There are many moments—mostly while studying for two biology exams over
Winter Carnival or going to lab on a Friday afternoon–that I reconsider this
lifelong interest in pursuing medicine. In the depths of Dana or while watching
the sunrise yet another morning, it just doesn’t seem worth it to be pre-med.
However, I find that every time I actually go into a hospital or work with
health issues, the excitement, the interest, and discussion that stems from
those experiences is unparalleled to any other field of study I have ever
pursued.

This past week, I have been working with a volunteer nurse from Canada on
the health coordination for One!’s school in Nallasopara as well as helping
with health check-ups for all the kids in the Khar and Nallasopara schools.
Another volunteer and I created all of the health folders for Nallasopara over
the last couple of weeks since they do not have a medical program there yet.
The children all get quarterly check-ups, but in this case we were triaging
those children that needed the most attention and could be given the care
immediately. For example, although getting a follow-up TB test is important,
the nurse did not have a test kit with her. Therefore, we looked at kids who
had dermatology problems such as fungal infections because that was an ailment
the nurse could immediately take care of with ointment or a prescription. In
rural medicine, you find that what we would think of as the most pressing
issues are not always the first ones attended to by health professionals. A lot
of that has to do with availability of resources, practicality of care, and in
some ways picking and choosing what to “heal.”

In addition, the nurse, Juniper, and I are training a community member with
no prior healthcare experience to be the new medical coordinator for the
families that live in this village (which includes writing down patient names,
deciding who needs to go see a doctor, doing follow-ups, and going with
patients to the doctor and asking questions on their behalf). I have mainly
been creating assessment sheets and questionnaires while the nurse does the
actual check-ups.

It’s been a challenge communication-wise because the nurse speaks English
and the medical coordinator speaks Hindi/Marathi and barely any English.
Because I speak all three and the coordinator feels comfortable speaking with
me, I have been serving as a translator between them.

Having gone on medical brigades and trips before, I am well versed in how to
conduct a check-up. However, I have never served as a translator before so this
task has been challenging for me. On Wednesday, I walked into the make-shift check-up area in the Khar school and immediately had one of the mothers start talking to me about her illness. Part of my research is to speak with families and gather “illness narratives” —-because I have found that the members of
this community start any story or complain about an illness with what they ate
or didn’t eat. Therefore, food has become the crux of any health story I have
ever heard in this community. It’s fascinating for me from a general health
perspective as well as thought-provoking data for my research study. For about
four hours, I sat next to the patients translating between them and the nurse.
These patients speak over three different languages and all of them have
various village dialects that are very hard to understand.

Essentially it was the nurse asking them a question in English, me
translating that into Hindi or Marathi, the patient replying, and then again
translating what they said into English. One of our last patients was a young
mother, about 18 years old with a one year old baby. She spoke Gujarati, which
I do not speak or understand. So this time the translation was from me to her
brother who spoke to her and then translated for me and I told the nurse. If it
sounds confusing—-it was like trying to put together a story from the
viewpoints of three different people. I often had to stop for a minute to make
sure I was making the correct translation and clarifying idiomatic phrases.

This young mother was not eating enough and therefore not producing enough breast milk for her baby. She told me she was eating only once a day so she could save the money her husband made. Her brother, the nurse, and I all tried to explain to her how important it was to eat 2-3 meals a day, if not for her—then for
her baby’s well-being. It was frustrating to see her just smile back blankly. I
felt as if everything was going in one ear and out the other.

And if that was not stressful enough, we had one mother who had sores on her leg from rat bites. She said they hadn’t healed for months and oozed pus every once in a while. When I asked her to show the nurse so we could clean them, she
shied away saying she didn’t “feel good” to let the nurse see her legs.
After some coaxing from me in the sweetest Marathi I could muster, she showed
us and then proceeded to tell me that she took a small butter knife and Dettol
(a brand of antiseptic) and scrubbed her legs raw every week. Upon here the
word knife, I didn’t even translate for the nurse before scolding this woman. I
got flustered and forgot that I was just supposed to be observing. However, imagining someone taking a knife to a wound just made me viscerally react.

And if that wasn’t enough excitement for one day, her son, Saif came in with
white jelly-like material covering both of his eyes. The nurse initially thought it was some bacterial infection, so we gave him a follow-up appointment but we both kept thinking about it after work. That night in our apartment we were going through common eye disorders on the internet and read symptoms on something called xerosis.

Xerosis is an abnormal dryness of the eye in which there is less secretion
from the membrane. Often, the cornea’s luster is reduced. If you looked at
Saif’s eyes, they looked like craters because his cornea was sunken in slightly. In addition, you could see small triangular spots near his pupils. You may be wondering what causes xerosis—-severe vitamin A deficiency. And Saif not only had a deficiency, but he had keratomalacia. Keratomalacia is an advanced case in which a kertain layer (white jelly-like layer) covers the eyes. Saif, like all the other children, gets one meal a day at the school. It consists of a lot of calories, but not many nutrients. A typical meal is rice, a little bit of vegetable like onion and potato, and sometimes an egg. However, the meal at the school is probably his only full meal of the day. The nurse consulted with a doctor back in Canada via email. The doctor’s response was that she had learned about xerosis and how severe it could be in the eye—but in all of her training, education, and practice—she had never seen a real case. It was a disease, she said, that medical students only saw in books. In developed countries, we often forget that what we call illnesses or problems of the past still do occur in other parts of the world in great frequency.

To me though, what was more interesting from an anthropological perspective
was what I heard another female teacher tell Saif’s mother as he was heading
out of the check-up area the next day. The nurse had already given Saif some
multi-vitamins and said she would follow-up with supplements to see if it
helped with his eyes in the next week. However, I heard this teacher speaking
in Marathi and chose to eavesdrop on the conversation. She was saying that Saif
should wash his eyes with rose water daily and use triphala lotion. Triphala is
an herb consisting of three different fruits and in Ayurveda is considered to
be a complete body cleanser and detoxifying agent. This teacher also went on to
say that walking on green grass and green hills would be good for Saif’s eyes.
To me, this last bit was the most interesting because vitamin A is known to be
found in green, leafy vegetables. However, this idea of walking on green, leafy
areas is definitely a traditional folklore type remedy.

Nonetheless, I am beginning to find a focus in my research hypothesis
focusing in on illness narratives and their connection with the food and
nutrition available in this community. Often I find myself asking families,
“Tell me about your illness or what happened last night” and being told
something about drinking a cold drink while having a cold or eating ice during
a hot day. Certain foods are only eaten in certain weather due to intrinsic
properties within them. A bad back or heartburn is immediately blamed on eating
some kind of food that causes an imbalance in the body maybe because it was
eaten in the wrong weather or cooked in the wrong way. Health in this community
revolves around food and what food means beyond its typical nutrient value.

by Fumnanya Ekhator

“You need it to be hard, because otherwise you could get hurt while the men are pushing on you.”[1] These are the words of Agnes Munyiva, a 50-year-old woman in the Majengo slums of Nairobi, Kenya. She is describing the hard lumpy mattress in the small rented room she uses for work. On the other side of Majengo, she rents another room, slightly larger, where she lives with the three youngest of her five children.[2] Her children have never seen her other room. Though she never discusses her work with them, she is sure they know. Agnes Munyiva is one of Kenya’s numerous sex workers.

Her twelve-hour workday day begins at 6 a.m. everyday and ends before sunset. She begins with a wink and a sly smile, seated on a low three-legged stool in the alley outside her rented room. “Karibu,” she says, Kiswahili for “welcome.” If a potential customer stops, she invites him in to negotiate the prices; it is usually set between 50 and 100 shillings. The transaction is silent and swift; there are families in the neighboring rooms. When it is over and her client leaves, she cleans up with a cloth and a pitcher of water before returning to her stool. A dozen men later, she returns home with about 500 shillings (enough for food), and sets some aside for the children’s tuition and other expenses.[3]

Agnes recalls painful memories of losing her friends in the business to a strange disease she had once called “plastic,” named for the wrapping the city workers would cover the bodies with once the women had passed away. Beginning in the early 80s, some women began to grow thin and weak “with sharp coughs and white fur that coated their mouths and throats.”[4] At the time, most scientists were still unconvinced women were susceptible to HIV or that the virus could even be transmitted through heterosexual intercourse. Year after year, Agnes continues to test negative for HIV, though she has fallen ill to other (more common) venereal diseases. She is one of the five percent of women believed to have protection against the world’s deadliest virus.

About 30 years ago, Agnes and a group of 40 other Kenyan women unlocked a world of possibilities in the realm of research. These women were found to be “immune” to HIV. Despite consistent exposure to the virus due to their line of work, the women repeatedly tested negative for the virus.
Scientists believed these women had HIV-specific immune responses in their genital tract that could protect against HIV infection. It also appeared that their killer T-cells were more effective at identifying and eliminating the HIV virus as soon as it entered the system.

While a single exposure often does not constitute infection, scientists have ruled out all possibility of chance; many of these women have had “500-2000 sexual exposures to infected men when they weren’t using a condom.”[5]

Interestingly, researchers found that in instances when women took breaks from their work and later returned, they fell susceptible to the disease; continuous exposure was necessary to maintain immunity. Almost seventeen years later in 2009, scientists in Thailand developed and tested a vaccine based on research gathered from these immune Kenyan women. The vaccine displayed an impressive 30 percent reduced risk of HIV contraction. The vaccine was a combination of two earlier versions and was administered to 16,000 people, making it the largest trial for a vaccine of its kind. The participants were regularly tested for infection every six months for three years. Results showed the chances of contracting HIV were 31.2 percent less for those who had been given the vaccine. Seventy-four people who received the placebo became infected, while only fifty-one people who received the vaccine became infected.[6]

Thirty years after the study, Agnes is not much better off than when she first arrived in Nairobi. She is reimbursed with free health care for the occasional STD she contracts on the job and treatment for respiratory problems that result from air pollution in the slum. Other than that, her life is unchanged; she continues to turn about eight tricks a day so she can feed her family. Have researchers no obligation to better the lives of those they literally use?

The ethics of science today require that these women receive counseling and condoms: an education that tells them that what they are doing is dangerous and unhealthy. Yet rather than being helped to pursue higher levels of education or training in another trade, these women are merely given condoms to make their occupation “less detrimental.” As a result, these women continue to live lives of shame in a desperate attempt to provide for their children.[7]

Ninety percent of Kenya’s poorest prostitutes find themselves infected with HIV.[8] Simultaneously, 33 million people in the world suffer from HIV worldwide.[9] Researchers face one of the greatest ethical dilemmas of all time: sacrifice the lives and well-being of some in the hopes of a preventative vaccine, or even a cure, for countless others. Should we ignore the suffering allowed, and in some ways encouraged, by a research community that gives so little for the well-being of those studied? Is it permissible to employ human beings as lab rats for the overarching cause of a cure? Is it even that simple?

A cure or a vaccine would be a world-changing discovery that could save millions of lives. But even today when we find ourselves with an effective tuberculosis vaccine, the disease still plagues developing countries where the governments cannot afford the medical technology needed to control and eradicate the bacilli. As of 2007, 2 billion people—a third of the world’s population—were infected with tuberculosis. Since 1990, the number of TB infections has increased four-fold in countries that are heavily affected by HIV.[10] Ultimately, it is likely that a vaccine for HIV, once developed, would not be readily available to those in the poorer countries; the very people without which there would be no cure in the first place.

1. Nolan, Stephanie. “Staying Alive: The Women Who are Immune to AIDS.” The Observer: 27 May 2007. Guardian News and Media. 4 May 2010. <http://www.guardian.co.uk/world/2007/may/27/aids.features/print>
2. ibid. p 13.
3. ibid. p 3.
4. ibid. p 5.
5. ibid. p 8.
6. “HIV Vaccine ‘Reduces Infection.’” BBC News: 24 September 2009. <http://news.bbc.co.uk/2/hi/8272113.stm>
7. Nolan, Stephanie. “Staying Alive: The Women Who are Immune to AIDS.” The Observer: 27 May 2007. Guardian News and Media. 4 May 2010, page 5.//8. Purvis, Andrew. “Cursed Yet Blessed.” Time: 6 December 1993. Time Incorporated. 4 May 2010 <http://www.time.com/time/magazine/article/0,9171,979763,00.html>
9. As of 2007. CIA. “TB and HIV/AIDS| Factsheet.” Centers for Disease Control and Prevention. January 2008. < http://cdc.gov/hiv/resources/factsheets/hivtb.htm>.
10. CIA. “TB and HIV/AIDS| Factsheet.” Centers for Disease Control and Prevention. January 2008. <http://cdc.gov/hiv/resources/factsheets hivtb.htm>

Photo Credits: http://apimages.ap.org

The dismal link between periods and girls’ schooling

By Michelle Lee

Orphans walking to school

Shahana, a young girl from Bangladesh, used cloth rags during her menstrual cycle.  One day, she washed the rag and dried it outside to prepare it for reuse. Without her knowledge, a parasite slipped into the rag.  When she used the rag the next day, the insect entered her vagina and infected her body.  After a week’s worth of stomach pains, she died.
While Shahana’s situation is an extreme case and menstrual-health-related deaths are not ubiquitous, unsanitary methods do result in various urinary and vaginal infections.1   Complications regarding female menstrual health have long remained problematic and unaddressed by both governments and non-governmental organizations.  These serious health effects impede girls’ access to a valuable education and limit female potential to contribute fully to their communities.
Kenyan Naisiae Tobiko is a first-hand witness to this unjust situation.  While she attended school, she noticed the consistent absences of girls from poorer families every month.  She learned that the girls could not attend school a few days each month because their families could not afford sanitary napkins.2  Expensive international brands of pads and tampons comprise an inaccessible market of sanitary products the average person cannot afford.  Females who cannot afford these products are forced to resort to subpar, unsanitary methods instead, such as using dirty rags or bark.3

Cases like the story of Shahana persist because local communities are reluctant to address issues regarding menstrual health.  Monthly menstrual cycles are stigmatized in many communities worldwide, oftentimes associated with cultural and religious taboos concerning blood.  In parts of central Uganda, some people consider menstruation a taboo topic and rarely discuss ways to improve hygienic practices.  In Bangladesh, there is a belief that menstrual blood is “the greatest of all pollution.”  Another cultural taboo exists in Sierra Leone, where some believe that using sanitary napkins may cause infertility.4

Discussion of menstruation-related issues at the local level is minimal, and communities are able to avoid initiating efforts towards addressing this consistently overlooked aspect of women’s health.  This issue also remains unaddressed at the global level as well; governments and non-governmental organizations alike have dedicated minimal time and effort to making sanitation products affordable and sustainable.4   This ill-fated deficit of education regarding hygienic menstrual practices, as well as the lack of funding toward constructing hygienic facilities, has far-reaching, detrimental impacts.

Not only has this unfortunate situation resulted in harmful health effects for females, but it has also spurred negative socioeconomic effects in local communities. Women must manage 3,000 days of menstruation in their lifetime, and 450 of those days coincide with the years of basic schooling.1  Each year, millions of girls and women do not attend fifty days of school or work because of their periods; many of them drop out of school or the workforce entirely.3   Education is key to solving many global issues such as gender-related injustices and economic inequalities.  A report released by Goldman Sachs Economic Research states, “There may be no better investment for the health and development of poor countries around the world than investments to educate girls.”5   Educated women are more likely to participate in the workforce, and there is a link between high education levels and low fertility rates. Statistics prove that female education correlates with higher national economic productivity and higher returns to investment.5

Fortunately, some people have recognized the importance of keeping girls and women healthy and in school.  Social entrepreneurs are using their compassion, innovation, and resolve to pioneer solutions to menstrual health issues, creating organizations such as Forum of African Women Educationalists (FAWE), Bangladesh Rural Advancement Committee (BRAC), and Sustainable Health Enterprises (SHE).  FAWE in Uganda encourages open dialogue about menstruation and related hygiene via locally run discussion workshops, which has led to an increased distribution of sanitary napkins.  FAWE is currently fighting for legislation in Uganda to supply sanitary napkins to female students without charge.  BRAC is working on a project to produce sanitary napkins locally, which keeps the products accessible and affordable.5   SHE’s market-based approach strives for sustainability, because as their website states, “Donations don’t work long-term.”  SHE’s mission is to empower women to be vehicles of social change in their own communities.  SHE provides education, training, and resources to women in developing countries to support entrepreneurship in producing and distributing affordable, eco-friendly, locally-produced sanitary pads.3

These initiatives, among others, provide hope that new and continuing efforts will address menstruation-related hygiene and health.  Permitting women to suffer preventable burdens of their menstrual periods is unjust and has far-reaching implications socially and economically.  The success of organizations such as FAWE, BRAC, and SHE are keeping girls in school, allowing them access to education and future opportunities.  Education is a crucial vehicle to harness the untapped potential in girls and women worldwide so they can contribute socially and economically to their local communities.  Women’s health, specifically menstrual health, is something that should no longer be overlooked.  Period.

SOURCES:
1Ahmed, Rokeya and Nahar, Qumrun. “Addressing special needs of girls challenges in school.” September 2006. South Asian Conference on Sanitation. 28 Apr. 2010 <http://www.wateraid.org/documents/plugin_documents/addressing_the_special_needs_of_girls.pdf>//2Friedman, Thomas. “Cellphones, Maxi-Pads and Other Life-Changing Tools.” 6 Apr. 2007. The New York Times. 28 Apr 2010. <http://select.nytimes.com/2007/04/06/opinion/06friedman.html?_r=3>//3“Sustainable Health Enterprises”. April 28, 2010 <http://www.sheinnovates.com/>.//4Ten, Dr. Varina Tjon A. “Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goal.” 10 Oct. 2007. Europe External Policy Advisors. 28 Apr. 2010 <http://www.eepa.be/wcm/component/option,com_remository/func,fileinfo/id,26/>//5Lawson, Sandra. “Women Hold Up Half the Sky.” 4 Mar. 2010. Goldman Sachs Economic Research. 28 Apr. 2010. <http://www2.goldmansachs.com/ideas/demographic-change/women-hold-up-half-of-the-sky.pdf>

PICTURE CREDITS:

http://www.orphanages.ws/images/GIDCCO/orphans%20walking%20to%20school.jpg//http://www.newstimes.com/mediaManager/?controllerName=image&action=get&id=93698&width=628&height=471//http://www.sishope.com/storage/inequalityphoto.png?__SQUARESPACE_CACHEVERSION=1269718128569//http://blogs.nationalgeographic.com/blogs/intelligenttravel/475-trip-lit-0912-school-girls-thumb-500×368.jpg

by Lancel Joseph

Gold mining in the Congo

The destructive extraction of gold is a major source of public health risk worldwide and has caused a high degree of environmental complications as well as societal problems. The negative impact of the “global gold rush” on humanity is particularly witnessed in developing countries that are heavily overwhelmed by poverty and weak economies. Destructive extraction of gold is particularly prevalent in African countries such as Tanzania, where extraction is not only a hazard in mining areas, but also contributes to downstream problems and negatively impacts the ability of communities to earn income.

The amalgamation of gold is a simple extraction process that entails the separation of gold from the gold-mercury amalgam by burning. It produces a vaporized form of mercury that people are exposed to via inhalation.1 This mercury accumulates in the food chain and becomes even more toxic when it transforms into methyl mercury. Methyl mercury pollutes soils, sediments, and lakes, which consequently contaminate fish and other food sources. Fish are a staple food for many developing countries. Over time, mercury becomes absorbed and heavily concentrated within protein-enriched meals and ascends the marine food chain. Community residents consume the fish, resulting in high toxic exposure to mercury. It is estimated that more than 100 million people around the world are exposed to mercury from small-scale mining.2

Gold mining in Burkina Faso

With the current gold mining process, methyl mercury in the food chain is becoming an invisible epidemic. The deleterious effects of mercury on the human body are well documented and have grabbed the attention of concerned humanitarians worldwide. Exposure to mercury as an adult can cause damage to localized areas of the brain, causing paresthesia (an abnormal tingling sensation), ataxia (a loss of full control of bodily movements), and other sensory abnormalities.4 Mercury poisoning has an even greater detrimental effect on pregnant women. Prenatal exposure to methyl mercury has adverse effects on a child’s cognitive and neuromuscular development.4 Effects are even seen in children breast-fed by mercury-contaminated mothers.

Due to the unstable Tanzanian economy, large mining companies own more than 90% of the mineral-rich land in the Geita region.2 Difficulty in attaining micro credit and money forces poor citizen groups to partake in hazardous and illegal gold mining. In 2007 and 2008, the President of Tanzania urged large mining companies to work in cooperation with the indigenous people. Cooperation would encourage improvement of technology and development of safety protocols that would diminish the hardships being inflicted upon poor small-scale miners. The ultimate goal would have been to combat both the economic shortcomings of his people and reduce health hazards for everyone.3 However, no action has been taken as of yet.

Ironically, some mining companies have switched from using mercury to cyanide.3 Unlike mercury, cyanide does not bioaccumulate. However, it is an extremely dangerous toxin, and it may pose an even greater health risk than mercury. Is this really the best solution? Are these mining industries really concerned about the people of Tanzania?

It is imperative that the public becomes more aware of the implications of small-scale mining in developing countries. Without increasing awareness, the enactment of laws and legislation is unlikely. Mercury contamination due to gold mining not only affects Tanzania, but also affects many other mineral-rich developing countries impeded by industrial exploitation. The onus is not only on industries to change gold amalgamation processes, but also on developing countries to protect the health of current and future generations.

Picture credits: http://blogs.reuters.com/mark-jones/2009/07/02/finbarr-wins-best-photo-in-diageo-awards/;http://blogs.reuters.com/africanews/2009/09/28/can-gold-save-burkina-faso/

1) Onyemaechi et al. “Modern Environmental Health Hazards: A Public Health Issue of Increasing Significance in Africa.” United States 2008.

2) Veiga et al., 2005 “Reducing mercury and responding to the global gold rush.” 2005, pp. 2070–2072.

3) Spiegel, Samuel J. “Occupational health, mercury exposure, and environmental justice: learning from experiences in Tanzania.” American Journal of Public Health, 2009 Nov.

4) Mozaffarian et al. “Fish Intake, Contaminants, and Human Health-Evaluating the Risks and the Benefits.” American Medical Association, 2006 Oct.

By Jyotsna Ghosh

The incredible success of Nicholas Kristof and Sheryl WuDunn’s Pulitzer Prize winner (and best-seller) Half the Sky helped focus American attention on the worldwide problem of obstetrical fistulas. Largely eradicated from Europe and North America with the advent of increased bridal age, delayed child-bearing age, and improved prenatal and delivery care, obstetrical fistulas—essentially tears near the vagina generally sustained in childbirth–continue to afflict at least two million women globally, according to the World Health Organization. WHO estimates a minimum of 100,000 new cases annually, nearly all in the developing regions of Africa and Asia. However, women’s advocacy groups point out that the WHO data are from 1989 and probably represent significant under-reporting of the true extent of the problem, due to poor record-keeping and to the shame attendant upon the condition.

Many factors contribute to the development of obstetrical fistulas. Kristof and WuDunn, like many of the international organizations working to prevent and treat the condition, trace fistula development back to the poverty and low status of women. Because girls in some traditional societies are not valued highly, they receive less nurturance and less actual nourishment than their brothers do. Malnourished, they are married early in puberty, their skeletal structure having had neither the time nor the nutrition needed to mature fully. As a result, the pelvis is often stunted, dramatically raising the risk of obstructed labor when a child is born.

Obstructed labor is frequently also prolonged labor. Contractions continue, but the narrowness or malformation in the pelvis does not permit the baby to pass through the birth canal. Instead, its head presses on the pelvis, sometimes for many days. The pressure cuts off the blood supply to delicate tissues. It is not uncommon, in such cases, for both the mother and infant to die if an emergency Caesarean section is not undertaken. Even if the mother is ultimately able to deliver successfully, in 90% of cases the infant will not survive. For the mother, the extended period of tissue “blood starvation” means the vaginal tissues will subsequently die and fall away. The woman is left with a hole between her vagina and her bladder or between her vagina and her anus. Urine and feces commonly drip from this hole. Ulcerations result. Infections have easy access to the internal organs. The kidneys are often affected, particularly since women desperate to limit the leakage may drink very little and consequently become seriously dehydrated. It is also very common for the duration of pressure during delivery to damage nerves in the legs and lower back, sometimes leaving women unable to walk. Nearly always, women who suffer long-standing, un-repaired obstetrical fistulas are unable to become pregnant.

Their infertility is one reason the victims of this preventable trauma are “social lepers” discarded by their families. Other reasons, however, also contribute to their isolation. The urinary and fecal incontinence is not only embarrassing and debilitating to the women themselves, but also causes them to exude a foul odor that leads to shunning by others. Half the Sky recounts histories of women cast out of their homes, lying in their own filth, unable to fend for themselves, and lacking the knowledge of the availability of medical treatment and the means with which to seek it.

For such women, the medical sequelae of obstetrical fistula are only part of the problem. The humiliation and social exclusion from family and community are just as devastating. Generally, victims are not allowed to prepare food and may be forbidden to participate in prayers or other religious activities. Furthermore, most are grieving mothers who have lost a newborn and know they will never be able to give birth again. All of these circumstances exacerbate the physical torment of the condition itself.

Organizations such as Campaign to End Fistula emphasize that obstetrical fistulas are treatable, generally for as little as the equivalent of $300 USD. Plastic surgery is effective, yet beyond the means of most women suffering from the condition. Not surprisingly, those working to raise awareness of obstetrical fistulas seek donations from wealthier nations, but they also stress the fact that treatment is not the ultimate goal. Prevention– through education, through empowerment of women, through improved access to medical care, and perhaps most importantly, through addressing the underlying poverty and oppression of women– is considered essential. Only 58% of women in developing countries give birth with the assistance of a physician or a professional midwife. Since an average of 15% of all births (including those in which pelvic stunting and other poverty-related conditions are not a factor) require emergency medical intervention, the risk for obstetrical fistula is clear and frightening. Entirely preventable, this affliction has been too long ignored.