Obstetric fistula repair and general medicine in Niger
As I stepped off the plane in Niamey, the dusty air caught the back of my throat and I began to cough. The hot sand blowing from the Sahara is one of the most certain features of the place, leaving the capital of Niger in a constant yellow hue. Another sad feature has been Niger’s lack of economic prospect - landlocked and with no substantial natural resources it remains one of the poorest countries in the world. With the highest rate of fecundity in the world but also the highest rate of infant mortality, it is unsurprising that the average age of a Nigerian is fifteen years of age with an average life expectancy of fifty-three years (1). With famines looming every year, it is a country that has suffered intensely over the last few decades.
From my perspective, it seemed an ideal place to push me out of my comfort zone and experience how medicine is practised in the more seldom visited regions of the world. I was able to arrange an elective which allowed me to work in two hospitals run by the Christian organisation SIM (Serving in Mission). The first was a general hospital in the small village of Galmi a few miles north of the Nigerian border and a six hour drive east from the the capital, Niamey. The second, Danja was further to the east near the large town of Maradi. Danja initially specialised in leprosy but more recently has started to develop into a fistula repair centre.
Galmi hospital: Tropical Medicine 101
Fig 1: Paediatric patient being rehydrated
A week after passing my oral examinations, I was sat in an office with another doctor, as we both went through half a dozen patients at a time. Each patient would give us their story in Hausa - sometimes with the help of other patients in the room - and we would try to make a diagnosis and come up with a management plan knowing that the patient would not be able to return next week to be reviewed. A lot of the illnesses I was confronted with were new to me: Pott’s disease, Histoplasmosis, Noma and Burkitt’s Lymphoma all passed though the clinic along with the more regular ailments of malaria, typhoid and HIV/AIDS. Meningitis and malaria were the main reasons for admission - illnesses I had never seen in the UK- I rapidly learned that spleens were no longer a cursory organ you would look for in an abdominal exam and that lumbar puncture was a crucial skill to acquire. With some help I did my first lumbar punctures as I struggled with the litres of sweat pouring out of every pore in my body - a combination of stress and heat. Invariably a turbid fluid would drip out and we would start the patient on heavy doses of IV antibiotics. Sadly not all these patients survived and the first patient I admitted with meningitis died. Death is not an uncommon sight in Galmi and it is treated with a quiet dignity amongst the Hausa people - there is no open expression of grief as we would expect in the West. The patient's family wash the face of the departed then rapidly disappear with the body without a word of complaint.
I then moved on to work in paediatrics with Dennis Schellhase, an American professor of paediatric pulmonology. His speciality was Cystic Fibrosis but this is very rare in Africans - in his time in Galmi, he had never seen a single case. What he did see plenty of was malnutrition and dehydration - the daily clinic would see us admitting child after child in various states of dehydration. However, the simple act of admitting was socially complex - the mother who most often came with the baby would have to get permission from her husband who may have been over the border in Nigeria working. If he was unavailable, it would then be a member of the husband's family who would decide if they would accept the admission. If a mother made this decision without permission, she was at risk of being divorced. Often, we would see a barely living child being taken for a long bus trip unlikely to make the journey there and back so the mother could make sure that she could have the child admitted for life saving treatment.
Danja hospital: fistulas and leprosy
When I moved to the second hospital in Danja, I was confronted with the issue of obstetric fistulas. Seldom seen in the UK, it is estimated that around two million women in sub-Saharan Africa and Asia suffer from this condition (2, 3) although the real number may be much higher. The United Nations Population Fund (UNFPA) in 2003 decided to launch a campaign to end obstetric fistulas. The main cause of obstetric fistulas is obstructed labour which is not rapidly relieved by a C-section (4). Typically in many Sub-Saharan countries obstetric provision is limited to the largest towns only. Added to this, there is the issue of marriage at an early age and malnutrition, both of which make the pelvic outlet smaller and the likelihood of obstructed birth higher. The fistula forms as a result of ischaemia to the perineal tissues during and after a lengthy or impacted birth. When the fistula has formed, these women become incontinent of urine or faeces via their vagina, making them social outcasts from their community. With often no means to provide for themselves, they often become destitute with no source of income.
I was able to work alongside the Worldwide Fistula Fund (WFF) - a charity set up specifically to address this need (5). Dr. Steve Arrowsmith has been doing fistula repairs in Africa for the last two decades and helped found the charity. Danja is to be a pilot project for the charity – they were doing a second run of repairs looking at the logistics of expanding the project with a new wing still being built whilst I was there. The patient age ranged from thirteen to over fifty – the majority of them receiving a vesicovaginal fistual repair. The thirteen year old girl's story was sadly not unusual – she could not remember ever having had a period before she was pregnant a year ago. The baby had died in obstructed birth and she had been left incontinent. Her husband immediately divorced her and she had travelled miles to Danja alone where she had heard she could have a fistula repair. Sadly, she suffered post-operatively as well as was struck down by a severe bout of malaria, dropping her haemoglobin dangerously low. Thankfully, she made a full recovery after transfusion of blood and treatment with antimalarials.
The surgery itself costs less than £300 yet the change it makes to patients life is inestimable. None of the patients would have been able to afford the surgery and the WFF depends heavily on donations to continue providing these operations for free. The challenge of making obstetric fistulas history is a great one and providing fistula repair is only part of the solution. The issue of early marriage has to be addressed by the government as it is a major cause of obstetric fistulas in Niger. Provision of adequate obstetric infrastructure and educating the population to seek rapid referral to these services is also crucial for prevention but it seems unlikely that all the necessary changes can be easily achieved in the next 20 years. With sufficient funds and more public awareness of the plight of these women, we may at least start to see a decline in the incidence of obstetric fistula.
Fig 2: Hospital staff and patients after the fistula surgery
Return to the UK
When I returned from Niger, I took me a while to adapt to life as a foundation doctor. Gone were the stoic Hausa people - in exchange I had to deal with social admissions, functional disorders and chronic management of the excesses of Western culture. Niger is not exactly an easy option for an elective and I often struggled to deal with the sheer poverty of everyone around me but the Hausa sense of humour a helped me get through it all and allowed me to see the brighter side of life on the edge of the Sahara.
Hopital de la SIM, Galmi, BP 44, Madaoua, Niger; www.galmi.org
Hopital de la SIM, Danja, BP 121, Maradi, Niger;
Niger is mostly an Islamic country but SIM is a Christian organisation which has been working in Niger for over 60 years now and is well respected within the local community.
Visa and travel:
Air France and Royal Air Maroc fly into Niamey via Paris and Casablanca respectively. Travel inside Niger can be done overland by bus which is very cheap. Visas for Niger have to be obtained in Paris as there is no embassy in the UK. Flights cost around £500 return. Buses cost less than £10 to cross the country.
Very hot especially from March to May. Expect 50 degrees Celsius on a regular basis. Malaria prophylaxis and meningitis vaccination is thoroughly recommended. Yellow fever vaccination is compulsory and has to be done before you apply for the visa.
Niamey will have stocks of everything (at a price!) but once you leave the major cities fresh food can be very hard to find especially if there is a drought.
Fluent French will be useful, Hausa however is often the only language spoken by the patients. English will not get you very far at all.
The area of Agadez was once the main tourist destination but, due to Al-Qaida operating in that area, it is now off limits.
1. International Human Development Indicators - UNDP [Internet]. Available from: http://hdrstats.undp.org/en/countries/profiles/NER.html
2. UNPFA. Campaign to End Fistula: The Year In Review. UNPFA; 2009.
3. Kelly J. Vesico-vaginal and recto-vaginal fistulae. JRSM. 1992 May; 85(5):257-258.
4. Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv 1996 Sep; 51(9):568-574.
5. Kristof ND. A Heroic Doctor, a Global Scourge [Internet]. Available from: http://kristof.blogs.nytimes.com/tag/worldwide-fistula-fund/