It's a Dance

 

Our 6^th fistula campaign in Vanga, 2023, is best summarized by a dance. There are several reasons. Fast and slow, complicated and simple, we moved and worked together to bring healing to many precious women suffering from injuries caused by childbirth and trauma. A quote that stuck with me prior to the trip, and in fact was written on my fridge before being taken over by a packing list, was an African proverb. “As the music changes, so does the dance.” Also, I recall an old journal entry in which I wrote, “When we get close enough to one another, we will step on each other’s toes.” Lastly, this campaign was full of dance because the gyn resident who joined our team this year minored in dance during college. What a joy to see how dance could uplift broken hearts and spirits, break through language and cultural barriers, and join us together with a smile! So, shall we?

 

Travel this year was smoother than ever before, with the lifting of covid restrictions. All four American members of the team benefit from extensive travel experience: Nancy Rice, NICU nurse, previously lived in Congo with us, Madison Strausbaugh, fistula team nurse from World Medical Mission travels so much that her desk calendar is still in January, and Dr. Torie Hayes would likely be living overseas if she weren’t in gyn residency. We had no lost luggage and made our connections, albeit running to our gate in Paris, Home Alone-style.

There was this one incident, however, with fish. Imagine a Toyota Landcruiser with many large boxes of “frozen” fish on the roof rack fighting the humidity and heat, melting down the sides and the windows, blurring our vision of Kinshasa traffic as we drove at 5am to catch our domestic flight to Vanga. Imagine luggage porters running after us, stuffing small fish that were steadily dropping out of our luggage cart straight into their shirt pockets. Imagine the smell. Soaked, cardboard-turned-mush boxes destined for Vanga to help feed our patients for the next month. We paid a little extra to park close to the entrance of the airport where we were weighed along with our baggage. The degree to which this was a ridiculous request for checked baggage is also the degree to which the MAF (Mission Aviation Fellowship) staff took it all in stride. Sure, we lost many fish to the pockets of the porters and people helping us to repackage the fish into plastic water-tight bags, but most of it made it to Vanga and was still edible!

We met many of the women suffering with fistula the day we arrived. They were awaiting surgery together in a pavilion just outside the main hospital. Since December, the Vanga team had been sending out radio messages and occasionally doctors themselves to rural communities and referral centers for recruitment. Some patients came from nearby, but others had traveled over 500km from Angola and the Republic of Congo to get surgery. The road to the hospital is still impassable by car, so by dug-out canoe or by motorcycle or by combination of bus-taxi-foot, the patients came. We screened, consulted, and scheduled for surgery these patients during our first full day on the ground. Then to connect with them prior to starting operations, we returned to the pavilion arm-in-arm with about twenty enthusiastic nursing students. Torie, the gyn resident, our team athletic director, and our dance instructor led us in a collective African line dance to the song Jerusalema. Oh, how we laughed! Though we had practiced at home, it was a whole new level to try to dance with 50 women on uneven dirt and grass, avoiding ants, tree branches, or random rebar sticking out of the ground, and laughing so hard at each other that we could not hear the music.

   

Operations started with our usual team, led by Dr. Paulin Kapaya, fistula surgeon and urologist from Kinshasa. Each OR has a culture of its own, but the whole team adapted quickly, with the Congolese staff warmly welcoming the assistance of Nancy and Madison as they learned the ropes of circulating and assisting with surgeries. It is always fun for me to come back to the same faithful nurses, doctors, and residents and to see them continuing the good medical care provided with such limited resources. The poor air conditioners in the wall fight hard against the African sun, but with cloth gowns and long days, it is always advised to end the day by jumping into the Kwilu River before sunset. The butterscotch water runs over smooth sand, daring us to compete with its current. And our other option of a bucket bath shower is much slower at rinsing out shampoo than swimming upstream for a few seconds!

 

The music changed with the arrival of a team of urologists, nurses, and anesthesiologist from Belgium. Médecins du Desert (doctors of the desert) is an organization with 13 years of experience doing fistula missions all over Africa, and they were invited jointly by Dr. Paulin and Dr. Junior (One of Vanga’s supervising doctors and my friend since we were both residents in 2012) to help with this year’s campaign. The rhythm and tempo in the OR changed, the composition both strange and beautiful. Medicine is an art as well as a science. MDD had a unique challenge to jump into surgeries after we had already consulted and scheduled the patients. Different protocols and requirements for reporting back to our various funding sources caused some duplicity and confusion. However, the diversity and depth of experience in tackling the difficult cases was a huge blessing. By the second day of operating and working together, our dance took shape. We were unified in our goal of helping more women with fistula, and getting in the trenches with the same goals significantly accelerates connection with others.

The weekend was a welcome rest from surgical work, and there was a lot of dancing! Saturday, the American team left the urologists to do and teach purely urological procedures and took a 2 hour boat ride up the river to celebrate the opening of a new hospital. After our canoe touched the shore, we clambered out and up the sandy slope to a waiting vehicle which took us to what we thought was just going to be a simple meeting for the Vanga team to discuss logistics of staffing the hospital. The Landcruiser stopped in front of a large group of people singing and dancing. They were gathered outside the new hospital building, shaded by tarps held up by bamboo poles. After greeting a long-time missionary friend, Katherine Niles, we were paraded into the gathering and placed near the front. We had just come from the river and weren’t quite dressed for the occasion which seemed formal with dignitaries and police and pastors and priests. We settled in, a bit confused. Later, Katherine said, “NONE of this was planned. I had NO idea!” She was even called upon to make a formal speech. Improv at its best.

Sitting there, guessing where we were in the formal program, I took note of the arrangement. As I mentioned, there were bamboo poles holding up tarps which were temporarily attached to the building. There were long rows of people under these tarps, but where the shade ended, so did the people. About 75 feet! back, there was a tree providing shade, and there were about 3 more rows of people sitting or standing, as if they were just behind the row. The sun cut right through the crowd. From where we sat, the speakers were quite loud and close to us. Dr. Tim Rice, not a novice at such things, put earplugs in as we listened to the speaker. However, this became complicated when this pastor finished speaking and came back to sit down, right next to him! In a particularly smooth move, Tim discreetly raised his left hand to his ear to take his earplug out. The row of us Americans behind him could not contain our smiles and then outright laughter after calling him out in private later that day.

 

The Sunday service is always filled with the choirs of children and men and women singing. One cannot help but smile seeing the joy. One particularly endearing part about the choirs is the small children that are a part of an adult choir. Our second Sunday there, the four of us Americans were invited to come up to sing. We decided the best course of action was to learn a Kituba song and the whole crowd joined in, thankfully drowning out our voices for the most part.

All of the teams, American, Belgian, Kinshasa, and Vanga teams were invited that afternoon to take a ride on a larger rented boat. What a delight to get to know the other teams outside the stress of the OR and hospital! As we neared our destination, a sandbar just in front of an island, ominous clouds threatened and lightning and thunder came rolling in. Being in one of the lightning capitals of the world, I usually avoid this danger, but frankly, we had no good options. Under a tree, in a boat, or in the water, we were about to get soaked and the lightning was still several miles away. Throwing caution to the wind, one by one everyone got out of the boat, ran across the sand, splashing, high-stepping, and dancing, flinging themselves into the river. For those that could not swim and had never been in the Kwilu, this was particularly delightful as the water was shin-knee deep. Rain came pouring down and we danced and laughed like schoolchildren, from the oldest Belgian professor to the youngest Congolese medical resident. When lightning encroached, we got out of the water, staying close but not too close to the trees and huddled around a fire. Rain continued, so we started our journey back, holding makeshift tarps over bamboo arches until we finally came out of the storm. Sometimes memories are best when the unexpected happens.

 

 
Surgeries continued and our Kinshasa and American teams left a couple days ahead of the Belgian team. Our postop nursing staff and the lovely ladies cooking for our patients will continue as we see the healing process continue. One by one the ladies will get their catheters removed. They will stay for at least a week before heading back home due to the extreme difficulty of following up and our desire to know and treat them if there is further leaking. Highlights for me continue to be the people of Congo as well as the long-term team who work in Vanga. I love coming year after year to see them, to hear how their families are doing. I was able to see a patient healed from her fistula a few years ago and a nurse who reported resolution of pain after following my recommendations. A couple stopped me to say thank you for a consult I did years ago for infertility. They were proud to tell me they have 4 children now. Working cross-culturally will always be a dance, and when the music changes, so must the dance. It is my sincere hope that we continue to work for the good of the poor and suffering among us, so that they can feel deep down in their souls that they are not forgotten by God.

 

There's a Place for Me

 

Imagine being newly married and pregnant. Imagine having a difficult and long labor without access to an epidural or pain medication much less a cesarean section. Now imagine you experience a stillbirth and then realize in the days after that not only are you having normal postpartum bleeding, but you are also unable to control your bladder. In fact, you are wet all the time. You begin to smell of urine, and your skin becomes calloused with exposure to the acidic urine. You stop drinking water, as the dehydration lessens the wetness. This causes the smell to increase with the concentration of urine and puts you at risk for kidney stones. Imagine your husband calls you “detestable” and refuses to let you stay with him. Your friends abandon you and laugh at your condition. You go back to your family without the expected grandchild or niece or nephew, and after a short time, they also decide that they cannot stand being around you or their house smelling. Imagine having no place to go, being utterly alone. The following three paragraphs are three different first-hand accounts, translated as closely as possible from their mother tongue to French and then English. Grab a tissue.

“I was expecting a child and for a whole week I had labor pains so I was taken to the hospital of [omitted for privacy] after having already labored in a health center. And I delivered a boy and the urine started to pour out of my vagina, but my son was killed mysteriously by the sorcerer. Now it has been 29 years that I’ve had this sickness. After having it, I started to be uncomfortable, as I had to wash all the time in order to not smell like urine. I couldn’t stay in the community because I smelled like urine, I avoided the church because I was wet just sitting down, and even my business I could no longer do because I was not going to be received well knowing that I would dirty their chair or their bed with urine but that also, I smelled like urine. My husband heard the news on the radio and we came. After this operation, I think that this time I will be healed and I have not had any more leakage of urine this time. It is a good thing. I will be able to get my life back and I will be happy.” -29 years after symphysiotomy, a process by which the pelvic bones are separated/broken apart at the cartilage in the front in order to expedite a delivery when a cesarean section is not feasible.

“I was suffering from abdominal pain and the doctors said that I had appendicitis and an ovarian cyst and that it was necessary to operate, but one week later, it hadn’t happened. We had changed the hospital and they told me that my vagina didn’t form all the way and they operated. Urine started to pour out of my vagina. We put in a vaginal compress and the doctors assured me that there would be no further leakage but it continued and as the days passed, there was a lot of urine and also poop that came out of my vagina. We returned to the hospital but they said they could not do anything more for me. Other girls my age laughed at me, I was uncomfortable to see girls my age who were in good condition and not me, and everything made me so sad that I got a stomach ulcer. I believe that I’ll be healed after this operation and that I will wait. I will be very happy to feel that all the openings were closed and I will be able to live like all the girls my age and think of getting married and having children and even my parents will be happy. We heard it on the radio, that’s why we came.” -young woman with transverse vaginal septum (a congenital malformation) who had a large 7cm left ovarian cyst and 3 separate fistulas: one into her bladder, one into her rectum, and one from her bladder to her upper vagina.

“Everything started in 1981 by the first pregnancy that I had and the infant was blocked by the head at the entrance of the vagina and the labor was long before I could deliver and the baby was dead. It was after that difficult delivery that I developed the fistula. My husband abandoned me after that, telling me that I leaked urine from my vagina and I was gross and he said a lot of other hurtful things before he left me. My brothers abandoned me, telling me that my urine leaked out of my vagina and that no one could look at me anymore or love me anymore, in the family or in the village and to live I was forced to sell my goats and chickens to be able to eat. I spent my life thinking of my situation, my state of being and my son that I lost who could have helped me. Instead, I was alone. For 41 years, I tried to get fixed and was operated on 3 times and that didn’t work. So, when I heard the information [about the fistula campaign] I came. I believe that this time I will be healed of this sickness and I will live my own life. I cannot do anything more.” -delightful older woman who came alone, without a fistula but without ability to control her urine as her urethra was destroyed.

This year, our fistula campaign presented more women with complex fistulas, malformations, double and triple fistulas, multiple prior repairs, no urethra, and bizarre presentations after symphysiotomy. For one, we even had to reconstruct a urethra out of skin from the inside of her mouth. These complex ones are done primarily by expert fistula surgeon and urologist Dr. Paulin Kapaya of Kinshasa, although we all work as one team with two operating tables in the same room in order to be able to discuss difficult steps and share ideas. We operated for 8 days instead of 6 as we had in previous years. Dr. Sarah Kennedy and I spent most of our days operating, as you might imagine. Thankfully the third member of the US part of our team, Katherine Krosley, was able to get out into the community, take part in a public health class at the nursing school, visit health centers, watch normal labor and delivery, experience the malnutrition center, and perhaps most importantly, spend some quality time with the fistula patients post operatively.

If you know Katherine, she is quite a talented musician. She can make up a song on the spot, infuse it with humor or sadness, and brilliantly deliver. Many people in Vanga were blessed by her songs. Each year after all of the surgeries are completed, we have a party to celebrate all the work we have done and all the work the postop and kitchen teams have yet to do. We always debrief about the campaign as a whole, both its strengths and weaknesses. This year, a strength that was highlighted was the psychological and spiritual healing spurred on by the time that Katherine spent with the patients, singing and playing guitar with some of the medical students and nurses, and hearing some of their stories which we have highlighted. Perhaps no one interaction made more of an impact on Katherine or the patient herself, than when she sang to woman who was utterly alone for over 40 years.

She sang… 

Who the Son sets free, is free indeed. I'm a child of God. Yes, I am.

In my Father’s House, there’s a place for me. I’m a child of God. Yes, I am.

There’s a place for me. We can’t even imagine the pain, the loneliness, the shame she has endured. Though her situation is difficult and complete physical healing which we trust in will be a miracle, she can know now that she is not alone. She’s a child of God. She may not be completely continent, but she can know she is completely loved. There’s a place for her, just as there’s a place for me.

Together, Ensemble

 "It would not be a trip with Shannon if there weren’t any excitement along the way,” Ryan remarked as we jumped into the car to hastily make our way BACK to the airport the morning of departure. He was referring to several other travel escapades we have had, the most memorable being an in-flight baby delivery. Sarah Kennedy, an OBGYN resident, and I had found ourselves in a bit of a frustrating back and forth during check-in. We had 9 bags filled to the weight limit stacked next to the desk, having just said goodbye to our families. 

We were anxious to get rid of our burden for a moment and get through the security line, but the process came to a screeching halt as the agent scrutinized our covid tests. “It needs to be 3 days before arrival. This won’t work.” We showed her the official embassy website (even updated this month) which clearly states a neg covid test is required from 3 days before DEPARTURE. She called the helpline. They wouldn’t budge. We couldn’t check in. I called Ryan to come back to get us instead of going to work.

Thankfully, the third member of our team, Katherine Krosley, had gotten her test a day later and thus, was given the green light. She stayed with our bags while Sarah and I ran to the car and sped to a just-opened urgent care with rapid PCR testing. Minutes ticked by, and finally we were told we had neg tests. As soon as the papers were in our hands, we ran out the door and back to the airport. Back through check-in, then to security and onto the gate where our plane was already boarding. Our seats weren’t together. When we finally made it to the first of our layovers in Atlanta, I grinned and said, “Sarah, meet Katherine. Katherine, meet Sarah.” We were finally able to establish our team.

Lounging during a layover

The details of this fistula campaign are very similar to last year. Same dates. Same place. Same urologist and his resident. But this year has felt more like a smooth zipper bringing all the people, organizations, and supplies together, slowly but steadily, whereas last year was a parting of the waters and a muddy slog through a COVID red sea, with ultimate success. Both feel equally orchestrated by the hand of God.

Our team was the first of the details to come together. I had dinner with the Krosley family just before Thanksgiving, when Katherine happened to mention that she had a free semester prior to starting nursing school, having just obtained a degree in public health. The conversation went something like this: Do you want to come to Congo with me? Yeah, I’d love that. Are you serious? Yes! I’m very interested. A few weeks later when we proposed dates of the trip, I let her know and she started making plans to come.

Sarah’s participation was a welcome surprise. I sent an email to the residency director asking if any resident would be able to participate, fully expecting to be told it wasn’t enough time to arrange a schedule and apply for funding, etc. But instead, it was, “I have a resident who is planning a career in global health and we’ll try to make it work.” We applied, got approved, and with hesitant excitement pressed forward. We knew if Congo went to level 4 or 5 health risk (covid) that it would be a no go. This was in January at the height of the most recent wave of covid in the US, and when the US itself was likely a level 4. Like I said, hesitantly excited.

Covid has kept planning a little dicey. I was not surprised to test positive in January given the sheer number of exposures I had every week at work. Katherine had it around the same time. The silver lining in this was the knowledge that for the next 90 days, a positive PCR would not hinder us from returning to the US. We would not be stuck overseas. It was eerily similar to last year when I had tested positive in December and got vaccinated Jan and Feb. This year I had the new variant, then got my booster.

World Medical Mission has again been instrumental in supporting our work. They have assisted in security, travel, and managing the funds donated towards the work. As much money as I can raise myself, and this year together with Sarah and Katherine, that is how much we can use. With the scale of work and the number of fistula patients continuing to grow as we get into an annual rhythm, I have had a long-term goal of having another resource to support us. It seems to be coming together! One of the doctors in Vanga applied for support and funding from the UNFPA, the United Nations Population Fund. I didn’t find out until we landed in Congo that they are indeed supporting us with materials and potentially even funding. Dr Paulin, the urologist on our team, is well-known in Kinshasa for fistula surgery. This, combined with the evidence of our commitment to repairing fistulas in this region over the last few years made a strong case for their support!

Box of supplies from UNFPA

Another new development has begun this year. One of the patients in my practice put me in contact with a microfinancing organization in St Louis who is already working in Congo, in another region. We discussed the possibility of helping the fistula women not only with their health and healing, but also in helping them get out of poverty by supplying a small loan and means to repay it. Sometimes this is in the form of animal husbandry, 2 pigs becoming a litter and giving back to the program 2 piglets to pass on to another in need. Sometimes it is a loan for materials to support a trade, such as supplies for a hair shop or an oven for a bakery. These details came together nicely and there is a team of 3 people joining us for the second week in Vanga. This is PERFECT timing, as we will have done the bulk of our operations and will be able to help facilitate discussions and teaching with the women who are convalescing.

Lastly, surgeries cannot happen without supplies. I was accepting items daily to bring to Congo. A satellite phone for safety reasons. Bags to help support a maternity safety kit to distribute to the community. Ethicon, the main manufacturer of sutures, donated a large box for the campaign. Throughout the last year, the hospitals I work at have helped collect unused items which are essential. A last-minute need for spinal needles was supplied within an hour of my asking the day before we left. All of the items we have stored in our basement, and it felt filled to the brim. We were able to get humanitarian fares and thus were able to bring 3 bags each. Nine bags filled with essential donated items- so exciting to watch all of this come together. In French, the word is "Ensemble"

So the snafu at the airport with the covid tests? Honestly it didn’t even make my heart race. I had such a peace that this barrier would not stop us. We are so grateful to be together, ensemble.