Hi. My name is Cat Norman. I am the photographer in this picture with one of the VVF patients, Yah G. I’m working on this website for you, and most of the stuff in here will be seen from my perspective, as that is how I witnessed it. In this website, I will continue tell the stories you read about in the brochure, introducing you to more of the women and keeping you in the loop with further efforts to offer surgery to the women of Liberia. Be patient with my writing as I express my emotions, my heart for the women that I met, and my concern for the hundreds and hundreds of women who are still suffering from complications they experienced in childbirth years ago.

So check back from time to time to read new posts or email globalhealth.info[at]vanderbilt.edu for more specific information about how you and your church can continue to partner with Ganta United Methodist Hospital.

We’ve just completed a brochure that gives a few of the stories of the medical trip to Ganta United Methodist Hospital in Liberia. Most of you are probably at this site because you read this.

If you didn’t get the brochure, and would like to read it, you can download all four pages here: Ganta Brochure

To see the faces of women who received surgery on this trip, please click on the picture of Elizabeth above.

A fistula is a hole. This hole develops over many days of obstructed labor, when the pressure of the baby’s head against the mother’s pelvis cuts off blood supply to delicate tissues in the region. The dead tissue falls away and the woman is left with a hole between her vagina and her bladder (called a vesicovaginal fistula or VVF). This hole results in permanent incontinence of urine. A majority of women who develop fistulas are abandoned by their husbands and ostracized by their communities because of their inability to have children and their foul smell.

Numerous factors contribute to the development of VVF in developing countries. Commonly, these are areas where the culture encourages marriage and conception at a young age, often before full pelvic growth has been achieved. Chronic malnutrition further limits pelvic dimensions. In addition, few women are attended by qualified health care professionals or have access to medical facilities during childbirth; an obstructed labor may be protracted for days or weeks. In developing countries, the predominant cause of VVF is prolonged obstructed labor (97%).

The magnitude of the fistula problem worldwide is unknown but believed to be immense. The World Health Organization estimates that approximately 2 million women have untreated fistula and that approximately 100,000 women develop fistula each year. In 1991, the WHO identified the following geographic areas where obstetric fistula prevalence is high: virtually all of Africa and south Asia, the less-developed parts of Oceana, Latin America, the Middle East, remote regions of Central Asia, and isolated areas of the former Soviet Union and Soviet-dominated eastern Europe.

If you’ve still got questions about VVF’s, the Fistula Foundation has put together a great FAQ page.

Direct information from the following sources:
eMedicine from WebMD (http://www.emedicine.com/Med/topic3321.htm)
Fistula Foundation (http://www.fistulafoundation.org/)

Very brief history: It was founded in 1821 when white Americans sent free blacks back to the Western coast of Africa. In 1989 the country erupted in a Civil War that lasted until 1997. Two years later, another Civil War began that didn’t end until 2005.

Liberian people suffered greatly during wars – no family went unaffected. Violence and rape sent people running into the bushes in fear and many fled the country. Medical care became almost unattainable during that time as hospitals switched hands and clinics shut down. Ganta United Methodist Hospital’s operations were changed during the war-time like most everyone else. Even today, three years later, the hospital is still trying to recover. (See the picture below I took of a bullet casing still embedded in the front wall of the hospital.) Though there are not specific statistics, there is no doubt that the war had some affect on the instance of VVF in Liberia. A VVF can easily be prevented with adequate access to healthcare, namely a C-Section during obstructed labor. But when there is none to be found, women were left to guess at problems with their midwife as the baby dies in their belly.

Ganta is in Nimba County in the northern part of the country. The women heard about the doctors coming for this trip through a radio announcement. Almost all the women who received surgery were from somewhere in Nimba County (one was from neighboring Guinea), even though it still took several of them three to four days to get to the hospital. The resident doctors at Ganta United Methodist Hospital have noticed the need for VVF repair in their area but lack the time and resources at this time to really tackle it head on. Our team that came from the States in June helped train nurses there, offer free surgery to patients who could not afford the surgery (all of them), and assist the resident doctors.

I am a fairly sensitive person when it comes to pain and death. I just about can’t watch someone else hurt – even actors in a movie. I hurt so much for them that I just about burst.

I’ll tell you in another post about the emotions surrounding the cesarean section that I photographed, but I wanted to first share some other hard aspects of being in a bush hospital and VVF repair. Below are four photos, three stories, of times when my emotions were churned.

Yei, age 57, came to the hospital with a VVF like all the other women. Post-op, she, like the other women, had abdominal pain. She complained of this much more than the other women, but what can you do in a hospital where a Tylenol equivalent is about the strongest pain medication they have available? She had just had surgery, so pain was no rarity. After a few days went by, the hospital’s surgeon Dr. Willicore decided to operate for a possible bowel obstruction. Once she was open on the table, they realized that it was in fact a ruptured appendix. They took it out, but later that night, after the surgery, Yei passed away. The surgery had come too late

At a bush hospital, they can’t do imaging like we can here in the States. They can only go on symptoms and feel and educated guesses. Women at her age rarely get appendicitis, and the clearest symptom could have just been VVF surgery related.

Hear Dr. Nathan Webb relate his experience with Yei: About Yei

Amelia, 31, came in with her mother Dororthy, 50. Both of them had VVF’s from complicated pregnancies. Both have incredibly small bone structures which most likely played a big role in their complications. Even though the mother had lost a child and developed a VVF, she didn’t seek the proper care in time when her daughter developed the same complication in pregnancy. They said they couldn’t afford the medical care. Dorothy had a fairly simple VVF, and healed quickly after the surgery. Amelia’s was much more complicated. She experienced a lot of post-op pain, and, as I’ve mentioned, got no great pain killer medication to help her with it. The success rate with the 42 surgeries the team did in Ganta was about 75-85% – which is great for this type of surgery. Amelia was unfortunately part of the 15-25%. She continues to leak.

I got a good couple portraits of one of the older VVF patients, Yah P., on the first day I went out shooting. She was out walking around, pre-surgery, full of hope and happy as an old Liberian woman can be. Her surgery was a bit different than a typical VVF and a sling was inserted to help her continence increase. I few days later, I went to the ward and she was sitting on her bed in tears. She was still leaking urine. Even though the doctors and the nurses tried to explain that her specific surgery took longer to heal, and that it was still too early to know, she would not be consoled. Her hope was gone.

It was quite sad to see. The women come in with such hope. And in a few cases, there is little that the doctors can do. In MOST cases, the women go home dry and overjoyed, but with Yah P., it was still too early to know. I don’t know even know if she finally healed or not, but I know that she was finally consoled somewhat, and we left her smiling.

There were so many emotional ups and downs connected to the healing process at a hospital. In these next two posts, I’m going to try to let you in on some of those.

Tories, 27, was one of the most out-going of the patients. She was a real leader with the others, showing them how to carry their bucket the best way and sharing her bed with another girl. When I interviewed her, she told me, “If I have the time after I leave here, I am going to be dancing and beating a drum because I have been healed and restored to good health once again.”

At the closing ceremony, she gave these words on behalf of the patients:
“I am very happy for the team and I pray that when they go back, they will think about our sisters who are left behind, that they will extend the same helping hand to them. The surgeon who works here cannot do all the surgeries alone – there are so many. Please come back to assist him to heal others too. When you have this problem, you have no relatives, no husband, no friends; you are neglected by society. People insult you. So we want our sisters to be like us, we want the Lord to restore their hope, for them to be healed. Thank you very much and may God bless you. We look forward to the next team who will come.”

One day, I was taking pictures in the ward and I noticed some commotion in the corner… Apparently a nurse had come in to move a girl to the Adult Ward to clear space on the beds for new VVF patients. None of the girls was willing to move to the other ward away from her ‘sisters’ in the VVF ward. Finally the girl grabbed her stuff and moved in with the girl in the bed next to her, determined to share a single bed rather than move down the hall to the other ward. A few days later, at least eight girls were sharing beds. No one had to move. I loved seeing this community develop. Most of the women with VVF’s lost their friends, family, and lovers due to their condition, so losing their new friends down the hall was just not going to be acceptable for them.

I loved seeing the hope and joy that the girls went into surgery with. While in the operating room, Kou, age 28, just could not stop smiling for the camera. Granted that she was numb from the waste down, but she was just so happy to be there. So joyful at the hope of being healed. And she was. She went home dry.

One day while we were there, I photographed a Cesarean Section (CS). I wanted to tell that part of the story – seeing as a lack of a CS when needed during a troublesome pregnancy is the cause of most VVF’s. Or, in a lot of cases, the CS is too late. For almost all women who develop a VVF, the baby is dead by the time a CS is done. I got a bit more than I bargained for though. I sat for the first half of their cutting and digging on a stool in the corner trying to fight off fainting. Then, when they finally got to the baby, it appeared to be dead and they had some trouble pulling it out. It was a good many months premature and they didn’t expect it to live when they went in, but I didn’t really realize all that. I just knew the mother looked too small to be ready. So I bolted after the baby made the hand-off to the nurse, still trying to recover from the emotional jolt and the general wooziness I feel around blood, needles, and pain anyway…

Apparently my dad, Dr. Norman, resuscitated the baby in the next room while I was bolting. So it was alive post-op. However, he spoke realistically about the fact that a premy that small didn’t stand much of a chance living over a week in a hospital with no facilities to care for babies that small.

Kind of a downer. I haven’t even seen a ‘normal’ birth or CS before.

I took a short trip to one of the villages to show, as much as I could, a sample ‘home’ environment for the women who came for VVF repair. It was lovely to sit with the women in a brick hut, coated with mud and decorative paint. See the picture above to get an idea of the community that these women live in.

While in the village, during a medical health survey, one of the women above admitted to a “very uncomfortable” vaginal health issue. As I understood, she has not been to a hospital. The instance of medical problems for women in Liberian villages is NOT uncommon. But financial concerns and shame keep the women silently suffering.

Florence is the brightest and happiest VVF patient here. She’s a 25-year-old girl with a bad limp from polio and has been suffering from a fistula for five years. Originally the doctors thought that she would have to have a hysterectomy in order to repair the leaking, but ended up keeping her uterus intact. Florence is overjoyed. She says she hopes to still have a child, as none of her pregnancies to date have given her a living child.

Florence currently cares for her brother’s children as a nanny. She said this is a very shameful position in her society and she is disrespected by all. She hopes that a healthy child and a loving husband can restore her position as a woman in the eyes of her family and peers.

Also, she is praising God, as now, after the surgery, she is dry.

Hear Dr. Nathan Webb speak about Florence: About Florence

Nathan Webb worked hard on completing informational surveys on the VVF patients while we were in Liberia. The little questionnaire he filled out asks questions like name, age, how many pregnancies has the girl had, how many C-Sections, etc. He does the survey in a private exam room connected to the main ward to respect the woman’s privacy and hopefully get some more accurate responses. Betty, pictured above, age 56, came in for her interview, but, unfortunately didn’t speak very well the dialect the nurse helping us was speaking. They waded through the questions until they got stuck on this one: How many sex partners have you had? After some discussion, finally, someone from the ward screams over the wall in Betty’s dialect: “He’s asking, ‘How many men have you had?’!” Betty about fell off her chair in laughter. Nathan about fell off his at realizing how public the private room was. Ply-wood doesn’t insulate much sound. And, me? I about fell off my chair trying to lean back to get as much of Betty’s face in the photo as I could with my 50mm lens on.

AUDIO

About Betty- Voice of Dr. Nathan Webb

I posted some audio links into a few of the older posts. Find them in the following posts to listen to Dr. Nathan Webb talk about three patients he remembers.

Betty

Florence

Yei

Also, keep an eye out for more audio in future posts.

United Methodist Committee On Relief tells the stories of the VVF patients from this trip to Ganta Hospital on their website. Go HERE to read about it.

If you want more information on Ganta Hospital specifically, they also have a whole section devoted to the other happenings at there. It can be found here.

Vanderbilt has recently completed a new brochure that is very concise and factual about information on the situation of VVF in Liberia. Download it by clicking here: NewBrochure

The first of two multimedia presentations covering VVF repair in Ganta, Liberia. This 3 minute video is meant to be an introduction to a speaker – a short summery if you will. Eventually, I’ll post another video that tells more of the story.

Updated December 2008.

This multimedia presentation is close to 7 minutes and includes a lot more of the story. Please enjoy!

Please make a tax deductible contribution to:
Vanderbilt University “VVF Fund”
C/O Friends in Global Health
2215 Garland Avenue
319 Light Hall
Nashville, TN 37232-0242

Or call (615) 322-9374 for more information.

The Liberia photo story is featured on my new website www.catnorman.com. Have a look!