In 1986, Igor Vaz was a Mozambican doctor working in rural Inhambane Province, in the midst of a civil war, when a surgeon-slash-priest arrived in the area. It turned out to be an encounter that would change his life.
The surgeon, Father Aldo Marchesini, was there to perform reconstructive surgeries on women living with a devastating, highly stigmatized medical condition – obstetric fistula.
At the time, surgeons able to successfully repair fistula were scarce at best, Dr. Vaz recalled. More were desperately needed – and still are.
Father Marchesini “just asked me, ‘Who will look after these ladies?’ and I said, ‘Look, I will,’” Dr. Vaz recalled.
A Shortage of Surgeons
Today, Dr. Vaz, who triples as a general surgeon, urologist, and gynecological specialist, is the head of Maputo Central Hospital’s Surgery Department, in Mozambique’s capital city. He’s also the founder of Focus Fistula, an organization devoted to repairing and preventing obstetric fistula, working with Mozambique’s Ministry of Health and UNFPA.
And he treats the most complex cases of fistula himself – with equipment provided by Direct Relief.
Obstetric fistula occurs when a hole develops between a woman’s vagina and her rectum or urinary tract, generally caused by prolonged labor without access to emergency care. The condition is devastating: Women experience ongoing incontinence, often with a strong stench, and tremendous social shame. Husbands frequently leave and their communities may cast them off. Stillbirth is 99 times more likely in fistula cases, according to The Lancet.
The condition is a serious problem in Mozambique, particularly for women living in rural areas with few economic resources, and who are more likely to deliver at home, Dr. Vaz explained. A 2017 Reproductive Health study found that Mozambique’s incidence of obstetric fistula was 1.1 per 1,000 recently pregnant women.
Nowadays, there are more surgeons capable of handling the simpler fistula cases – in part due to Dr. Vaz’s efforts to train surgeons in urologists in fistula care. “The aim of our program is to give [fistula surgery] training in the medical school, as part of the training of all general surgeons,” along with urologists and gynecologists.
But Dr. Vaz said a student might spend three to six months training to perform the corrective surgeries – not enough time to learn to care for the most complex cases. And most of them simply won’t specialize in the surgeries. “A very, very few of them will do fistula surgery on a routine basis,” Dr. Vaz said.
In addition, he explained, most doctors spend little time in the public sector because private practice is so much more lucrative – but because fistula tends to affect lower-income women, that means there are fewer specialists able to care for them.
To fill gaps in qualified surgeons, Mozambique already allows for technicians – nurses or similar health workers with some surgical training – to perform simpler procedures such as C-sections and appendectomies, Dr. Vaz said. His organization has begun training them to repair simpler fistulas as well.
But some cases are more complex. Bowel may need to be removed, for example, or a urethra reconstructed. A complex setup, including a surgeon, urologist, anesthesiologist, and blood bank may be needed. Dr. Vaz estimated that only a small handful of surgeons in the country, perhaps four, are capable of helping these women.
So he travels around Mozambique – with occasional trips to other countries where fistulas are an ongoing problem – establishing surgical camps and treating these complex cases himself.
The staff will announce their arrival on local radio, informing women living with incontinence that surgery may be an option for them. (He explained that many of his patients feel their situation is hopeless or believe that their condition is a punishment from God.) As part of the process, they’ll meet with the community and explain what the camps are for.
At one event in Beira, he recalled his team treating a total of 35 complex cases: “We had a team of 10 surgeons working in three rooms at the same time.”
Treating patients around the country has its challenges. “One of the hospitals, the lighting was bad, the theater was not good enough, the table was broken,” Dr. Vaz recalled. His patients had to be transferred to another hospital.
Dr. Vaz explained that the support he receives from Direct Relief goes far beyond a basic fistula kit and allows him to deal with the most complex cases. “Most of the material we take to the camp is given to us by Direct Relief,” he said.
A new shipment, recently sent to Mozambique, included a wide variety of surgical instruments worth more than $70,000. Dr. Vaz said the materials amounted to a complete set of medical equipment for abdominal, vaginal, and colorectal surgery.
Under the Surface
Treating fistulas that have already happened “is the tip of the iceberg,” Dr. Vaz said. He’s also concerned with prevention, which presents a number of challenges – and isn’t going as well as he’d like. “This is not working properly,” he said straightforwardly. “The survivors of all of the trauma of the delivery…talk about where they have been failed.”
He was also concerned about the conditions of some of the delivery rooms he’s seen, and described running into maternal and child health workers who were inadequately trained and motivated.
In addition, he said, working with small numbers of complex cases makes it more difficult to gain support from donors, who tend to prefer higher numbers of surgery and near-perfect success rates that just aren’t possible when dealing with particularly difficult fistulas.
But the rewards are tremendous. Dr. Vaz recalled one patient who had lost her baby after a prolonged surgery, eventually culminating in a C-section and “a huge fistula.” One surgeon told her it was inoperable; another created two stomas on her abdomen in an attempt to reverse her incontinence. Embarrassed by her condition, she hadn’t spoken to her family in years.
When Dr. Vaz encountered her in the city of Beira, he told her her fistula was too complex to be treated on the spot, and asked her to move to Maputo. Over the next year, she underwent six separate surgeries to correct the fistula.
“And now,” he said simply, “she is well.”