looked down. The boy was standing on a severely twisted foot. I too became excited and we immediately began to look for his parents.

A child with a foot deformity is not usually something people get excited about while passing through a small West African village. But the boy, two-year-old Mohamed Bangura, had a congenital condition called clubfoot and I was in Sierra Leone to work on a national clubfoot treatment program with Seattle-based organization Mobility Outreach International.

The local government hospital recently started offering treatment that would enable Mohamed to walk normally for the rest of his life. It was not even a ten-minute motorcycle ride away from Mohamed’s village and I wanted to make sure his parents knew about it.

Every year, approximately 200,000 children are born like Mohamed, where one or both of their feet twist inward so that the bottom of the foot faces sideways or even upward. Clubfoot affects about 1-3 in 1000 births worldwide.

The rates at birth are the same here in Seattle as they are in Sierra Leone — but what happens to a child born with clubfoot varies greatly from place to place. While clubfoot has no borders, permeating all class, geographic, and ethnic boundaries, treatment for it is only the norm in the developed world.

Until the end of the last century, doctors performed surgery to treat clubfoot. But due to weak health infrastructure in developing countries, most children born with clubfoot lack access to surgical interventions. The vast majority of cases in the developing world go untreated, leading to a lifetime of disability, poverty, and social stigma for those who are afflicted. Untreated clubfoot makes walking painful and challenging at best — impossible at worst.

Fortunately, the game-changer for clubfoot arrived in the late 1940’s when orthopedic surgeon, Ignacio Ponseti, created a non-surgical treatment that corrected congenital clubfoot through foot manipulation and bracing.

The treatment, now called, “The Ponseti Method” uses a series of casts and a tenotomy (a minor procedure that cuts the Achilles tendon), followed by the wearing of two boots held together with a bar to hold the feet in place. This method remained mostly unpracticed until the late 1990s when the parents’ online Yahoo group, Nosurgery4clubfoot, brought attention to the treatment and its success.

With the Ponseti Method, people born with clubfoot went on to become gold medal Olympians and Super Bowl Champions. Furthermore, it is cost effective, uses basic materials, and does not require surgeons or operating rooms. Overall, The Ponseti Method has transformed the way the global health community views clubfoot.

However, while the Ponseti Method boasts a 97% success rate, it is by no means a quick fix. In order for it to be most effective, the treatment must begin before the age of two (as a newborn is best) and the shoe brace must be worn 23 hours a day for three months and then during sleeping hours until the child is four or five years old.

This makes early identification and referral of clubfoot cases vital. It means educating parents to ensure that their child wears the shoe brace according to treatment protocol. Weekly transportation for casting is a challenge and shoe braces needs to be supplied or made in country.

Implementation of the Ponseti Method requires a public health approach.

In 2009, a group of organizations with the vision of eradicating neglected clubfoot worldwide formed the Global Clubfoot Initiative (GCI). This group has successfully communicated the importance of incorporating Ponseti clubfoot treatment into global health programs. GCI now incorporates 25 partner organizations, all with the mission of spreading the Ponseti Method throughout the world.

Mobility Outreach International (MOi), a 26-year old organization that was originally created to bring critical orthopedic surgery and prosthetics and orthotics to landmine victims in Vietnam, is a founding member of the Global Clubfoot Initiative.

MOi launched its clubfoot program in 2006 when Seattle volunteer surgeons saw an extraordinary number of children and young adults immobilized by neglected clubfoot. Today, MOi supports Ponseti treatment programs in Sierra Leone, Vietnam, and Haiti, and has served over 6,000 children

Today on World Clubfoot Day, we celebrate what would be Dr. Ponseti’s 101^st birthday. His ingenuity has made it possible for children born with clubfoot to live a life full of opportunity, independence, and mobility.

When I found Mohamed’s mother, she told me that she had already heard of treatment at the local government hospital through a radio advertisement. Mohamed started treatment that Friday. A year later, he is still wearing a shoe brace at night as part of his treatment, but now he’s an active 3-year-old who can walk, run, and play.

Jana Shih

Jana Shih has worked on health projects in West Africa, East Africa, Vietnam, and Haiti. She received her MSW and MPH from the University of Washington and is currently a program officer for Mobility Outreach International.