And, wrote Vladimir Nabokov,
I became aware of the world's tenderness, the profound beneficence of all that surrounded me, the blissful bond between me and all of creation; and I realized that joy...breathed around me everywhere, in the speeding street sounds, in the hem of a comically lifted skirt, in the metallic yet tender drone of the wind, in the autumn clouds bloated with rain. I realized that the world does not represent...a predaceous sequence of chance events, but shimmering bliss, beneficent trepidation, a gift bestowed on us and unappreciated.Medicine in Africa is different. Frustrating, even, in some ways. Wounds break down that aren't supposed to, for reasons that make no sense except for the chronic malnutrition, anemia, and dust-and-mud homes patients go back to. Patients board the ship with inexplicable fevers, with two-year-long leg swellings that are either an infectious disease you've never heard of or a tumor you've never seen before. Every day you confront deficiencies in yourself.
But medicine in Africa can also be beneficent trepidation.
Vesicovaginal surgeries began this week. If you've never heard of a vesicovaginal fistula, don't worry. Neither had I until about a year ago. Here's some background.
A woman born in Sweden today has a lifetime risk for dying in childbirth of 1 in 29,800. In the US, it's 1 in 2500; in Liberia, that risk is 1 in 16.* Six percent of all the women that we meet here in this country will die, at some point, from bearing children.
As distressing as those numbers are, though, it's not the women that die after childbirth that have the saddest stories. It's those that live. Obstructed labor—in which the baby gets stuck at the pelvic outlet, in which the baby's head is simply too big to fit through the mother's pelvic bone—occurs with alarming frequency. It's estimated that as many as 5% of all labors require some sort of obstetric help. Unfortunately, in the absence of that obstetric help, the baby struggles, trying to get out; obstructed labors last anywhere from three to ten days, up to 240 unanaesthetized hours. Eventually, the baby dies.
Unfortunately, in the interim, every single uterine contraction has effectively strangled the thin tissue that separates the vaginal vault from the bladder or from the rectum (you'll pardon the explicit language). Deprived of its blood supply, that tissue dies. And, a few days after delivering a dead child—sometimes in multiple pieces—the mother starts noticing a persistent leak. Urine is no longer contained in the bladder; it follows the path of least resistance, down her leg, onto her dress, and into the world around her.
She begins to smell, through no fault of her own. A swarming aura of urine and feces surrounds her. Social and psychological isolation is the logical outcome. So, in the middle of villages that sit hours away from the nearest road, these women are abandoned by their husbands, their mothers, their families, and secreted away into makeshift shelters, where they spend the remainder of their lives.
Two hundred years ago, the problem was so prevalent throughout the world that a flashy, swish Fistula Hospital existed right in the middle of Manhattan, on the site of the current St. Bartholomew's Church, right next door to some of the highest-priced Manhattan real estate. But, in the intervening two centuries, modern obstetrics developed, and obstructed labor became a thing of the past. With it went the vesicovaginal fistula and its attendant shame.
Not so in Africa. Prevalence estimates for vesicovaginal fistula vary widely, but they run in the hundreds of thousands. And, with a simple procedure, they can be repaired.
Our first VVF ladies are on the wards right now, recovering from the first week of surgery. It takes two weeks or so to recover, and that's not a bad thing. It gives us a chance to get to know them, to get to show them acceptance after years of marginalization, to show them love without any disgust, without any upturned noses. And when they recover, there's an outright party. Each VVF patient is given a new dress, symbolic of her new re-entry into normal society, and sent off amidst the pulse of drums and the harmonies of West African voices. It's with a bit of trepidation that those of us who've never seen VVF surgeries stepped into this week. But it's with the hope of beneficence.
By the way—if you're at all interested in finding out more about vesicovaginal fistulas, a great documentary, A Walk to Beautiful, opened in theaters in NY and LA two weeks ago. It will also be playing on PBS on May 13. It's amazing.
*WHO, UNICEF, UNFPA, Maternal Mortality in 2000,
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