Guest Blog – My Personal Experience: Healing Women in Ethiopia
March 31, 2015
Guest Blog by Dr. Rahel Nardos, MD, WFF Board Member
One at a time, the women walked into the operating room with their IV bags in their hands. If they were anxious or afraid, their stoic faces did not show it. Faithfully, each woman leaned her head against one of ours as our anesthesiologist placed a spinal anesthesia that would allow her to have her surgery without pain. It is impossible not to appreciate their vulnerability and be humbled by the level of trust that these women placed in our team. They did not speak our language, most had no education, and none had the opportunity to build a doctor-patient relationship over a period of time. They saw this as their only opportunity for healing:
I have lived with this condition for 10 years. I did not know what it was and why I had it. I figured it was my womb that was falling out of my body and I wondered if something broke during childbirth. But I didn’t have anyone to ask. I simply accepted it as God’s will and suffered in silence. I am so grateful that help is finally here.
Patient at Mekelle
This February 2015, I traveled to Mekelle, Ethiopia with 13 colleagues from Oregon Health & Science University (OHSU) where I am an assistant professor in research and global health. What made the trip special was that for the first time, the OHSU global women’s health initiative, Footsteps to Healing, joined forces with Worldwide Fistula Fund (WFF), Mekelle University and Hamlin Fistula Center. For the past 5 years, Footsteps to Healing has provided surgical care for women in rural Ethiopia – 250 to date. Here was an opportunity for us to greatly expand training impact through a “dream team” collaborative partnership, while still providing healing surgery to women. Our shared goal is to build Ethiopian health care capacity through formal training of women’s health care providers.
We operated on 39 women in total while training four OB-GYN faculty at both the Mekelle branch of Hamlin Fistula Center and Ayder hospital at Mekelle University. Most patients were young with advanced stage uterovaginal prolapse. This is a condition that results from loss of pelvic floor support, allowing the uterus, bladder and even the rectum to herniate through into the vagina. This in turn severely impacts a woman’s quality of life and even her ability to perform basic bodily functions, such as emptying her bowel or bladder.
Although uterovaginal prolapse exists in developed nations, the severity of its presentation in young rural women in Ethiopia is unprecedented. Ethiopian women are particularly at risk at a younger age due to poor nutrition; a lifetime of heavy lifting, including carrying firewood or fetching water from miles away over rugged terrain; and multiple vaginal deliveries following prolonged labor. With limited access to trained obstetric providers, these women are at greater risk of obstructed labor, which causes muscle, nerve and connective tissue trauma that results in urinary incontinence and pelvic organ prolapse over time.
According to a recent survey by Ethiopia’s Tigray regional health bureau, there are an estimated 1,600 women with symptomatic pelvic organ prolapse just in the Tigray region alone. This is a silent epidemic that has not yet gotten attention. Because of the lack of trained teams of pelvic floor specialists, including surgeons, pelvic floor physical therapists, and nurses, women in Ethiopia with chronic pelvic floor disorders have very little or no access to care.
One key WFF prevention program is to collaborate with strong teaching institutions like Hamlin Fistula Hospital, Mekelle University and others to develop the first formal Pelvic Medicine and Reconstructive Pelvic Surgery (Urogynecology) fellowship in Ethiopia. This program will specifically focus on training Ethiopian gynecologists in advanced pelvic floor medicine and reconstructive pelvic surgery.
One of the most challenging clinical questions I faced as a surgeon in Mekelle was how to provide durable surgical intervention for these very young, nutritionally compromised women with the most severe forms of pelvic organ prolapse, knowing they would go on to do long hours of physical labor right after they were discharged from the hospital. How long will our surgeries last in this population? In the US, we have what we need for non-surgical, conservative management options, like removable pessary devices, which will support a woman’s organs without surgery. Without that, what do we do for women who still want to preserve their fertility?
These are questions I hardly face as a urogynecologist in Oregon, as the majority of my patients are older, don’t have severe prolapse, are able to take time off from work to recover, and have conservative options other than surgery to manage their symptoms. These questions speak volumes about the need for comprehensive pelvic floor care for women in Ethiopia, and about the need for research to assess appropriate and safe therapy for this population.
The commitment of our Ethiopian partners was evident from the start. They welcomed us at the Addis Ababa Airport and ensured that all our medical and surgical supplies sailed through customs without a problem. Their warm and welcoming faculty, Dr. Usha and Dr. Hale, who are in charge of International Relations and Partnerships, provided us excellent logistical support. Dr. Usha even invited us to her home twice for a delicious homemade Indian/Ethiopian meal. Our partners collaborated with local organizations such as the Tigray regional health bureau and non-governmental humanitarian organization as the Hope Community Village to recruit our patients from rural Tigray, to transport them, house, and nurture them both before and after the surgeries, and to cover all of the necessary hospital expenses. Mekelle University graciously provided lodging, food and transportation to our entire 13 person team. It was truly heartwarming to see this type of multi-institutional commitment to helping women in Ethiopia who have been in the shadows.
The impact of our recent surgical mission in Mekelle can be seen with one look at our patients’ effervescent smiles after their surgery. They bow their heads repeatedly, raise their hands high above their heads whispering words of gratitude to God and to the team that has provided their care. They can now return to their homes and engage in normal social, physical and intimate activities once again. As our nurse Bella said:
The Ethiopian women we met are beautiful, graceful, hard-working, and so much in need of intervention. Women cared for each other, they knew who had been in pain or had not eaten and advocated for them. Despite the language barrier, we were able to communicate.
Performing the surgeries, with my Ethiopian learners on one side and my OHSU resident learners on the other, I remember feeling the power of this partnership and the weight of responsibility of teaching perhaps the next generation of Ethiopian urogynecologists. Since our February trip, our newly trained local partners have continued to perform uterovaginal prolapse surgeries on their own, providing much-needed care to women in the Tigray region.
Our team enjoyed working with the Ethiopian team, including the nurses, operative room technicians, residents, and faculty at both Hamlin Center in Mekelle and Ayder Hospital at Mekelle University. Of course there were some logistical challenges, but none of the challenges was insurmountable. We found common ground in that we all wanted to provide safe, much-needed care to Ethiopian women. Between our busy surgical duties, we found time to visit the beautiful stone churches that canvass the mountainous landscape outside of Mekelle. We also took time to enjoy each other’s company through many delicious dinners at local restaurants. We concluded our last day at a festive cultural restaurant in Mekelle, courtesy of Mekelle University, the Dean of College of Health Sciences, the medical director, the chair of OB-GYN and many others. Everyone in our team were on their feet dancing to the beat of the festive Tigrigna songs. We were very touched by words from Dr. Hale, the coordinator of international collaboration:
We would like to take OHSU’s team as a template for meaningful global health collaborations. They were a group of cheerful people whom every one of us would love to see return 12 times a year. Understanding the importance of the work they have been doing in helping the women in need, everyone loved to meet them: the university dean, the medical director, the department head and people from the regional health bureau. Such is a partner that our heart goes to. We will make every effort to keep them with us.
Although this type of work is often seen as a humanitarian mission that impacts others, this was an experience that profoundly impacted our team as well. According to our resident gynecologist, Dr. Yanit:
The trip was and will undoubtedly be one of the highlights of my residency career…On a personal level, I will never forget how grateful, humble, and hospitable the women and staff were in Ethiopia… From a professional standpoint, I learned to operate with limited medical resources at my disposal. I gained exposure to severe pelvic floor prolapse and obstetric fistulas, which we do not routinely encounter at OHSU… and I was part of a project that hopes to create a sustainable collaboration with the goal of improving health outcomes in Ethiopia.
Dr. Yanit’s sentiments were shared by Dr. Halawa, a third year anesthesiology resident “I was blown away by Mekelle and Ethiopia, especially it's warm, kind staff and humble, gracious patients. We had an amazing team. It was hard work managing with limited supplies and limited equipment, but you leave a better anesthesiologist and more appreciative of the resources we have in the US. The smiles of the patients are worth all the hard work. Best experience in all of residency!”
Our 2015 team consisted of two perioperative nurses, one OR nurse, one OR technical director of perioperative services, two OB-GYN residents, one anesthesia resident, two urogynecologists, one urogynecology fellow and two anesthesiologists.