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.

Photo: Getty Images
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Bomb Isil? That's exactly what they want

The government appears not to answer the nature of its enemy, warns Maria Norris.

As MPs are set to vote on further airstrikes in Syria, it is difficult to shake off the feeling that the government does not fully appreciate the complexity of the problem Isil poses. Just a cursory glance at its magazine, the pronouncements of its leaders and its ideology reveals that Isil is desperate for Western bombs to fall out of the sky. As Martin Chulov argues, Isil is fighting a war it believes was preordained since the early days of Islam. Isil’s obsession with the city of Dabiq, in Northern Syria, stems from a hadith which prophesises that the ‘Crusader’ army will land in the city as a precursor to a final battle where Islam will emerge victorious. Dabiq is also the name of its magazine, which starts every issue with the same quote: "The spark has been lit here in Iraq, and its heat will continue to intensify -- by Allah's permission -- until it burns the crusader armies in Dabiq". Isil wants a war with the West. If we don’t negotiate with terrorists, then we also should not give them what they want.

Further, bombs are indiscriminate and will inevitably lead to the suffering of those trapped in Isil territories. Isil is counting on this suffering to swell their ranks. Civilian suffering from airstrikes only underline the narrative that the West is at war with Islam, which plays directly into Isil’s hands. And despite misleading headlines and the genuine government concern with individuals fleeing to Syria, Isis is supremely unpopular. It is no wonder that its magazine is filled with glossy adds begging people to move to its territories.  You cannot be a state without people. Terrorist attacks such as Paris thus have a two-pronged purpose: they provoke the West to respond with its military, and they act as a recruitment drive. The fact that fake Syrian passports were found around the sites of the Paris attacks is no coincidence as Isil are both seeking to stem the flow of refugees from its territories and hoping to provoke an Islamophobic backlash. They hope that, as more Muslims feel alienated in the West, more will join them, not just as fighters, but as the doctors, nurses and teachers it desperately needs.

In addition to this, airstrikes overlook the fact that Isil is a result of what Fawaz Gerges calls a severe, organic institutional crisis in the Middle East. In a lecture at the London School of Economics earlier this year, Gerges pointed out the dysfunction created when a region that is incredibly resource rich also is also deeply undemocratic, riddled with corruption, food insecurity, unemployment and poverty. This forms an institutional vacuum that is filled by non-state actors as the population does not trust its political structures. Further, the civil war in Syria is also the site of the toxic soup of Middle Eastern state dysfunction. Iran supports Assad, Saudi Arabia and the Gulf countries, fund anti-Shia groups in Syria. Throw in the Kurdish conflict, Turkey’s ambiguous position and Russian bombs, it is difficult to see how airstrikes will solve anything.

Finally, it is crucial that Isil is seen as a direct result of the Iraq war. The American-led invasion destroyed the institutions, giving the Shia majority power almost overnight, creating deep dissatisfaction in the Sunni regions of Iraq. On top of this thousands of foreign fighters flooded Iraq to fight the invaders, attracting disenfranchised and angry Sunnis. The result is that since 2003, Iraq has been embroiled in a sectarian civil war.  It is in civil war, inherently connected to the Iraq War, that you find the roots of Isil. As even the Prime Minister concedes that ground troops are necessary, albeit it regional ground troops with its own set of problems, it is important to consider what further monster can arise from the ashes of another ill-thought out military intervention in the Middle East.
We have had decades of military intervention in the Middle East with disastrous consequences. Airstrikes represent business as usual, when what we actually need is a radically new approach. Who is funding Isil? Who is buying its oil? How to curb Isil’s recruitment drives? What can be done about the refugees? How to end the conflict in Syria? What happens to Assad? These are questions hopefully being addressed in talks recently held in Vienna with Russian, Ira, the USA, France, Syria’s neighbours and the Gulf states. Airstrikes do not answer any of these questions. What airstrikes do is give Isil exactly what it is asking for. Surely this is reason enough not to bomb Syria. 

Maria W. Norris is a PhD candidate and a teacher at the London School of Economics and Political Science. Her PhD is on the UK counter-terrorism strategy since 9/11 and its relationship with identity. She tweets as @MariaWNorris.