- The Washington Times - Sunday, March 5, 2006

BAHIR DAR, Ethiopia

It is a smelly, offensive and debilitating condition in which women injured in childbirth uncontrollably leak a trail of urine or feces.

The condition, known as fistula, all but disappeared in the Western world in the late 19th century, when Caesarean section births became widely available.

But in sub-Saharan Africa, the condition remains widespread, sentencing as many as 3 million women to a life of abandonment and enforced solitude.

“I thought it was something the doctors did to me, or maybe God,” says Bireeh, a young woman racked by incontinence and infection after a three-day labor ended with a stillborn son.

Abandoned by her husband, she turned up at the Hamlin Fistula Hospital in the northern Ethiopian village of Bahir Dar.

A 30-minute surgery followed by two weeks of convalescence should be enough to repair the damage of childbirth, and doctors say Bireeh probably will be able to bear children.

Several Western physicians, inspired by their Christian faith, have worked in Ethiopia for more than 40 years to repair the lives of fistula sufferers.

Their efforts lately have drawn benefactors in the United States, spanning the political spectrum from conservatives to liberals.

In Congress, they range from Rep. Christopher H. Smith, New Jersey Republican, to Rep. Carolyn B. Maloney, New York Democrat, who are both attempting to win U.S. funding to treat the condition.

“No woman should have to live with this degrading condition,” says Mr. Smith, who proposes channeling $5 million through the U.S. Agency for International Development next year and $7 million the following year. His bill has passed the House and awaits approval in the Senate.

A rival measure, sponsored by Mrs. Maloney, would steer $34 million through the U.N. Population Fund (UNFPA), with the money earmarked exclusively for fistula care.

Basic surgery

“Obstructed labor exists in every part of the world, but it’s usually handled with a C-section in a hospital,” says Dr. Andrew Browning, an Australian gynecologist who performed more than 200 fistula repairs in the past year at the Bahir Dar facility.

The surgical techniques are relatively simple with a success rate of 93 percent, according to the Hamlin Fistula Relief and Aid Fund, www.fistulatrust.org.

Experienced doctors with well-equipped medical facilities can handle the complications of obstructed childbirth, making fistula a rare condition in developed nations.

But in sub-Saharan Africa, where women typically struggle in dirt-floor huts to give birth alone or with untrained midwives, labor can go on for days.

When it ends, usually with a stillborn child, the woman can be left with a ruptured birth canal, bladder and rectum, leaving her unable to control the flow of urine or feces.

The condition is a particular problem for impoverished rural women in nations such as Ethiopia, Nigeria, Chad, Tanzania, Congo, Bangladesh and Sri Lanka.

The Hamlin Trust, which runs three specialized hospitals in Ethiopia and plans to open two more, estimates that about 150,000 Ethiopian women suffer from the condition. It is able to operate on 1,500 women each year, free of charge.

Just 9.5 percent of pregnant women here have a skilled medical attendant at the birth, and just 40 percent have access to medical care following a difficult labor, according to a recent Ethiopian Health Ministry survey.

For context, just 37 percent of all Ethiopians have access to potable water and 28 percent to proper sanitation.

In Ethiopia, the vast majority of fistula sufferers are from first-time pregnancies, although the Hamlin hospitals also see victims of rape, botched female circumcisions and even accidents.

By far the most striking patient in Bahir Dar during a visit in early February was Alem, a beautiful and babbly 7-year-old who was raped by a family friend on her way to school.

The damage was so severe that doctors had to repair anal and vaginal fistulas, fix her bladder and reconstruct soft tissue in the cervix.

Dr. Browning says the child probably will not be incontinent, but he cannot say whether she will be able to bear children.

Orange buckets

Like every other patient in this tidy 30-bed hospital, little Alem is tethered to a bright orange bucket by a catheter that diverts urine from the injured bladder.

Another patient, Taiyech, has borne four living children ages 2 to 16 years. She says the midwife pulled on her stillborn baby too hard during her last labor, damaging nerves in her legs and likely injuring her birth canal.

Agenwo, 12, has been incontinent since a ritual circumcision was performed when she was about 3 weeks old. Dr. Browning says she was probably cut too deeply and is confident he can repair the damaged tissue that has led to lifelong incontinence.

“There is a school in my village, but I can’t go because I’m sick,” the girl says shyly, crouching over a drain in the shade behind the hospital. “I don’t want to get married. I want to go to school and be a pilot.”

Ahai is a fragile young woman of about 22, who spends her days outdoors draped in a filthy orange shawl. An emotional pendulum, she chatters happily with other patients or sobs hysterically in a corner.

Ahai’s baby died at birth and her husband divorced her. Her fistula is so severe that she constantly leaks a stream of urine despite the catheter.

An orphan who was shunned for two years by her village, she has no intention of going back.

“I can’t go home. I have no home,” she says, shortly before learning that doctors probably could not reconstruct her urethra. “I want to live here, and work here.”

Finding employment

About two dozen women with incurable fistulas work at the Hamlin hospitals in Bahir Dar and Addis Ababa as aides preparing patients for surgery and mopping up the unending puddles of urine.

Most are illiterate, but uniquely able to communicate with fragile and frightened patients.

“I was like them once, and I understand them, what they are feeling and what they are needing,” says an extraordinarily gentle woman named Masay, 30, who has worked at the Bahir Dar hospital for nearly 18 months.

The nurses aides receive about $25 a month, as well as meals and lodging, by far the best wages they are likely to find in this part of Ethiopia.

Dr. Browning says most of the patients have problems far beyond the fistulas that brought them here. Many suffer from tuberculosis, HIV, infections, anemia, malaria, malnourishment or parasites.

Some have kidney and bladder stones because they stopped drinking water in a desperate attempt to control their incontinence. Often they have gone to witch doctors, who unsuccessfully try to cure the condition with magic charms.

Not surprisingly, the hospital staff says, nearly every patient arrives clinically depressed.

Patients are never charged for care, which runs about $300 to $400 for surgery and two to four weeks of convalescence, paid for with a $2 million annual budget from the Hamlin Trust.

“They come in here ragged, smelling badly, and so sad, so lonely. They are convinced they are the only one with this affliction,” says Ruth Kennedy, an empathetic British midwife who has lived in Africa for more than 20 years.

The main hospital

Ms. Kennedy runs the 130-bed Hamlin Fistula Hospital in Addis Ababa, and she seems to know most patients by name and history.

She strides through the dorms, kitchens, physical therapy rooms and lushly planted grounds greeting patients in Amharic or Somali and with a hug or a touch.

Many of the women learn to knit the woolly shawls they all wear, while others are happy to sit in the gardens among others who understand.

The hospital was founded in 1974 by Catherine and Reginald Hamlin, a husband-and-wife physician team from Australia. Moved by their Christian faith, they first began traveling to Africa and performing surgeries in 1959.

The hospital staff and visiting doctors feel a similar calling, with their surgical missions often funded by Christian denominations.

The Kellogg Foundation gave the Hamlins money for the original hospital in Addis Ababa, which has developed into a premier training facility for gynecologists and urinary specialists treating fistula.

“The training is one of the most important things we do here,” says Dr. Hamlin, a vigorous widow in her late 70s — who raised nearly $3 million after an appearance on Oprah Winfrey’s TV show two years ago. Reginald Hamlin died in 1993.

The Addis Ababa hospital has two smaller satellite facilities, here in Bahir Dar and another in the village of Mekelle. Two additional hospitals are planned in strategic locations.

The foundation also sends mobile medical teams throughout the country, and many towns in rural Ethiopia have at least one physician who has had some training at the main hospital in Addis Ababa.

In addition, the foundation operates a village on the outskirts of Addis Ababa for chronic sufferers who were so badly damaged in childbirth that they cannot be cured and require continuing medical care.

Dr. Browning marvels at the strength of the women lying in the tidy iron-framed beds in rural Barhir Dar hospital.

“For many patients, simply being here is good news,” he said. “Some of these women have been through surgeries, others don’t even know what’s happened to them, they think this is something God has just meted out.

“For many, this is their last hope to live an ordinary life.”

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