Delivering Hope in Somalia: Doctors Continue to Treat Fistula in Harrowing Conditions

NAIROBI, Kenya — Though political instability, violence and chaos surround them, surgeons and backup teams dedicated to ending the misery of obstetric fistula continue their work in Somalia. The gratitude of their patients keeps them going in the most desperate of situations.

For instance, Dr. Saidkasim Sakhipov, of UNFPA, the United Nations Population Fund, recalls the sheer joy of a 61-year-old Somali woman who underwent a successful fistula repair.

“She told me ‘Can you imagine for the last 31 years, I could not pray because I could not do wudu (Islamic ritualistic washing before prayer)’.”

Because they cause incontinence, obstetric fistulas often leave women isolated not only from spiritual comfort but also from their families and friends. Women with the condition are often ostracized, removed from their homes and shunned by their communities because of their ‘uncleanliness’ and the smell that they are often unable to prevent. It is the satisfaction of restoring women’s sense of dignity and their place in the community that keeps the Campaign to End Fistula going in a place like Somalia, a country wracked by disorder, chaos and strife.

In Somalia, and its semi-autonomous states of Somaliland and Puntland, doctors and staff operate in harrowing conditions. It is hot, windy and dusty, with temperatures soaring towards 45 degrees Celsius (113 F) at times. The country has been in political upheaval since 1991. A fledgling government is struggling to cope with intensified armed attacks by different insurgent groups, an influx of foreign fighters, assassinations, serious injuries to innocent civilians and officials, more than 100,000 internally displaced persons and a battle for control of the capital.

Operating on the fly

Due to the security situation, UNFPA staff, including those working on the Campaign to End Fistula, are working from offices in both Somalia and Kenya. Nearly every month, UNFPA officials hold discussions with Government and NGO representatives in Somalia on progress in implementing the fistula programme. In this context, a UNFPA team recently undertook a technical mission to Puntland. Although it has gained notoriety as the launch pad of pirates, Puntland offers some stability, as does Somaliland.

In Somaliland, operations are performed by local physicians Dr. Ibrahim Saeed Qaws and by Dr. Abdulrahman Ali Mohamed who was trained with support from UNFPA. In Puntland, Dr. Abdulcadir Giama, an expatriate surgeon who travels from Italy, performs the operations. A staff of a dozen nurses and anaesthesiologists support the doctors in their efforts.

Under the harsh conditions, each doctor is able to perform about two fistula repair surgeries a week. In a country where everything else is falling apart, those surgeries give the women the chance to build back their lives. Still, with some 70 to 100 new cases each year, a substantial backlog of women needing treatment persists.

Rebuilding lives

The story of one young, Somali woman who travelled to Puntland to undergo surgery with Dr. Giama is typical. After struggling for more than five days in labour with a traditional birth attendant, she lost her baby. Then, the 18-year-old woman noticed she could no longer control her urine. Luckily, she heard about the centre and was able to make the trek for treatment. When a girl gets married in Somalia, the groom gives her father yarad (dowry). The young woman now believes that the yarad should be awarded instead to the doctor who gave her back her life.

She was one of the luckier survivors. Most of the women living with fistula remain silent and unseen, hidden away in tents. They are often the poorest of the poor, young and often lacking an education. In Somalia, the common practice of female genital mutilation/cutting compounds the health risks of delivery for women. Many of the women are also nomadic, which means their access to skilled medical care is transitory. In any case, the government is not strong enough to provide a functioning health system that can prevent fistulas by providing better obstetric care.

The long road to hope

UNFPA has been working in collaboration with the Coalition for Grassroots Women Organizations, a women’s NGO which managed to transfer 15 patients from camps for internally displaced persons in Mogadishu to Galkayo Medical Centre in Puntland. The journey is arduous and takes two and half days to travel by road in a rented minibus. It is further complicated by the fact that the women must navigate through the treacherous zones of the South/Central regions of Somalia that are controlled by different groups of insurgents.

In these regions riddled with violence, women continue to deal with the vulnerabilities that are part of their reproductive lives. In an environment with few laws, sexual violence is often used to humiliate and further devastate enemies. Brutal sexual assault can lead to traumatic fistula, which requires psychological counselling as well as medical care.

The climate has not made the mission any easier. A serious drought in several parts of Somalia is feared and people are losing their livestock and cattle, the mainstay of their livelihood. The economic crisis has meant a decrease in remittances from abroad that many Somalis rely on.

“Since 7 May, the situation has deteriorated,” said Dr. Sakhipov, referring to the renewed insurgency attack on Mogadishu. A surgeon by training, he has been in Somalia intermittently since April 2007, and is carrying on with the mission, one day at a time. “You never know what will happen tomorrow,” he said.

— reported by Rohina Phadnis