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With curly lashes and soft, fulleyebrows, Almaz looksyounger than her 20 years,

even more so when she starts to cry.“I’m scared,” she says in Amharic, dig-ging her nails into the palms of herhands. “I don’t want to die.”

She is about to undergo surgery inthe sleek, gleaming white operatingtheatre of Addis Ababa’s Fistula Hospi-tal, the world’s most renowned centrefor treating obstetric fistula, a termused to describe vesicovaginal or rec-torvaginal fistula occurring after failedor obstructed labour.

Almaz (not her real name) is 1 of2300 patients treated annually by thehospital’s 6 doctors and, like manywho arrive, is frightened and suspi-cious. She is also wary after spending ayear alone in a hut, her husband havingleft her when she gave birth to a still-born. She’s been incontinent since, andrarely visited, except by her sister andfriends dropping off food.

Almaz hopes to join the ranks ofthe 93% to 95% of women whose ob-stetric fistulas are successfully closedat the facility that has become a havenfor Ethiopian fistula sufferers sincebeing established in 1974 by Aus-tralian surgeon Catherine Hamlin andher late husband.

Fistula Hospital Chief Executive Of-ficer Mark Bennett says that about 20%of patients continue to battle inconti-nence and other complications postsurgery, because what’s left of theirbladder is too small to hold muchurine. In rare cases, where the bladderhas been completely sloughed outthrough the vagina and cannot be re-paired, stoma surgeries are performed,explains Dr. Hailegiorgis Aytenfisu. Formost women, though, surgery means“they can urinate normally. They canget married. They can even have an-other baby.”

It is a welcome outcome forwomen in Ethiopia, where obstetricfistula is so prevalent that a founda-tion established by Hamlin — whocontinues to perform surgery at age84 — is in the process of building 5more treatment hospitals. Three arealready operational.

Skeptics wonder if the focus wouldbetter be placed on educational meas-

ures, given that obstetric fistula is es-sentially preventable with a cesareansection. But it’s difficult to shift the fo-cus when demand for treatment con-tinues to rise.

It’s a function of cultural, politicaland economic factors, Bennett says.Ethiopian women become susceptibleto obstructed labour at a young age.Growing up in poverty, they’re made to

Finding a balance in the

treatment and prevention

of obstetric fistula

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Patients with fistula wrapped in colour-block blankets knitted by women in Australiaand Europe. Because of the elevation, it can be cool in Addis Ababa.

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fetch water and till soil, and they don’tget enough nutrients to satisfy theneeds of their young bodies. “And ahigher proportion of women inEthiopia are small.”

But the clincher is that 85% of thepopulation live in rural areas, oftenmore than a day’s journey — by foot,bus or ride from a stranger — from thenearest hospital. Roughly 95% ofEthiopian women give birth at home.“It’s considered normal to give birth athome and it’s probably considered nor-mal that a certain percentage of womendie giving birth,” says Bennett.

Another young woman, Werkenish(again, because of hospital policy, nother real name) surveys the garden thatHamlin built at The Fistula Hospital,which was featured on The Oprah Win-frey Show, and a smirk comes over hertribal-tattooed face as she reminiscesabout her life. She was betrothed at 10and taken to her mother-in-law’s tolearn how to cook njera (an Ethiopianbread) and roast coffee beans.

She eventually developed a severe vesi-covaginal fistula after 5 days of labourand spent a year seeming to constantlylaunder her sheets and clothing. One day,she told her husband to find anotherwoman because she was no longer fit tobe a wife. “My husband was disappointedbut what could he do?” asks Werkenish,who now lives with her parents.

There are signs, however, that man-agement at the hospital are finally heed-ing such calls. “It seems a futile task ifyou keep sewing up women if you’renot reducing the numbers coming,”says Bennett, noting that Ethiopia’s ex-panding population is increasing thedemand for fistula surgery.

In hopes of easing that pressure,the Hamlin Foundation is building 25prevention clinics in addition to 5treatment hospitals. Each clinic will bestaffed by 2 midwives, who will en-courage women to seek antenatal care.The foundation has also hired advo-cacy officers in recent years to speak atchurches, markets and schools aboutthe causes of fistula and how to pre-vent it. “It’s important we teach thewhole community,” says Amanuel,“because a woman might say ‘I need togo to the hospital,’ but unless her hus-band agrees with her, she won’t go.”The advocacy officers target traditionalbirth attendants (women who have ex-perience cutting umbilical cords but noprofessional medical background),teaching them to recognize obstructedlabour and identify women whoshouldn’t give birth vaginally.

But Amanuel predicts preventionwill be a long and arduous task. “You

Most women with obstetric fistulasare ostracized by their husbands and,sometimes, even by their families.“Usually the first thing women will no-tice is that they’re not invited for thecoffee ceremony,” a daily ritual inEthiopia, explains Bethela Amanuel,public relations officer at the hospital.The smell of stale urine and feces can beoffensive, and with little understandingof conventional medicine, rural Ethiopi-ans often see fistulas as a curse or thefault of the woman.

In reality, fistula happens becausewomen don’t have access to cesareansections, and critics of Hamlin’s well-funded organization say focus wouldmore properly be placed on improvingaccess to cesarean sections rather thansurgical repair of fistulas.

“It’s shameful that more fistulahospitals are being built when fistula is100% preventable,” says Dr. RonaldLett, the Addis Ababa-based director ofthe Canadian Network for Interna-tional Surgery.

Dr. Yifru Berhan, an Ethiopian gyne-cologist and head of a medical schoolin the town of Hawassa, agrees. “It’sunfortunate that we have hospitals tomanage the complication but not toprevent the complication.”

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An Ethiopian woman carries a bucket of urine inside a clinic at the Addis Ababa FistulaHospital, which has performed more than 32 000 free operations on women sufferingfrom the humiliating injury that typically results in a constant leak of urine. A fistula iscaused by a tear in the tissue between the vagina and adjoining organs due to pro-longed labour, particularly in young, undernourished women.

Fistula Hospital officer Bethela Amanueldemonstrates how a fistula occurs.

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have to make sure that people havetransport to get to the hospital; youhave to have good roads; you need an-tenatal clinics that are close enough forwomen to get to for a check up. Youhave to make sure there are schools sothere is a choice for the girls. You haveto make sure the nutrition value is dif-ferent. You have to change the cultureof early marriage.”

Women prone to fistulas are poor,rural and barely educated, living as theydo in a culture which sees the school-ing of girls as a “waste,” addsAmanuel, who grew up in Ethiopia’staxi-jammed capital. “They’re the mostvoiceless members of our society.” —Wendy Glauser, Addis Ababa, Ethiopia

DOI:10.1503/cmaj.080693

which concluded in 2006 that healthcare workers in Ontario need whistle-blower protection to ensure they reportpublic health risks promptly and “with-out fear of consequences.”

Manitoba is the only jurisdiction in Canada that now enforces suchprotection.

It emerged after a 1994 dispute inwhich anesthesiologists at the Win-nipeg Health Sciences Centre boy-cotted the hospital’s cardiac surgeryprogram and asked administrators toreview its safety. The doctors wereforced back to work under threat oflosing their jobs.

A subsequent pediatric cardiac sur-gery inquest found that several deathsin the program could have been pre-vented and led, in turn, to ManitobaRegulation 64/2007, which protectshealthcare professionals from reprisalswhen they make complaints about thequality of clinical care.

Similar protections are more wide-spread in the United States, where theJoint Commission on the Accreditationof Hospitals prohibits retaliatory action.

California has gone a step further,mandating that once a complaint ismade, reprisals within 4 months arepresumed to be retaliation, and the hos-pitals can be fined up to US$25 000. —Miriam Shuchman MD, Toronto, Ont.

DOI:10.1503/cmaj.080694

cerned about O’Connor’s practice andconduct, primarily because he failed,they say, when requested by theprovince, to produce records for the pa-tients he’d claimed had cancer.

Howard May, a spokesperson for Al-berta Health and Wellness, says hisagency “went out of our way to get Dr.O’Connor to come forward with infor-mation, and he didn’t do it.”

O’Connor disputes this, saying thatwhen he was asked to provide thenames of people he knew had specifictumours or cancers, he did.

“I was asked for direct input and Igave them the information.”

O’Connor adds that he was accusedof causing “undue alarm,” but mem-bers of the community have told himthey are concerned, not alarmed.

He believes his advocacy “has giventhem the encouragement and the moti-vation to go ahead.” One complaintagainst O’Connor remains unresolved.(The College declined to investigate an-other and closed the case on the third).

Spurred by the O’Connor case, thegeneral council of the Canadian MedicalAssociation passed a resolution in 2007urging that doctors be protected from“reprisal and retaliation” when theyspeak out as community advocates.

Pressure to protect whistle-blowingdoctors and nurses in Canada has alsocome from public health and legal ex-perts, including the SARS Commission,

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Whistle-blowing doctors whotake stands on behalf oftheir patients typically have

few protections against retaliation. But that’s begun to change in some

countries and states, like California, inwhich hospitals can be fined forreprisals. Some argue such protectionsshould be systematic throughout Cana-dian medicine.

Their arguments are being bol-stered by the experience of Albertafamily physician Dr. John O’Connor,who over the past 2 years has foundhimself embroiled in controversy afterpublicly surmising that the develop-ment of the tar sands was linked tohigher rates of cancer in the NorthernAlberta town of Fort Chipewyan inwhich he works.

O’Connor’s concerns drew interna-tional media attention and have sincespawned a pair of investigations.

His statements also prompted an as-sault on his medical licence, led by 3physicians who work for Health Canadaand who filed complaints about O’Con-nor with the College of Physicians andSurgeons of Alberta in 2007.

One of those, Dr. Hakique Virani,says the Health Canada trio are con-

The Athabasca tar sands have been linked by Dr. John O’Connor to “clusters of diseases”among his patients in Fort Chipewyan, Alberta. O’Connor was accused by Health Canadaof “causing undue alarm” and “blocking access to data” in his patient files.

Medical whistle-blower

protection lacking

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