Shaebia Interview

 

Interview with an American Medical Team from Stanford University on Their Recent Trip to Eritrea

 

Recently, Shaebia.org’s contributing writer Issayas Tesfamariam conducted an interview in Dr. Mary Lake Polan’s office at Stanford University on November 1, 2002. Dr. Mary Lake Polan coordinated the Stanford Fistula Project in Asmara, Eritrea from September to October 2002. Dr. Mary Lake Polan, M.D; Ph.D., is the Chair of the Dept. of Obstetrics & Gynecology (OBGYN) at Stanford Medical Center, Stanford University, Stanford, California The project included: Dr. Carol Glowacki, a urogynecologist, Dr. Joelle Osias, an endoscopist, Dr. Amreen Husain, a gynoncologist, all from Stanford Medical Center at Stanford University and a noted fistula surgeon from John Hopkins University (Maryland, USA), Dr. Clifford Wheeless. Following are excerpts

 

 

Issayas: Welcome back from your recent trip to Eritrea, and thank you for your time. What was the purpose of your trip to Eritrea?

 

Dr. Mary Lake Polan

Dr. Mary Lake Polan: We went to Eritrea to bring some surgeons from Stanford so that we could teach the surgeons at the Mekane Hiwet Hospital in Asmara about complicated vesico-vaginal fistula. They have been taking patients and some of them were simple repairs but in terms of complicated plastic surgery and swinging tissue flap with multiple fistulas we have some techniques that they were interested in learning.

 

Issayas: What kinds of surgical procedures did you perform while you were in Eritrea?

 

Dr. Joelle Osias:

Dr. Joelle Osias

We performed a total of 37 surgical procedures. Some of them were complex and others were simpler. We saw patients who had their first surgical operations. We also took patients who have had previous repairs that had failed. Some patients were no longer being able to use their normal urinary system to empty their bladder so we had to divert the urine through the rectum and reconstruct the perineum and the sphincter. So this was the more elaborate procedure and the patients who had smaller defects we were able to reconstruct their urethra. There were also some of them who had successful repairs but who have still been leaking and we were able to perform a procedure that would help to correct their urethra so that they could be now fully functional. The range of problems was complex. We had to tailor our surgical interventions to each patient’s specific problem.

 

Issayas: Dr. Amreen Husain, you are a gynoncologist. What does that mean?

 

Dr. Amreen Husain:

Dr. Amreen Husain

As a gynecologist, I primarily care for women with cancers of the genital tract such as cervix, ovary uterus, etc. The bulk of my practice is surgical and so you could say I am a gyn cancer surgeon.

 

Issayas: What is a fistula?

 

Dr. Joelle Osias: Fistula basically is an abnormal opening communication between two cavities. In normal circumstances there is a separation between the vagina and the urethra, but after traumatic birth there could be an opening between the urethra and the vagina or between the vagina and the rectum. And these openings cause social problems. Also, patients who have leaking will have no control of their bladder.

 

Issayas: What kind of social problems does fistula cause?

 

Dr. Mary Lake Polan: Women are divorced by their husbands and unable to find and keep jobs. Their families ostracize them because they smell bad.

 

Dr. Amreen Husain: The fistulas cause social problems with respect to patients being divorced and abandoned, being infertile, and also being unemployed due to the odor that frequently is associated with these fistulas.

 

Issayas: Before the surgery how were the women with fistulas be able to urinate even though they have no control over it?

 

Dr. Mary Lake Polan: Urine just leaked out constantly and they had no control over it.

 

Issayas: With the diversion procedures how were the patients be able to use their urinary system to empty their bladder?

 

Dr. Amreen Husain: With the diversion procedures because catheters and stoma care is not available for patients in Eritrea, we had to connect the urinary diversions to the rectum so that after the procedure the patients empty the bladders into the rectum which they then empty when they have a bowel movement. They thus have control of the urinary leaking. Prior to the surgery they had leaking through the fistulas.

 

Issayas: Does FGM (Female Genital Mutilation) make fistula worse? And if so, how?

 

Dr. Mary Lake Polan: Yes, it contributes to prolonged labor sometimes making it difficult for the baby to be delivered. These labors which can last four to five days cause fistulas.

 

Issayas: How were the women selected for the surgery?

 

Dr. Mary Lake Polan: The women who were operated on responded to the advertising in Asmara and throughout the country. They did radio and television advertising. Some patients who have had the operation at the hospital but whose procedures had not worked and they were still leaking urine were recalled by the doctors. Patients were brought in from throughout the country. For example, Dr. Leltti who has been doing fistulas in Keren brought her patients to Asmara.

 

Issayas: Can the Eritrean surgeons now perform the surgical procedures you performed?

 

Dr. Mary Lake Polan: They can now do many of the procedures that they could not perform before like bulbo-cavernosus flap. We had a total of 8 days of surgery. The first four days, our surgeons operated with the Eritrean surgeons assisting. The second four days, the Eritrean surgeons did the procedures while our surgeons assisted them. The Eritrean doctors now can perform most of the simple and moderately complicated procedures. I think they may still need some help on the more elaborate surgery that Joelle talked about.

 

Issayas: Is fistula a major problem in the developing world?

 

Dr. Mary Lake Polan: Yes, it is estimated to occur at a rate of 350 fistulas per 100,000 deliveries. So it is a very high number.

 

Issayas: What other kinds of major gynecological problems in Eritrea need your expertise in the near future?

 

Dr. Joelle Osias: There is a broad range of needs. The doctors that are there are able to perform in terms of basic gynecological care. The immediate needs for now in order to perform the basic surgical procedures would be supplies and other supplementary equipment such as EKG monitor, heart monitor and others. In terms of the more elaborate procedures that need high tech besides needing the equipment and the supplies they need training in using the equipment which will be useful for gynecological improvement for the quality of care in Eritrea.

 

Issayas: Did you get a chance to talk to officials of the National Union of Eritrean Women (NUEW.) to discuss collaboration and prevention efforts to tackle women related health issues such as FGM and others?

 

Dr. Mary Lake Polan: You know, Issayas, I did not. I was not there long enough to make contact with them. I understand they have strong women’s organization in Eritrea. While we were there we took care of surgery for the outcomes of FGM and obstetrics labor. We did not have the time or the resources to address the issues about why obstetrics labor occurs. That, I think, will be the second stage. After you address the basic initial problem, it certainly will be good to try and put in place education and care delivery systems that prevent the formation of fistulas, rather than coming and cleaning fistulas after they occur.

 

Issayas: In the case of fistulas, for example, men in particular and the whole society in general need to be educated. Do you have any plan to work with the Ministry of Health and other government ministries to educate and inform the public? Because, I think, cure should go hand in hand with information, education and prevention.

 

Dr. Mary Lake Polan: We would very much like to do that. We would like to put together an educational package and hopefully we would be able to do using computers and interactive teaching, so that we could teach trained birth attendants about signs and symptoms of abnormal labor and when a patient needs to get to the hospital before she is labored for five days. I did make contact with USAID in Asmara, who are evaluating the entire delivery care system in Eritrea for emergency obstetrical transport system. The report that they are producing is not yet finished, but I am looking forward to seeing it. What they are looking at is what medicines, what equipment, what transportation system is available at every single level, from health station to health centers, to peripheral hospitals to the central teaching hospital in Asmara and how you would define the needs to put some kind of transportation system in place so that a woman could always reach a cesarean section location within six to eight hours.

 

Issayas: Do you have any other future plans to continue helping Eritrean women in Eritrea?

 

Dr. Mary Lake Polan: We plan to make another trip to Eritrea. We first want to see the follow up from these patients. And we need to generate more resources because the way we did this trip was with donor funding from two foundations who we will go back to write the report. When we generate more funding, we would like to return with cardiac monitors. There was an obstetrical patient who came in and was in an emergency situation, and we happen to be there so we cared for her. But this highlighted the basic fact that there are some instruments and some technologies that would be very helpful in the Eritrean situation. Cardiac monitoring is one of them. We would like to be back with a cystescope so that we can examine the bladder while we try to repair it and look at it from inside. I am not sure when we will be back, but we will be going back probably within nine to twelve months.

 

Issayas: Would you like to comment on your work in Eritrea, and Eritrea as a country in general?

 

Dr. Amreen Husain: I had a wonderful experience working in Eritrea and I am hopeful that we can successfully help in establishing a fistula center there. There is a great deal of commitment on the part of the Ministry of Health and the Eritrean physicians to accomplish this. I think that is a reflection on the entire country as well, the attitude that the people will get together to do whatever it takes to get ahead.

 

Issayas: Dr. Polan, any concluding remarks about your work in Eritrea or Eritrea in general?

 

Dr. Mary Lake Polan: You know, Issayas, we had just an extraordinary experience in Eritrea. The physicians, the nursing staff, the anesthetists were committed, hard working, and very well trained. It was also a pleasure to take care of the patients. Everybody made an enormous effort to make this project successful. So we felt very welcomed and much supported by the Ministry of Health, the gynecologists, the nursing staff, the hospital and everybody. In terms of the project, yes, it was a wonderful experience and we feel very good about it. We are now trying to regroup and get some more money and some more equipment. In terms of the country, we all had a wonderful, wonderful time. Actually it was fun. Remember that we were four women and one man and everybody felt safe and cared for. We were able to move around the city and the country with total ease. We visited not just Asmara but also Keren, Hagaz and the markets. The entire experience was wonderful.

 

Issayas: In conclusion, I would like to thank you, for your time, your group -- Dr. Amreen, Dr. Joelle, and Dr. Carol -- for volunteering but most importantly for the life changing experience, both physical and psychological procedures you did for the backbone and lifeline of Eritrea, the Eritrean women.

 

Dr. Mary Lake Polan: You are welcome.

 

For Stanford university campus report see: http://www.stanford.edu/dept/news/report/news/october30/eritrea.html

 

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