Obstetric Fistula: Africa’s silent epidemic

While all women of reproductive age are vulnerable to suffer fistula, the underage girls who are victims of child marriages, female genital mutilation and teenage pregnancies are at highest risk.

Obstetric Fistula is a silent epidemic in Africa. It’s a hole in the birth canal caused by prolonged, obstructed labour due to lack of timely and adequate medical care. As a result of this, in most cases, the baby is stillborn or dies within the first week of life, and the woman suffers a devastating injury, which leaves her incontinent. While all women of reproductive age are vulnerable to suffer fistula, the underage girls who are victims of child marriages, female genital mutilation and teenage pregnancies are at highest risk.

It’s a deeply unpleasant condition, resulting in constant leakage of urine and feaces through the vagina. Naana Otoo-Oyortey from the diaspora charity FORWARD tells me: “It’s a health issue that’s exacerbated by social factors. Many of these girls will be excluded from community life and abandoned by their husbands and families, isolating them socially and economically.”.

Another diaspora charity, MIFUMI, sent me a number of case studies. Justus Osuku, a peasant from Gweri in Soroti district, married his wife when they were both 14, during the infamous Teso insurgency in the 1990s. They were living in the Internally Displaced Peoples Camps in Soroti when his wife developed the problem. He resisted the social pressure to send her away: “I loved her. I married her when she was normal. I did not see the reason to send her away at a time when she needed me most.”

He is unusual: the overwhelming majority of husbands send their wives away, citing reasons ranging from the unbearable smell to community stigma. FORWARD is conducting research in Sierra Leone to explore the impact on the lives of women and girls who are blighted by it. The research involves 45 women affected by fistula and their recommendations will inform policy and decision makers in Sierra Leone and beyond.

One of those women, Jamma, was 18 when she got pregnant. When the labour started, she went to the local health centre but the nurse was away so she had to wait for three days. She finally gave to a stillborn baby and developed fistula. She suffered from it for two years until her friend told her about the treatment in the town. Her friend paid for her transport but the journey was very difficult. Nobody wanted to sit with her because of the smell. She was abandoned, first by her husband and then her grandmother.

On 23 May this year the UN celebrated the first International Day to End Obstetric Fistula. There is a lack of evidence as to how many women worldwide are living with the condition, but they live mainly in Sub Saharan Africa and Asia, and number in the hundreds of thousands. In Uganda there are at least 200,000 such women and 1,900 new cases are reported annually, according the National Obstetric Fistula Strategy.

“It’s a poor person’s illness,” Evelyn Schiller of MIFUMI tells me. “The issue of transport in rural Africa makes it difficult - there are very few cars in these areas. Surgeries can be lacking basic equipment like surgical gloves, clamps and oxygen. It usually takes three or four surgeries to correct it because it’s a complex repair process. We need to improve health education and antenatal care, train doctors to repair them, and above all raise awareness.” 

Mother and son walk together near the Ethiopia-Somalia border. Photograph: Getty Images

Alan White's work has appeared in the Observer, Times, Private Eye, The National and the TLS. As John Heale, he is the author of One Blood: Inside Britain's Gang Culture.

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“Journalists are too scared to come”: Refugees on the forgotten war in Yemen

Only the few who have managed to flee the war-torn country can reveal the suffering of those left behind.

Last weekend’s BBC Our World report on the humanitarian crisis caused by the Yemen civil war highlighted that not only is the conflict a forgotten war, it is also an unknown war. Since war broke out 18 months ago in March 2015, surprisingly little has been written about the conflict, despite its similarity to ongoing and widely-reported other conflicts in the region, such as the Syrian crisis.

The main conflict in Yemen is taking place between forces allied to the President, Abdrabbuh Mansour Hadi, and those loyal to Zaidi Shia rebels known as Houthis, who forced Hadi to flee the capital city Sana’a in February. The loyalties of Yemen’s security forces are split, with some units backing President Hadi and others his predecessor Ali Abdullah Saleh, who is seen as the leader of the Houthi forces.

While these two forces have been at war, separate terrorist groups have been gaining more and more influence on the ground. Opposed by both the Houthis and Hadi’s forces, al-Qaeda in the Arabian Peninsula (AQAP) have staged deadly attacks from strongholds in the south and south-east. They are also opposed by Islamic State, which has claimed responsibility for a number of suicide bombings in Sana’a.

After rebel forces closed in on the president's southern stronghold of Aden in late March, a coalition led by Saudi Arabia responded to a request by Hadi to intervene and launched air strikes on Houthi targets.

I have spent the last couple of months working in the “Jungle” refugee camp in Calais, home to refugees from Sudan, Afghanistan, Syria, Iraq, Eritrea, Somalia – to name just a few. Having heard very little about the civil war, I was surprised to meet a handful of Yemeni men living inside the camp.

Hussein*, 28, is a film producer and dancer from Yemen who fled the country two years ago and has travelled through 11 countries to reach the Calais camp, where he has been living for just over a month. In a mixture of English and French, he tells me how groups of Houthi militia forcibly try to confiscate cameras and notebooks from both local and international journalists. He knows local journalists, friends of his, who have been threatened, tortured and even killed by Houthi forces.

He pulls out his phone and shows me a picture of his friend, Mohammed, who worked as a photojournalist, documenting brutality as a result of the war. Mohammed’s friends and family have not heard from him since April; the best-case scenario is that he is being detained, but Hussein seems pretty certain that he is dead. As a result, many who otherwise would have reported on the conflict have fled from besieged cities such as Sana’a, Aden and Taiz to the relative safety of the countryside in the north of the country, or have left Yemen altogether.

His friend Jamil, with whom he shares a tent, adds: “from other countries journalists [they are] too scared to come”. He claims that there are only “five or seven” foreign journalists in the capital city, Sana’a and tells me about journalists from the UK, France and the US who, after spending days being held up by countless militarised checkpoints while trying to reach the main cities, are then interrogated and detained by Houthi forces. If they are let go, they are harassed throughout their visit by National Security officers.

After watching his mother die during an airstrike in the city of Hodaida in January, Jamil took the decision to flee Yemen and claim asylum in Europe. He is worried about his father and his friends who are still in Yemen, especially after hearing reports that random border closures and cancelled domestic flights have been preventing crucial aid convoys of food, medical supplies and trained aid workers from accessing the citizens who are desperately in need of humanitarian assistance. Jamil reminds me that Yemen was in economic crisis even before war broke out, with widespread famine and limited access to healthcare or clean water.

Movement within the country is restricted and dangerous, and in the last twelve months alone, four Médecins Sans Frontières (MSF) facilities have been attacked and destroyed by airstrikes. Writing on 15 September 15, MSF head of mission in Yemen, Hassan Bouceninem spoke of:

“Other health centers, schools, markets, bridges . . . [that] have been attacked and destroyed by airstrikes, shelling, or bombs. Such attacks create direct victims but the war (economic failure, access problems, closing of hospitals, no health staff etc.) also causes a lot of indirect victims within the population.”

Such widespread instability and the resultant lack of access for journalists and aid workers means that it is difficult for the world to know how much Yemen is suffering. Only by speaking to the few who have managed to flee can even begin to grasp the realities of daily life for those left behind.

*Names have been changed to protect the identities of our sources.

Neha Shah has been volunteering in the Calais camp.