Return to CCBRT

A worthwhile day, yesterday. I felt content with the day's business when I crashed into bed last night, and marinating on it for another 24 hours has only made me more pleased that I went back to the CCBRT hospital. It wasn't particularly a happy day (though I suppose the women on the operating table will be pretty happy in two weeks, if everything heals properly). But I saw a lot, learned a lot, built up some relationships. And that's the point of this summer, right?

It occurred to me during a chat with David "The Yellow Dart" Foster that maybe I should explain what obstetric fistulas actually are, though again hopefully in blog-appropriate terms. You don't really hear about them in the US and Europe because...well, they don't really happen there. An obstetric fistula is basically a really bad complication of childbirth. As Dr. Masemga told me, every patient story he hears is essentially the same: The mother is stuck in labor at home for 3, 4 days, pushing hard, before someone finally takes her to the hospital. There, via C-section, the doctors deliver the baby - usually stillborn. But the pressure of the baby's head pushing for so long actually destroys the tissue between the birth canal and the bladder, rendering the woman incontinent. So then your child has died, you can't control your urination, and your husband/partner often leaves because you smell bad all the time. (The CCBRT fistula intake form actually has the question "Did husband leave because of fistula: YES/NO". Most of the ones I've seen circled yes.) Women do go on, of course, and show amazing resilience, but it's essentially life-shattering.

So that condition, then, is what the VVF operating theater sets out to remedy. CCBRT actually has a special theater set aside for fistula repair surgeries, with a special table that can be rearranged as different stages of the surgery require. Part of what made my second day in surgery more rewarding, I think, was that I had an idea of what was supposed to be going on and how I could help - adjusting the overhead lights for the surgeon, hoisting patients onto stretchers, fetching suture material, etc. Small things, but made me feel useful and more involved.

The other improvement for me was my chance to actually talk with the visiting surgeon, Dr. Masemga. He's actually based near Kilimanjaro, but as one of the premier fistula surgeons in the country, he agreed to do a week with CCBRT while their usual fistula surgeon was on leave. We started the day in the same silence as Monday, but towards the end of the first procedure a friendly Indian surgeon dropped in and made a point of asking a few fistula-related questions in English, assuredly for my benefit. Dr. Masemga was happy to respond, and then happy to recieve a few follow up questions from me as well. Ice = broken. It later turned out that out of Dr. Masemga's three trips to the US, one was to Duke University (where I went to college) and another was to the National Institutes of Health (where I worked for three years). The fates wanted us to bond. I wondered later if my perception of the surgeons' indifference wasn't mostly due to Dr. Robert, the vaguely grumpy assisting surgeon playing second fiddle to this hotshot visiting young guy. (Dr. Masemga's maybe in his mid-30s.) Who's to know.

So the team made its way through four repair surgeries yesterday. All were pretty fascinating to me, but two of the cases really stood out. One was an older woman whose fistula had actually come from radation treatment for her cervical cancer. Rates of cervical cancer are much higher here in the developing world, and the few women who actually do get treatment and manage to survive sometimes have tissue destruction that's functionally the same as childbirth-based fistulas. Luckily hers was a very small tear, easily shut.

The other case was the last woman of the day. So many things about her just made my chest tighten. For one, she was 17. For two, she was so delicate, really willowy and beautiful and not at all built for childbearing. Her fistula had developed from her first child (stillborn), and her husband had left soon after the fistula became apparent. Then, during the course of the surgery, the doctors actually determined that she had not one but two fistulas, the expected one connecting her bladder and vagina, but also a second one tearing from her vagina into her rectum. So the surgery ended up being twice as long and complex. But the final sadness was that she'd been circumcised some years ago. (FGM, many call it.) The resultant tightening and scarring made the surgery very difficult, just as it had made her first childbirth experience very difficult.

I was grateful that she was the last case of the day, I think. The more I thought about all the things conspiring aginst her, all the cultural and institutional forces that control her life and limit her choices in fundamental ways, the more overwhelmed I felt. But as I write this today, I'm sort of heartened by the key fact that she wasn't passive in the face of all this - she did get to a surgeon, and a very good one at that. The odds are good that she'll heal well, and that she'll march out of CCBRT in two weeks with her congratulatory kanga and go on with her life, with a chance for a partner and children (via C-section) and normal social life again. Those things shouldn't be underestimated, even if the greater problems that brought her to CCBRT in the first place still remain.