From Fistula Treatment to Healthy Communities

Heidi Breeze-Harris

A preventable, treatable injury sustained in childbirth, fistula is a “canary in the coal mine” — an indicator of failing health systems and an indicator of places where civil societies are deeply failing women and girls.

Two million women in the developing world are suffering from a debilitating childbirth injury that was virtually eliminated in the United States in 1895. That injury is obstetric fistula.

If perchance you didn’t know about obstetric fistula before reading this issue of Rewire, you are not alone. One of the hallmarks of this terrible injury is that it goes largely un-discussed and women who suffer do so in isolation.

So what is fistula? A fistula is a hole in the body where it does not belong. In this case the hole is caused by an obstructed, unrelieved labor that can last as long as five days. This traumatic labor most often results in the death of the baby (in 90% of cases, according to the Campaign to End Fistula) and the mother is left with a fistula, or a hole, between her bladder and the outside world through which she will leak urine and sometimes feces, uncontrollably, for the rest of her life unless she is treated.

This woman, who has lost her child, now soaks her mattress and clothes with urine and waste. She smells. Sometimes she tries not to drink so the liquid will stop coming. She is sometimes told this labor was somehow her fault. She may have nerve damage in her legs making it difficult to walk. Often she can no longer work. And without treatment she cannot bear more children. Sometimes she is discarded by her husband — these women live in shame and isolation the likes of which we cannot imagine. They are usually unable to board a bus and they are afraid to take communal meals for fear of bringing shame on their families. To say fistula robs them of their dignity is a gentle way of saying it robs them of living. Victims of fistula can be as young as twelve years old. But no matter at what age a woman gets a fistula, without treatment her life is no life at all.

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The Good News

And yet as horrifying as fistula is, it is treatable and preventable. Fistula is an injury, not a disease. This is not a matter of whether fistula can end, it is a matter of when. The Waldorf Astoria in New York City now stands at the site of the last fistula hospital in the United States. Except in rare cases, fistula is a memory in the developed world. And it can be made a memory everywhere.

To treat one woman with fistula costs an average of $300 — a bargain for a life returned. Treatment consists of physical therapy followed by a surgical procedure that takes from one to seven hours on average to perform, and then proper post-operative care, rest and further physical therapy. The full process helps women ultimately become “dry,” or able to hold their waste without leakage. Approximately 90% of women with fistula who get surgical treatment are cured.

One By One, the organization that I co-founded and now run, works toward the elimination of obstetric fistula worldwide by engaging the public and providing financial support to those who treat and prevent fistula in the developing world. One of our current grantees is the Bugando Medical Center’s Fistula Project (BMC) located in Mwanza, Tanzania. Philomina Marko was treated at BMC in 2007 for a fistula she sustained in 2002. Her story, following, speaks volumes about this tragic condition and the amazing transformation that a relatively inexpensive surgery can provide. Philomina says,

“I am 28 years old and I live in Nyakahanga, a village in western Tanzania near the Ugandan border. On March 15, 2002, I went in to labor with my second child.

"I had my first child when I was 18 years old. Everything went smoothly and so my parents and mother-in-law saw no reason for me to deliver my second baby in a hospital.

"I labored at home for two days, until I was too exhausted to continue. When my family realized that my life and the baby’s life were in danger, they collected the money to take me to the nearest hospital three and a half hours away. I was rushed to the operating room where a doctor took out my baby. My son, Joseph, is alive and healthy thanks to this surgery.

"When I returned home, I knew something was wrong. I couldn’t control my bladder. I was scared of what my family and people in my village would say, so I tried to hide the leaking. I did not understand why this was happening. It was a very lonely and sad time for me.

"Then one day, I was listening to the radio and I heard about fistula and the Bugando Medical Center. They said I could get help there. I begged from family, friends and neighbors until I had the 25,000 Tanzanian shillings ($20) for the trip. It took me five years to save enough money to make the journey to Mwanza.

"When I arrived at the Bugando Medical Center, the doctors fixed my fistula and the leaking stopped. They were very kind to me, they even gave me money so I could travel back to my family in Nyakahnga Village.

"Before I left, I told the nurses ‘You work very hard here, and people are cured. I will go home and tell other women so they have a chance to be healed too!’

"I am looking forward to being back in Nyakahanga with my husband and my two children, and living without this terrible injury.”

Fistula – The “Canary in the Coal Mine”

As Philomina's story demonstrates, treatment is critical and valuable and must continue for women who have fistula. And yet, treatment is not the path to ending fistula for all women, everywhere. Fistula is a “canary in the coal mine” — an indicator of failing health systems and an indicator of places where civil societies are deeply failing women and girls. To end fistula the prevention strategies must include medical and social and economic programs.

Some medical prevention strategies include more ready access to emergency obstetric care, maternal waiting centers near properly staffed and supplied clinics, training for skilled birth attendants and the community-based education to help those attendants attend more births. One of One by One's grantees, the Campaign to End Fistula, (a program of the UN Population Fund) is the largest fistula treatment and prevention organization of its kind, working in over forty countries worldwide. The Campaign specializes in many of these strategies.

One By One echoes our colleagues at the Women’s Dignity Project (an important fistula organization in Tanzania) in saying that poverty and the concomitant social issues related to gender equity are root causes of fistula and need equal attention if we are to truly see the end fistula.

The status of women and girls simply needs to go up. Girls need to be able to eat more – literally consume more calories – to help their bodies from being stunted. Girls need to do less hard labor such as fuel and firewood gathering which readily consume the few calories they do eat. Girls need to go to school and marry after age eighteen. Our friends at the International Center for Research on Women are working on an important piece of federal legislation on funding for programs that would help prevent child marriage. Just absorb this striking statistic — 100 million girls will marry before the age of eighteen in the next decade (see Rewire's previous feature series on child marriage.) From the perspective of fistula, this statistic matters because when girls marry young, they begin childbearing earlier. When they begin childbearing earlier their chances of dying or being injured, including getting a fistula, go up significantly.

Statistics show that keeping a girl in school is the most successful way to keep her from early marriage and thus early childbearing. With this education her chances for survival go up along with her economic prospects. As an added bonus, some schools offer feeding programs so the girls’ body will be nourished alongside her mind. There are only added bonuses to keeping girls in school.

Girls and women need access to voluntary family planning and the gender equity to feel safe with that access. Equipping women and girls with voice and choice about the size of their families and the spacing of their children could literally save the lives of countless women and children. Re-funding the UN Population Fund so that they can continue their important work on voluntary family planning and gender equity would be a huge step for the United States since its de-funding of UNFPA in 2002.

From Treating Fistula to Healthy Communities
In Swahili there is a word for pregnancy that means “carrying death.” In Chad a local proverb says, “A woman who is pregnant has one foot in the grave.” Add to that the statistic that one woman is dying in pregnancy or childbirth every minute of every day for a total of 529,000 women a year — dying of entirely preventable causes. One can begin to feel where these proverbs come from — the grim reality of childbearing in the developing world.

Women with fistula are the ones who survived their harrowing childbirth experiences. But not without a cost and not without reminding us of the tragic experiences of both the dying and those who are left behind, injured and devastated.

Fistula is an indicator of where motherhood is not safe. And where motherhood is not safe, nor is womanhood nor girlhood. One By One sees treating women with fistula as a step on the road to preventing fistula, which is a step on the road to safe motherhood, which is a step on the road to gender equity. The final destination we foresee is a world where women and girls and men and boys, together, bring their gifts to creating healthy communities. One By One is proud to be even a small step on this road that, with great community leaders, is becoming more and more traveled every day.

Thank you to Philomina Markos and the Bugando Medical Center Staff for sharing her story and picture.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.