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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Unlikely sisters in the Gaza Strip

A former Jewish settler in Gaza recalls her childhood friendship with a young Palestinian.

It was well after midnight, one summer night in 1995, when Inbar Rozy, a 13-year-old living in the former Israeli settlement of Alei Sinai in the northern Gaza Strip, heard her parents answer the phone. Sitting up in bed, surrounded by potted plants, candles and fairy dolls lit by shafts of light from a nearby security outpost, Inbar listened closely.

“I could hear everyone talking around me, making calls,” Inbar said when we met recently in Nitzan, southern Israel. When she got up to find out what was happening, her parents told her to make up a second mattress. As dawn broke, they led into the room a young woman carrying a small bag and wearing a black shirt and jeans. “She had shoulder-length dark hair dyed with red henna and beautiful eyes – big, black with thick eyelashes,” Inbar told me, smiling. “[She was] quiet. She looked scared.”

The woman was Rina (her surname cannot be given for security reasons), a talented artist in her early twenties studying at a local art college, where she had fallen in love with a Christian boy. For Rina, coming from a traditional family, marrying a non-Muslim would be strictly forbidden.

When her parents found out, they were furious and forbade her from seeing her boyfriend. But her male cousins felt this wasn’t enough. Earlier on the day the girls first met, Rina’s cousins had attempted to kill her in retribution for her perceived “honour crime”. Seeing that another attempt on her life was likely, Rina’s father called a relative, who in turn called Inbar’s father, Yossef, a friend of many years. There was no doubt she had to leave. Ironically, a Jewish settlement protected by the Israel Defence Forces was the safest place in Gaza for her to be.

In 1967, Israel seized the Gaza Strip from Egypt during the Six Day War. In time, it settled 21 communities on a third of the land, with a population of 8,000 by 2005. Soldiers guarded the settlements from 1.5 million displaced Palestinians, tens of thousands of whom were displaced in 1967 and moved to live in nearby refugee camps. In Gaza, before Israel’s ultimate withdrawal from the Strip in 2005, relationships between Israeli settlers and Palestinians were fraught. True, many Palestinians worked in Israeli settlements, earning wages higher than elsewhere in the Strip, but the two communities lived largely separate lives.

In the mid-1990s, even after the Oslo Accords, violence was simmering. Israeli military incursions increased with the outbreak of the Second Intifada in 2000. Thousands of home-made Qassam rockets were launched by Palestinian militants at settlers and those living in southern Israel. Security measures hardened. The veteran Israeli journalist Amira Hass, who spent several years living in Gaza, describes neighbourhoods that were “turned into jails behind barbed-wire fences, closed gates, IDF surveillance, tanks and entry-permit red tape”.

And yet, in spite of the forced segregation, Inbar’s family enjoyed close links with their Palestinian neighbours. Inbar’s father worked as an ambulance driver, and on several occasions he helped transport those who lived nearby for emergency medical treatment in Israel. “Every Tuesday, my father’s Jewish and Arab friends would come to our house and we’d eat lunch together,” Inbar remembered.

Given the gravity of Rina’s situation, she couldn’t leave the house. Secrecy was paramount. The girls spent weeks together indoors, Inbar said, chatting, watching TV and drawing. “I’m not sure that as a child I actually understood it for real,” she said. “She taught me how to paint and sketch a face from sight.”

Almost as soon as Rina arrived, Inbar’s family began receiving anonymous phone calls asking about her. “My dad told me, ‘Don’t mention anything about Rina. Say you don’t know what they’re talking about – because otherwise they’ll come and kill us,’” Inbar said.

While the girls got to know each other, Inbar’s mother, Brigitte, found a women’s shelter in East Jerusalem for Rina. Whereas today Gaza is closed off by a military border under heavy surveillance, at that time it was porous. Brigitte drove Rina in to the capital, where she was given a new name and identity that would enable her to begin a new life, on condition that she contact no one in Gaza.

Today Inbar, who is 33, works at the Gush Katif centre in Nitzan – a museum dedicated to the memory of the Israeli settlements in Gaza. Despite her parents’ objections, the family was evacuated in 2005. Unlike most settlers in Gaza, some residents of Alei Sinai were determined to stay on, even if that meant forfeiting their Israeli citizenship. “I have no problem with living as a minority in a Palestinian state,” one of Alei Sinai’s inhabitants, Avi Farhan, told the Israeli daily Haaretz at the time.

Inbar now lives in Ashkelon, a city of 140,000 in southern Israel, and finds the big city alienating, especially when she recalls the warm relationships that once existed in Gaza. “I’ve never felt less secure,” she told me.

Years later, she learned that Rina had developed cancer and died. “The day before Rina left . . . she drew a portrait of me,” she said, describing how her friend had outlined, in charcoal strokes, the features of the teenager. Her parents packed the portrait with all their belongings in a shipping container the day they left Gaza. Soon after, the container was destroyed in a fire.

“I think if people had given it a chance . . . they would have had these kinds of friendships,” Inbar said, looking back. “We’d get along fairly well if we didn’t look at others as the monsters over the wall.” 

This article first appeared in the 27 August 2015 issue of the New Statesman, Isis and the new barbarism