Category — Fistula and Childbirth Injury

If you need transfer to hospital, this S Kivu clinic will carry you 4 km to the nearest hospital in this exact chair, the "Ambulance Chair"

Today we travelled to a regional health clinic to find out what services and deficits exist for pregnant women at risk for maternal death or vaginal fistula. We found a hard working, well trained, and devoted “Titular Nurse”. In this facility with no electricity, no lights except a kerosene lamp, dicey plumbing and a pharmacy stocked with one medication (Ampicillin), they do indeed deliver babies, but only the “easy” ones with no complications of labor, like obstructed labor, or infection, or prolapse of the umbilical cord, or fetal distress, or heavy bleeding. If a woman has a complication during labor (or for that manner any man, woman, child or infant whose care is beyond the capacity of this facility), and you can’t get to the hospital on your own, they literally put you in this chair and carry you 4 kilometers over incredibly rough terrain (even the goats stumble) to the regional hospital. It seems the ambulance broke about a year ago, and with no funding to fix it, emergency transport is carried out by “Ambulance Chair”.

In an infrastructure and cash-strapped country, where corruption rules and chaos is not a choice, what’s more important? Funding more “fixing of Problem X” or funding ways to prevent Problem X while maintaining current methods by which Problem X gets fixed?  From what I gleaned at the hospital today, the doctors and other powers-that-be choose option #2.  To sum up, “retention and prevention” are the keys to fistula eradication in South Kivu, DRC- find ways to retain the talented local fistula surgeons who leave to find the “beyond fistula” training they cannot get at Panzi Hospital, and develop ways to improve obstetric care so that fistulas don’t occur in the first place.  When money is scarce, common sense pays bigger dividends.

The internet is slllloooow as cold molasses on a winter day here. It took me 45 minutes to post this post- (bad news)

It’s the dry season, hasn’t rained in 6 weeks, and without a single paved road in Bukavu, it’s a veritable dust bowl. So I promised our driver “I’ll make sure it rains tonight.” At 9 pm it POURED BUCKETS for about an hour. By now, this man must think I’m a witch – (good news)

More tomorrow, Mouseketeers.

What’s with my brain’s insistence on using Frank Sinatra’s “New York” as the default song-stuck-in-your-head soundtrack whenever I’m working in Democratic Republic of Congo?

Freshly arrived in the southern Kivu region of the Democratic Republic of Congo after 18 hours flight time and 5 hours drive from Kigali, Rwanda, I am pleased to report that Rwanda seems content in the wake of the recent “transparent” election on August 9th that allows President Paul Kagame to continue his program of healing and reunification (one version) or subversive neo-dictatorship, take your pick. On the way I read all manner of editorial and article on this election, leaving me pining for Camu’s imaginary political party for (forgive any misquote here) “people who are not sure they are correct”. The legacy of Belgian-mandated tribalism in this region is beyond the capacity of this well fed, safely raised American to pass judgement on, so I’ll stick with prayer that Kagame can heal his people. I will say this, despite USAID signs all over the country, the Chinese are all over Rwanda, laying electrical cable, engineering mountainside roads, investing in agribusiness…

Today’s drive from Kigali to the bordertown of Cyangugu was painless except for the usual money headache. Everyone here wants brand new USD, no tears, no wrinkles, 2006 mint. In Congo, the cash (and you can only use cash) needs to be small, and apparently, now in Rwanda, the USD cash needs to be big. I was ready for small – did not bring any big – inducing a polite, understated, sotto-voce full on caniption from the Rwandan driver about his tiny-tender, brand new USD $5’s fee. Thank goodness the Congolese relay driver had Benjamin in his wallet or I would have been driving halfway back to Kigali to wait for a bank to open on Monday.

Now on my 3rd return to Panzi Hospital www.panzihospitalbukavu.org, this time I am here to facilitate the regional needs assessment for a newly minted joint venture between Harvard Humanitarian Initiative www.hhi.harvard.edu and the Engender Health division of USAID www.engenderhealth.org designed to improve fistula care in this difficult and lately recognized disaster zone.

I’ll leave you with this quote from a 2007 treatise published by Dr. K. Ramsey of the United Nations Population Fund in the international journal of Gynecology and Obstetrics:

“Women in most developing countries still risk their lives and their health in childbirth despite the existence of life-saving interventions (the most obvious being cesarean section). In regions such as Africa and Asia, where approximately 95% of annual (worldwide) deaths occur, at least 20 women experience an obstetric morbidity (injurious complication of pregnancy that does not cause the mother to die) for every woman who dies…. The most devastating of these injuries is probably obstetric fistula, a condition that was virtually eliminated in industrialized countries nearly a century (A CENTURY) ago.”

International Journal of Gynecology and Obstetrics (2007) 99, 5130-5136.

Doesn’t that make you sad and furious and wanting to make it stop? Does me.

(c) 2010 Lauri Romanzi

(c) Lauri Romanzi 2010

Vaginal rejuvention, a mystical term with many facets, new darling of cosmetic surgery and battle cry of the “anti-medicalization of female sexuality” crusade, is a marketing term with no formal medical definition, this despite the American College of Obstetrics and Gynecology 2007 Clinical Practices Bulletin on the topic that was rife with both admonishments against some, and guarded approval of other, procedures advertised under this “VR” label. Some 3 years after the ACOG bulletin, concern and confusion reign on as the definition of vaginal rejuvenation continues to mutate.  

As a reconstructive pelvic surgeon and urogynecologist, I’ve been dealing with “Vaginal Rejuvenation” requests of all types since the term went public. As far as I can tell, the public’s interpretation of vaginal rejuvenation falls into three groups, listed here in order of increasing controversy and decreasing volume of safety & efficacy data:

Procedures to correct prolapse and incontinence

Procedures to alter the appearance of vulvar structures

Procedures alleged to enhance female sexual gratification

For a perspective-setting preview, consider reading this 2009 review of vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, here:

NAFC Quarterly Update Vaginal Rejuvenation & Childbirth Planning

These 2 articles, written for the National Association for Continence quarterly newsletter, dovetail nicely. As it turns out, much of what patients consider “vaginal rejuvenation” has a lot to do with childbirth-related changes in pelvic floor anatomy and function. As a contributor and member of NAFC (National Association For Continence, www.nafc.org), I share this fantastic online resource for information on pelvic floor disorders.  While the NAFC focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing up-to-date information on sex and well being to the public.

THE INSIDE SCOOP ON VAGINAL REJUVENATION

UPDATE 2010

Vaginal rejuvenation is a tenaciously fashionable concept, still with no strict medical definition. Yes that’s right, things vaginal continue to be fashionable. And, as with fashion, much is left to creative interpretation.

For many women, the childbearing, peri- and post- menopausal years come with pelvic, sexual, urinary, rectal or vaginal problems. Vaginal laxity, pelvic prolapse, poor bladder control, vaginal dryness, sexual pain, or waning sexual response can truly affect how you feel about yourself and your ability to enjoy your life. In medicine, we use “quality of life” questionnaires to measure the affect of such symptoms on health‐ mental health, ability to work, play, travel, enjoy sex, and feel normal and intact as a woman. If things aren’t right, you have options. These options, under the newly minted term “vaginal rejuvenation”, continue to spark controversy, raising concerns about safety, efficacy, and medical ethics.

With those options come obligations. Your obligation includes examining your motivations, taking stock of the overall impact of the condition(s) on your quality of life, and obtaining several medical or surgical opinions before you start any therapy or sign up for any surgery.  The doctor’s obligations include sorting out whether your condition(s) warrant physical, medical or surgical therapies or some combination thereof, and to help you understand what the risks, benefits and alternatives are for your personal mix of issues and symptoms.

Vaginal rejuvenation skipped onto the medical stage a few years ago, with no formal medical definition, in response to increased demand for  cosmetic alteration of gynecologic structures, most commonly the labia minora (inner vaginal lips). It has since come to mean any variety of procedures and treatments, many with an established record of use for generations, and others with no established history, little to no safety or efficacy data, and no predictable result.

“Vaginal Rejuvenation” for pelvic organ prolapse, vaginal laxity, and incontinence

Women with vaginal laxity, prolapse or  incontinence  might not know what “prolapse” or “incontinence” truly mean, but all women instinctively understand the notion of vaginal rejuvenation.

For a new mother, vaginal rejuvenation may mean improving pelvic muscle tone, and vaginal snugness with Kegel muscle exercises in a formal postpartum rehabilitation program of biofeedback (think “vaginal video games”) and pelvic floor electrical stimulation. For a 43 year old tennis‐playing mother of 3, it could mean minimally invasive surgery for “exert and squirt” type urinary incontinence (stress incontinence), with “perineoplasty” to restore the perineum (connective tissue between vagina and anus) back to normal, “rejuvenating” bladder control and vaginal snugness to pre‐baby condition. Or uterine resuspension, bladder lift, rectum reinforcement (rectocele repair), perineoplasty and a minimally invasive sling for combined prolapse and stress incontinence – what I call “the blue plate special.”

Vaginal Rejuvenation Traditional Medical Terminology

Vaginal muscle fitness = Pelvic Floor Rehabilitation a.k.a. Kegel Exercise

Lift a dropped bladder = Anterior Colporrhaphy*

Tighten a vagina permanently widened by childbirth= Perineoplasty

**Fix a bulging rectum = Posterior Colporrhaphy

Repair a leaky bladder = Urethral Sling or Urethral Bulking Injections

Restore anal control = Anal Sphincteroplasty

Lift a dropped uterus = Uterine Resuspension, aka Hysteropexy

***”Vaginoplasty” = creation of a vagina (often using  loop of intestine) in a woman born with congenital absence of the vagina, or creation of a vagina in a woman whose vagina is scarred shut from disease (fistula, radiation effect, infection, radical pelvic cancer surgery). More recently, under the marketing concept of vaginal rejuvenation, it has come to mean any combination of procedures from any of the basic three categories (prolapse/incontinence, cosmetic, sexual enhancement) for women without congenital or acquired obliteration defects of the vagina.

*Also referred to as “anterior repair”

** Also referred to as “posterior repair”

***On “vaginoplasty”, in the realm of “vaginal rejuvention” for women born with normal vaginal anatomy, this procedure, commonly attached to the word laser, as in “Laser Vaginoplasty” or “Laser Vaginal Rejuvenation”, carries no description in any medical or surgical textbook or peer review journal.  As of June, 2010, neither “laser vaginoplasty” nor “laser vaginal rejuvenation” are now or ever have been taught in any surgical or gynecological residency training program, nor in any urogynecology, female urology, plastic surgery, or other reconstructive surgical subspecialty fellowship training program. If you want to know about laser vaginoplasty, patient choice is restricted to consultation with a doctor who paid to be trained by the founder of the laser vaginal rejuvenation procedure. These doctors pay a fee to spend several days learning the procedure(s). The fee includes the franchise purchase, after which purchasing physician participates in an exclusive, robust webmarketing network restricted to purchasers of the franchise, the only doctors who may perform the laser vaginal rejuvenation procedures. These franchise-purchasing physicians are under contractual obligation that forbids discussing or otherwise disclosing the actual technique to anyone who has not purchased the franchise, including colleagues or the press. As such, and despite patient satisfaction testimonials on the franchise physician websites, there is no scientific, peer reviewed data in any peer reviewed medical journal documenting the actual technique, efficacy or safety of laser-based vaginal rejuvenation procedures

For some women, “rejuvenate” = “relubricate” (see When rejuvenate = relubricate). Vaginal dryness, poor lubrication and reduced clitoral sensitivity, common symptoms after menopause, are easily remedied with low‐dose vaginal estrogen therapy, treating the target areas without giving your body a full dose of estrogen.

With “vaginal rejuvenation” in the public lexicon, many women with prolapse or menopause-related vaginal dryness or problematic urinary incontinence eagerly seek out a little rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” , “vaginal atrophy” or “incontinence.” For women over 50, the risk of severe pelvic organ prolapse or urinary incontinence are about 5%, and this increases in women who are overweight, or who have birthed children, particularly large babies and long pushing stage of labor.  A recent study of over 3000 women ages 50‐61 showed 6% with symptomatic, high‐grade prolapse.  Some estimates show 50% of women who’ve born children will have variable degrees of pelvic organ prolapse, from asymptomatic to gravely symptomatic.  By 2050, the number of women with urinary incontinence is expected to increase by 46%, and those with pelvic organ prolapse by 55%, with the number of American women with at least one pelvic floor disorder increasing from 28.1 million in 2010 to 43.8 million in 2050.

Whether you call it prolapse repair, incontinence therapy, or vaginal rejuvenation, pelvic floor disorders condition and related treatments (with “laser vaginal rejuvenation” the exception) come with generations of experience documented in medical and surgical texts and reams of data in myriad peer-reviewed medical journals.

“Vaginal Rejuvenation” to alter the appearance of the vulva and vaginal opening

Reduce and remodel inner labia = labiaplasty

Restore the hymen to a virginal state = hymenoplasty or “revirgination”

Reduce wrinking of outer labia = labial filler injections (of fat, collagen or other filler)

Labiaplasty reduces and remodels large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Women requesting labiaplasty reduction and recontouring of the inner labia minora is often  report physical discomfort from labial catching, chafing, rubbing and folding in clothing or with sexual or other vigorous activities like tennis, yoga, running and biking. Women’s current propensity to depilitate all vulvar hair and wear thongs, the ad infinitum wearing of jeans formerly reserved for the under-30 set, intertwine with inevitable yet subtle changes in inner-outer labial consistency and relative size and natural age related vulvar wrinkling, resulting in unprecedented complaints of physical discomfort from this artificially increased labial exposure. I find many such patients adamantly unwilling to restore Mother Nature’s natural labial cushion that comes from full-growth pubic hair, full crotch underwear, and pants that aren’t painted on. I tell every labiaplasty patient every time, and 9 times out of 10, this (self-selected and therefore biased) group opts for the labiaplasty operation over nature’s blueprint.

The role of enculturation cannot be underestimated. On the other end of the labial alteration spectrum, from a region of the world more famous for rite-of-passage female genital mutilation than female sexual gratification, comes the regionally popular central African practice of labial elongation, believed to enhance female orgasm, female ejaculation, and sexual satisfaction for both male and female sides of the coital equation: Rwandan women enhance gratification with \”labial elongation\”

Hymen restoration involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures requiring virginity at the altar, but gaining popularity here in the States from women seeking “revirgination”. This procedure meets with much scrutiny, given the inherent cross-cultural and socio-ethical issues involved.

Labial bulking of the outer labia reduces age-related wrinkling as the body’s youthful fat pads diminish not only in the vulva, but also in the cheeks, hips, extremities and around the joints. These fat pads are well understood by cosmetic surgeons, who commonly plump up  facial cheeks made hollow by age-related loss of facial fat, often using liposuctioned fat from the patient’s own buttocks, abdomen or thighs. Popularized by these same cosmetic surgeons, women with age-related fat pad volume loss in the labia majora reportedly undergo similar bulking filler injections into the labia majora in cosmetic surgery offices.

As with rhinoplasties, lip enhancements, cheek and buttock implants, liposuction and all other cosmetic procedures, these “not medically necessary” labial alteration procedures are not covered by insurance. The physician is obligated to evaluate patient motivations, and to do their professional best to avoid performing them on women addicted to cosmetic procedures or suffering from body dysmorphia, both contraindications to cosmetic procedures.

A woman seeking labiaplasty for severe congenital asymmetry or labia that routinely catch, tear or chafe with sporting or sexual activities are not the same as patients responding to cruel comments from an unworthy sexual partner or insecure because they “don’t look like the women in porn movies”. Labiaplasty procedures are included in surgical texts, with techniques and data published in peer reviewed medical and surgical journals. Much controversy surrounds labial and hymenal procedures, taken as yet another sign of the increased medicalization of female sexuality, with “female sexuality as a newly minted profit center for unethical surgeons and greedy pharmaceutical corporations” as the banner-head under which such protests march. (see Professor Leonore Tiefer)

The controversy rages on, hitting fever pitch with the next category of rejuvenation procedures:

“Vaginal Rejuvenation” to enhance sexual gratification

Clitoral unhooding

G-Spot amplification (a.k.a. the G-shot)

Sub-clitoral bulking injections

This category of VR procedures carry significant risks, with sparse to no efficacy data published in peer reviewed medical or surgical journals.

Clitoral unhooding reduces or removes the skin folds over the clitoris. As an anatomy instructor at Weill Cornell Medical College, I consider clitoral unhooding an inherently risky procedure, given its proximity to the clitoral nerves and the small and vulnerable clitoris.

G‐spot amplification, another “sexual enhancement” procedure involves an injection of collagen or other bulking agent (same fillers used for facial wrinkles) into the front vaginal wall. The theory behind such an injection is to create a temporary (as collagen always absorbs and disappears) bump beneath the Grafenberg’s spot to enhance sexual response.

Sub-clitoral injections underneath the clitoris using filler bulking agents such as collagen or hyaluronic acid are purported to “lift” the clitoris, increasing exposure of the sensitive clitoral glans, allegedly to enhance sexual sensitivity.  This poorly documented procedure continues to flirt around the Upper East Side of Manhattan, offered primarily in cosmetic surgical offices.

Each of these sexual enhancement procedures carries the risk of scarring, pain, infection and numbness. Benefits are unclear, as the miniscule amount of peer-review data currently available used non-validated patient questionnaires administered by the surgeons themselves as opposed to blinded reviewers, and did not include objective measures of nerve function and other measures of genital function and sensitivity.

What say the gynecologists?

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these vaginal rejuvenation cosmetic and sexual enhancement procedures in Bulletin #378,  finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” while reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” the mystery-shrouded, copiously marketed laser vaginal procedures, and clitoral unhooding, until each procedure garners the necessary peer review safety, efficacy, and technique disclosure warranted by medico-ethical standards of clinical acceptability.

For synopsis ACOG bulletin: ACOG committee opinion #378 on cosmetic gynecology

What say the plastic surgeons?

Nothing, really.

from American Society of Plastic Surgeons: ASPS weighs in on vaginal rejuvenation, sort of

There are a number of different vaginal rejuvenation procedures that can be performed by board-certified plastic surgeons. Here, an ASPS Members Surgeon explains the reasons why women may seek out procedures such as this. Learn more about cosmetic procedures.

Note: Some of the procedures and technologies presented in the following videos may be under investigation and presented for research and educational purposes. More scientific study may be needed to determine efficacy and success rate. The American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Educational Foundation (PSEF) do not endorse the procedures or technologies presented nor do the statements of the individual physicians represent the opinions, positions, or recommendations of the ASPS or PSEF.

From The American College of Surgeons, The American Society of Aesthetic Plastic Surgeons and the American Academy of Cosmetic Surgeons: Zero.

Except for ASPS saying “we can do it”, these non-gynecologic surgical societies, whose vaginal rejuvenating members aggressively online advertise cosmetic gynecologic procedures, provide no medico-ethical professional statements for us to consider, despite the widespread adoption of things gynecologic into the plastic surgeon’s arena. This “plastic/cosmetic surgeon as vaginal rejuvenator” phenomenon spawned a competitive explosion in the marketing of “vaginal rejuvenation”, replete with page after page of graphic, genital BEFORE AND AFTER images, something gynecologic surgeons had never previously adopted into office, online or related marketing practice. Given the robust vaginal and vulvar enthusiasm demonstrated by many plastic and cosmetic surgeons, you’d expect their professional societies to weigh in on the ongoing vaginal rejuvenation debate with something more than “we can fix your vagina and we have the images to prove it”  regarding this controversial corner of medicine.

If you’re interested in cosmetic “vaginal rejuvenation”, begin a conversation with yourself about your motivations and perspective: Cosmetic Gynecology Personal Perspective Litmus Test

While doctors, medical societies and health advocates rage on in the debate about what is and what is not acceptable vaginal rejuvenation, each patient is fairly clear about her individual rejuvenation goals. Vaginal rejuvenation is whatever you need it to be‐ Kegel exercise to improve vaginal muscle tone, bladder control and orgasm; vaginal estrogen for lubrication and clitoral sensitivity; prolapse operations to resuspend the dropped uterus, bladder and rectum; perineoplasty to restore vaginal snugness after childbirth; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone, each available as needed to get your pelvic life back on track. The cosmetic procedures to alter the labia or hymen, and to a greater extent, the operations promising sexual ehancement, carry relatively escalated levels of scrutiny due to concerns about the medicalization of female sexuality, and the variable dearth of data regarding both safety and efficacy.

REFERENCES OF INTEREST

Medicalization of Sexuality:

Professor Leonore Tiefer Home Page

Forecasting pelvic floor disorders:

Pelvic floor disorders 2010 – 2050

Labiaplasty technique:

Labiaplasty overview and link to technique monograph

Labiaplasty technique

Clitoral unhooding and mixed genital plastic surgery:

Female cosmetic genital surgery

Multicenter study of female genital plastic surgery

Hymen restoration:

Should doctors do virginal reconstruction for adolescent girls? Cultural considerations cannot be ignored,

Reconstructing the hymen: mutilation or restoration?

Hymen reconstruction:ethical and legal issues

Perineoplasty:

Vaginal laxity and post-perineoplasty images

Perineoplasty in women with sensation of a wide vagina

Combined anal sphincteroplasty and perineal reconstruction for fecal incontinence in women.

Kegel muscles and sex:

female orgasm: role of pubococcygeus muscle

vaginal contractions in female orgasm

The Science of Sex circa 1982

Orgasm mechanics the same in women and men

i need your help. i have problems with fistula, thank you. I am from Kosova.

Hello Kosova,
Fistula is a terrible problem. You will be best served at a University-based medical clinic in urogynecology, urology or colorectal surgery. If you are able to travel to New York, please notify us at contact@urogynics.org or by calling 0012129354343.  Please keep in touch.

Dr Romanzi

Summertime is high season for gardening.  Pregnant gardeners need to take extra precautions to avoid chloasma and melasma (dark blotches) on the face and neck, protect backs, knees and pelvic support, and avoid gardening aids that may be toxic if inhaled or coming in contact with skin.  For the full scoop on healthy gardening while pregnant read this piece from www.sheknows.com, including content from Dr. R:

Gardening during pregancy – your skin, your joints, your pelvis, your baby!

(c) Amy Wentz

Dr. Romanzi, 19 years ago I gave birth to my daughter, and while she was being delivered I was torn from my vaginal opening to my anus. The Dr. didn’t repair the torn skin correctly, and I am very self conscious about this. I also have a very hard time wipeing my BM all the way. Is their anything that can be done for this?

Thank K

Dear K,
Even with correct technique at the time of delivery these deep tears often don’t heal perfectly due to the swelling and hormonal changes in skin and deep connective tissues during pregnancy and delivery that result in less than optimal healing from childbirth tears. That said, it is very likely that your anatomy and function can be restored or significantly improved with reconstructive surgical repair of the perineum (perineoplasty) and/or anal sphincter (anal sphincteroplasty). Sometimes perineoplasty alone is enough. Whether one or both procedures might be advised can only be determined through clinical examination, after which various other imaging and colorectal tests might be advised to determine the optimal procedure(s) for your personal situation. It’s been 19 years! Pull this up to the top of your priority list and get the information you need. Thanks for sharing your story. Please keep us posted!

Dr R

As my colleagues and I prep our data on gender based violence and childbirth fistula  in Eastern D.R. Congo  (http://www.panzihospitalbukavu.org/) for presentation at conferences around the globe in 2010, the words of an African colleague working at another fistula center in Addis Ababa (http://www.fistulafoundation.org/hospital/history/)  continue to haunt all such efforts to end the limitless chaos created by generations of colonization, corruption, lack of infrastruture, self-serving leadership and poor access to education that puts  all Congolese  women in constant danger – “We’ll know we’ve succeeded when we can close our fistula hospital because it is no longer needed”. – see http://www.hhi.harvard.edu/programs-and-research/gender-based-violence/democratic-republic-of-congo for the latest from Lake Kivu. We all look forward to the day that all African women can reap the benefits of the modern obstetrical practices that lifted the bain of childbirth fistula from the lives of  their European and North American sisters in the late 1800s.

Congo Chronicles October 2008 -

Fishing boats at dusk, Lake Kivu, Democratic Republic of Congo

Standing in the middle of a battalion of Chinese soldiers on line at the Rwandan side of the Congolese border, apprehension tickles my belly as I contemplate the active end of the assault rifle resting over the shoulder in front of mine. Sent by Harvard Humanitarian Initiative to work at Panzi Hospital in Bukavu in the conflict-rife Eastern region of the Democratic Republic of Congo, I will myself to stay the course, thus far entailing 17 hours of flight time followed by a 5 hour ride from the airport in neighboring Kigali, Rwanda to the bordercrossings at which I now stand. Everywhere, dozens of troops in fatigues murmur in Chinese dialect.  Chuckling amongst themselves, exchanging cigarettes and places in line, their smug presence is a mystery that remains unsolved for the entirety of my time in this place.   Panic flirts all the way to the front window, with cultural disorientation and unrelenting challenges to personal space my only refuge.  New York-ing my way to the front of the line, the Rwandan customs officer brusquely dispenses me to the second half of this crossing, a 50 yard taxi ride over one rickety foot bridge overstuffed with  heavily burdened pedestrians crossing back and forth between Rwanda and the Democratic Republic of Congo (DRC). 

The road serves as sidewalk to an endless two-way stream of humanity afoot under bundles and burdens of all shapes and sizes- huge bags of mangoes, towering stalks of bananas, all manner of wood, hand pulled carts loaded with stones, school children with books, almost all of which is transported by head – for instance ten 14 foot long stripped sapling trees balanced on the head of a 12 year old, each end extended 7 feet beyond and behind his wafer thin frame. There is no time to contemplate the skill and grace required to maneuver such cargo through a packed crowd of fellow travelers, so distracting is my passenger’s view of the incessant near-contact between the car I’m in and pedestrians passing inches away on all sides- left, right, front and behind.

Safely over the footbridge,  piercing cries outside my car window, rivet my gaze to the sight of a Congolese policewoman smacking away at the face of a local peddler, on whose head perches a bundle of mangoes, again and again and again.  Gun waving in her other hand, the officer smirks at her victim’s unsuccessful attempts to alleviate her wrath.  No one dares help, the stream of burdens and bodies barely stopping to glance her way as she stumbles under the blows.  I cannot breath, cannot look away, cannot speak as she falls to her knees. My car pulls up another 5 yards where the scene disappears as quickly as it came, stopping in front of the muddy wood-framed Congolese customs house- part two of the border crossing.    Following the driver, the dim-lit dirt floored room harbors a table covered with filthy, crumpled Congolese currency being counted by a woman barely visible behind the shoulder-high pile of cash.  Hustled into a back room, my visa and letter of introduction to Panzi Hospital is scrutinized and stamped with flourish, and I am back in the car for another 5 yard ride to the “gate”.  Said gate, a comical 4 feet wide in the middle of an enormous road, is manned by two plainclothes guards, both of whom argue ferociously with the driver as he adeptly negotiates  the impromptu “gate fee”. 

On the short drive to Panzi Hospital, the driver shows me the sites of Bukavu, situated on a five-fingered peninsula jutting into Gran Lac.  Bukavu’s history as boating resort to the colonialist Dutch is difficult to envision as we bob in and out of endless unpaved, deeply rutted roads the color of Tennessee red clay and trundle through enclave upon enclave of wooden shack houses.. Passing an enormous, prison –looking building replete with window bars, I am informed that it is neither prison nor an armory, but rather a bank, a bank without money.  The treasury printing presses, I am told, were destroyed by rebel forces some years ago, and with no new money and no bank security, the bank, open for business, has no business to tend to. This tidbit fails to surprise me, as if all taking place on the other side of a looking glass.  Fifteen minutes on the other side of this glass is all that’s necessary to comprehend the difficulty of everything in the Democratic Republic of Congo.  

All the way to the hospital gate, dozens of mobile phone kiosks spill over with customers between stretches of boarded up shops.  Most commerce takes place roadside, merchandise displayed in neat rows on open sheets of cloth, tarp and plastic.  We dive headlong, no horn, no braking, into endless rivers of pedestrians battling bravely with the occasional private car, overstuffed commuter van or diesel transport truck for the prized sections of flat road. Monty the taxi driver, speaking just enough English to compensate for my utter lack of French or Swahili, barrels inscrutably through the crowds on his mission to deliver the Mzungu (Swahili for white) doctor to her destination. The 5 hour drive from Kigali to the border pales in comparison to the bravado and driving dexterity with which the driver, talking non-stop, wends his way to the hospital itself, where I am to spend the night before beginning the next week’s work. 

Panzi Hospital,  Democratic Republic of Congo, South Kivu

The low, flat buildings of the hospital grounds are a well kept, and tranquil oasis, reminiscent of an empty church on a hot Saturday afternoon, that sudden, soothing presence of something bigger than yourself.  Within the fenced-in hospital campus the generic tenor of suffering is buffered with solace and hope.  Various people live on the grounds, workers and patients.  Female patients with live “in the back”, down a hill in a wooded area of encampment.  There is a large, covered hangar style room with tables.  The women’s clothing is hung on branches and rock piles to dry after laundering.  These are the fistula women and the female war victims. 

Women living on the grounds of Panzi Hospital

My colleague, Dr. Julia Van Rooyen, is gathering gender-based violence data on these victims de guerre as part of her fellowship with Harvard Humanitarian Initiative and it is she who sent me here, to help with the surgical overload created by decades of political chaos and the current brutalization of the populace by competing rebel forces.  In the clinic, the women with childbirth fistula carry medical booklets labeled “VVF” for vesicovaginal fistula, and those of the women with rape-induced fistula are labeled “PTG” for post-trauma de guerre.

VVS = Fistula due to obstructed labor – PTG = Fistula due to rape trauma

Next morning, I am introduced to my colleague Dr. JeanBaptiste Yunga, a relentless, wiry thin surgeon with impeccable skills and compassionate work ethic to match. This place, perpetually short on supplies, is run as efficiently as any military operation. Sutures that are used for one knot in the States are used to close an entire incision here. The Panzi Hospital turn-over time between cases is minutes – back home, halves of hours, often more than one, are spent waiting for the lumbering paperwork beauracracy to move the patient from waiting area to operating room and then finally to rest on the operating table.  Here there is no such thing as informed consent – just patients who want to be dry, want to be normal, want to go home again, trusting the doctors and staff to make it happen for them.  We operate – fistula upon fistula, story upon story, one blending into the next til the surgical technician declares the list finished, the day over, and it’s time to go home. And you wonder, you hope, you imagine, that you made a difference, even the tiniest dent, in this tsunami of suffering.

 Dr. JeanBaptiste de Yunga, center, and the Panzi Hospital OR team

 Welcome to DR Congo.  This central African country is the former Zaire and the current site of extensive, complicated rebel activity, Interhamwe, Mai Mai, and interminable political gang rivalry, that predate my arrival by many years, all of it brutal. Beyond imagination- men, women, and children routinely suffer the most heinous of atrocities for reasons that seem to have only one common underpinning- utter chaos makes for more profitable rape of the land itself- a legacy harking back to the Belgian colonialists. With avocadoes, bananas, and mangoes dripping year-round from every tree, Democratic Republic of Congo is truly The Garden of Eden meets Hell on Earth. 

 Apparently, the rebel forces, and there are several in this unclean fight- residual ex-pat Rwandan rebels known as the Interhamwe, Congolese in-fighting between fractious camps with presidential aspirations, and skirmishes triggered by global industries devoted to demineralizing the landscape for obscene profit margins, are particularly fond of the weapons available under the umbrella we call “sexual trauma’.  Women, men, children, raped, mutilated, held captive for months, some for years, “tending” to the rebel camps in slavery, subjected to physical and psychological carnage that would make Caligula pause. 

The stories terrify.

Women made to cut out the unborn baby of a live village-mate, leaving the mother to die as they are forced to cook, and then eat, said baby while the rebels taunted and beat them- parents made to watch as their children’s fingers were cut off, knuckle by knuckle, bleeding to death slowly, eviscerated at the last minute, dogs attacking the fresh intestines, as the parents were hauled into the bush to serve the rebels for months before they escaped with only their unimaginable story to show for it.  And rape, all sorts of rape, if you can imagine it, it’s been done to these people, and by people I mean everyone – the sexual mutilation is not restricted to women. My third morning, as I inhale a mandatory morning coffee and hover over a precious few minutes access to the unreliable internet, a query unlike any other interrupts my focus: “When a man’s penis is cut off, does that make him stutter?”  Distracted, I lift my gaze to meet the wide-eyed Brandi Walker,   red-headed, cracker jack American administrative coordinator. Hailing from the backwoods of Georgia with masters degrees in English and Public Health and a fierce devotion to the women of Eastern DRC- I ask her to repeat, and so she does.  “You know, if man’s penis is cut off, can it mess with his voice?  Make him stutter?  Can it affect the coordination of his tongue, make it hard to form words? A local man just burst into Dr. Mukwege’s office – he’s been walking for days, escaped from the Interhamwe.  They cut off his penis.  He couldn’t get his words out. He was shaking all over and no one could understand him.  So I was wondering, is there a connection?”  Apparently, male dismemberment is one of the latest trends of these self-proclaimed warriors, and I am told that most of those who do not perish immediately from the mutilation go on to commit suicide.

But I am not there to re-fashion dismembered penises, I am there to fix fistulas.  Childbirth fistula, the bain of women since time began, is a hole, an abnormal connection caused by a wearing away of skin and connective tissue that separates the bladder from the vagina (vesico-vaginal fistula) or between the rectum and vagina (rectovaginal fistula). 

Fistula due to obstructed labor in childbirth was a problem of Europe and North America too, until the advent safe anesthesia in the late 1800’s and the discovery of penicillin in the 1940’s turned cesarean section from a last ditch effort to save a baby from the belly of a dead mother into a routine procedure, single-handedly plummeting maternal mortality and obstructed labor-related vaginal fistula rates to near-zero.  New York City was host to the world’s first Fistula Hospital, located on the site of the Waldorf Astoria on Park Avenue until it was rendered obsolete by the advent of modern obstetrical practices.

In many poor nations lacking in civil infrastructure and modern medical care, the likelihood of dying as a result of pregnancy is no different than it was in 1800, as high as 1 in 7 pregnancies.  In Europe, North America and other wealthy regions with double-digit cesarean section rates, this child-bearing related death rate is 1:400,000 – an obscene difference beautifully exposed  by Dr. Lewis Wall, Director of the Division of Urogynecology and Reconstructive Pelvic Surgery at the Washington University School of Medicine in St. Louis, MO and Founder of the WorldWide Fistula Fund.  It’s simple, really.  In our natural state, babies tend to get stuck in labor, such mothers may die, stuck babies die, and women who don’t die from such labors where the baby is, literally, “stuck” in the soft-tissues of the vagina for days on end, survive the nightmare only to birth a dead baby and find themselves constantly leaking urine, feces, or both through the vaginal fistula holes located where normal healthy vaginal tissues used to be. 

A lucky, 18 year old fistula mother – her fistula was reparable and her baby survived.

A history professor once impressed me with the fact that resistance always starts in the lap of oppression, where to my naive mind it made the least sense.  I thought that the people in the safest areas with the most resources should recognize exploitation and iniquity in whatever form – slavery, racism, corporate corruption, caste systems, child prostitution, whatever – reaching out from their positions of privilege and strength to end the suffering of those less fortunate.  To  understand why the Civil Rights movement started in the deep South, why Toussaint L’Ouverture battled decade upon decade until the people of Haiti were freed to create the first black Republic in the Western Hemisphere, and years later, why the Berlin Wall had to come down from the inside out, not the outside in, remains one of the highlights of my formal education.  

And no less inclined to seek its own solution is this place, where the rebels are the oppressors and the indifferent are the government leaders of Congo, neighboring Rwanda and the world-at-large. This seed of resistance comes in the form of Dr. Denis Mukwege, a Shaquille O’Neal-sized son of the Congo, born in Bukavu, a few miles from this hospital in Panzi.

Dr Denis Mukwege  www.panzihospitalbukavu.org

Standing like an elm tree in a hurricaine, Dr. Mukwege , champion of his people, holds fast to his boyhood home with its memories of water skiing and international visitors coming to the lakeside resort that Bukavu used to be.  Now, the post office is inhabited by feral chickens and homeless families and his boyhood school sits abandoned on the point of a cliff overlooking stunning, and empty, Lake Kivu. 

I’ve worked in other fistula repair centers, but this is different.  Yes, as in other fistula-prone places, there are women from villages who speak their native tongue only, no French, no English, no reading, no knowledge of anatomy, no clue that the fistula is not their fault and not the results of evil spells.  But here in Bukavu, where all manner of NGO (non-governmental organizations) and UN Peacekeeping Forces cruise around in LandRovers and the unpaved roads turn to torrential rivers of mud during the daily downpours of the 9-month rainy season, the burden of conducting normal daily functions requires a resilience and fortitude that I’ve encountered in no other place.  If you can make it happen in DR Congo, you can make it happen anywhere.  Sorry, Frank, but this place makes Niger look palatial, and compared to New York?  Fuggedhaboudit.