It’s late June, but it’s chilly in Asella, Ethiopia—the city is higher in altitude than Denver—and the patients in the hospital are wrapped in blankets. Dr. Mulu Muleta puts on a white doctor’s jacket and starts making her rounds. She checks in with each woman, holding the patient’s hands, or touching her shoulders, as they speak.
One patient, Hawa, wears a bright purple and white gown. She’s 33 years old. When she was 16, she lost her first baby and developed an obstetric fistula, a condition sometimes caused by a very prolonged labor, when the baby’s head presses on the nearby tissue, causing it to lose its blood flow and die. That can create a fistula—it’s the Greek word for hole—between the vagina and the bladder or rectum; the urine or feces (or both, in the case of a double fistula) then trickles out through the vagina.
This results in a double tragedy: In 90 percent of obstetric fistula cases, the baby is stillborn. For the mother, the condition causes chronic incontinence—a form of prolonged torture—and stigmatization.
Hawa lived with her fistula her entire adult life, bearing three children successfully despite the injury. In the hospital today, she is still wearing a catheter after having surgery to repair the damage caused by the fistula. Muleta, who estimates she has performed more than 10,000 of these procedures, is one of the best in the world at it.
Hawa says she had no idea her problem was something that could be fixed. “Seventeen years, every day and night, I was soaked with urine,” she says, with Muleta translating. “I was crying at home daily, day and night. This is the suffering I have been through.” Unlike many husbands, hers stayed with her while she suffered, until he died seven years ago.
Perhaps the most heartbreaking thing about fistulas is that they are preventable. In countries with widespread quality health care, fistulas can usually be averted through medical interventions such as cesarean sections. As Kate Grant, CEO of the Fistula Foundation, puts it, “Fistula’s really just a symptom of other things. It’s poverty, and it’s the way poverty tends to be even a more profound and destructive condition for women, and particularly women in labor.”
In Ethiopia, most women give birth at home. If a woman runs into trouble during a home birth, she has to get transportation to the nearest facility, which can be expensive, Muleta says. When she arrives, she has to hope there is a surgeon there to treat her, along with the necessary drugs and supplies, like anesthesia. If these delays can be eliminated, then fistulas (and other pregnancy-related problems) can often be curtailed. But, realistically, a woman facing pregnancy complications in Ethiopia is likely to have to wait for treatment, especially if she had to travel from a rural area.
Globally, it’s hard to know how many cases of obstetric fistula there are, says Karen Beattie, a medical anthropologist with EngenderHealth, but estimates range from 1 million to 2 million existing cases worldwide, with anywhere from 6,000 to 100,000 new cases annually. One factor that makes the cases difficult to count: The afflicted woman might be ostracized, divorced from society and hard to reach.
An Unflappable Surgeon
If you spend a day with Muleta, you’ll see that she seems to be unhappy when not operating or working with fistula patients. She recalls that once, after a period of time away from a labor ward, she smelled spilled amniotic fluid—a reminder of birth—and felt “satisfied,” pleased with how it made her feel. She is also stubborn, a risk taker and a survivor.
Muleta was born at home in a village called Abebe, about 60 miles west of Addis Ababa, in 1961. She was one of seven kids, the daughter of a hardworking farmer and landowner. He valued education and paid for his children—and some other kids from the village—to go to school, even if Muleta sometimes went without shoes.
This was during the time of “the Derg,” the military and Communist regime that governed Ethiopia from 1974 to 1987. They demanded her father’s land. He refused. “He was shot, and he was killed in his house,” she recalls, “because they said he is owning land, and the land should be for the poor. They came and they just killed him. That was it. It was not only that, they took all the resources we have.” She was just a teenager.
Not long after that, her mother was in a car accident. She remembers that her mom was still dressed in black at the time, in mourning for her husband’s death. The nurses cared for her mother at the hospital—she eventually made a full recovery—and Muleta helped out, too. “I was really impressed by that,” she says. She imagined she might become a nurse, to help others. Thanks to the encouragement of a high school teacher, she enrolled in medical school. She graduated in 1984, and after two years of required service in rural areas, she began her residency in obstetrics and gynecology at Black Lion Hospital in Addis Ababa. She, along with one other woman, became the first female Ethiopian-trained ob-gyn in the country.
While there, she rotated through Addis Ababa’s Hamlin Fistula Hospital—perhaps the most famous fistula hospital in the world, having been featured in the short film “A Walk to Beautiful” and celebrated by Nicholas Kristof in The New York Times. After her residency, she began working at Hamlin, where she trained with Dr. Catherine Hamlin, who, along with her husband, founded the hospital.
It’s common for talented doctors in developing countries to leave, but Muleta never seems to have considered it. She is “literally one of the best fistula surgeons in world, and she could go many other places,” says Grant, of the Fistula Foundation (which supports an organization, Women and Health Alliance International, that employs Muleta as one of their surgeons). But, Grant adds, “she’s chosen to stay because of her commitment to her own population.”
An untreated fistula is a horrible thing. The women are frequently ostracized, and their husbands often leave them. One woman, Muleta recalls, had come to the hospital, blinking her eyes more than usual. Muleta asked her why. It’s because she had lived the past four years in a shed, in the dark, and wasn’t used to the light.
“Luckily she had a mother, and her mom was washing her clothes, every day, because she is leaking urine and feces both,” Muleta remembers. The woman avoided leaving the shed, because when she did, kids would stone her. Another woman had spent two days riding on a bus to get to the hospital—sitting on a bucket because she was leaking urine.
“When they are cured…they cannot believe,” she says. “And the reaction they show, that really gives you a lot of satisfaction.”
A Quest to End Fistula
In March, the country’s minister of health, Dr. Kesetebirhan Admasu, visited the Hamlin Fistula Hospital and pledged to end obstetric fistula in the next five years. The government has formed a task force, which Muleta is on, to try to make that happen by 2020.
The stakes are high. Among fistula patients Muleta has interviewed, “suicidal ideation is something which happens to everyone,” she says. “Everyone thought of killing herself at one point, living with that condition.”
The Fistula Foundation’s Grant says she thinks that “it’s unrealistic that every case is going to be treated or eradicated by then,” but applauds the fact that the government set the goal in the first place and announced it. The country has made enormous progress, she says. With fistula, she notes, there isn’t really hard data, but one proxy for it is maternal mortality—how likely a woman is to die as a result of giving birth. And that has improved. In 2010, the rate of maternal mortality in Ethiopia was 1 in 67, but it was worse in 2000: a devastating 1 in 24, according to Save the Children. That rate in the United States in 2010 was 1 in 2,400.
In its 2014 State of the World’s Mothers Report, Save the Children ranked 178 countries, with the country at the top of the list (Finland) being generally the best place to be a mother (in terms of health), and the country at the bottom (Somalia) being the worst. Ethiopia is 149th, sandwiched between Pakistan and Ghana. Its placement on the list isn’t great, but from 2000 to 2008, Ethiopia was in the bottom 10. The thousands of government-trained health extension workers deployed in recent years have helped the situation; they are posted in remote areas and counsel women on family planning, encourage them to give birth in facilities and vaccinate children.
In fact, it was a health extension worker who told Hawa, the patient who had had a fistula for 17 years, about where to seek treatment. Asked how she felt now that her problem was fixed, she said simply, with Muleta translating, “It’s beautiful, I’m happy.”
Rob Verger traveled to Ethiopia with the International Reporting Project.