I have just returned from Dar Es Salaam in Tanzania where I have been working with the women on the Fistula Ward of CCBRT hospital (Comprehensive Community Based Rehabilitation in Tanzania). I felt very privileged to be accepted as I was, with sketchbook in hand, on the ward.The experience as a whole was challenging and I would go so far as to say life changing. The culture ‘shock’ was so profound that I found myself having to redefine many of my perceptions of what it is to be – let alone what it is to be ill.  The project is deeply affective and I and here follows a post from my wordpress blogsite for the Drawing Out Obstetric Fistula project. Please feel free to check it out as there is a lot more information and visual work there about the project as a whole.

Operating across the cultural divide

DSCN0271The theatre clothes are the same but the environment is very different. I feel strange as I enter the operating theatre at CCBRT, a room not unlike those I have been in in the UK but equipped quite differently.

The most obvious difference was the type of operating table. It was shorter than usual and could come apart in the middle so that the patient lay supported only up to the hips with her legs in stirrups. This was a fistula operation.

The first patient is already on the table having had an epidural to numb everything below her waist. She is to be fully conscious throughout the procedure. Her notes show that she has a very small fistula which it is hoped will be easily repaired. She is a young girl barely into her twenties and she has had four deliveries already, all still born. The operation begins after the anaesthetist repositions the table so that the patients head is now lower than her hips. The surgeon inserts a speculum into her vagina and locates the fistula. I am invited to come close and see for myself, and the surgeon explains the procedure to me every step of the way as he gently and carefully cuts around the fistula and brings the tissues over it to cover the opening. The patient remains silent and very still even in spite of the anxiety and fear she may well be feeling. She coughs obediently when asked some way through the procedure.

All is going very well. There are two surgeons now and the nurses attending. Everybody seems to be very pleased as the fistula is repaired and the last is stitch cut off but then, a problem appears, urine is still leaking into the vagina. The two surgeons work quickly and accurately together to find where the second fistula must be. It is deep and there is nothing they can do vaginally. The patient will need a second, abdominal operation.

The second patient walks into the theatre. She looks afraid, confused by the strange surroundings. She is helped onto the operating table and asked to sit up, she is to have an epidural, and injection into the spine. She sits obediently, her face now expressionless. When the needle enters her spine I watch for a reaction, but she doesn’t flinch, her expression doesn’t change at all. She is lain down on her back and her feet are put up into the stirrups. The surgeon goes to talk to her, just a greeting I think and some reassurance. She murmurs a response but does not meet his gaze and on returning to me he lets me know that “they are unused to people talking to them. They don’t know how to react.” I feel that this might be a little harsh considering the situation that the girl is in, semi-naked and strapped to a bed that is so angled that she is virtually upside down. Holding a conversation with anyone, let alone a white man in authority, is clearly the last thing on her mind.

The operation begins and it becomes clear that it is going to be problematic. Once the surgeon inserts the speculum and opens up the vagina to view the extensive scarring in the tissue becomes obvious. This ensures that the fistula, although easily located is difficult to close because of the lack of elasticity in the surrounding tissue. The surgeon works quietly and confidently. Through his years of experience he has developed the impressive precision and delicacy of touch that is obviously necessary in such an operation. There is lots of bleeding and the second surgeon continuously mops it up using the swabs that I saw the women folding just the other day on the ward. They fold hundreds of these light textile squares which are then sterilised for use in the theatre.

The operation continues for a long time but there is never a sound or movement from the patient. Only at the end, when the table is once more flat and the straps are taken off her legs does she ask for water. The surgeon looks tired, it was a difficult operation but he is not unhappy with his work.

There are two more women waiting outside.