How One NWP Physician Is Making a Big Difference for Women in Ethiopia
October 1, 2019
The following account, by WFF Board Vice Chair and Northwest Permanente urogynecologist, Rahel Nardos, MD, describes one non-profit partnership that helps Ethiopian women who have a debilitating medical condition.
Berhe and Tsehaitu locked in conversation
The two women, locked in deep conversation as if they were long lost friends, caught my attention in the hospital ward. They were in their hospital gowns laying on mattresses on the floor of the Hamlin Fistula Center in Mekelle, Ethiopia, awaiting their long anticipated surgery.
I was still in my surgical scrubs, having stepped out of the operating room where I have spent the morning mentoring two of the five Ethiopian doctors who are currently in our urogynecology fellowship training program. I sat on the floor next to the older of the two women and asked if I could talk to them for a few minutes.
They spoke the local dialect, Tigrigna. The nurse translated my Amharic to Tigrigna, but the big smile on their faces told me they were happy to talk to me.
The two women had met at the hospital and bonded over their shared predicament and hope of cure. I asked Tsehaitu, the older of the two women, how old she was. Her face lit up with a proud smile as she told me with confidence that she was 86 years old.
Now, having been born and raised in Ethiopia myself, I know that most Ethiopians, especially those from rural communities, didn’t know their birthdays or even their birth years with certainty. Doctors often try to estimate by asking how long it has been since menopause or how old their children were.
Tsehaitu however was very confident about her age saying that she was three years old when the Italians came to colonize Ethiopia, albeit unsuccessfully. This historic fact is hard to dispute and my own grandmother who is now 98 years old uses this historic year to mark her age, silencing all of us age-doubters in the family.
Tsehaitu told me that she had had debilitating pelvic organ prolapse where loss of support of her vagina caused protrusion of her uterus and other pelvic organs outside of her body for the last 25 years. This is a devastating condition for women. It severely limits their ability to be physically or sexually active. They struggle with basic bodily functions such as emptying their bladder and bowel.
This is made worse by the taboo around talking about this condition and the fear of not knowing what this is and why this is happening to them. Even in the United States, where women are relatively well educated and have access to medical information, patients sometimes end up in emergency rooms for fear that this thing that is protruding from their private parts is cancer. Fortunately in the United States, women have easy access to both conservative and surgical treatment and generally get help before their condition gets worse.
This is not the case for Ethiopian women whose access to appropriate care for this condition is almost non-existent. Most women affected by this are from rural communities and tend to be poorly educated and have little access to medical information. They often believe that their condition is a punishment from God.
Ethiopian women seem to suffer a more severe form of prolapse at younger ages as they are exposed to prolonged and sometimes obstructed labor due to lack of access to timely obstetric care. Other risk factors include multiple vaginal deliveries (a risk for pelvic floor injury), heavy physical exertion, poor nutrition, and lack of access to trained pelvic floor health providers.
Tsehaitu tells me that she sought care for this condition many years ago at a referral hospital, but she was told that in order to have surgery, she needs to get someone in her family to donate blood on her behalf. This is the only way the hospital is able to voluntarily collect blood for any emergency situations that need blood transfusion.
In my 11 years of doing volunteer medical work in Ethiopia, I had not heard this particular barrier to care, and I was taken aback. I asked Berhe, the second patient, how long she had had her prolapse, and she said she had had it for 10 years — and like her friend, she was discouraged from seeking care for the same reasons.
Ironically, I was relieved that they didn’t have their surgeries at that time because if they did, they would likely have received surgery from providers who have not been properly trained to repair their prolapse. Their surgeries would have likely failed, and they would have been in the same predicament.
Thanks to the ongoing partnership between Worldwide Fistula Fund, Hamlin Fistula Hospitals, Mekelle University College and Health Sciences, and Oregon Health and Science’s Footsteps to Healing program, they would receive appropriate surgery by skilled local surgeons who are trained in pelvic medicine and reconstructive surgery.
This partnership has resulted in launching one of the first formal urogynecology fellowship programs in the country. We graduated our first two urogynecology fellows in 2018, and they are now providing training for five trainees alongside our visiting faculty. The program also includes an inter-professional team approach to care that includes nurses, doctors, and pelvic floor physical therapists.
On this trip, I was deeply humbled by the unwavering commitment that our fellows demonstrated to learn and to elevate the care of women in Ethiopia. They are indeed pioneers. I have no doubt they will play a prominent role in advancing pelvic floor care in Ethiopia.
Women like Tsehaitu will no longer wait 25 years to regain their dignity and health.
(Reprinted by permission of Northwest Permanente, P.C.)