Through a pioneering treatment for club foot, Ugandan-born Canadian Dr Shafique Pirani (a Muslim) has brought hope to thousands.
By ISABEL NANTON
By ISABEL NANTON
Some parents believe club foot is a curse. Many believe the deformity cannot be corrected.
Atop a hill in Uganda’s capital city, Kampala, in a single-storey building below a corrugated iron roof, part of the Upper Mulago Hospital, 33-year-old Mariam Kemirembe is nursing her five-week-old baby, Shafique Gumisisiriza. Outside, mauve jacaranda-tree blossoms ripple in the breeze and a trussed live turkey, brought to the clinic as a gift, sits patiently in the shade. Inside, under the scrutiny of eight “orthopaedic officer” students, baby Shafique is receiving 20 minutes of treatment that will dramatically change his life. On January 18, 2009, he was born with the most common congenital physical disability in the developing world – club foot, which in almost half of all cases affects both feet. Left untreated, his club foot would remain twisted inward and become increasingly painful, so that when he started to walk, his body weight would be borne on the thin skin on the top of the foot. In a developing country such as Uganda, this lack of mobility would almost guarantee a lifetime of poverty.
Slowly circling the medical team at Mulago is a Ugandan-born Canadian, Dr Shafique Pirani, whose pioneering orthopaedic work may give the infant a better chance in life. Born in 1957, Pirani suffered a life-threatening bout of polio at age three, which left him with a pronounced limp. At seven, he went to England with his mother for some corrective surgery. There, they met an orthopaedic doctor who was himself disabled.
“Your son will make a fine orthopaedic surgeon,” the doctor told Pirani’s mother. From then on, says Pirani, “Mum felt I could be something. Like any mother, she had been worried about what was going to happen to me.”
In 1972, when Pirani was 15, Ugandan dictator Idi Amin forced out the country’s Asians. Initially, the Pirani family went to England, then settled in Canada in 1973. In 1982, Pirani graduated with a medical degree from the Charing Cross Hospital Medical School in London, England, then he moved to Vancouver to train at The University of British Columbia as an orthopaedic surgeon. He went to The Hospital for Sick Children in Toronto from 1990 to 1991 to become a paediatric orthopaedic surgeon. It was here that he became fascinated with the problem of club foot, which at the time was thought to be treatable only with major surgery. He subsequently returned to British Columbia, where he began his practice at Royal Columbian Hospital in New Westminster.
In 1996, Pirani read a book by Dr Ignacio Ponseti, a highly respected paediatric surgeon from Iowa. For decades, Ponseti had advocated a method of fixing club foot by applying a series of casts to babies’ feet soon after birth, since the foot of a newborn is predominantly cartilage, then applying a brace, so that surgery was not necessary. Pirani tried it, found that it worked just as well as – if not better than – surgery, and became a passionate advocate of the Ponseti Method, incorporating it into his practice. He hasn’t performed club-foot surgery on a child under two since 2000.
In the land of Pirani’s birth, the health system had become severely compromised. Among the victims were almost 10,000 children with untreated club foot. These kids were a familiar sight, hobbling on turned-in feet or leaning on crutches, watching from the sidelines as their friends played soccer, danced and ran around the schoolyard.
On a family visit to Kampala in 1998, Pirani breakfasted with Canadian paediatric orthopaedic surgeon Dr Norgrove Penny, who said he had been operating on hundreds of Ugandan children with club foot, with no end in sight. Pirani realised that by using the low-cost Ponseti Method he could help alleviate the problem. But with fewer than 12 orthopaedic surgeons in a country of 25 million people, club-foot care would have to involve the training of other health-care workers. Ugandans needed a way to detect and treat club foot that was low-cost and self-sustaining. In Pirani, Ugandans found a native son who, as a colleague says, combined “the abilities of a clinician, surgeon, diplomat and innovator.”
After returning to Canada, Pirani gathered pilot data and applied for a million-dollar Canadian International Development Agency grant, which he was awarded in 2004. Then, in collaboration with The University of British Columbia, the Ugandan Ministry of Health, Makerere University Kampala and the Christian Blind Mission, the Uganda Sustainable Clubfoot Care Project was launched the following year. Since then, hundreds of healthcare professionals have been trained to detect and treat club foot using the Ponseti Method.
Mariam Kemirembe’s five-week-old son, Shafique Gumisisiriza, gets the casts to correct his club feet. Photo: Isabel Nanton
Here in Kampala on this Monday morning, Pirani meets Sam Kyaligonza, 48, father of five-year-old Solomon Kyomuhendo, who is sitting on his lap. Pirani has asked Kyaligonza and Solomon to come to the clinic for a follow-up, so he can see the results of the Ponseti Method. Solomon’s father shakes his head. “When my son was born, I never expected this,” he says. “There had never been such a deformity in our family. However, my son was treated at Mulago free of charge from two weeks old, and now he is faster than a cheetah.”
Later, Pirani watches as members of the Ugandan orthopaedic team – Diana Mutuhe, 26, and Teddy Mutamba, 26 – expertly work on baby Shafique, gently moulding his foot to correct the deformity.
While Mutuhe holds the infant’s foot in the correct position, Mutamba applies cotton padding to the leg and then, beginning with the toes, applies four or five layers of wet plaster up over the knee, moulding the cast to hold the foot in the proper position. Most club feet are corrected with about five casts; before the final one, it’s generally necessary to cut the Achilles tendon, through a small incision just above the heel, to fully straighten the foot. The procedure is so low tech that when baby Shafique comes for his next cast, in a week, the first one will be loosened in a bucket of warm water. To prevent relapse once the feet are corrected with the casts, Shafique will be fitted with soft leather shoes held apart by a six-millimetre-long metal bar, which are made on-site. These will be worn 23 hours a day for two months, then only at night for the next four years.
Club feet have long been a source of superstition and misunderstanding in Uganda, according to Dean Nathan Wanaswa, contributor to Ponseti Clubfoot Management (known as “The Red Book”), now the manual used for club-foot correction by healthcare workers in the country. In that book, Wanaswa, who is a tutor for orthopaedic officer students in Mulago and a trainer in the Ponseti Method, writes, “Some parents believe club foot is a curse. Many believe the deformity cannot be corrected and are embarrassed to show their child in public.”
Now, radio spots in six local languages tell Uganda’s rural and city caregivers to check for a club-shaped foot at birth, that the condition is treatable and where to get treatment. Ten thousand training manuals, with detailed photos of the treatment method, have been printed.
“It’s not complicated,” says Pirani. “You need an orthopaedic officer trained in the Ponseti Method in every district, as well as plaster and braces.”
Dr Amandua Jacinto, commissioner of clinical services at the Uganda Ministry of Health, says, “This is one of the stories I will tell in my retirement, that club foot intervention as a public health programme has succeeded. Thanks to Pirani, a minimum of 1500 babies have been treated since the programme’s inception and it is expanding to include the whole country.”
Adds Stella Nyange, who runs the clinic office, “Results are real and tangible, bringing hope to mothers who are held responsible for the condition.”
At the Mulago Hospital’s Monday club foot clinic, Namusisi Daisy Masolo talks about Mark Musaazi, her six-year-old son. At birth, Mark’s right foot was clubbed and Masolo worried about how he would cope with a deformed foot. Persuading her husband that it was necessary, she travelled the eight kilometres to the clinic every Monday to have Mark’s foot put in a cast. “And now my mind is settled,” says Masolo. While Mark hops confidently on his right foot, showing Pirani his flexibility, she says quietly, “He doesn’t have a nickname at school and he wears regular shoes.”
Slowly circling the medical team at Mulago is a Ugandan-born Canadian, Dr Shafique Pirani, whose pioneering orthopaedic work may give the infant a better chance in life. Born in 1957, Pirani suffered a life-threatening bout of polio at age three, which left him with a pronounced limp. At seven, he went to England with his mother for some corrective surgery. There, they met an orthopaedic doctor who was himself disabled.
“Your son will make a fine orthopaedic surgeon,” the doctor told Pirani’s mother. From then on, says Pirani, “Mum felt I could be something. Like any mother, she had been worried about what was going to happen to me.”
In 1972, when Pirani was 15, Ugandan dictator Idi Amin forced out the country’s Asians. Initially, the Pirani family went to England, then settled in Canada in 1973. In 1982, Pirani graduated with a medical degree from the Charing Cross Hospital Medical School in London, England, then he moved to Vancouver to train at The University of British Columbia as an orthopaedic surgeon. He went to The Hospital for Sick Children in Toronto from 1990 to 1991 to become a paediatric orthopaedic surgeon. It was here that he became fascinated with the problem of club foot, which at the time was thought to be treatable only with major surgery. He subsequently returned to British Columbia, where he began his practice at Royal Columbian Hospital in New Westminster.
In 1996, Pirani read a book by Dr Ignacio Ponseti, a highly respected paediatric surgeon from Iowa. For decades, Ponseti had advocated a method of fixing club foot by applying a series of casts to babies’ feet soon after birth, since the foot of a newborn is predominantly cartilage, then applying a brace, so that surgery was not necessary. Pirani tried it, found that it worked just as well as – if not better than – surgery, and became a passionate advocate of the Ponseti Method, incorporating it into his practice. He hasn’t performed club-foot surgery on a child under two since 2000.
In the land of Pirani’s birth, the health system had become severely compromised. Among the victims were almost 10,000 children with untreated club foot. These kids were a familiar sight, hobbling on turned-in feet or leaning on crutches, watching from the sidelines as their friends played soccer, danced and ran around the schoolyard.
On a family visit to Kampala in 1998, Pirani breakfasted with Canadian paediatric orthopaedic surgeon Dr Norgrove Penny, who said he had been operating on hundreds of Ugandan children with club foot, with no end in sight. Pirani realised that by using the low-cost Ponseti Method he could help alleviate the problem. But with fewer than 12 orthopaedic surgeons in a country of 25 million people, club-foot care would have to involve the training of other health-care workers. Ugandans needed a way to detect and treat club foot that was low-cost and self-sustaining. In Pirani, Ugandans found a native son who, as a colleague says, combined “the abilities of a clinician, surgeon, diplomat and innovator.”
After returning to Canada, Pirani gathered pilot data and applied for a million-dollar Canadian International Development Agency grant, which he was awarded in 2004. Then, in collaboration with The University of British Columbia, the Ugandan Ministry of Health, Makerere University Kampala and the Christian Blind Mission, the Uganda Sustainable Clubfoot Care Project was launched the following year. Since then, hundreds of healthcare professionals have been trained to detect and treat club foot using the Ponseti Method.
Here in Kampala on this Monday morning, Pirani meets Sam Kyaligonza, 48, father of five-year-old Solomon Kyomuhendo, who is sitting on his lap. Pirani has asked Kyaligonza and Solomon to come to the clinic for a follow-up, so he can see the results of the Ponseti Method. Solomon’s father shakes his head. “When my son was born, I never expected this,” he says. “There had never been such a deformity in our family. However, my son was treated at Mulago free of charge from two weeks old, and now he is faster than a cheetah.”
Later, Pirani watches as members of the Ugandan orthopaedic team – Diana Mutuhe, 26, and Teddy Mutamba, 26 – expertly work on baby Shafique, gently moulding his foot to correct the deformity.
While Mutuhe holds the infant’s foot in the correct position, Mutamba applies cotton padding to the leg and then, beginning with the toes, applies four or five layers of wet plaster up over the knee, moulding the cast to hold the foot in the proper position. Most club feet are corrected with about five casts; before the final one, it’s generally necessary to cut the Achilles tendon, through a small incision just above the heel, to fully straighten the foot. The procedure is so low tech that when baby Shafique comes for his next cast, in a week, the first one will be loosened in a bucket of warm water. To prevent relapse once the feet are corrected with the casts, Shafique will be fitted with soft leather shoes held apart by a six-millimetre-long metal bar, which are made on-site. These will be worn 23 hours a day for two months, then only at night for the next four years.
Club feet have long been a source of superstition and misunderstanding in Uganda, according to Dean Nathan Wanaswa, contributor to Ponseti Clubfoot Management (known as “The Red Book”), now the manual used for club-foot correction by healthcare workers in the country. In that book, Wanaswa, who is a tutor for orthopaedic officer students in Mulago and a trainer in the Ponseti Method, writes, “Some parents believe club foot is a curse. Many believe the deformity cannot be corrected and are embarrassed to show their child in public.”
Now, radio spots in six local languages tell Uganda’s rural and city caregivers to check for a club-shaped foot at birth, that the condition is treatable and where to get treatment. Ten thousand training manuals, with detailed photos of the treatment method, have been printed.
“It’s not complicated,” says Pirani. “You need an orthopaedic officer trained in the Ponseti Method in every district, as well as plaster and braces.”
Dr Amandua Jacinto, commissioner of clinical services at the Uganda Ministry of Health, says, “This is one of the stories I will tell in my retirement, that club foot intervention as a public health programme has succeeded. Thanks to Pirani, a minimum of 1500 babies have been treated since the programme’s inception and it is expanding to include the whole country.”
Adds Stella Nyange, who runs the clinic office, “Results are real and tangible, bringing hope to mothers who are held responsible for the condition.”
At the Mulago Hospital’s Monday club foot clinic, Namusisi Daisy Masolo talks about Mark Musaazi, her six-year-old son. At birth, Mark’s right foot was clubbed and Masolo worried about how he would cope with a deformed foot. Persuading her husband that it was necessary, she travelled the eight kilometres to the clinic every Monday to have Mark’s foot put in a cast. “And now my mind is settled,” says Masolo. While Mark hops confidently on his right foot, showing Pirani his flexibility, she says quietly, “He doesn’t have a nickname at school and he wears regular shoes.”
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