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Right Livelihood Awards/Newscom

Delivery from shame

Health | Dr. Catherine Hamlin pioneered fistula surgery, helping countless outcast women, but now she needs more doctors to carry the work forward

Issue: "Clutching two, dropping four," April 23, 2011

When women arrive at the Addis Ababa Fistula Hospital, they usually reek of urine and feces. Often they have walked many miles and their husbands have abandoned them as social outcasts. Common in countries where women labor in childbirth without any medical care, fistula is an injury resulting from days, even a week, of obstructed labor. The rare woman to survive such trauma and blood loss is left with an open wound that dribbles human waste-and her child is usually dead or severely malformed.

If Ethiopians ever forget what fistula is, one woman they can thank is Dr. Catherine Hamlin, an Australian-and a Christian-who in 1975 opened the first fistula hospital in Addis Ababa with her late husband Reginald. It remains the only fistula hospital in the world.

Hamlin, 87, has spent a lifetime first developing the surgery, then sewing up otherwise "useless" women. Each woman who walks in smelling of human waste walks out of the hospital in a new dress. Reginald, who died in 1993, would call out to the repaired women, "Who is this looking so pretty and happy?"

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Patients also receive a Bible and can attend Bible studies at the hospital, surrounded by lush gardens and cared for by nurses who themselves are sometimes ex-patients. The women who can't return to normal life-the ones who must live with a catheter or can't remarry-work at the hospital or move into the nearby village for fistula women, where they learn to be independent and start their own businesses: making cheese, growing vegetables, raising chickens, or tailoring clothes.

On a recent visit to Washington, Hamlin drew glances from passersby as she described the first attempts to remedy fistulas in the 19th and early 20th century, using bent spoons inserted into vaginas and silver jeweler's wire to sew up women. When a woman has prolonged, obstructed labor, "the bladder and the rectum get squashed-a piece of tissue drops out," Hamlin explained, creating a hole so the woman is incontinent. "It's not a tear, so you have to make the bladder come together so it heals. Scar tissue forms so there are all sorts of problems." Usually the baby is stillborn. "A few hours later, she says, 'I wish I had died with the baby,'" Hamlin said, describing a typical fistula patient.

A 2005 study of fistula patients in Kano, Nigeria, revealed that 67 percent of women with fistula were abandoned by their husbands. Some women develop disabilities and atrophied muscles because they lie in one position, perhaps on their sides, for weeks, months, years, hoping the hole closes and the leaking stops. Suicide rates are high among these women, Hamlin said. One patient's uncle told her that he had cut the rope as his niece was jumping from a tree. A missionary doctor once told her that fistula patients will "break your heart because you can't do much for them."

The Addis Ababa Fistula Hospital, which the Hamlins founded, has repaired fistulas in over 35,000 women. Two million women and girls around the world currently live with fistula, most in sub-Saharan Africa and Asia, according to the World Health Organization, and about 50,000 to 100,000 develop fistulas each year. The fistula problem is acute in Ethiopia because of the continued practice of child marriage, despite its illegality, so young teenagers whose bodies aren't fully formed become pregnant and terrible labor often follows. Girls who grow up with poor nutrition, too, often have smaller pelvises, which make labor and delivery difficult. And women in rural areas of Ethiopia, who have less access to healthcare, have three times as many children as women in cities.

Thanks to the Hamlins, Addis Ababa has become the global headquarters for fighting fistula: The first meeting of the International Society of Obstetric Fistula Surgeons was held there in 2008. But the country faces a major hurdle to solving fistula: "We need many more doctors," said Dr. Fekadl Ayenachew, a top Ethiopian gynecologist and surgeon with the fistula hospital. The Addis Ababa Fistula Hospital and its rural offshoots pride themselves on being staffed by Ethiopians, who know the culture, the area, and the people, and have more invested in the place. Mamitu Gashe, one of the fistula surgeons at the hospital who now trains other surgeons in fistula repair, was first a fistula patient, a peasant who became pregnant at 16. But the hospital struggles to retain Ethiopian medical personnel, though it is the top institution for training doctors in fistula repair. The doctors often leave for better pay in Western countries, chiefly the United States. Ethiopia has 170 obstetricians and gynecologists serving a population of 82 million, and only 40 of those serve rural areas, which hold 85 percent of the population.

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