Women’s Nightmare: Fistula
Meron Vallery
University of Maryland University College
Dr. Gemeinhardt
HCAD 600
Oct 26, 2012

Abstract
Since in the United States and Europe Fistula was eradicated in the beginning of twentieth century, if you ask women and men about fistula they would not know. To answer what fistula is to know how many kinds there is. There are two kinds of fistulas. The first is obstetric fistula which is a devastating illness that affects young girl who suffers from prolonged labor and the second one is traumatic fistula where it is caused by violent sex or rape. As a result it causes tearing of the vaginal and bladder tissue and passes feces and urine involuntarily. Both fistulas were once a global problem but in the US women are educated to postpone early marriage and pregnancy until their young body mature to have a child. Also a cure was discovered by two American surgeons J. Marion Sims and Thomas Addis Emmet, that cure was c-section and surgical procedure to fix the tearing of bladder and vaginal tissue. Although fistula is eradicated in industrialized countries, it is still a major problem for young girls in the most impoverished rural and remote area of in the developing countries especially the sub-Saharan African and some Middle East countries. To eliminate fistula several NGO’s have been working with those countries that has been affected by fistula. Hamlin Fistula Ethiopia Foundation (UFE) and United Nation Population Foundation (UNFPA) are to name a few. On this paper we will address on the ngo’s strategic approach on national and international level, are their enough funds available, what ethical issues they are facing, and what are the weakness and strength of the ngo’s approaches toward the problem on international healthcare.

Women’s Nightmare: Fistula Among the two fistulas obstetric fistula affects and stigmatizes young girls and their family and makes them socially outcast. Around the world there are over 3 million cases of fistula patients mainly targeted at sub-Saharan African and Middle East countries. Obstetric fistula is one of the most devastating injuries that a women and young girl faces and stigmatized from it due to prolonged labor and not having medical treatment on time. Ethiopia is one of the many developing countries that are affected by fistula. Many factors that influence fistula are early marriage, female circumcision, no road access, and not knowing if there is treatment. Many women and young girl lives in the remote village where there is no roads access to the city therefore they encounter life threatening problems due to prolonged labor. Majority of girls in Africa tend to marry at a young age where their body has yet to grow, and mentally not prepared. In Ethiopia most girls get married at 12 years of age where their body is not capable of supporting the baby to full term because their own body is not fully grown yet. Then fistula becomes a major problem because it tears their virginal and bladder tissue. Almost all fistula patients in Ethiopia or other developing countries do not know there is a clinic that treats fistula free of charge or less money. On this paper we will be looking at two NGO’s that are focusing and taking great measure to treat fistula and a different strategy approach that they are taking to eradicate fistula from developing countries. To eliminate fistula as a global health problem the country along with ngo has to provide access to obstetric care, treat fistula cases, educate family planning, enhance gender equality, and address medical, social and cultural problem. Since industrialized countries eradicate fistula developed countries are not interested to do research on fistula. With ngos help fistula problem has been decreasing as a result of better transportation, trained nurses and surgeons and education on family planning. From the many ngos Hamlin Fistula Ethiopia Foundation (HFE) and United Nation Population Foundation (UNFPA) stands out the most. Hamlin fistula foundation was open in 1974. Before Hamlin foundation was open there was no facility that treats fistulas what so ever. Hamlin Fistula Hospital which is located in Addis Abeba, Ethiopia is the only facility in the world that treats fistula patients without charges. Since the facility opened around twenty-four thousand fistula patients were being treated free of charge. Hamlin fistula hospital added pathology laboratory, library, and house for resident doctor. The hospital also specializes in training both nurses and surgeons specifically for fistula procedures. “The hospital has been successful with this program over the years, training thirteen Ethiopian Post-Graduate doctors and fifteen foreign doctors in the technique between October 2004 and March 2005” (Hamlin, 2002). The approaches toward international and national level is not only to provide surgical training, but also to include those who are suffering from childbirth related injuries, and rehabilitate them back to where they were before the problem occur with dignity and sense of self worth. HFE focus on the well being of the patients physical and as well as mental status. By giving those new dresses when they leave the facility empower the girls to start a new life.
Another approach is taking care of those who cannot completely cures in a long-term care facility. “Ethiopian government donated sixty acres to the hospital to build a village where these women could learn to be independent, yet receive the medical care they require” (Hamlin, 2002). For those who require a long term care there is a village called Desta Mender. The village is a home for twenty three patients and has the capacity for one hundred patients. The women share a cottage. While local farmers grow crops for the village the women attend school, care for livestock and make crafts. They also earn money and support themselves, creating a peaceful community and are not being shunned by their family member. There are many problems that affect the hospital. One of the main problems is that there is a lack of bed space, the number of admitted patients rises especially after the harvest season when their family can send them after selling and getting money for transportation. Many fistula patients cannot make it to the hospital due to the roads being in horrible condition. The journey to the hospital is too far and also fistula patients are too weak. Yearly in Ethiopia about eight to nine thousand women suffer fistula only fourteen hundred make it to the hospital for treatment. To increase fistula patients, Hamlin Hospital planned to expand and build five more fistula clinics. Out of those five planned clinics only one has been built at Bahr Dar and opened to patients. It also has a permanent doctor and nurses. Due to lack of funding the other four facilities has not been completed. While HFE is targeting to train nurses and surgeons to treat fistula United Nations Population Foundation (UNFPA) is mainly focusing in developing a strategy to prevent, treat, rehabilitate and eradicate fistula from developing countries. UNFPA aim to ensure that every woman is treated with respect and dignity regardless of her background, and every man, women and child is capable to live life to the fullest with equal opportunity of healthcare. UNFPA plan to educate women to have planed family to decrease fistula problem, to provide obstetric care for fistula patients and to eradicate fistula.

UNFPA has launched a campaign in 2003 to prevent and eradicate fistula from developing countries. “The campaign to End Fistula has greatly aided in the relief of fistula in over thirty countries worldwide, including twenty six countries in Africa alone” (Hancock, 2009). Actually the campaign has been providing medical equipments, beds, and trained health workers. Aside from providing equipments and training UNFPA, is responsible communicating with various resources to reach as many victims as possible.
While the campaign to End Fistula start to progress, there is much more work needed to eradicate the problem of fistula in developing countries and especially Ethiopia. Along with Hamlin Hospital, UNFPA has directly supported twenty seven thousands of fistula patients to get surgical treatment. “UNFPA serves as the secretariat for the International Obstetric Fistula Working Group- the main decision making body of the Campaign to End Fistula” (Wakabi, 2008). It provided partnership, research and provide evidence regarding prevention, treatment and rehabilitation for women with fistula. Even though developed countries don’t do any kind of research on fistula, but much more research is needed to address fistula problem. On 2010 John Hopkins University with WHO start to research and examine the relation between surgical prognosis, long term treatment, psychosocial, and rehabilitation outcome following fistula surgery. Ethiopia is one of the three countries that launched the study. Still funding is an issue. “Study results will help to develop a prognostic cost effective programs and national strategies” (Muleta, 1997). To eradicate fistula in developing countries you have to change the mind set and cultural beliefs of the people. For young girl to have the physical maturity, you have to educate the girl to postpone early marriage, and spacing births apart. Also a community assessment has to be implemented in certain regions to end child marriage. Funding for fistula foundation has been decreasing. Hamlin fistula hospital in Addis Abeba need much more funding than the other developing countries due to the fact the hospital gives treatment free of charges. HFE fund is kept at Australia under HFA from 1196 thru mid 2012. HFA was the authorized representative for HFE until July 2012. All HFE funds were kept in HFA due to major Ethiopian currency problem. When HFE needs a fund it will e-mail HFA, once HFA approve the fund will be wired through a bank. By mid 2011 AusAID and HFA signed a contract for Australian government to fund for three years.
Hamlin facility that is in Tigray region the funding comes directly from Australian government. “In 2010, the Fistula Foundation awarded approximately 50% to hospitals and health organizations working in thirteen countries in Africa and Asia” (Jackson, 2012). Prior to 2009, the Fistula Foundation provided funding only to Hamlin Fistula Hospitals in Ethiopia. After 2009, Fistula Foundation starts funding four other countries with fistula problem.
Much of the funding for fistula has been donated through private donors. The organizations need much more funding coming from the government as well. So far UNFPA has raised 31 million US dollar from 2004 to 2008. U.S. was one of the top countries that give fund to UNFPA. After 2008, Barack Obama stated fund for fistula will be restored.
There are many ethical issues surrounding the obstetric fistula in the sub-Saharan Africa. Many people may say do developing countries even have a code of ethic. May be it’s due to cultural differences with the western. The ethical issues are from the widest aspect of human right issues that affects especially women in the most devastating way, to the surgeon’s responsibilities to perform a complex issues regarding clinical research. Anyone and everyone that is involved in giving healthcare for fistula patients need to realize the delicate nature of the patient population and the importance of special needs that the patients require for those who give them special care.
In recent year there has been a code of ethic established for fistula surgeon aiming with the common goal and putting in prospect how to eradicate fistula by the end of 2015. This specific code of ethic aim that the fistula surgeon should provide the best care possible for fistula patients with the resource that have been provided with. The surgeon has to consider the nature of fistula patients and treat them with respect, the patients must be included in the decision making aspect of the care, and they should not be placed as an experiment. Fistula surgeon must give a referral especially after the surgery whether they need long term care or not.
The code of ethics emphasize for the surgeons to advance their skills and review the objective data for treatment results. It also state that any surgeons not to abuse their power by taking advantage on their patient for her or his own benefit or allow by others to be abused. Last the code of ethic for fistula surgeons states that to acknowledge the sensitivity of social inequalities that arises for the development of obstetric fistulas and put lots of effort to eradicate the injustice. Surgeons should be the ladder to prevent fistula and break the barriers that block access to obstetric care.
There are some strength and weakness with both NGO’s. The weakness that HFE faces is that the fact the funding is being kept in Australia. HFE should have a central funding place. Also putting the patients in one village is not productive. Although it’s very hard what the HFE should have done is to build a long term care facility near the patient’s village so they can be around their family. They also have a strong approach on treating fistula. Giving treatment, room and board, to a patient for free of charge makes HFE one of a kind. HFE training its own patient so they can become nursing assistant is very good. Because they have been in the patient’s shoes so they know exactly how they feel and they know that they will overcome the situation with pride and dignity.
The campaign UNFPA establishes to eradicate fistula is a huge responsibility. It takes lots of money to fund and to implement. Their strongest side is the strategy that they lay to eradicate fistula. Even though they have risen over 31 million over a four year period they still need much more money to completely eliminate fistula from developing countries.
Since American women have been exposed to an excellent health care, if you tell American women they would not understand the extensive damage that fistula patient endure. It is very difficult for media to announce about fistula. Most donors like to donate to a well known organization and diseases too. Fistula and complication from child birth will continue until healthcare in Africa becomes like the US and Europe. The main thing to do to eradicate fistula is to change the mindset of fistula patient and the cultural beliefs of their populations. Delaying early marriage is the number one step that needs to be taken in order to eliminate fistula. By postponing early marriage it will give a time for the body to develop to its normal size so they can carry the baby to its full term.
Having a strong healthcare system and education will give a rise to social and economic status. Another key point is providing family counseling after surgery to fistula patient as well as the family is very essential. Sometimes even after surgery the patients does not heal therefore if they have a family counsel then the patient might have a chance to be treated as a decent human being as well as productive member of society.

References
Hancock, B., Browning, A. (2009). Practical Obstetric Fistula Surgery. London: Royal Society of Medicine Press. Retrieved from http://www.rcog.org.uk/book
Hamlin, E., C., Muleta, M., Kennedy, R., C. (2002). Providing an Obstetric Fistula Service. BJU International, 89(1), 3-5.
Islam, A., L., Begum, A. (1992). A psycho-social Study on Gento-Urinary Fistula. Bangladesh Med Resource Council, 18, 82-94.
Jackson, R. (2012). Birthing Kits, NGO’s and Reducing Maternal Mortality in Ethiopia.
Muleta, M. (1997). Obstetric Fistulae: a retrospective study of 2010 cases at the Addis Abeba Fistula Hospitals. Journal of Obstetric and Gynecology, 17(1), 68-71, DOI: 10.1080/01443619750114194
Wakabi, W. (2008). Ethiopia Steps up fight against Fistula, 371(9623), 1493-1494