The Dutch doctor and the river spirit

Dr Kees Waaldijk operating
Dr Kees Waaldijk operating (© Eric Beauchemin)

In Africa, some 2 million women have VVF or vesico vaginal fistula, a condition caused by prolonged labour. According to Dr. Kees Waaldijk, a Dutch doctor who works in northern Nigeria, “these women are shunned even more than leprosy patients.” In Africa alone, between 1.5 and 2 million women suffer from the condition. No one knows how many women never reach a medical centre and die in the bush.

Original broadcast: March 6, 2002

Photos: Eric Beauchemin

Transcript

Radio Netherlands presents “The Dutch Doctor and the River Spirit”. The programme is produced by Eric Beauchemin.

It’s nice because they have nice voices and the lead singer sings a few lines before and then the pack comes after them. Well, the basic thing is that they sing, that they have this fistula problem and that they were outcasts and that they didn’t know where to go. They heard about the tall doctor whose living on the way, on the road to Batsari. If you go there, he will cure you. They sing that Allah may protect this doctor, may give him a long life, and that he may perform many, many operations, that Allah may protect against armed robbers and car accidents and all evil things in life. They sing that in every centre where we come. They always sing it when I come back from leave, always, always, always. They’re waiting there and we have to tell them to stop because they will sing because they are very happy I’ve returned.

The tall doctor on the road to Batsari is Dr. Kees Waaldijk, or simply Dr. Kees as he prefers to be known. Three decades ago, he arrived in northern Nigeria to set up a leprosy and tuberculosis care and control programme. But his life changed in 1984 when he came across a case of VVF or vesico vaginal fistula.

That means that there is an abnormal connection between the bladder and the vagina and this results in the fact that the woman is not able to hold her urine because it dribbles out of the bladder, uncontrollable. The cause of this is in Africa, it is obstructed labour. Since there is no real obstetric care, this labour may last for a week. And in this case, the hard skull of the infant is compressing the soft tissues of the woman against her pelvic bones and then the blood supply is interrupted. If this condition lasts longer than three hours, the tissues in between die. So this tissue will sloff off and give an abnormal hole between the bladder and the vagina. And what happens to the baby? Well the mechanism is following: the head of the kid is stuck inside the maternal pelvis for days. Then the infant dies inside the woman and then the head, the largest circumference of the baby, shrinks and then it may pass through the birth canal. So the woman survives for the price of a dead baby and a fistula.

Dr. Rahmatu Hassan Mohammed
Dr. Rahmatu Hassan Mohammed

It’s a condition that affects between 1.5 to 2 million women across Africa. Of every thousand women who delivers a baby, 2 to 5 get a fistula in the process. With the continent’s high population growth rates, the number is increasing rapidly. It’s most common during the first pregnancy, and the consequences are always devastating. In Nigeria, about 200,000 women suffer from the condition. According to Dr. Rahmatu Hassan Mohammed of the Foundation for Women’s Health Research and Development, who works in the the Muslim north of the country, like Dr. Kees, it’s mostly girls who are affected.

These are young girls who are illiterate, who have no means of income, who were at the mercy of their parents before they were married out at the age of 10, 11, 12. And now got married and they had a year or two of marriage, marrying somebody they never knew before. They didn’t court the husband. They just found themselves arriving at the doorstep of this man, they became wife. They became pregnant and they have pregnancy and they have this problem. So what happens invariably is that they have not had a life at all. They have no exposure to the world. So they have this trauma suddenly, so their whole thought is that the world is wicked. There’s no god, there is nothing on earth of use to them. The world is nothing to them. To them, life has been unfair.

Dr. Kees carries out 1500 VVF operations a year. He’s “repaired” – as he calls it – 16-thousand women, since he began doing these operations in 1984. I joined him for a day at the VVF ward at the Murtalah Mohammed Specialist Hospital in Kano. Even though it’s the largest city in northern Nigeria, the power supply is erratic and the hospital often has to use an electric generator.

The first operation for VVF was described by a Dutchman and his name was Hendrik van Roonhuizen. He described this thing in 1663 in his book “Aandoeningen der Vrouw”, and I’m very proud of it actually because the strange coincidence is that we’re both from the same city: Amsterdam. So it looks like a Dutch tradition is being continued by me and I think that is in line with what I like. It is not sure if Hendrik van Roonhuizen ever performed an operation because this has not been documented, not been described. I think he must have done one or two because it’s difficult to describe an operation, I think, if you’ve never performed one. I think that is the case, yes.

Vesico vaginal fistulas are believed to have existed for as long as human beings have been around. The first evidence was found in a 4-thousand year-old Egyptian mummy. Until the middle of last century, VVF was quite common, even in the developed world.

It is from the United States that the fistula repair started. It was a man called James Marion Sims who described the technique and perfected the technique in 1865 or 56, I’m not sure about that thing. From that time he was very well…became very well known, and the first fistula hospital in the world was opened in 1860 and in New York City, and this hospital was closed down in 1950 because there were no more obstetric fistulas in the United States. They were able to establish a network of obstetric units, evenly distributed throughout the country where at any time, day and night, an emergency Cesarean section could be performed for any woman who had an obstructed labour. EB: And was that also a problem here in Europe? It was the same problem in Europe and I think the last obstetric fistula in Holland – real obstetric fistula – was seen in 1952.

Until medical care improved, women in the industrialised world had to rely mainly on midwives. In Africa and much of the rest of the developing world, women still depend on traditional birth attendants with little or no training.

We did a small survey. It turned out that the majority of the traditional birth attendants started when they were 55 years old and that none of them had any form of education. So it is more that they had been with a lot of deliveries, that they were respected women in the society, but professionally speaking they didn’t know a single thing. EB: So basically women are on their own? Basically the woman is on her own. Yes. And I think the mother is with them and the grandmother and then the traditional birth attendant. And then they all wait or pray to Allah that a child might be born.

One particular case remains etched in Dr. Kees’s memory. The victim was a 17-year-old girl who had already gone through the trauma of two still births.

The third time she started to deliver, she was walking around in the field for two days. On the third day, the head of the kid was born, but she had lost all strength and she could not expel the baby. Then they called for the medical person in that village, but he said he couldn’t handle it. Then they organised a donkey to transport this woman to the road. But since the head was in between her legs, she couldn’t sit at the donkey, so one of her brothers mounted the donkey and carried her in his arms to the main road. I think this lasted three to four hours on walking, walking the donkey, the whole family with it, and the woman in the arms of the man. On arriving upon the main road, they had to flag down a taxi. But that is always the problem with taxis. When they see that there is something not very kosher, the price increases or they don’t stop. So then after some time, they were able to get a taxi, but the woman could not sit in the taxi. So the mother entered the taxi, some passengers had to leave, and then she was half hanging in the arms of her mother in the taxi, and the taxi brought her to the hospital and then upon arrival at the hospital, the doctor came, pulled out the child, and everything was OK, except for the fact that during this long process, she had developed an obstetric fistula.

Young women waiting for a fistula operation
Young women waiting for a fistula operation

You see there is a wrong feeling in Europe and the United States that child birth in Africa is, well is a very simple thing. You just sit or squat behind a tree, you push one time, the child is out. Well, that is not the case. Unfortunately that is not the case. Because there are so many problems with child birth and specifically with the first child birth because this is the test case, that by tradition, because there are so many problems coming, that with the first child birth, the woman goes back to her parents’ house to deliver. Because so many children die either at birth or in the first week. And that’s a very high figure – that’s 10 to 20%. If we tell that in Europe, people are horrified. So they start leaking urine mostly in the parents’ house. Then her husband hears this and then he starts saying, well this is not in his family. There must be something rotten with that woman, either she’s not hygienic enough and in fact she’s diseased, etc., etc. So then he does not turn up to pick her up and to have the joy of a new baby arriving, because the baby is dead. There’s nothing. There’s nothing to count for. Only a woman that is smelling like anything.

It is believed that they have offended the gods of the river or something like that, all sorts of things. It might be she stepped of the eggs of a gene and the gene is now annoyed. EB: What’s the gene? Is it a spirit? Gene is a spirit, the spirit of the river. So in some cases it could be, they would say might be the mother was promiscuous when she was pregnant with her and this is the result or it may be a curse from a co-wife or somebody the family must have offended. And of course invariably it’s always the mother’s fault. It’s always the maternal side of the parents that are at fault. So this is the reason why…they don’t normally go for medical treatment until they’ve roamed around and around, looking for all sorts of ways to appease the spirits that must have caused this problem.

And then the neighbourhood starts avoiding that house as well. I know cases where a woman had a VVF, an obstetric fistula, and her parents had a small restaurant in. But nobody came anymore to the restaurant and those people were jobless. They had to close down the restaurant. EB: And it was simply because she had VVF. Yes. People associate this with abnormal sexual behaviour, with sexual infections, etc., etc., etc.

The husband divorces the girl, invariably girl, sometimes women. And she goes to her parents’ house because culturally chronic diseases are taken care of by the parents, not by the husband. So she now comes home and nobody thinks it’s a health problem. Nobody takes them to the hospital or they look for means of taking their children to the herbal people, the local doctors to relieve them of their leaking. So in the end, they even get fed up of spending their money on her because of course they have other children. So now the girl is also driven out of the house because of her smell. Even the parents get fed up.

Dr Kees Waaldijk operating
Dr Kees Waaldijk operating

The problem is in the social consequences. Because when you start leaking urine or faeces through your private parts, there are no hygienic pads or anything like that in Africa, so anybody can see it, but what is more important, anybody can smell it. If nothing is being done, the woman is ostracised first from the community and in the end from her own family as well, and this is the tragic part of the obstetrical fistula patients. They become outcasts. Since I also work already for the last 30 years on leprosy, I can say that the obstetric fistula patient is more an outcast than the leprosy patient. EB: Is it simply because of the smell? Yeah, the smell… They are still attractive, and people still want to do something to them, but to live with somebody…you see, you cannot stop this dribbling of urine. It’s dribbling 24 hours a day, day and night, every second some urine comes. The women is highly intelligent intelligent and she noticed that when she drinks little, she will leak little, but if you drink little, the urine becomes concentrated and starts smelling even more than when it’s diluted. Anybody of us – if you’re a European, American or African – we do not want to sleep next to a woman and getting wet by her urine all the time, and by the smell. EB: So where do the women go then afterwards? They end up on the street and as beggars and as low cost prostitutes because they’re highly attractive and the men do not mind to have sex with her because that’s over in a couple of minutes and that’s different from sleeping next to her. So when they’re young, they’re still attractive, so they can get males to, for their survival and then they start begging. And many times very aggressive begging because I know women who go to shops, pull up their skirts, and say start smelling in the middle of shop, and they say we need money for our treatment. So it’s very aggressive begging.

That was a terrible thing because this woman was 65 years old, minimum, and she got her fistula when she was 15 years old. So this woman had been leaking for 50 years. And it was not a very difficult fistula. I operated once and she was healed. And then the woman was actually very angry because she said, look, I am having this thing for 50 years and I didn’t know where to go, nobody told me it can be repaired. So I wasted 50 years of my life, and I think she was very right. Because it started when you’re 15 and you have your whole life in front of you. And it was wrecked, and I was deeply touched by what she said, but she was right. EB: And you fixed her in 15 minutes. Yeah, no, something like that, 20 minutes or something like that, yes. It was a simple, a very very simple operation, very simple operation, and I think that’s terrible.

Late one morning in a compound near the Emir’s palace in Kano, a group of women pound cassava for lunch. Among them is 20-year-old Rifkatu. 5½ years ago she got a fistula. It wasn’t her first pregnancy, but she’s not sure whether it was her 2nd, 3rd or 4th. After two days of labour, she was finally taken to hospital only to discover that the baby had already died inside of her. But then the real nightmare began: she started to leak.

20-year-old Rifkatu Ibrahim
20-year-old Rifkatu Ibrahim

It started immediately after she delivered. EB: Did your husband stay with you? No, the husband divorced her. EB: Who did you go to live with afterwards? I stayed with my mother. EB: What happened to your children? Did they stay with your husband or did they come with you? All of them died. Only one, one is alive. And that one is staying with my mother. She will stay here for at least a month before the operation. EB: Do you think that once you’ve been operated on that you can go back to your husband? I will not go back to my husband, but if I am OK, I will marry another one. EB: Why won’t you go back to your husband? That one is not prepared to take care of me when I sustained this VVF problem. You expect me to go back to the matrimonial home?

Like the other hundred or so women in this rehabilitation centre, Rifkatu is learning how to read and write. She’s also getting vocational training and when she leaves, she’ll receive a credit to start her own business, the dream of many poor African women. Dr. Rahmatu Mohammed of the Foundation for Women’s Health Research and Development runs a similar scheme for girls and women who’ve been through this ordeal.

Shelter for VVF patients
Shelter for VVF patients

They go back to their villages with empowerment. They now have income because we give them some revolving loan. They have income because they have learned so many trades. They’ve learned how to make soap, how to make pomade, how to knit, how to sew, how, actually learn how to read and write! They now go back to their villages. And before they even heal or graduate from our centre, you see the husbands who have abandoned them now hears that they are in a place where they are healing, they come. So they always go back to their villages with some sort of status, prestige, to teach other women what they have learnt and then to buy and sell and be human beings themselves.

It took roughly 100 – 150 years to set up a network of obstetric units in Europe and the United States. And I think the same is possible in Africa and from now on it will take at least 150 years before we are able to set up the same kind of network for obstetric units throughout Africa. EB: But that would require an enormous amount of money. Yeah, an enormous amount of money, because I think for this network, there are some 20,000 obstetric units required throughout the inhabited parts of Africa, and then you have only half the coverage we have the United States or in Holland or in England. So how much would that cost? I cannot predict that because the building is the cheapest. But you need not one gynaecologist. You need at least 3 because they have shifting duties, anaesthetists, blood bank, fully equipped, so this is an enormous amount of money.

I am really of the opinion that I’m running a public health programme. Now this was one of the major problems in getting funding for the project because if you approach people like the Dutch government or the United Nations, they say, no, this is surgery, this is cure. We’re not willing to give you funds because we only are funding prevention. Well, I explained to them there are a couple of types of prevention because if we operate a woman very early, we prevent her from becoming an outcast and if she is an outcast, we are preventing her from becoming further down the road. So it is just how you look upon prevention. But it’s a real public health problem. Luckily there are some other organisations in this world as well, and we have a major funding by the Schumacher Kramer Stichting in Amsterdam and the Stichting van Tiel tot Tropen in Tiel of course who told me, Kees, we are willing to fund you in things nobody else wants to fund you, and I am very grateful to those people. Without those two foundations, I could not work.

Dr. Kees is employed by the Nigerian Ministry of Health and one of his main responsibilities is to train African medical personnel to treat VVF patients. So far he’s trained over 150 doctors and 150 nurses.

I am a documentation freak, because I’ve…all my operation reports since I did my first one – that must have been somewhere in 1970 – I have them all. And I’m really a bit of a documentation freak but it also had to do with the fact that a lot of people think that doctors in Africa are of low standard and of low documentation because many people say, OK, this man went to Africa because he couldn’t work in Europe properly. And I don’t think there’s anybody who has this documentation in the whole world, not even in the big universities, not in the United States, not in Europe, nowhere. It’s really very extensive documentation, operation reports written on computer. I have more than 35,000 colour slides of my operations. I have video clips, I’m not going to say clips of my operation reports. I use this for scientific purposes. I set up studies in a prospective way, so if I think we have a new operation technique, I say OK, from now on we have to look at this and this factors, and then after some time, I have to find out if that is true or not.

We as surgeons don’t have all the facilities we have in Europe, but if you make your work interesting, it stays interesting. And I must say I’m intrigued and…I’m really intrigued and obsessed by this problem. If I really look deep inside in myself, I say no, Allah made me come to this world for the VVF. This is how I look upon this thing. And I think this is a good feeling, good feeling, yes, good feeling.

“The Dutch Doctor and the River Spirit” was produced by Eric Beauchemin. This has been a Radio Netherlands’ presentation.