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Welcome to GiveWell’s podcast sharing the latest updates on our work. Tune in for conversations with GiveWell staff members discussing current priorities of our Research team and recent developments in the global health landscape.
Elie Hassenfeld: [00:00:00] Hey everyone, this is Elie Hassenfeld, GiveWell's co-founder and CEO. Today I'm talking with Meika Ball, a researcher at GiveWell.
We're gonna talk about a grant we made in 2023 to MiracleFeet. It's an organization that treats clubfoot, which is a condition where one or both feet twist inward at birth, and that causes pain and eventually mobility loss if it's not treated. It affects about one out of every 800 babies who are born, most of them in low- and middle-income countries. And only about a fifth of the kids in those countries who need treatment are getting it.
And if you’ve followed GiveWell for a while, you might notice that this doesn't sound like the kind of grant that GiveWell usually makes. And it really isn't—most of the grants that we make go to programs that prevent child deaths, and this grant is about treating a condition that causes disability, not death.
Surgical and corrective interventions like this have long been on our minds. But these kinds of programs have posed challenges for us historically. Surgeries and [00:01:00] corrective treatments don't always work. There are complications like relapse, incomplete correction, and when you fund an organization like MiracleFeet, the mechanism is different. It requires training, and supplies, and awareness campaigns, and partnerships with health systems. And so that makes the question of causal impact, meaning what kind of impact do donor dollars have, harder to pin down.
MiracleFeet specifically, and its treatment of clubfoot, has been something we've considered for a long time. And it wasn't until 2022 that we were finally in a position to move forward. By then, we had grown enough to take a different approach. We were making smaller grants where there was learning value that justified the upfront investment, even when the evidence base was uncertain. We also had the capacity to think more about monitoring, so that meant we could support the hiring of external evaluators.
And I think this trajectory of this work at GiveWell is important to notice. We saw the need, we wanted to engage, we tried to engage, but at many points in the past, we just couldn't do it well enough that we wanted [00:02:00] to move forward. But we've now reached the point where we think we can execute on this ambition we've had for a long time to identify a problem, develop the capacity to understand a potential solution, and then deliver funding alongside high quality monitoring to help us follow these grants and learn over time.
So today we're going to cover a few different things. First, what MiracleFeet actually does, how the program really works on the ground. Then, some notes and takes from Meika’s recent visit to Côte d’Ivoire to see this program up close and in person. And then finally, what makes this grant so different from our usual work, what we've learned to date—we're two and a half years into this grant now.
So Meika, nice to chat with you. Thanks for doing this. Before we get into the conversation, can you just briefly introduce yourself and your role at GiveWell, and how you ended up working on this program?
Meika Ball: Yeah, thanks for having me. I'm a Program Officer on GiveWell's New Areas team. On that team I look at a variety of cause areas, but in particular, one of my roles is that I manage our grants to MiracleFeet. And I've been overseeing those grants [00:03:00] for the majority of time that we've been supporting MiracleFeet's program.
Elie Hassenfeld: So before we get into what makes this grant different for GiveWell, let me just ask a little bit about clubfoot in general and how this treatment works.
Meika Ball: Yeah, so as you mentioned, clubfoot is a congenital condition where the feet are twisted inwards and downwards at birth. So the global gold standard for treatment is something called the Ponseti method. And this is a method of treatment, it involves two main phases, so there's a corrections phase and then a maintenance phase.
In the corrections phase, the child will receive roughly weekly casts, so plaster casts around their leg and foot that are slowly shifting the foot back into a more typical alignment. This can take between three and six weeks generally in order to get the foot into a typical enough position that the child can then receive a tenotomy. This is a small surgical incision on the Achilles tendon, it's typically an outpatient surgery with local [00:04:00] anesthetic. And it's just cutting that achilles tendon because that tendon is too tight, it's holding the foot in too rigid a position. At that point, the child will then receive a final cast, which stays on for a couple of weeks until they've healed.
And then they move into the maintenance phase, which is done by bracing. So you could think of this as there's like a bar with two shoes on the end that are holding the feet in outward positions. And for the first three months, a child will wear that almost 24/7, most of their day. And then after that point, they will only wear this brace at night, and they'll continue to wear it at night up until they're around four or five years of age. So it could be a long process, but the initial correction period happens fairly quickly within a couple of months.
And so MiracleFeet’s work supports this treatment in a variety of countries that they work in, and they do that through identifying local partners in those countries, training healthcare workers, providing educational materials, working with the Ministry of Health. They also [00:05:00] provide the physical treatment materials, so like the braces themselves. As well as funding for the treatments, so there are no out-of-pocket costs for patients in settings that MiracleFeet supports.
And so then in Côte d’Ivoire, which is where we visited recently, we got to see all of that in practice. We also learned a bit more about their work that they do in Côte d’Ivoire, specifically around advocacy with the Ministry of Health and what they do in collaboration with the Ministry of Health, as well as other forms of work they're trialing around transport stipends and other sorts of incentives to support caregivers bringing their children back for treatment.
Elie Hassenfeld: And then just to like really nail down what MiracleFeet itself is doing. So it's, you know, paying for the educational materials and supporting education. It's paying for the braces and the materials in the procedure. It's ensuring that patients don't have to pay so they can come in and just get treated. And then I think you also said that it's training healthcare workers, and I'm just curious if you could say more about like, that aspect of its program and what that's [00:06:00] like.
Meika Ball: So MiracleFeet typically run three sets of trainings in any country. And so there's basic treatment, there's advanced treatment, and then there's using their digital monitoring tools. And so the basic treatment they're providing to most providers in the country who they identify as being potential clubfoot providers.
And so what they're typically doing, I think it might differ a little bit between countries, but what they're typically doing is identifying facilities that can be clubfoot provider facilities. These might be major hospitals, it might be major maternity hospitals where a lot of babies are being born. It could be a disability treatment center, things like that. So where they're going to catch the most children, finding the doctors there who either are already trying to provide some sort of treatment for clubfoot or might be providing treatment for an adjacent case. And they bring them in, train them on the full Ponseti method.
There's an advanced training which is done in some contexts, which is more about how you treat cases that are associated with [00:07:00] other conditions. So if a child has spina bifida in addition to clubfoot, for example, or older cases of children above age five or above age 10, for example. Then, the third training, it might be provided to specific people at the facility about how to use the digital monitoring tools.
Elie Hassenfeld: Say more about like where you went. So we know it was Côte d’Ivoire, but tell us a little bit about what you did and what you were hoping to learn on the trip.
Meika Ball: Yeah, so myself and a colleague, Maggie, spent a few days in Abidjan, primarily, on the southern coast of Côte d’Ivoire. We visited two separate facilities, one within Abidjan, one about an hour drive away. We also spoke to healthcare workers, we met with the Ministry of Health, we met with MiracleFeet’s implementing partners, and we also got to speak to caregivers of children with clubfoot, as well as disability advocates in the country.
For me, I think a big part of the value of going maybe sounds a bit simple, but it's literally just to see the program in action. [00:08:00] We try really hard when we do our research to learn about a program and to ask lots of questions about risks to the program and where things could go wrong. But I think once you see a program really happening day to day, it just sparks lot of other questions about how programs are functionally working—what the workflow of a provider looks like, how many rooms they're working in, how many people might be in there, all those sorts of basic things that you might not think to ask about otherwise. So literally just seeing the program in action was really important to me.
And then also I think the chance to talk to people about the impact of this program. We have a lot of uncertainty about disability weights and to what extent they're capturing the challenges maybe of living with a disability in low income settings, and what it means for people to have that treated in a low-income setting, or low- and middle-income setting. So, just being able to talk to people about what it meant for them to have their child treated, what their worries were, what the challenges of seeking that [00:09:00] treatment were, I think is really important for us to be thinking about when we, you know, sit at our desks and model these programs.
Elie Hassenfeld: Right, right. And so you and Maggie had a chance to record some of these daily reflections while you were there. We're going to listen to those now and then we can talk a little bit more about that experience.
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Maggie Lloydhauser: Hi, I’m Maggie. I'm a Senior Philanthropy Advisor at GiveWell. So, I work with our donors, helping them understand our work.
Meika Ball: And, hi, I'm Meika. I'm a Program Officer at GiveWell. I work in our New Areas team, and I manage our grants to MiracleFeet.
Maggie Lloydhauser: Okay. We are here together in Abidjan, Côte d’Ivoire. We're in our hotel room, it's almost 10:00 PM. We've had a really wonderful, full, long day seeing a lot of amazing stuff that we're here to just record a couple minutes of reflections from the day.
Meika Ball: Yeah. So today we spent most of the day visiting one facility. We got to, you know, do everything from meeting all of the doctors involved, meeting parents who were there. [00:10:00] We observed casting of five children's feet. We observed a tenotomy, which is a small surgical procedure done as part of the Ponseti method. We saw parents in their educational sessions and had braces fit, and sort of all elements of the spectrum of care.
Maggie Lloydhauser: Meika, do you wanna talk a little bit about kind of the background of clubfoot in Côte d’Ivoire, specifically in MiracleFeet's operations here?
Meika Ball: Yeah, I think that was an interesting learning from today was to sort of hear about the before, of before MiracleFeet entered the country. I think we heard a lot about how minimally Ponseti treatment was really done.
It seemed like, in many cases, surgical methods were more frequently used, which can be negative for a few reasons. It's a more invasive method, but also it can lead to poorer outcomes in later years. So children can get severe arthritis starting from their early teenage years, for example. And it's also much more expensive. So we heard a quote of around $1,000 per foot, so $2,000 in the cases of [00:11:00] children with clubfoot in both feet.
We also heard today about how limited the understanding is of the clubfoot prevalence in Côte d’Ivoire. We heard multiple people talk about how surprised they were about how many children they were finding across the program. And I think that partly speaks to sort of limited data on these cases, but also partly speaks to the stigma of clubfoot. We heard a lot about how people will hide it from people in their neighborhood, will not want to show, or let people know that their child might have clubfoot. And that contributes to making it quite hard to understand what that prevalence really is.
And so MiracleFeet in their work so far have done trainings across the country. They support facilities that are trained in Ponseti method all across Côte d’Ivoire and are sort of seeing a real increase in the number of children receiving treatment.
So Maggie, I'm not sure, do you want to talk a little bit about what we saw from the children themselves and what that was like.
Maggie Lloydhauser: [00:12:00] Yeah, so our day-to-day, we did have a sort of a welcome meeting with the administrator of the hospital and then we really went straight into it. Meika and I were standing very quietly against the wall, just kind of watching all the care proceed.
So they immediately started bringing babies in—they do this every Tuesday. So every Tuesday they spend the entire day doing clubfoot clinic days, so it's quite consistent care for the parents.
We saw casting first—each of the casts, there would be between three and five casts in like a typical case of clubfoot, and they're each on for one week. So it goes on, you know, three weeks or four weeks, potentially five. So the first baby who came in was only nine days old, very tiny and cute, and was given this score out of six, of 4.5 out of six. So right when the baby came in, we could kind of see like, oh wow, you can really see this seemed quite extreme.
Meika Ball: Six is the maximum.
Maggie Lloydhauser: Yeah, that's right. And then the cast got put on. And the next baby came in and his feet looked great and his score was a 1.5 out of six, so meaningfully better than the 4.5 out of six. And then I got to look through his little like booklet—this is the book [00:13:00] that the mother gets to take home that tracks his health over time. MiracleFeet does electronic recording on their end, but this booklet is what's jotted in. And it was only his third week, and he had gone from a five, to a three and a half, to a one and a half.
So it was very striking to realize that he had started out worse than the baby we had just seen who looked quite extreme to us. And we did get to speak to some of the moms later, including that second baby's mother, about just the excitement of the progress their kids were making. You could really see like how invested the parents were, and in some cases really surprised.
Like this mother had not brought her son in until he was six months old because, in the meantime she had no idea that she could get treatment for this. She had tried some traditional healing, it didn't seem to make a difference, so she stopped going. And then someone mentioned it to her, and she brought him in and was just like absolutely elated by the whole experience and really, really seemed like proud and happy at how much progress he was making.
Yeah, we've talked a little bit about kind of the importance of awareness and all the stigma. Was there anything else you wanted to say on [00:14:00] that?
Meika Ball: I think, yeah, a big takeaway was just how important it is to spread awareness because it seemed like people just really didn't know. They didn't know it was, and more importantly, where they could actually go and get treatment for it. MiracleFeet, in conjunction with the Ministry of Health, are doing a lot of work around training midwives to recognize it and diagnose it quickly.
For example, it's being entered into the maternal child health books that mothers and midwives have with them putting posters in facilities. And the idea there is not just that, you know, someone with a child with clubfoot can see the poster and know where to go, but also that anyone could see that and think, oh, I know someone whose feet look like that. I know I have a niece, or a friend, or someone. And just hopefully spreading more information about where people can go and that they can actually receive treatment for this. So that's a big part of the program.
Maggie Lloydhauser: And we heard a lot of stories like that, anecdotally people coming and seeing it and saying like, wait, there's a cure for this. Like, I know someone, and I'm gonna send them to you, which was very powerful.
Meika Ball: We heard one story about MiracleFeet's [00:15:00] implementing partner who were driving around in a car with a poster on the back, and they stopped for fuel and someone came and took a photo of their poster because they knew their neighbor had a child with feet that looked like the feet on the clubfoot poster.
Maggie Lloydhauser: Like the before.
Meika Ball: Yeah, yeah, exactly. So like all sorts of sort of anecdotal stories around things like that.
Maggie Lloydhauser: That was cool. And actually we went yesterday, Meika and I got to go to a different facility, a primary healthcare facility, which would not be equipped to treat clubfoot. And they had a big poster on the wall as well.
So it seemed like there's just a lot of postering, which is, you know, simple and effective.
Meika Ball: Yeah.
Maggie Lloydhauser: Cool. Okay, well that's kind of all from day one. Yep. We'll see what we have to add another day.
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Maggie Lloydhauser: Okay, we are recording again from our hotel room in Abidjan, Côte d’Ivoire. We've just had our second full day with MiracleFeet, our grantee who does clubfoot work here, and we had a lot of meetings today with a bunch of different stakeholders across the city.
Meika Ball: So we started off by visiting the Ministry of Health. We had a meeting there with the team that [00:16:00] really supports all the work related to clubfoot treatment and detection. I think this meeting was mainly set up for relationship management, making sure that all of the partners meet and sort of work together and on the same page.
But I think it was also quite exciting to see the level of what felt like quite clear buy-in from the government. They're really supportive of the program.
Maggie Lloydhauser: Maybe a good sign of engagement is that the Ministry of Health building was being used for this big training of over a hundred midwives. So there were midwives nominated from a bunch of different facilities across the area, and they were doing a training on recognizing clubfoot and referring it for a treatment.
And they also brought in a community advocate, so she volunteers a lot with the program that MiracleFeet is engaged with. And she's 21, and she's living with untreated clubfoot. So she shared a bit of her story, and then she walked all around the room so that people could see what untreated clubfoot looked like in reality.
And she just sort of really asked them to look for cases [00:17:00] and refer cases, so that babies could get treatment early. And she was thanking them for the work that they're doing.
Meika Ball: Then in the afternoon we went and had meetings with two of MiracleFeet's implementing partners here in Côte d’Ivoire, so the two groups who are really the ones on the ground implementing this program, facilitating some of the trainings with the Ministry of Health and following up with the program's progress. They talked a bit about the history of clubfoot treatment in Côte d’Ivoire, and also the progress that the two implementing partners have achieved.
I think the one other takeaway for us is just the importance of data. It got mentioned again and again by lots of the stakeholders at the meeting. Just the benefits of now being able to really see how many children are actually being treated, how many children are being referred to these facilities. Prior to this work, there really was a lack of understanding of how prevalent clubfoot is in Côte d’Ivoire, how many cases there actually are, and so there was some discussions about how to get even more data [00:18:00] on this to assist with program development going forward.
Maggie Lloydhauser: So we also had a surprise at the end of our day, which was that one of the stories we had heard about yesterday of a family that had moved and stopped bringing their twin boys who have bilateral clubfoot, so both boys have both feet affected. They had moved out of Abidjan, to a couple hours away, and they had stopped being treated.
And this was something that the community development manager knew, he noticed they didn't come, and then he was able to check in on them in the app. And he actually went out to their house and learned that they had moved, and then kind of tracked them down, called them, and talked to the children's dad. And just talked to them again about going, and also referred them to a clinic closer to where they were now, and helped them understand that they could still proceed with treatment uninterrupted. And then he, it sounds like, was checking in and has stayed in close contact.
And when this mom learned that MiracleFeet had representatives coming, and also GiveWell had representatives coming, she insisted, it sounds like, really insisted on coming to say thanks and have us meet [00:19:00] her boys.
So they came into the room at the end and we got to see her sons—very sweet energetic, cute toddlers running around, no problem. And she came to share her thanks for the work that everyone in the room had done to make that possible. And we got to hear more of her story and, including one anecdote that she told of her husband's aunt or something saying that she should stop doing this, and that they should go to a traditional healer. And she said, no, I've seen kids get better with this. I've seen the kids at the clinic, like they do get better, and my kids will too. Yeah, it was a good day.
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Maggie Lloydhauser: Okay, we are at Abidjan Airport. We're about to fly out back to our respective homes. But we just wanted to do a little closing recording on our last day with MiracleFeet. Meika, do you wanna start with the first facility we saw?
Meika Ball: Yeah, in the morning we went to another facility. This one had only been operating its clubfoot clinic for about a month. And so we were there when a doctor who works in another facility was there visiting to do a supportive supervision visit with the doctor and the nurses [00:20:00] there. So we got to again sit in on a casting session, where they put casts on four infants while we were there.
It was sort of interesting because it's a new facility still. They still seem to be working out some of the kinks. So there are a few inefficiencies in where you know, the clinic was set up within the hospital, the air conditioning wasn't working, and it was a very, very hot day today. I think Maggie and I both struggled quite a bit in the heat. But, despite that, like everyone seemed incredibly, you know, competent and dedicated, and I think all the results today were really positive to see.
Yeah, and then in the afternoon we got to visit a patient's home. I don't know, Maggie, if you wanna talk about that a little bit?
Maggie Lloydhauser: Yeah, sure. So we drove all the way out to this patient's home, which was quite a long drive, like an hour and 45 minutes maybe. And drove to quite a rural area, a small village where we got to go in and sit kind of outside their home in chairs and just hear their stories.
So yeah, we heard from the parents just about their experience, like the father talked about how when it first was [00:21:00] going on, he was just having these sleepless nights, just wondering like, how can my daughter live a quality life? Like, how is she gonna live like this? And the mother talked about just crying all the time, being worried all the time.
And then the moment that they got to Don Orione, which is a facility we visited on our first day, they just felt so supported. Everyone, like the other mothers, and you know, the other parents, and the providers just made it clear that their daughter was gonna get better. And as soon as the first cast came off, her foot looked so much better, like they knew that this was gonna work.
And so, despite the fact that the mother would leave at four in the morning and often not get back until eight, nine, or ten at night, she was really glad to have put in the work and like very, very happy that she could get this care.
It was a powerful end to a very inspiring, powerful week. Like seeing a lot of kids getting really meaningful help, and a lot of parents making big sacrifices to do that. And then a lot of providers, both at the nonprofit level and also at the hospital level, who were just extremely dedicated to this program. And, you know, across the like Ministry of Health, and the [00:22:00] midwives, and just all different people we saw involved who just seemed really dedicated to helping these kids make this change. So it was a really great week, and we're gonna run and catch our flight.
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Elie Hassenfeld: So it sounds like you had a chance to see a lot over just a few days.
I want to shift gears a bit and talk about ways in which this program is different from other programs we fund. It's, you know, relatively rare compared to many of the programs we fund, and how that's affected the approach that we've taken and the research that we do.
And so, some of the broad differences here that create new challenges and questions for us. So first, you know, it's a disability prevention or treatment oriented program rather than mortality, meaning we're not trying to prevent death. You know, often the programs we support are very common problems, this is a very rare problem. So I'm just curious, like how do these differences affect the way in which we approach the work with MiracleFeet?
Meika Ball: Yeah, so I think in terms of how we model or think [00:23:00] about the program, I don't think it affects our process too significantly. I think the main way that it comes through is just that with a disability treatment program, there are additional modeled estimates that go into thinking about the benefit of that program.
GiveWell has very clear values that we place on mortality averting programs. When it comes to disability treatment programs, we need to think about how that compares. And that's a really challenging question. We use what's called the disability weights from a group called GBD, Global Burden of Disease Disability Weights, which score different health states between zero and one. So this could be, you might get a score for a different mental health disability, or a different injury, or just a different condition. And we don't have one of those for clubfoot, we have one for similar conditions that we use. But thinking about what goes into those weights, how much we should rely on them, are they capturing stigma, how similar different conditions are to each other.
Those are all pretty challenging questions that we need [00:24:00] to think about when it comes to disability treatment programs, as opposed to our more usual approach.
Elie Hassenfeld: The question there that you're really pointing at is just this question of, how would someone value or trade off the ability to use money to, let's say save a child's life, versus treat some number of these conditions that lead to disability?
And that's, the Global Burden of Disease that you mentioned has this metric, the Disability-Adjusted Life Year that, you know, tries to put everything together to enable these comparisons. Those comparisons themselves are very hard to make, regardless of the fact that they provide that data or try to provide those estimates, and then in this case, those estimates don't even exist, which makes it even more challenging.
Meika Ball: Exactly, yeah.
Elie Hassenfeld: And then I guess like another thing that's different, I don't know if this meaningfully affects our research, but just the fact that the cost per child reached, or treated in this case, is extremely high compared to what it would be with something like vitamin A supplementation where you're reaching a ton of children, it's preventative. And here, the cost to complete this [00:25:00] treatment for an individual child is actually like, pretty expensive.
Meika Ball: Yeah. So I think in our model, I mean we apply a lot of downward assumptions, we're assuming around $1,500 per child successfully treated. I think the difference here is that you assume like that's a hundred percent of those children receiving this treatment are treated.
Whereas, with a lot of our preventative programs, maybe they're very, very cheap per child, but only a very small minority of those children might have otherwise been affected. And so we think this program is cost effective. So on a cost-per-outcome basis, it ends up looking quite similar.
Elie Hassenfeld: Right. You know, another difference is that it's fairly complicated. It requires a lot of ongoing intervention and adherence over time.
Yeah, I'm curious how you think about that. That seems like it would introduce a lot of obstacles to successful completion of this full course over a time period that spans many years where parents of young children need to require them to, you know, perform this consistent [00:26:00] behavior over a very long period of time.
And so, I don't know, how do you think about that challenge?
Meika Ball: I think it's really hard to know precisely what this will look like, particularly in the later bracing phase when people aren't coming in nearly as often. In our model, we apply, I think fairly conservative assumptions around this. So we apply haircuts for loss during the casting phase, and then also loss during the bracing phase to account for this risk. I think it's really hard to know.
But also, I think on the site visit, we saw elements of the program that try to address this. And I think one of my key takeaways is how important this is. So for example, at one of the clubfoot clinics we visited, all of the mothers and caregivers were out the front with their children. So that included people who had come in for their first visit all the way up to people who were there for a bracing check.
And we spoke to some of the mothers who talked about how important that was, being able to see almost like the future path of their child's treatment [00:27:00] as convincing them how important it was to continue coming back, and that it really could be resolved if they continued coming back.
We also spoke a lot to one of MiracleFeet's implementing partners who are regularly checking the data to see whether patients are dropping out and trying to follow up with them if they are. So there is a lot of work going in as part of these programs into trying to ensure that adherence remains high.
I think one of the main reasons that adherence is challenging is because people live very far away from facilities. I just want to make it clear that this is really challenging for parents. It can take a lot of time. And that's very hard to address, I know in Côte d'Ivoire, MiracleFeet are trialing things around providing transport stipends if that is like a real challenge for people. Yeah, just to provide a bit of color on why adherence might be challenging.
Elie Hassenfeld: So it sounds like there's a very intensive treatment period in the first few months, and then it lasts about five years. How often does that whole process not fully resolve the condition? You know, how [00:28:00] often is it the case that after five years, the clubfoot remains an issue for children?
Meika Ball: Yeah, so our understanding is that if the treatment is fully adhered to, it has around a 90% to 95% success rate, where the patient is, fully functional feet, you wouldn't notice any difference. Obviously, that becomes more challenging if there is a drop off of adherence. If people stop bracing, they may need to come back in for additional casting or to restart some treatment.
We have some uncertainty about long-term relapse rates. There's relatively little data on sort of the long-term outcomes of clubfoot, but our understanding is that, even if there are later stage relapses as children get older, it is like relatively easy, like they may not need to go to full surgery in order to recorrect the feet.
Elie Hassenfeld: Yeah, that's really interesting. Okay, so we've covered what MiracleFeet does, how it's different. We're a few years into this grant now and would love to hear more about what we've learned so far, and to what extent we’ve [00:29:00] received data and information back that has helped us answer some of the key questions we had going into the grant. So on these big questions, what do we know now?
Meika Ball: So I think the key learning for us is that it does seem true that MiracleFeet’s program is causing more children to be treated. I think we have pretty high degree of confidence that there was limited treatment prior to the program starting. We're getting data from MiracleFeet about the number of children being treated. I think over the past couple of years, it's somewhere around 1,200 children have now been treated through the program. We think a relatively small share of those children would've been treated otherwise.
I think the other big questions we had at the start of the program are still uncertainties for us, and we expect to dig into these more as we sort of come to the end of grant period. So these are things around looking at additional data on longer term impacts. I know MiracleFeet is working on some additional studies right now trying to get at this question over a slightly longer period of time, thinking more about how disability weights relate to [00:30:00] feet functionality. and those sorts of things. So we'll be digging into those more over the next little while.
Elie Hassenfeld: What are the biggest open questions here that you think we'll never be able to answer that really matter to this grant?
Meika Ball: I think we'll be able to get better estimates of longer term outcomes, I don't think we'll ever feel very confident in the entire lifetime expectation of someone's outcomes. It's just not feasible to be able to collect data out that far. And Ponseti treatment hasn't been done for that long in many countries, so we're not going to be able to collect that in the near term, certainly.
While I think it is very true that in Chad and Côte d'Ivoire without MiracleFeet’s support, these children would not have been treated, I think there's an open question about ongoing support. So after an initial period, I don't know what that period is, after some initial period of support when the Ministry of Health has taken on a lot of this work and is actively supporting a lot of this work, thinking about that counterfactual value of a program, [00:31:00] I think is something we don't have a great sense of at the moment. And maybe isn't an open question right now, but might be as we continue in the future.
Elie Hassenfeld: Right. Because it sounds like a big part of this grant was, in some ways, MiracleFeet demonstrating to healthcare facilities, to the Ministry of Health in various countries that this was a problem that needed to be addressed that wasn't being addressed.
But I guess the open question is, now that it's on the agenda or it's on the minds of the Ministry of Health, in the future, would they be more likely to keep it on the agenda and be willing to pay those additional costs in a way that they weren't in the past, because they weren't convinced it was a problem that needed attention.
Meika Ball: Exactly. And to be clear, I think that's a huge success for the program if that was to happen. It's something we're thinking about in the Philippines talking to MiracleFeet about, because the government is taking on a newborn screening program. They're piloting screening of four congenital conditions at the moment. And if that was to roll out nationwide, right, that could be hugely impactful, even if MiracleFeet was to withdraw support if [00:32:00] that continued into the future. So, as sort of more of this work is being supported by governments, thinking about how to continue supporting that and sort of what level of support is needed.
Elie Hassenfeld: Yeah. That's so interesting. I'm really curious if there were things you saw that really changed your mind about how you thought about this grant. Have you thought about the way we assess programs, you know, whether it's about MiracleFeet specifically, or, I mean, you in your role cover a lot of programs beyond just MiracleFeet, it’s one of many and one of many questions that you're focused on. Was there anything you saw that really affected how you expect to do research either in this case or more broadly in the future?
Meika Ball: I think a couple of things. So one is that, as we sort of talked about, like when we made the initial grant, we weren't really thinking about working with the government integration with existing systems, all of that. And I think this visit has really changed my mind on that element of the program. We got to speak to the government, speak to organizations [00:33:00] supporting this, and it just seemed very clear that everyone was really enthusiastic and dedicated to this program. People are thinking about really creative ways to ensure that it is well-integrated into the existing health system. I just think that's like a benefit that we probably hadn't thought too heavily about at the beginning of the grant. I also think it probably depends a lot based on the country, but it's something that we can certainly dig into more as we think about these grants.
I also think that one question we had at the beginning of the grant was really to what extent this sort of treatment in a low- and middle-income setting can achieve the same sort of high quality outcomes that you might expect in a high-income setting like the US. And we noted that as an uncertainty. And I think after the trip, it is really not an uncertainty for me anymore. It seemed very clear that children were being treated at a really high quality level. Children were running around with no clear challenge at all, you could see the progression in these children's feet literally [00:34:00] week-to-week. So I think we had noted that as a concern, as we always might, but I think it has mitigated some of that concern for me.
You know, it was, I think quite an emotional trip for us to be able to see, you know, these children and makes me really glad about the work that we're supporting.
Elie Hassenfeld: Yeah. Well that's great, Meika. I'm glad you're able to do it, I'm glad we're able to support this program, and thanks for going through it with me.
Meika Ball: Thanks, Elie.
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Elie Hassenfeld: Hi everyone, it's Elie again. I think this conversation was so interesting to me, because it really is such a great illustration of how GiveWell has grown and what we're able to do now with our larger, more experienced team. We have thought about surgery from the very beginning of our work, and being able now to support a program like clubfoot that we had considered so many times over the years, is really amazing.
And this conversation shows something really interesting about how GiveWell works, in that we tend to focus on doing the things we do as well as possible. And what I mean by that is [00:35:00] we're primarily focused on finding programs to direct money, donor money to, that can do a lot of good. That's our primary focus. You know, we tend not to think as much about the potential indirect benefits or upside that might come from the programs we support.
And it's really interesting to hear about a case where there really could be this benefit that is, you know, far beyond what we imagined happening. We thought of this program as directly supporting, via MiracleFeet, the additional clubfoot treatments in these countries. And, you know, there's some possibility, which of course we have to wait and see whether it comes through, but there's some possibility that the impact of this grant will be even larger. That by getting it on a country’s radar, this program will happen more in the future without the need for additional support. And that's also really exciting because it means that more children will be able to get this treatment into the future without, or potentially without, requiring additional philanthropic support.
As always, thanks for your support in enabling us to do this kind of work and support this program and the [00:36:00] children who need clubfoot treatment. I would really like to hear what you think about these podcast conversations. If you have feedback, please send it in. If there are ideas, or things you'd like to see us do differently, please let us know. We'd love to see it, and it can help us ensure that these conversations are as interesting and informative for you as they possibly can be. Thank you so much.