Anjum Bibi – a 32-year old mother of six, lies under anesthesia on an operating table as a group of doctors and nurses methodically go about preparing to operate on her torn urethra – a result of a prolonged and obstructed labor that not only resulted in a still-born baby, and left her with severe injuries and unable to control her bodily functions. For nearly three months, Anjum Bibi suffered from this humiliating and crippling condition – commonly known as fistula, that left her as helpless as a small child, forced her to withdraw from public life, and unable to perform even the most basic of life’s needs like cooking, prayer and playing with her children. In desperation, she undertook a near 400 km across Baluchistan’s forbidding landscape to arrive at this operating table at Karachi’s Koohi Goth Hospital in the hope of finding a cure. It was a small price to pay to overcome the debilitation and humiliations of the last many months. Fistula, a little known but crippling consequence for thousands of women in Pakistan, is a living death, leaving women isolated, ostracized, and helpless.
Anjum Bibi had nothing to lose when she arrived at the gates of the hospital, for she had already lost most everything she had. Now, as the doctors quietly moved about the small, compact operating room, setting up their equipment, donning gloves, and whispering last minute instructions to orderlies and nurses, she could finally hope to end her suffering. Considered to be one of the finest private hospitals in the country dedicated to maternal health issues, it will now take the medical team here a few hours to operate and help her return to normal life. “This is a condition of a poor woman and the poor girl.” Dr Shershah, one of the senior surgeons at the hospital, explains in his indignation written all over his face as he prepares his instruments for the operation. “Poverty is the real health issue in this country. And because this problem inordinately affects the poor, no one really cares about it.”
And she is not alone. It is estimated that nearly 3000-4000 women fall victim to fistula each year in Pakistan, a result of a lack of access to basic maternal care. The lucky few manage to find their way to the Koohi Goth Hospital which remains the only recognized fistula center in the country. Set up by Dr Shershah Syed in 2005, the hospital’s immaculately clean campus spans nearly 16 acres and is an oasis of calm in the midst of one of Karachi’s most chaotic and poor industrial and residential municipalities. Patients from all over the country, and some as far away as Afghanistan, come here seeking help for their problems. Like Rasheeda Bibi from Kharan, Baluchistan, a 35-year old mother of three, who struggled with the condition for over two years before a friend told her about the hospital in Karachi. “My life had been a living hell.” Her hands work across a set of prayer beads as she waited in the packed maternity ward to see when the doctors will operate on her. “I was shunned by everyone – no one would sit near me, or come to meet me.” She had previously gone to Quetta, the capital of Baluchistan, to seek treatment, but the doctors there had failed, leaving her and her family deep in debt. “I had to sell my jewelry, and borrow money from family members all to rid myself of this curse.” Koohi Goth was her last hope.
A large number of patients at the Koohi Goth Hospital are from the rural areas of the country which continue to suffer from a lack of basic health units or emergency obstetrical care. Poor road infrastructure, and lack of basic health care facilities particularly in the rural areas, are often cited as the major reasons for the prevalence of this problem in Pakistan. However, social and cultural factors also play a large role. According to Dr. Shershah the continuing practice of underage marriages in Pakistan is a major reason for the high rates of fistula in the country. “These are children having children,” he says. “And their bodies are nor mature and formed to deal with childbirth.” Like Rehanna Akhtar, of Risal Pur in Pakistan’s Khyber Pukhtunkhwa (KP) province – a mother of three, was 16 when she got married. She had three children in quick succession, but the third proved the most difficult. A Caesarian birth left her with a ruptured bladder, urinal leakage and crippling pains. “I had so many worries, and I thought that this would kill me.” Her face still carries the weight of her worries. “People kept saying that this problem couldn’t be cured.” As Dr. Shershah add in his characteristically clear and succinct way. “It destroys families. It is difficult to be around a person who smells and is in constant need of cleaning up. There are cases where husbands remain with their wives, but very few.” His face is pensive. “Usually they just leave their wives.”
But Rashida Mohammad’s’ husband did not leave her. And it made all the difference in her life and her struggle with fistula. A 44-year old mother of one, she developed a fistula condition after her hysterectomy. “It broke me mentally and emotionally.” She sits nervously on a chair across from me in her home in Karachi’s Orangi Township – one of Karachi’s largest slum inhabited by nearly 1.5 million people. “Life became unbearable.” Though she suffered from fistula for about six months, the fear, anxiety, shame and insecurity it inflicted on her psyche and sense of self are written starkly across her face. “I am here, and able to sit here and talk to you because of my husband’s support.” Rashida visited government and other private hospitals – a process that left her and her family in debt and without a cure, before they were told about Dr. Shershah’s work at Koohi Goth. “There is a clear lack of skilled birth attendants.” Dr. Suboohi insists. “Its not enough that a woman gets to a proper hospital.” Rashida had learned this the hard way, suffering continued problems at the hands of inexperienced doctors at government hospitals. “The sad part is that it is a very inexpensive treatment.” Dr. Suboohi sighs in frustration.”Its just the lack of knowledge and experience that then creates deeper problems for the women.”
Despite the dire state of maternal health in Pakistan – where nearly 8000 women lose their lives in pregnancy-related complications every year – expenditure on public health constitutes a mere 1.0% percent of gross domestic product, according to statistics from the World Bank. Accordingly, awareness of the disease is relatively low, and only a few surgeons in the entire country are equipped to treat such cases. But professional interest in it, according to Dr Suboohi Mehdi, a senior surgeon at Koohi Goth, is also very low. “This is a low paying medical condition – its lacks the status of cardiovascular or plastic surgery. This is another big problem we face here.” The wards at the hospital are full, and when I meet Dr. Suboohi Mehdi she is just emerging from completing yet another fistula operation. “Every month we see at least 20-25 cases” She adds, throwing off her surgical gloves and cap, “And every Sunday here we perform at least 10 – 12 fistula surgeries.” But more is needed. There are not enough qualified fistula surgeons in a country that see nearly 3000-4000 reported cases every year. Pakistani organizations like the Pakistan National Forum on Women’s Health (PNFWH), and international organizations like the United Nations Population Fund (UNFPA) with its partners DirectRelief and The Fistula Foundation, are investing more in education, mid-wife training and building rehabilitation and free treatment centers across the country.
In a country with a long history of indifference to maternal health problems, these programs are severely needed. Given the devastating consequences fistula has on the lives of women, these programs are a national necessity. They can mean the difference between a living death for a woman and a healthy, normal life. As Sharifa Mir from the UNFPA vehemently pointed out “Thousands of women are suffering, and we cannot simply accept this pain and misery.” And where the government may be slow to act, private institutions like Koohi Goth Hospital, are working hard to spread the word. “We have been effective in getting the word out in the community.” says Dr. Suboohi. “We see more and more women coming to the center because they heard about it either on the radio, or read it in a local newspaper.” But one institution cannot do it alone. “We need a lot of trained doctors because this problem is only growing.”