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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Clinton vs Trump: How does the electoral college work?

A brief history.

If you have even the vaguest awareness of US politics, you'll no doubt recall the role Florida played in the 2000 presidential election. The result in the state was so close that arguments about recounts and hanging chads went on for weeks, before the result was finally settled – and the next president decided – by the US Supreme Court.

The odd thing about Bush v Gore, though, is that nobody questioned which of the two had more votes: it was Al Gore, by more than half a million. (The number of contested votes in Florida was something like a tenth of that.) To put it another way, it was always clear that more Americans wanted Gore as president than Bush.

And yet, the outcome of the election ignored that entirely. It turned instead on who had won Florida. That, the Supreme Court decided, had been Gore's opponent: George W. Bush became the 43rd president of the United States, and the rest is history.

So why did a man who everybody agreed had come second become president? Why did the whole thing end up turning on the number of votes in a few counties of former swamp?

History and geography

The answer comes down to that weirdly undemocratic American invention, the electoral college. The founding fathers, you see, did not actually intend for the president to be chosen by the people.

Much of the constitution was the work of the over-achieving Virginian delegation to the Constitutional Convention of 1787. Their plan, written by James Madison, suggested that the president should be chosen by Congress.

That idea was rejected on the grounds that it would undermine the president's independence. Some delegates feared that allowing a bunch of men who spent all their time locked in a room together arguing pick the head of state would lead to “intrigue” (yes), and suggested the president should be chosen by popular vote instead.

So they settled on a compromise. Each state would pick “electors” – how they did so was their own business – and these would in turn pick the president. Senators and congressmen were specifically barred from becoming members of this electoral college; but an aspect of the original plan that survived was that the number of electors in each state would be equal to the number of representatives it had it Congress.

Some of the oddities in this system have been ironed out over time. By the mid 19th century most states were choosing electors by popular vote: the presidential election may be indirect, but it's an election nonetheless. After the 23rd Amendment passed in 1961, those who lived in Washington DC, previously disenfranchised because it isn't a state, were given the vote too (it gets three votes in the electoral college).

But others anomalies remain. Here are three:

1) A lack of proportion

One of the big issues in 1787 was persuading the original 13 states to agree to the new constitution at all. Many of the smaller ones (Delaware, New Hampshire) were nervous that, by joining the union, they would instantly be dominated by their much bigger neighbours (Virginia, Pennsylvania, Massachusetts).

To keep them on board, the Constitutional Convention agreed the “Great Compromise”. The size of the delegations each state sent to the House of Representatives would be roughly proportional to the size of its population; in the Senate, though, every state would get two senators, whether it had several million people, or three old blokes and a dog. In other words, the US constitution had to deliberately over-represent smaller states in Congress, just to persuade them to sign up to the thing in the first place.

All this still applies today – and because size of a state’s delegation to Congress determines the number of votes its gets in the electoral college, smaller states are over-represented in presidential elections, too. The result is that a vote in California is worth less than a third of a vote in Wyoming:

Image: Fzxboy/Wikimedia Commons.

2) A lack of faith

The people don't choose the president: the electoral college does, with electors generally voting based on the votes of the people in their state.

But the operative word there is “generally”: while most states have laws requiring electors to vote with the popular will, or rendering their vote void if they don't, some 21 states do not. So, occasionally, there are “faithless electors”, who don't vote the way their state wants them to. In the 57 presidential elections between 1788 and 2012, there have been 157 incidents of such faithlessness (although, to be fair, in 71 cases this was because the electorate's preferred candidate was dead).

This has never affected the outcome of an election: the closest was in 1836 when the Virginia delegation refused to vote for vice presidential candidate Richard Mentor Johnson on the grounds that he was having an affair with a slave. (Being massive racists, they were fine with the slavery and the abuse of power; it was the interracial sex they had a problem with.) But Martin Van Buren's election as president was never in doubt, and even Johnson was confirmed after a vote in the Senate.

Even in those states which don't have laws to punish faithless electors, becoming one is still often a bloody stupid thing to do, since it generally means betraying the party that made you an elector in the first place, an act which will almost certainly wreck your career. Nonetheless, it is constitutionally possible that, when the electoral college meets after November's election, some of its members will ignore the result entirely and propose, say, Kevin Spacey as the next president. And those are the votes that count.

3) A lack of interest

The biggest oddity of the system though is the fact of the electoral college at all. The voters don't pick the president: the electoral college does. The result is that presidential campaigns need to focus not on individual voters, but on states.

Most states allocate their electoral votes on a winner takes all basis. There are two exceptions to this: Nebraska and Maine both hand out one electoral vote to the winner in each congressional district, and two to the state-wide victor. This rarely makes any difference, since both states are small, and any candidate who carries the Maine 2nd is likely also to have carried the whole of Maine. Just occasionally, though, it does: in 2008 Obama narrowly carried the Nebraska 2nd (Omaha, basically), prompting grumpy local Republicans to redraw the boundaries to dilute the local Democratic vote and so ensure this wouldn't happen again.

In the vast majority of states, however, winning 50.1 per cent of the vote will be enough to get you 100 per cent of the electoral votes. In an election with more than two candidates, indeed, you don't even need to do that: a simple plurality will get you 100 per cent of the vote, too.

This, combined, with demographics, mean we already know how something like 363 of the 538 electoral votes on offer will go. Only around 13 states are considered competitive this year. In the other 37, plus the District of Columbia, we might as well already know the result.

The result is that, for the next few weeks, there will be endless reports about Florida, Virginia and Ohio. But you're not going to hear so much about how voters are feeling in California or Delaware or Arkansas or Texas. The first two will go for Clinton; the last two will go for Trump. The campaigns will ignore them; the voters may as well not show up. State-wide demographics mean the result is already clear.

In a true popular election, every vote would count equally. In the electoral college, they do not. The result, 16 years ago, was four weeks of legal wrangling over a few hundred votes in Florida. The result, this year, is that it’s entirely possible that Donald Trump will become president – even if Hillary Clinton gets more votes.

Jonn Elledge is the editor of the New Statesman's sister site CityMetric. He is on Twitter, far too much, as @JonnElledge.