Survivors

**This post will have medical terms and opinions about sensitive topics so if you are squeamish about medical things or strong opinions maybe you want to sit this one out**

They call the fistula patients the survivors because anyone who has endured more than they have found death in relief. Today I sat in awe of an 18 year old girl who spoke no word of English or Swahili but had more courage and strength than any girl of that age should be asked to have.

She was probably ten years old when the women she trusted in her community took her to a hut somewhere where they held her down most likely screaming and afraid with no anesthetic in dirty conditions. Here some half-blind elderly woman cut off the "offensive" clitoris and inner labia and sewed her shut. There would be no doubt when she was sold off to her husband, probably far older than her, that she was virginal when the whole village heard her screaming night after night as he ripped her open. Out of that trauma came the blessing of a pregnancy. Just a baby herself but finally her womanhood had given her something to smile about.

This smile would not last long as she would be forced to labour at home. The village she lived in too remote to easily get to a hospital and deeply rooted fear that doctors would cut her open and her relatives would not be able to pay for even in the public hospitals medical services cost more than most people can afford. Finally after labouring and convulsing for more than three days the people of her village take pity on her as she looks so unwell. The girl was taken to the nearest hospital where her blood pressure was 220/110, she was unresponsive with a GCS of 5/15, a temperature of 39.5 and purulent drainage from where the baby would not come out. The baby would not come because the baby had already died long ago from any one of the complications this poor girl had endured: obstructed labour, eclampsia and sepsis. For some reason in East Africa most places will do an emergency Caeserean section for obstructed labour, probably because they cannot stomach the other option. After all that this poor girl endured the Caeserean complicated the fistula she was probably already developing from obstructed labour and as she left the operating theatre urine wept through the cervix that wouldn't allow her baby to come out.

I met this beautiful girl in VVF (vesicovaginal fistula) clinic where she stated that she wasn't leaking but that she had trouble holding her urine if she needed to go to the bathroom. When she had been seen immediately after delivery, after she recovered from the brink of death from all the other things trying to take her into their fatal embrace, she was told that she was to wait for 2-3 months to see if maybe it would heal on its own. This is a survivor, a champion, told to try to do something on her own. Well she has already proven that she can do anything. She tries the local herbs the traditional healer tells her to use causing inflammation in a place that has already endured too much and she begins to be able to hold her water in a place it just shouldn't be. Finally we press to examine her to make sure everything is as good as she claims. When she gets on the examing table the urine pours out of her in betrayal. We tell her and her uncle that we can fix her the next day and they smile gratefully.

We came to the hospital in the evening today because that was the earliest we could get time and people will come in the dark of night to help these brave women. The sky was a dark grey and the skyline looked like a charcoal painting as we took our instruments out of the car to the awaiting nurses in the theatre. I saw her there without her hajab and she looked even younger than she had the day before. I asked her "Habari?" ("How are you?") and she answered with the only Swahili word she has learned "Msuri" ("Good") with a smile. She sits there on the operating table, her small 5'2'' frame bent in half as she receives a spinal anesthetic not able to communicate with any of the doctors or nurses in the room. She just boldly enters this world hoping to be rid of this constant reminder of that agony. As we put her in position we see her mutilated vulva, a perfect line where her clitoris should have been, intact and pristine and almost mocking all the disasterous consequences that followed. The skilled hands of surgeons who have married their work seperate the post-traumatic embrace of this girl's bladder and cervix allowing her to have some quality of life in her village - not reaking of her shame. Her surgery went well - in fact when asked to cough to test the bladder repair she did it with gusto! Hopefully she will come to hospital when she gets pregnant again as she will have to have another Caeserean section - this her village will blame on the doctors instead of on the mutilation done in the name of chastity. I know she will do well but I also have to think - how did it get to this point? How are women having to endure so much pain and suffering? We have to do better.