Footnotes for "Why we're funding clubfoot treatment through MiracleFeet"

[1] "Congenital talipes equinovarus (CTEV), also known as clubfoot, is a congenital condition characterized by one (unilateral) or both (bilateral) feet twisting inward…. In a shallow literature review, we found that untreated clubfoot is commonly reported to cause disability, deformity and pain. People with untreated clubfoot are also reported to face social exclusion and reduced income. We have not vetted these claims but they appear plausible given that clubfoot is not expected to resolve without treatment and there are theoretical and empirical associations between physical disability and worse economic outcomes." GiveWell, Ponseti Casting for Clubfoot, December 2022

[2] We plan to publish a formal write-up and cost-effectiveness analysis for this grant in the near future. Much of the information in this blog post that is specific to MiracleFeet's program comes from conversations with MiracleFeet and materials that are still unpublished.


  • "The Ponseti casting method of treating clubfoot aims to correct foot alignment and typically includes:
    • Stretching the affected foot and using a series of casts over approximately 6 weeks, which is designed to gradually change the foot’s alignment,
    • A surgical procedure (percutaneous achilles tenotomy) aiming to improve the foot’s flexibility, and
    • Use of a final cast for three weeks and then use of splints/braces at night in order to maintain the alignment"

    GiveWell, Ponseti Casting for Clubfoot, December 2022

  • "Fortunately, clubfoot is treatable with the nonsurgical Ponseti method—a simple, highly effective, and low-cost solution that restores full functionality and mobility in 95% of cases. It involves a series of weekly casts to gently reposition the feet and a simple outpatient procedure to release the Achilles tendon, followed by use of a foot abduction brace, worn for 4-5 years while sleeping to prevent relapse." MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished)


  • "We train providers in the Ponseti method and ensure clinics are equipped with all necessary treatment supplies, including braces. We establish early detection and referral pathways by raising awareness of clubfoot in communities and training frontline health workers (such as nurses and midwives) in clubfoot identification, with the goal of ensuring families access treatment before a child’s first birthday (when treatment is easier on the child and optimal results are most likely). Once children are enrolled, our clinic teams educate and follow-up with parents to minimize patient dropout and optimize long-term outcomes."
  • "To monitor treatment quality and support our partners in providing safe and effective care, MiracleFeet uses a sophisticated monitoring and evaluation system, known as CAST (discussed more in the section below). CAST gives us visibility to treatment data at the patient, clinic, country, and global levels so that issues can be quickly identified and addressed."

MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished)

[5] "Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is one of the most common congenital conditions, affecting 1 in 800 births." Clinton Health Access Initiative, "Preventing Lifelong Impairment: Access to Clubfoot Treatment in Low- and Middle-Income Countries," 2021, p. 1

[6] We base this statement on notes from an unpublished conversation between GiveWell staff and an expert on disability that took place December 13, 2022.

[7] The more precise estimates from our unpublished cost-effectiveness analysis are 9,785 cases treated, 9% of which would have been treated absent MiracleFeet.

[8] This estimate factors in a 78% estimated initial correction rate (i.e., 78% of the time, the Ponseti method works to restore the affected foot to proper alignment) and a 47% estimated relapse rate among those initially corrected (i.e., in 47% of these cases, we expect that the corrected foot will lose some of its mobility gains). Thus, 9,785 x 91% (to account for those who would otherwise receive treatment) x 78% (initial correction rate) x 53% (who don't relapse) = 3,681. In addition, we expect that even children who experience relapse will still benefit from treatment through the benefits experienced before relapse, and our intuition is that cases of relapse after treatment will be less severe than those that are never treated.

[9] See individual pages for each of our top charities for more details about these programs.

[10] "With severely hampered mobility, these patients are unable to work; thus, this deformity contributes not only to ill health but also to poverty.” Grimes et al. 2016, p. 1.

[11] We typically use the Institute for Health Metrics (IHME)'s Global Burden of Disease (GBD) study. The IHME value we chose for clubfoot is described as "disfigurement level 2 with pain and moderate motor impairment due to congenital limb deficiency."

[12] "We invest heavily in the ongoing mentorship of providers, and all partners are trained in the use of MiracleFeet’s mobile phone-based patient management and M&E [monitoring and evaluation] system, known as CAST. Built on Dimagi’s Commcare platform, CAST is currently used by providers in 30 LMICs to track enrollments, record treatment data, and manage appointments. Providers enter patient data during in-clinic appointments, and data then flows into a Salesforce database where individual patient records are aggregated into key performance indicators on treatment quality." MiracleFeet, "MiracleFeet Proposal for GiveWell," December 2022 (unpublished)

[13] A write-up about this grant is forthcoming.