VVF ladies

I've been feeling increasingly disconnected from the work going on downstairs over the past couple of weeks. Zoe has been sick and I'm pretty sure she's hitting the dreaded four-month sleep regression a little early (it figures that my child would be an overachiever), so my life has been consumed with keeping her happy when she's awake and putting her to sleep without her screaming her little head off. Easier said than done, apparently. I know amazing things are happening down there, but it seems so far away.

The other day I had to go downstairs to pick up some medication, and instead of taking the aft stairs down to Deck Three, I used the forward ones, the ones that would mean I had to walk the hospital hallway before crossing over to the starboard side where the pharmacy is. I'm not ready to have Zoe in the wards yet (we're going to wait until she's had another round of immunizations and is a little older before we let her get passed around among the patients and caregivers), but I just wanted to at least be near the patients, if only for a few steps.

When I hit the telltale green floor on Deck Three, Rebecca, one of the hospital chaplains, was leading a straggling group of VVF women on their customary walk. Catheter bags in hand, they were a ragtag bunch as they shuffled slowly down the hall. When Rebecca saw me coming, she started herding them to one side so I could pass. Enyo, I told her, It's good. Don't worry. Her face broke into a wide grin and we started singing together as I caught up to her.

Enyo, enyo, enyoto
E-enyo.
Nussya nussya Mauwa,
E-enyo.

It's good, it's good, it's so good.
God has done it,
and it is good.

The ladies turned as I passed them, drawn to the sleeping baby on my chest. Their eyes were full of hope and pain and despair and joy, empty hands unconsciously reaching out to her. I slowed when I reached the head of the line, matched my pace to theirs and sang with them as Rebecca started the next song.

Il est la.
Il est la.
Il est la.

Over and over they sang it.

He is there.
He is there.
He is there.

I don't know where their faith comes from. So many mamas without babies, mamas who have suffered the cruelest loss. Zoe nestled her head deeper into my chest as we all sang together and I just don't know if I could be that strong if I had lost her and had my life so horribly shattered.

I reached the aft stairwell, my cue to turn and go about my day. I waved farewell, and as I crossed over to the other side of the ship, their voices followed me.

Il est la.
Il est la.
Il est la.

We put up a curtain in the middle of D Ward today. Split it into two sections. One for the patients, all four of them. Tani and Gafar and Josee and a little boy having his crossed eyes straightened. On their side of the ward it was crayons and bubbles and brightly coloured paper cut into strips so we could each make a rainbow zebra.

On the other side of the curtain the lights were low as a group of nine women sat in a huddle of chairs and stools. They were silent, eyes fixed on the floor, the translator working with them failing in his feeble attempts to bring conversation to their side of the ward.

The only thing connecting the two groups was the smell. It seeped around the flimsy curtain, reaching its fingers into every corner. Stale urine creeps sharp into your nostrils, impossible to ignore. Today, it was everywhere in the hospital. Ladies in beds in A and B Wards, recovering from surgery. More in the Pilot's Entrance, waiting on plastic chairs for their turn to be called. And in C Ward, curtains set up to make little rooms where woman after woman was examined and then sent back to wait. All up and down the corridor they waited.

My little group in D Ward was quiet as the time wore on. Once I had settled my kids on the other side with their latest craft (something to do with styrofoam plates and cardstock feathers), I pulled back the curtain to see them all still sitting, silent.

I asked them through the translator if we could sing, expecting the usual brightening of faces and lifting of voices. Instead, one woman, clad in bright blue and green that belied her downcast face, spoke for them all.

We cannot sing until we know the result of our exams.

I don't know yet either whether or not they'll get surgery. There are two weeks left until the VVF surgeons leave, and there were so many women there today. And because I didn't know either, I did the only thing I could do.

I sang for them.

After what seemed like forever, with my poor wavering voice shouting out words in a language I don't speak, the lady in blue and green joined in, lifting her eyes to meet mine for the first time. One by one, they added their voices, until they were teaching me new songs and we were laughing and finally I couldn't smell the urine anymore.

Sometimes things are good, no matter which side of the curtain you're on.

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In other, completely unrelated news, we're all going to be on TV! Very soon! Wednesday, in fact! If you're in the Eastern time zone in Canada, the Mighty Ships episode featuring Mercy Ships will be airing at eight PM on Discovery Channel Canada. Program your VCRs kids, because none of us have seen it yet and I wouldn't mind hearing if it's any good.

(Granny and Jenn's mom, I'm talking to you.)

The ladies danced today.

To you, that might not mean much. It might conjure up images of women in a club, dressed far too scantily for their own good, gyrating to repetitive beats from over-sized speakers. Here, it is so much different and so much more.

Our ladies are the ones forgotten. I flip through their charts and see their pain in black and white on their screening forms. When was the pregnancy? The answers vary. Five years ago. Seven. Fifteen. The baby? Stillborn. Stillborn. Died within one week. Very seldom is alive circled, and these women have carried their sorrow like a cross pressing heavy on their shoulders. Do you leak urine constantly? Yes. Yes. Yes. And with each yes, another reason to stay hidden, another board across the window and so daylight barely reaches their souls.

But today they danced.

Five of them gathered in an empty ward, a tray of makeup on a bed in the corner. Each woman donned a brand-new gown, the fabric still stiff with wax, the colours vibrant against their dark skin. Around their necks handmade necklaces, jewelry crafted while those of us not cursed to live apart whispered words of hope to their upturned hearts. Loving hands wrapped and re-wrapped headdresses, fabric formed into peaks that nearly brushed the low ceilings of Deck Three when they stood to admire themselves.

One by one, we held up the mirror. One by one, the women gazed into it, seeing, maybe for the first time in five, seven, fifteen years, their own beauty. Eyes bright with hope. New cloth unstained with urine. The chairs dry under their legs as they sat and stared.

I didn't have a chance to sit in B Ward while they danced, while they told their stories of joy and triumph. But I was there while they prepared. I was there in the quiet moments while they breathed deep and composed themselves before taking the stage in front of nurses and doctors and sisters still in bed, catheter tubing running from beneath blankets, hope growing with each hour that passes dry.

I was there. I felt the grip of arms thrown around my neck, the softness of freshly-combed hair against my cheek. I saw the smiles, first hesitant, but gaining strength the longer they looked at themselves, transformed. I shared in their joy and could not begin to understand the pain that made it so unbearably sweet.

For all of this, I count myself blessed among women.

It's funny, really, that I thought moving to D Ward would get me further away from the VVF ladies. Like I said, it's not that I dislike them or anything, it's just that I'm not the best at caring for them; little people are more my thing. So just imagine my surprise when the sheet of paper on my desk this morning listed sixteen of those women, all crammed into C Ward, the little-used ten-bed ward which also falls under the domain of the D Ward charge nurse. Sixteen, plus a caregiver and two babies; the ladies were sleeping in the AFM version of bunk beds, one on top, another on the mattress underneath.

The first thing you notice when you walk onto a ward full of pre-operative VVF women isn't that the place is inevitably overflowing with bags and blue pads and bathrobes. It's the smell. It hits you a little like a slap in the face, the stale urine flowing from broken ones, and it's impossible not to notice it. But there's more; there's always so much more when it comes to these women.

I waltzed through the room with a bucket of toothbrushes and couple of tubes of toothpaste and was greeted with smiles and handshakes and a shy arm around my waist as I passed between the beds. I checked name badges and made notes of surgery dates, realizing with a thrill of joy that every woman in the ward had been scheduled. In talking with the coordinator later, I learned that all but three or four of the women who came to screening yesterday received a date for surgery.

Fifty-five women were scheduled. It seemed crazy to us when we prayed it, but we've been asking God to send only the ladies who needed surgery to us. And that's exactly what He did. So when I wandered through C Ward, all I saw was hope. Not a single downcast face, just pure, unadulterated hope shining from their eyes as they held out their hands for a toothbrush.

We make such a big deal about the VVF ladies around here, praying and planning and waiting for their arrival. We use dedicated nurses and a dedicated ward and everything about their care is specialized. Which, at the end of the day, makes so much sense to me.

These women have been given nothing by the world. They have spent, some of them, entire lifetimes shut out of society, unable to go out in public because of the telltale wetness they leave behind. They have been devastated in every sense of the word. And then they come to us, and we sing them welcome, providing soft mattresses and loving arms to help them into bed. We look them in their eyes and tell them of Love, and they respond with the joy I saw this morning when I handed out toothbrushes.

So maybe I like them after all.

I know I've already mentioned how busy we are down on the wards. We're so close to the end of the outreach, and it's the time when we're faced with the reality that if we don't do the surgeries we've planned, they may never happen. Every morning, when we meet to decide who will be admitted for the day, we're holding lives in our hands, trying to weigh futures against the already-bursting wards. Suffice it to say, this is not my favourite time of year.

But in amongst all the heartbreak, there is joy. I was working in B Ward this morning when I heard the drums start to pound in A. Four of the VVF ladies had come back to dress in fine, new dresses. They had come to put on makeup and string necklaces and bracelets. They had come to dance, because they were dry.

In the midst of the celebration, I needed something from the desk in A Ward, so I tried to quietly sneak in and out. One of the disciplers called me to the front of the room. Sis Alice, you will pray for one of our women. You will present her with her gifts.

I tried to say no, to go back to my work, but when I looked at the bag she was holding out to me, I realized how foolish it would be to pass up the opportunity. I took the package and looked over to the ladies, four women in all their finery, sitting proudly in front of a room of people where only weeks ago, they didn't dare to show their faces in public. On the far left I saw the beaming face and wiggling eyebrows of one of my favourite ladies, Irene. I headed to her chair with my gifts and my meager French and I tried to explain what I was giving her.

Scented soaps, so she can wash and know that, in Christ, she is clean. A Bible, so she can study the word of God. A mirror, so that she can know how beautiful she is. She grabbed me around my neck, planting a loud kiss on my cheek, and we bowed our heads together to pray. I prayed in English, but she seemed to know what I was saying, inserting loud Amens! when I asked God to give her joy, to make her a testimony to her village.

And then I slipped back out. Back to the relative quiet of B Ward and back to the endless work that waited for me.

Much later, around eight in the evening, when I was finally finishing up some extra paperwork that needed to be done yesterday, I stopped in D Ward on my way back to my cabin. There in the corner was a familiar face. Anicette and her mama have been Mercy Ships fixtures this outreach, spending long months on the wards and in the Hospitality Center. Ani was far too small for surgery when she first came to us, malnourished because of her cleft lip and palate. But under the watchful care of our feeding program, she's gained ounces and pounds.

Today, when I went to her bed to give her mama a hug, little Ani's lip sported some sutures, the steri strips over top of them making a smooth, unbroken line. She gazed up at me with her big dark eyes and held tight to the finger I offered. Her mama, Zenabou, called over another patient's visitor and relayed a question to him in Fon that he then asked me in French.

Is she beautiful?

My heart shattered into a million pieces, thinking of all the patients on the wards right now. All the VVF ladies, all the little kids with crossed eyes and huge tumors and burn scars. They all just want to know if they're beautiful, and so I answered for all of them. For Irene and Bidemi and Belvida and Pascaline. For Anicette.

Oui, elle est belle. Hier. Aujourd'hui. Demain. Elle est belle.

Yesterday, today and tomorrow. They are all so beautiful.


(Photo by Meg Petock.)

There are some things I take for granted. Until today, I didn't realize that the act of flattening cardboard boxes was one of them.

I was sitting at the desk with my back to the patients today when I heard a woman exclaim in surprise. I turned around, expecting to see something dramatic, but all that met my eyes was Lindsay, who was in the middle of putting away the supplies that had just been delivered from the hold. She held in her hands a flattened cardboard box, and the patient in Bed 9 looked like she was about to faint from the sheer wonder of it all.

We started laughing, and Lindsay slowly pushed the box back into its original form, folding the tabs back together to make the square. Eugenie, the lady in Bed 9, stared, her eyes as wide as the moon. She shook her head and looked to her neighbours for support. Robbed totally of speech in her amazement, she asked with quick, birdlike gestures of her wrinkled hands whether they had ever seen something so incredible.

By now, the patient in Bed 8 had started to giggle. She, apparently, had seen this trick before and wasn't quite so flabbergasted. But Eugenie was still totally mesmerized, so Lindsay flatted and re-folded the box several more times while the little old lady's astonishment grew by leaps and bounds.

We couldn't keep something like this to ourselves, naturally, so we called another one of our friends over from the other ward to join in the fun. By this point, unfortunately, Eugenie had had about as much of the magical box as her little old heart could handle. As soon as she saw Lindsay coming with her big square of cardboard, she laid herself flat down and pulled the covers tightly over her head, only re-emerging when she was certain the danger was past.

We figured maybe she just needed to start out small, to overcome her new fear of magical boxes, so I scrounged up the smallest little container I could find. I brought it to her bedside like a peace offering, planning to show her that, indeed, she too could flatten and re-fold boxes. She grabbed it from my hand, and smacked me with it. And then she threw it across the room. Eugenie, it would appear, was having none of it.

So I put it on my head like a hat and minced back and forth in front of her bed until her reluctant laugh sounded through the ward and she didn't look quite so scared or quite so amazed, but just like herself again, her white, woolly hair resting on her pillow.

At which point we discovered that, somewhere in the midst of all the fun, one of Lindsay's other patients had gotten dressed and hopped in a car headed for the Hospitality Center without having heard a word of the discharge instructions she needed.

But it's okay. She, along with four or five other ladies will come back in the morning. Because tomorrow they dance.

For today, we're just going to work on the box thing.

The ladies are back.

A Ward has been filled with a sense of anticipation for the last few days as women wrapped in their best lappas have shuffled in and out, answering endless questions about their medical histories. The stories vary, but the end result is the same; I was pregnant, and now I am wet. Some ladies come with babies and little children, but these are the rare ones. Mostly, they share the same thing. The baby died. It was inside for too long and it died and now I am wet. When I meet their eyes, I read fear and rejection and despair and this unquenchable, overwhelming hope.

(Just know, as a caution, that I'm going to get slightly graphic in this paragraph. Not so much information for the kids.) Women with obstetric fistulas (we call them VVF ladies, as an umbrella term) are the modern-day lepers. During a prolonged and difficult labor, the pressure of the baby's head against the bones of the pelvis causes soft tissue to die. When the baby is finally born (almost always dead), the woman is left with gaping holes between her bladder and vagina. The rectum or urethra or any combination of all three can be affected. This, effectively, tears a woman's life apart, because when she develops a fistula, a woman becomes an outcast. Often, she is turned away from her family. Her husband leaves her and she lives on her own outside the village, smelling of urine and feces. Unable to stop the flow of her humiliation.

Maybe you've never heard of vesico-vaginal fistulas (VVFs). I'm not surprised. It's a problem that's almost unheard of in the developed world, where woman have access to medical care and hospitals and cesarean sections when things go wrong. Here in developing nations, it's estimated (by the WHO) that fifty to a hundred thousand women every year develop fistulas. There are over two million living with fistulas. And there are only about thirty thousand surgeries being performed every year.

You do the math.

We're standing in the gap in one of the biggest battles you can imagine. We've screened and selected twenty-one ladies. Twenty-one, in the face of a hundred thousand. I look at the statistics and I want to cry, knowing how many more will go to sleep tonight, weeping her shame as the bed underneath her grows wet again.

But for these twenty-one, we are offering the world. We are offering love where they have known rejection, acceptance where they have known disgust. We are going to try and put back together the ruined pieces of their lives, and I've got a front row seat.

The first lady came back from surgery this morning. She rolled into the ward on the OR stretcher, grinning at anyone who would look her way. I grabbed her chart and flipped to the operative report. Words like excellent, and full closure stared up at me, and I grinned as her nurse tried to straighten out the absorbent pad on the bed. The nurse smiled back at me. We might not need this.

Because this lady, and twenty more, might go home dry.

(For more on VVF, there's an amazing documentary about the fistula hospital in Ethiopia. If you've got a big enough stock of tissues, go check out A Walk to Beautiful.)

I was in the clinic at the far end of the hospital this morning when I heard the drums begin to call. Voices raised in ululation beckoned me back to my ward, and I followed the sound of the singing.

As I walked the length of the ship, the hall was deserted save for a woman clad in a hospital gown, a faded lappa tied tightly around her waist. She moved slowly away from D Ward, her eyes on the floor, hands clasped tightly behind her back. I passed by, drawn by the tumult spilling from the open door.

Inside, the room was alive with the kind of vibrance I've only ever found here in Africa. Translators and patients clapped and stomped and played any instrument they could get their hands on, from bongos to cowbells to rattles pieced together from bowls and scraps of metal. At the head of the room sat Sietou, resplendent in a bright yellow dress, her headdress piled impossibly high above a beaming face. The swirl of noise and music pulled passersby off their courses while nurses from the operating rooms and the other wards paused in their work to stand at the door. Everyone was gathered to celebrate her, to watch her dance.

Sietou's story is familiar in its heartbreak. Her parents died when she was young. She got pregnant, and the baby died inside her, tearing her apart and condemning her to the life of an outcast. She had another baby, but when she went to his father for money, he turned her away, threatened her with a cutlass, told her he'd cut off her head if she ever came to him again. So she's been alone, and she's been wet. For eleven years she's been living on the fringes of society, leaking urine from a body that betrayed her in her moment of greatest need.

Today, Sietou danced. She laughed and she sang and she hugged and she danced. And her chair, when she left it again and again to take her place in the whirling crowd, was dry.

And out in the hall, the old woman walked slowly back and forth, back and forth, the lappa around her waist slowly growing wet again as she shut her ears to the sound of a celebration she had no part in.

Once again, I find myself in the middle of a stretch of nights. This time it's a little different. I've been stationed in B ward, a hodge-podge of cases thrown in and shaken together. Last night I set a new personal record- ten patients, and only three of them were kids. Five of the others were ladies who came in for surgeries to repair vesicovaginal fistulas (VVFs).

Here's the thing- I am a woman from a developed nation. If, someday in the future, I am having trouble delivering my baby, I will have access to healthcare, and I will be able to get to a hospital. Pardon me for going a little statistical for a while, but this is important. According to the WHO and UNICEF, I will have a one in 28,000 chance of dying trying to deliver that baby. If I had been born in Northern Africa instead of the US, (if my heart really was African like some of the Liberians delight in telling me) that chance would jump to one in 210. I really can't comprehend those odds.

But our ladies with VVF aren't among those who die in obstructed childbirth. They are the survivors, huddled and shattered on the edges of society. After enduring up to ten days of labour, the woman is left exhausted and for any number of reasons, unable to deliver the baby. Locked in the birth canal for days on end, every contraction pressing its head against the bones of the mother's pelvis, the baby eventually dies.

Once the baby is finally delivered, (often by force, which causes even more trauma) the mother is left with a broken heart and a hole between her vagina and bladder or rectum. She cannot hold her urine. It leaks constantly, running down her legs, soaking her clothes, effectively shutting her away from society.

I know this is graphic, and I apologize. I would love to sit here and just write happy stories about Abraham and Anthony, but there are other realities to come to grips with here in West Africa. So here I am, trying to understand why women suffer for years on end, unable to be part of society because they don't have access to a surgery that costs, by most accounts, less than 500 dollars.

All of our women on the wards right now are repeats. The chances for a successful closure of the fistula decreases with every operation performed, so report in the mornings has felt like a long, sad string of defeats. Wet. Wet. Wet.

Last night I took care of a woman who's on her third surgery. She wouldn't meet my eyes for the first few hours of the shift as I settled her in for the night, medicating her pain and emptying her catheter. Around two in the morning, I saw her lying awake and went over to her bed. I held her hand for a moment and then slipped my other hand underneath her sheets.

You're dry.
Thanks God.

And she turned over, closed her eyes and didn't wake up until after I had left for the day, secure in the knowledge that, for the first time in many years, she had slept in a dry bed.

I'm on my way back in to work now. Back to my ten patients and my screaming babies and my spinning head. And, hopefully, back to my dry ladies.