The Hospital by the River
Author: Catherine Hamlin

Background

This book is a fitting testimony to the inherent value of selfless commitment to improving the lives of the less fortunate. It documents the work of the author and her husband as obstetricians at the Princess Tsehai Memorial Hospital in Addis Ababa; they had only gone there on a three-year contract in 1959 to set up a school of midwifery, but it turned out to become their life work. They were drawn into the relentlessly gruelling work of vesico-vaginal fistula (VVF) surgery and advocacy, a task they passionately carried out in the belief that it was ‘work that God wanted us to do and we were thankful that we so enjoyed doing it’. They saw the care they gave to the distressed young women as a labour of love, the author remarking that ‘looking after them was never a hardship‘. The book’s appeal was enhanced by its detailed documentation of the socio-cultural drivers of VVF, the history of Ethiopia and of its royalty, and the challenges of working in resource-poor environments (pages 1, 2 and 89).

Synopsis

At the centre of the book are the truly heartbreaking obstetric fistulas which made the lives of the affected women a misery. The author characterised the typical victim as a teenager pregnant with her first child whose labour gets obstructed. The foetus then dies in-utero and is expelled, but only after it has damaged and obstructed the blood supply to the tissues of the vagina and bladder, and resulting in permanent urinary incontinence. Rejected by her husband, and shunned by other villagers, the author said the girl is ‘abandoned to her shame…forlorn and alone for months. Or years. Or a lifetime’. The author painted a tragic portrait of victims who are ‘offensive to smell, dressed in rags, often completely destitute‘. She emphasised the tragedy of the situation when she added that ‘these girls and women had suffered more than any woman should be called upon to endure. To meet only one was to be profoundly moved and called forth the utmost compassion that the human heart was capable of feeling’ (pages pages vii-x and 86-88).

To illustrate the real agony and anguish of the girls, the book recounted countless heart-wrenching anecdotes in graphic detail. For example, the first case of VVF the two obstetricians encountered, within two weeks of their arriving, was a seventeen-year-old girl who had given birth to a stillborn child after being in labour for five days. The author said ‘she had suffered a complete breakdown of the bladder, and urine was just pouring out uncontrollably‘. She added, rather gravely, that ‘her husband of course has left her’ and it was her father who carried her to the hospital. Equally symbolic of the horror of VVF was the story of Mahjo whose depression was evident in her downcast eyes and in her sad and hopeless demeanour, and whose wretchedness was manifest in ‘her posture and every gesture‘. Other disheartening anecdotes the author narrated were of the woman who ‘had been in labour for days, her uterus had ruptured, and the two babies were in her abdominal cavity, but with one head delivered’; the woman whose ‘pregnancy had developed out of the uterus to quite a late stage of gestation’ but ‘the baby had finally died and become calcified‘; and the woman who ‘was being attacked by a hyena just as she was giving birth’ – whose ‘thigh and buttocks were badly mauled, and the baby was eaten‘ (pages 58-59, 142-145 and 259).

Many of the stories in the book explored the ‘dreadful complications‘ and ‘horrendous pathology‘ that accompany VVF, and these ranged from keloid scar tissue that may be large enough to completely occlude the vagina, to enormous fistulas that defied surgical closure. The author conveyed the sense of the complexity and severity of such complications with the pathetic story of Leketidane Gebre Yohannes who arrived ‘with a dead baby inside her and a history of being in labour for five days’. A craniotomy, or compressing of the baby’s head was done, and the decomposing baby delivered. Lete’s injuries were severe – a fistula into her rectum and a hole into what remained of her bladder. Most of the bladder had been destroyed and it was reduced to the size of a thimble‘ and she required an ileal conduit operation. The horror of many of such stories was however countered by the sense of gratification that came with curing the victims and watching them ’emerge like a butterfly from the chrysalis’; an evocative example of this was Mamitu Gashe who recovered from ‘shocking injuries to her bladder, rectum and birth passage’, and, being ‘intelligent and quick to learn’, trained to become ‘a confident and competent fistula surgeon‘ herself (pages 51, 127, 216-228).

The practical aspect of treating VVF was a major theme of the book, and the narrative reflected the steep learning curve both obstetricians scaled as neither had seen or treated VVF before coming to Ethiopia. They scouted for information from such sources as Pasha Naguib Mahfouz, ‘one of only three or four living surgeons who had wide experience dealing with these injuries’, and Chassar Moor, who was about to publish a book ‘which would become the standard text on the subject at that time’. The author said they ‘spent numerous evenings reading the literature and discussing the techniques‘, and by starting with ‘a relatively easy case’, they went on to establish their expertise. As a result, more cases turned up at their hospital, and as their ‘reputation for saving lives’ and as the news of their work grew and spread, she said ‘gynaecologists and surgeons from other developing countries came to visit us…to watch and learn our techniques’. To cater for the influx of multitudes of ‘fistula pilgrims‘, they not only sacrificed all their time and most of their salaries, but they also got actively involved in fund-raising for the sake of ‘our poor, neglected fistula patients’ (pages 9-10, 55, 77, 85-89, 110-111, 200-208, 282-290 and147-154).

To complement her autobiographical narrative, the author also provided a very enlightening history of obstetric fistula. She traced its first recognition to the Persian physician Avicenna who described it in his book, Al-Kanoun, and she highlighted the archeological evidence that the Egyptian Queen Henhenit probably had VVF – a situation that gave her ‘the dubious honour of having had the earliest known vesico-vaginal fistula’. The author chronicled subsequent historical depictions of VVF by Felix Platter in Switzerland, and Luis de Mercado in Spain, but she attributed the emergence of successful VVF treatment to the definitive technique introduced by American Marion Sims. She referred to Sims as the inventor of the speculum that now bears his name, and which enabled the repair of VVF. She credited Sims with the ‘the special genius‘ of understanding VVF, and she described how he perfected his repair technique by repeatedly practicing, without anaesthesia, on the slave girls Anarcha, Betsy, and Lucy. She also described how Sims raised funds to build the first hospital dedicated to fistulas, and how ‘he went on to demonstrate his techniques all over the world’, feats that earned him the title of ‘the father of modern gynaecology‘. (pages 77-85).

Opinion

The heart breaking stories that define this book are mitigated by the hope that the author and her husband provided for the victims of VVF. The writing is unpretentious and the tone of humility rings true throughout. There is a tone of conservatism that may seem out of place in the modern world, but the sincerity behind this is genuine. Her uncritical acclaim of Sims was a nadir in the book as it downplayed the fate of the slaves who endured Sims repeated experimental interventions. There was also perhaps a disproportionate, and overly sympathetic, account of the travails of the Ethiopian royal family especially after the coup that toppled the emperor. These flaws however did not diminish the author’s detailed portrait of VVF, and of the social, cultural, and political factors that directly or indirectly influence VVF.

Overall assessment

This book is a celebration of what is best in the human spirit, depicting humanitarianism in its most unalloyed form – that guided by a higher faith. The author’s life and work is a testament to the supreme values of medicine – the fulfilment of the responsibility to lessen the burden of all those who suffer. The book captures both the dignity with which VVF victims bore their suffering, and the selflessness which provided them relief from it. The morals of the book are legion, from dedication to practical work, to sacrificing time and resources for the welfare of patients. The book’s lessons apply to the wider field of medicine, and I recommend it to all doctors

Book details

Publisher, Place, Year:  Monarch Books, Oxford, 2001
Number of chapters: 25
Number of pages: 308
ISBN: 978-0-8254-6071-9
Star rating: 5
Price: £10.99