A Social Death

As a consequence of fistula, the mother emanates an unpleasant odor often driving her husband away and causes her to be socially ostracized, pushing her to isolation and depression. She is condemned to a life of loneliness – without the companionship of her husband, friends and children. While she does not die, the development of a fistula is akin to social death as the village treats the fistula victim as a scourge- pushing her to live at the edge of the community with no social support. Research shows that girls and women with fistula often eat alone, sleep alone, and pray alone. As the women were wheeled into the surgical floor, I noticed the how frail the women were- most exhibited physical signs of extreme malnutrition, some women’s backs curved and others with deep cracks on their feet, skin peeling off.

Many of these women were brought to the hospital by their parents or brothers. One of the doctors had become particularly close to a 16 year old girl with a clubbed foot, who was accompanied and supported by her doting father- she did not have fistula but a congenital abnormality that caused her to leak. Not all patients are shunned by their families and many women had been supported by their parents, husbands or siblings to seek care. The persistence of the women who actually make it to the hospital is not an indication of success, because for every 1 woman who comes 10 more couldn’t afford the journey or were too scared to travel outside their house when confronted with the ugly side of humanity. So, these surgeries are only treating the ‘tip of the iceberg’ since nearly 3 million women with obstetric fistula still need treatment.

The commitment of the Eritrean government* to repair the health infrastructure is a hearting sign of developing countries diagnosing their weakness and not simply applying bandages in the face of crushing poverty. These stronger health infrastructures are crucial to the achieving better maternal health- so that fistulas never occur.

*The Eritrean fistula team have consistently partnered with the Ministry of Health, the UNFPA, and local healthcare providers to shape brighter futures. In the past six years, together they have helped to strength the country’s fistula policies and established the Fistula repair center and hostel. For more information about the Eritrean Maternal Health Project and the UNFPA’s programs in Eritrea please refer to http://obgyn.stanford.edu/gynonc/eritrean.html

A Safe Place

Eritrea‘s culture is vibrant and its people diverse with 9 ethnic groups and a 50% split between self identifying Muslims and Christians. Across the courtyards of the fistula ward, bright cloths were hanging out to dry having been hand-washed to remove of the lingering stench of urine. The fistula wards were a place of healing and sisterhood. Sometimes the surgeries were successful, other times the women continued to leak because of the extent of scarring and damage. In the mornings, the doctors came in to examine the post-operative patients and the leaking women would turn on the sides or pull their blankets over the heads to hide their tears and disappointment. For these women, the head nurse (affectionately called “Sister”) and other patients provided comfort and encouragement- next time, maybe next time surgery would heal them.

The ward is a safe space for the women and on the last day of the surgical mission, the patients invited the team to a special coffee ceremony. We walked into the decorated ward, with flowers and grass carefully placed on the linoleum floors, and saw the women in their colorful shawls sitting around the coffee pots waiting eagerly for the doctors to take their seats. The ceremony deeply touched us because we were privileged to be included. The women danced to traditional Eritrean music, blaring from an old stereo and invited us to join them. We were pretty bad dancers, but then one of the doctors managed to hook up her I-pod and played some Beyonce and Black-Eyed Peas- we explained “this is our music” and were met with blank stares and giggles.

Luckily, I brought my digital camera to the ward this day, and I started to snap pictures of the patients, showing them on the screen how they looked. As I took more and more snapshots, the atmosphere in the ward became less formal as everyone wanted their pictured taken. The smiles and laughter humbled the team and we realized many of them had never seen their pictures.

God Will

I recently had the opportunity to visit Eritrea as a part of the Eritrean Maternal Health project. The Maternal Health project was founded by Stanford Medical School and supported by UNFPA and the Eritrean Ministry of Health. One if its major concerns is obstetric fistula.

Obstetric fistula is a childbirth injury that happens as a result of obstructed labor in places where medical care is largely unavailable. As a woman- typically young, extremely poor and illiterate- squats for days alone, attempting to deliver her baby, the trauma adds up and an internal hole develops. Contents from the bladder and rectum cannot be willfully controlled, so the fistula victim constantly leaks urine and/or feces. The corrective solution for the medical aspect of this disease is a surgery, which costs around $300 and is often done for free usually in endemic areas, but barriers to surgery include transportation, lack of infrastructure and limited resources of the state to reach out to very pregnant woman in the countryside.

Eritrea is a rural nation with hills and rough terrain. Traveling in the rural areas consists of riding on a camel, constantly going up and down and potentially causing more trauma to the fistula patient. Dr. Hapte, one of the OB/GYNs (and father figure for the fistula patient) at the Mendefera Hospital ( the same site of the Eritrean National Fistula Center) spoke of the shame of traveling on buses when the fistula patient is still leaking- sometimes other bus riders forcibly evict the leaking woman because of the strong urine smell.

I am a Somali-American woman who practices covering my hair with hijab- so in many ways, I looked like many of the woman. Many of the patients in Eritrea were Muslim women. Names like “Fatima”, “Zahra”, “Mariam” and “Zeinab” filled the pages of the simple hospital logbook. My “salaams” were met with timid smiles and then eager questions about who I was, where I am came from and why a Somali-American was in Eritrea. After sometime, I realized that these women were expecting that I would turn my nose in disgust and were hiding their catheters (bags that hold urine) from me, hiding their shame. It was strange to them that people would care to talk to them when from the past months and years, their families and societies had pushed them away. Many women have internalized this and believe that the fistula condition was “God’s will”.