The Hamlin Fistula Hospital

Obstetric fistula is an affliction of poverty and ignorance, the destruction of a woman’s life, the loss of her health and dignity; her hopes for her future role as a mother and as a participating member of the society in which she lives. It is an injury exacerbated by superstition; belief in an influential spirit world tightly interwoven with lives ruled by seasons and by natural fortune or calamity. It is an accident of topography and time; of the vast space and distances of the African and Asian continents and the great void between life in a rural village and in the city. The poor woman may be a citizen of the same country as the rich owner of hotels and shopping malls but she is excluded from medicines and hospitals by her lack of knowledge, untold miles, destitution and fear.

Fistula is a medical condition, most prevalent in the poorest communities in sub-Saharan Africa and Asia, especially Afghanistan. Child or teenage marriage, childbearing before the pelvis is fully developed; malnutrition, small stature and poor health, as well as high parity in older women, are all contributing factors to obstructed labour and obstetric fistula. It ruins the lives of women expected to bear children, usually many children, under the most primitive circumstances. It may be the first of those anticipated children who, stillborn, also condemns a small ill-fed and child-like mother to the outcast status of fistula patients. As she mourns the child who has died, she also discovers that she, and she imagines herself uniquely cursed, has been damaged appallingly by her long and fruitless labour. She is leaking urine, faeces, or both, uncontrollably. She stinks and is to be hidden from view by her family. She brings shame on herself and on them by her loss of the basic physical control learnt as a child. Somehow, this woman has, by conscious or unconscious omission or commission, offended the mysterious shadowy world of the spirits, who need constant propitiation in their ordering of human life according to an unknown design. Religion, whether animist, Christian or Moslem, makes little difference to such deeply ingrained folk beliefs,

In the world where women like most of us live; a world of monitored pregnancies, foetal and maternal monitors and birth plans; it is hard to imagine the gulf that separates us from that other woman, a young girl who understands neither her pregnancy nor the birth process. She can only rely on information from other women in the same position as herself. For us, a labour that lasts five, six days even, is inconceivable – how does a woman survive that except in the hope and expectation of the baby who will be born. That baby will be dead after 48 hours and can only then be expelled when the skull has become soft, fluid enough to squeeze through the bony narrow pelvic passage. Many mothers will die, the others will often wish they had, rather than survive the tearing of bladder or rectum when their dead baby’s head finally crowns and it is pulled from them by untrained hands. Fistula patients are survivors – the ones who escape the UN tables of death in childbirth. In Ethiopia a third of obstructed labours result in maternal death. In a 2005 study, it was estimated that 40,000 women in that country were living with obstetric fistula. In the UK the last case of fistula was at least 100 years ago; in the USA the unique fistula hospital in New York closed in 1895.

The Hamlin Addis Ababa Fistula Hospital is the only unique fistula hospital in the World today. Founded by two young doctors from Australia, the Drs Catherine and Reginald Hamlin in 1959, it has become a centre of care, excellence, outreach, training and new initiative. Now widowed, Dr Catherine Hamlin remains a guiding presence in the hospital, still operating at the age of 85 and teaching the delicate skills she and her husband developed. The doctors and nurses in the hospital and in its growing number of smaller outreach and treatment centres have a grand design and a determination not only to clear the backlog of fistula cases in Ethiopia but in the whole of Africa. They aim to reach other affected areas of the world through training programmes for doctors and nurses from other countries, as well as operating as often as possible themselves.

In the end prevention is the only real and best cure for obstetric fistula and the Hamlin Hospital is working on their dream, a training school for midwives for every rural community. This is still only part of their work. Their patients cannot in many cases ever return home. The repair work of doctors and nurses is not always enough. Even those who are easily cured will return to the hospital to have new babies and must be housed, often 2 to a bed, while they wait for assisted births – they are told to start towards the hospital as soon as they feel their baby move. Others who have nerve damage to their legs, either from the effects of obstructed labour or from years lying in a foetal position attempting to retain their bodily fluids, may need physiotherapy and rehabilitation before they can have an operation. Other still may be too injured ever to return home; they may need stomas, and the hospital must find the money for every stoma bag, several per week. They may be so ill that they require long-term and loving care until they finally die from the kidney or other organ failure that is a result of long-term damage. Many long-term patients are employed as nursing aides; others are trained in handcrafts or as productive members in micro-enterprises at a new rehabilitation/resettlement village, Desta Mender. The Hamlin Hospital refuses no one and constantly works to repair shattered lives as well as medical conditions.

Recently, with the interest of world commentators and the powerful advocacy of media personalities, in particular Oprah Winfrey, the veil of family shame and secrecy surrounding fistula has been lifted. Obstetric fistula has become a term to be understood and to shock women in safer parts of the world into action. We, after all, expect long lives and the facilities to give birth to our children in safety. Meanwhile the Addis Ababa Hospital must find the money to cover the whole circle of birth, life, care and death, including for patients who will be unable to return to a village where there is no hygiene and no water closer than an hour or two’s walk. They must feed and clothe and, they hope, train their chronic patients to be self- sufficient, as nursing aides, tailors, farmers, or cooks. They will remain the responsibility of the hospital for life, deprived of their expectations of family and friends and the familiarity of a native place.

The hospital, with help from around the world, embraces this responsibility as doctors and nurses juggle with medical duties and the endless administrative requirements of building and rebuilding a community as much as a medical facility. Those who die, usually of renal failure, are deeply mourned. Others are, with constant follow up and advice, able to return to husbands and families. They understand that they must seek help in future pregnancies in time to give birth by caesarian section. They have the chance to have live, lovingly greeted babies and are sent home and welcomed again with delight.

No one is ever turned away and women continue to arrive at the hospital – damaged and fearful, they have braved the opprobrium of fellow travelers, borrowed fares from family, church or who knows where, when they hear of the possibility of a cure for their terrible condition. These are young women whose lives are hard enough, their expected life span averages 41 years. They should not have to suffer the loss of life and dignity that women in richer countries know is their right. In the end it is money that counts most in the endless circle of ignorance, superstition, conditions of poverty and in the provision of education, medical expertise, medicines, care and essential services to combat and ultimately end a preventable condition such as obstetric fistula. Supporting the Addis Ababa Hospital and its work is one of the most effective ways to remove the stigma of fistula, the continued existence of which shames us all.
http://www.hamlinfistula.org

To the Volcano

‘Only twenty minutes to the top,’ says Tesfa, for the 5th time in the last hour or more and still agile himself, loaded with a growing weight of other people’s kit and cameras.

We scramble painfully over crumbling lava formations following an invisible path ever upwards in the darkness, our small torches lighting only the next unsteady step. 11 Kilometres sounded an easy evening stroll from the bottom but we feel like hobbits at our last gasp struggling across the burnt landscape of Mordor.
Suddenly we are there, the air colder and fresher at the summit, the sky lighter and a cutting wind blowing up dust between a handful of rocky shelters in a roughly improvised campsite. An unseen camel or two groans disagreeably in the lee of a makeshift wall where the dim crouched shapes of tribesmen, sleep upright, with blankets over heads and ancient rifles propped nearby.

Just a steep cliff to climb down, its base hidden in the deeper blackness but we shy away at the top, pit ponies without blindfolds, by this time the spark lost and anticipation for the goal ebbing away. We are exhausted. You can do it if you don't look down and we have been waiting for this moment, our goal the heart of the volcano, the only lava lake in the World. This is Erta Ale, the Mountain of Smoke, the perpetual flame at the centre of the killing heat of the Danakil Desert in Ethiopia
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‘Can I hold your hand Tesfa?’

Another walk in the dark, crunching across the caldera, wobbling between shifting footholds and sudden holes in the surface, ever weaker torches failing faster even than sore feet and middle-aged knees. Then we are much, much too close to a ragged edge and can only stand swaying, not believing our eyes, dumbfounded but for the ‘O my Gods’ over and over again. Below us a glowing portal to the underworld; a seething, heaving, living lake of fire; a constant tidal swell breaking against the glowing cliffs of the pit as great gouts of bright molten rock bubble up and burst from the burning surface, hurled into the air like sea spray hitting rocks.
We are mesmerised. We may stand here, as smoke clouds billow away from us in the wind, until tomorrow, or the day after, or until the crack of doom. Rivers of fire run randomly across the seething pit in burnished burning ribbons and then die down; quieten down; sigh; build strength for another assault on the walls in an endless attempt to break out of the mountain and pour the contents of hell down its blackened slopes once more.

Saints and Stories

Initial irritation over female exclusion from many of the famous rock hewn churches and monasteries of Northern Tigray was at first sight of their inaccessible perches on the heights of vast rocky outcrops, transformed to sighs of relief. Guide book descriptions of ascents by rope; words and phrases like vertiginous; ‘not really dangerous if you take it slowly’; and, my favourite, ‘it’s amazing the grip a toe can get’; offered additional discouragement. As it is there are enough churches and monasteries all over Northern Ethiopia to keep travellers of both sexes happy for months; plenty require at least a serious scramble to reach them.



Visits to those populating the islands of Lake Tana mean a boat ride that may include a sight of hippopotamuses and enough bird life, including fleets of pelicans, to convert the least ornithologically minded. Fishermen row past in the uncomfortable looking semi-submerged papyrus boats that have been used here for millennia. Contemporary life in Ethiopia often seems barely a step ahead of the life and legends so gloriously painted on the walls of Orthodox churches and so alive to those who worship there.

Lake Tana is the largest in Ethiopia with monasteries and churches on at least 20 of its 37 islands. One of the most famous, open to all, is Ura Kidane Meret, actually on the Zege peninsula but more easily reached from the busy modern town of Bahir Dar by boat. Walking up the rocky path to the 16th and 17th century monastery, we meet al l the monks heading for a funeral on another island. Funerals in Ethiopia involve as many people as possible including the merest acquaintances and certainly all available ecclesiastics. The church, centre of the monastery buildings is a round building with stone and mud walls and a corrugated iron roof replacing the original thatch. The sweep of the bamboo ceiling as it curves round the circular ambulatory is like a great Noah’s Ark but the true treasure of the church is its interior, revealed when a flowered curtain is drawn aside.

It would take hours to see every detail and years to understand every story of the Orthodox canon, inspiration for the decoration of hundreds of the estimated 50,000 Ethiopian Orthodox churches and the greatest delight to the tourist. The truth is that they can be read like cartoons and are as lively as moving pictures; moving indeed in their faith and sincerity however gloriously far-fetched the stories behind them. It is easier, after a few days wondering how on earth first millennium builders achieved the monolithic rock churches of Lalibela, to suspend disbelief and accept tales of architecturally inspirational trips to heaven by their founder and an angelic night shift. After that the saints’ lives follow easily enough. After all, if you had stood praying on one leg for somewhere between 7 and 22 years, depending on who you believe, the spare limb might very well fall off. If as well you had only eaten one seed a year delivered by a bird you might think you deserved God rewarding such devotion with no less than three pairs of wings and, in some paintings, another for the detached leg.



A great favourite of the painters is Gebre Manfus Kiddus. Preaching one day to the animals in the desert, he found a bird dying of thirst. Lifting it, he allowed it to drink a tear from his eye and is usually depicted with a revived black bird flying round his head as he stands surrounded by lions and tigers. There are varying views of his hairy apparel; some say it is his beard, others furs; the beard is obviously the most likely. Ura Kidane Meret is no exception in its equally splendid depictions of the baddies of the bible and more alternative religious stories. They are, with the exception of the devil who has two, always painted with one eye only; thus Judas Iscariot is quickly spotted at the Last Supper. Somewhat unsuccessful attempts are made to make the wicked look so as they put martyrs gruesomely to death and dismember well-known saints by unexpected means in a most cheerful fashion.

Back on the lake, jets of the Ethiopian airforce overhead are doing their best with the sound barrier; a dramatic pointer to a faster, less spiritually imaginative world. In Bahir Dar at the basic but charming Ghion hotel, where weaver birds with bandit eye masks steal the breakfast off your plate, modernity has been defeated by a 24 hour power strike. Good luck as it turns out for the tourist. Lake Tana is the source of the Blue Nile and the famous Blue Nile falls, the Tis Isat or Water that Smokes, are nearby, now a mere trickle of their former self due to an upstream hydro-electric plant that supplies most of Northern Ethiopia. The total lack of any water in the hotel caused by no electricity ceased to matter as we walked towards the thunder of the falls in full tumbling spate. Due to the power shut down, the gates have had to be opened, a privilege nowadays only granted to occasional visiting heads of state.