Many a time the focus on well-being tends to be put on patients, with little consideration to the daily realities of health care providers. Much as it’s their professional obligation, imagine the agony medics endure seeing patients in so much pain, as well as what it means to save someone from life-threatening conditions like obstetric fistula.

Dr Arlene Nishimwe has been working with The International Organisation for Women and Development (IOWD), a New York-based non-government organisation that helps to treat fistula patients in Rwanda.

Nishimwe says while in medical school she learnt about fistula, but encountering it first-hand was yet another heart-wrenching experience.

It’s that need to see your patients get better, to see them have life once again; it’s that need that makes you forego all other things just to see them get better, she says.

"It was a whole new experience when I saw these women; they had so many different touching stories and it was really painful to hear them. They narrated how they endured living with fistula, how they were stigmatised by their families, abandoned by their husbands, and left to live in solitude for over 20 years; it’s so sad indeed,” she narrates.

Helping other people is more of a calling to Nishimwe, and she says that is why she chose medicine as her career path. "However heartbreaking the stories of the different patients may be, it’s worth it knowing that you helped save someone’s life,” she says.

When Nishimwe joined IOWD she was in her fourth year at medical school and as she puts it, her encounter with fistula patients will forever leave a mark in her medicine career.

Nishimwe describes her experience with the women in the operation room as more of a revelation, a transition that sees these women get a new lease to life.

"Seeing all this has had an impact on my life. However tough the process can be, in the end it’s an honour being a part of the team that saves these women’s lives and to see them smile once again when they recover from the horrible condition.”

Dr Gerard Mbabazi, another IOWD Rwanda team member, says talking and listening to the stories of the affected women gives him reason to wake up every day dedicated and wanting to contribute towards improving their health.

"It’s not easy to find words to describe what these women go through; it is unbearable for any human being. My eyes get crowded with tears when they are narrating their painful conditions,” he says.

Mbabazi, however, says he is overjoyed being part of the restoration of these women’s dignity and transformation back to a happy normal life.

"When I chose to become a doctor, I prepared myself for whatever circumstance that I might come across during my career, good or bad. Of course some scenes can be hard to bear, but as a healthcare provider I don’t mind that. I mostly care about how to help the patient get better so that she goes back to society a happier healthier human being,” he says.

Insight into fistula surgery

An obstetric fistula is a hole between the vagina and rectum or bladder that is caused by prolonged obstructed labor, leaving a woman incontinent of urine or feces or both.

Dr Joan Blomquist, a US-based medic volunteering with IOWD, explains that during the surgery of obstetric fistula, the primary operation done is to close the hole between the bladder and the vagina so that urine can no longer leak.

She says the exact process varies depending on exactly where the hole is. For example, if the woman developed the fistula after a vaginal delivery, then the hole is usually between the bladder and the vagina and can be fixed with a less invasive procedure done through the vagina.

However, if the fistula developed after a C-section or other operation, then the hole may involve the cervix, uterus, or even the ureter (tube that connects the kidney to the bladder) and is thus much more involved, she points out.

"In that situation, the operation usually involves an incision on the abdomen and may include a hysterectomy. After either operation, it is important to keep the bladder empty so the tissues heal properly. Therefore, most women have a catheter in the bladder for about 2 weeks after surgery. Complete healing takes several months,” explains Blomquist.

It goes beyond health care

Barbara Margolies, the executive director and founder of IOWD, says for the past seven years, they have been working with Rwandan medical students during their fistula missions to Kibagabaga Hospital in Kigali, and that every student has been an absolute pleasure to work with.

"When they start working with us, they tend to be quiet and very serious, but after one mission, they are relaxed and comfortable with our teams and even though they work very hard and very long days, we laugh and share ideas and stories, and even cry, with one another. On a personal level, I have watched so many students grow into mature, dedicated, compassionate and confident individuals,” Margolies notes.

"Unquestionably, we could not do our work without the Rwandan medical students assisting us! They are an absolute necessity to IOWD’s programmes at Kibagabaga Hospital and now at Rwanda Military Hospital where they help us in our pediatric programmes,” she adds.

IOWD started the fistula programme in Rwanda in April 2010. In October 2017, they will have completed 23 missions to Kigali.

"A very dear friend of mine, Dr Odette Nyiramilimo (former Senator and recently retired from the East African Legislative Assembly), knew there was a need to help fistula patients in Rwanda. She introduced me to a former Minister of Health, Dr Richard Sezibera and he invited IOWD to come to Rwanda. That was the beginning of a wonderful relationship with the Rwandan people and the Ministry of Health,” Margolies recalls.

IOWD’s medical teams examine and offer free surgery to repair women with obstetric fistula. They also offer free medical care to women with gynecologic problems; free pediatric general care, pediatric urological surgery and pediatric general surgery.

They have examined approximately 2,697 patients, performed 885 surgical procedures (not all are fistula; some are hysterectomies, cancer cases, prolapse, benign tumors, repair of extreme mistakes of episiotomies, among others).

All surgeries are performed by IOWD urogynecologists/ pelvic floor reconstructive surgeons and urologists, and assisted by Rwandan Ob/gyn residents and Rwandan nursing staff.

The organisation also provides all medical supplies, instruments, anesthesia medications, and antibiotics necessary for surgery and post- operative care. It also offers post-operative follow-up exams for all former surgical patients.

IOWD offers an outreach educational programme in health centres by using an over-sized "flip” pictorial book to explain pregnancy and fistula.

Margolies says she is thankful for the support from the Ministry of Health in providing operating theatres.

"I also appreciate the role of Rwandan staff for always assisting in surgery and in post- operative care; providing food, housing and transportation for the patients,” she says.