Where does that Kalagane Ambulance Chair take you? Nyatende Hospital – 4 km away.

Site Visit Nyatende Hospital (referral hospital for Kalagane Health Center)

We spoke with the senior surgeon, Dr. Vincent Cibavunya.

He has been there for 10 years. He has 6 MDs working with him at Nyatende now.

This is a Catholic hospital, beautifully constructed and impeccably maintained with a stately, separate maternity building.

When Dr. Cibavunya arrived, almost all deliveries happened at home with high infant mortality and stillborn rate and many fistulas.
He did a study to determine that the major factors were cultural bias against hospital birth, ignorance of the benefits of obstetric care, and financial barriers (all over Congo, women pay on average 7 USD for vaginal birth and 15 USD for Cesarean Section).

He instituted an outreach program with his doctors and nurses and local churches and pastors going village to  village and house to house, to explain the benefits of obstetric care and hospital birth. This continues with monthly staff meetings with the regional health center clinicians.

He also worked with some group to create a sort of health care credit union that allowed a reduction in all OB fees.

Today, 85% of births in the Nyatende cachement area occur in Nyatende, infant mortality is very low and fistulas are a rare occurrence. Another MD who has been there 3 months states he has yet to see a fistula. When they do have a fistula, he states they always refer to Panzi Hospital www.panzihospitalbukavu.org.

Prolapse is more common, with about 10 cases per month at Nyatende.

Incontinence is also reportedly rare.

Most surgeries performed at Nyatende Hospital currently are partial thyroidectomy for goiter, and lots of ENT, nasal polyps etc.

Kiel Bonhomme, Dr. Tina Amisi, Dr. Cibavunya, Dr. Tchango, Dr. Romanzi

WHO, UNFPA, USAID and any number of fashionable Stateside and European fundraisers are throwing millions of dollars with the attendant beauracracy and fanfare at the seemingly unstoppable tragedy of fistula caused by lack of basic obstetric management in third world settings around the globe. Seems Dr. Cibavunya forgot to read these myriad reports, having singlehandedly recognized and dealt with this exact problem in his cachement area with a few dollars, a few local institutions, and a lot of common sense. Hmmm.

Within 40 years of the advent of general anesthesia in the mid-1800’s, the world’s first fistula hospital, founded in New York City by Dr. J. Marion Sims, was rendered obsolete, razed, and replaced by the current Waldorf Astoria Hotel in 1893.

Well into the 21^st century, it is time, and as demonstrated by Dr. Cibavunya, it is well within possibility, to implement the rudiments of modern obstetric care that will preclude the need for expensive, stigmatizing, tragic, single-focus fistula centers – we need only apply the obstetrical practices and standards of care available in North America and Europe at the end of the 19^th century.

Hats off to Dr. Vincent Cibavunya and Nyatende Medical Center, South Kivu, Democratic Republic of Congo.

(C) Lauri Romanzi, 2010

If you need transfer to hospital, this S Kivu clinic will carry you 4 km to the nearest hospital in this exact chair, the "Ambulance Chair"

Today we travelled to a regional health clinic to find out what services and deficits exist for pregnant women at risk for maternal death or vaginal fistula. We found a hard working, well trained, and devoted “Titular Nurse”. In this facility with no electricity, no lights except a kerosene lamp, dicey plumbing and a pharmacy stocked with one medication (Ampicillin), they do indeed deliver babies, but only the “easy” ones with no complications of labor, like obstructed labor, or infection, or prolapse of the umbilical cord, or fetal distress, or heavy bleeding. If a woman has a complication during labor (or for that manner any man, woman, child or infant whose care is beyond the capacity of this facility), and you can’t get to the hospital on your own, they literally put you in this chair and carry you 4 kilometers over incredibly rough terrain (even the goats stumble) to the regional hospital. It seems the ambulance broke about a year ago, and with no funding to fix it, emergency transport is carried out by “Ambulance Chair”.

In an infrastructure and cash-strapped country, where corruption rules and chaos is not a choice, what’s more important? Funding more “fixing of Problem X” or funding ways to prevent Problem X while maintaining current methods by which Problem X gets fixed?  From what I gleaned at the hospital today, the doctors and other powers-that-be choose option #2.  To sum up, “retention and prevention” are the keys to fistula eradication in South Kivu, DRC- find ways to retain the talented local fistula surgeons who leave to find the “beyond fistula” training they cannot get at Panzi Hospital, and develop ways to improve obstetric care so that fistulas don’t occur in the first place.  When money is scarce, common sense pays bigger dividends.

The internet is slllloooow as cold molasses on a winter day here. It took me 45 minutes to post this post- (bad news)

It’s the dry season, hasn’t rained in 6 weeks, and without a single paved road in Bukavu, it’s a veritable dust bowl. So I promised our driver “I’ll make sure it rains tonight.” At 9 pm it POURED BUCKETS for about an hour. By now, this man must think I’m a witch – (good news)

More tomorrow, Mouseketeers.

What’s with my brain’s insistence on using Frank Sinatra’s “New York” as the default song-stuck-in-your-head soundtrack whenever I’m working in Democratic Republic of Congo?

Freshly arrived in the southern Kivu region of the Democratic Republic of Congo after 18 hours flight time and 5 hours drive from Kigali, Rwanda, I am pleased to report that Rwanda seems content in the wake of the recent “transparent” election on August 9th that allows President Paul Kagame to continue his program of healing and reunification (one version) or subversive neo-dictatorship, take your pick. On the way I read all manner of editorial and article on this election, leaving me pining for Camu’s imaginary political party for (forgive any misquote here) “people who are not sure they are correct”. The legacy of Belgian-mandated tribalism in this region is beyond the capacity of this well fed, safely raised American to pass judgement on, so I’ll stick with prayer that Kagame can heal his people. I will say this, despite USAID signs all over the country, the Chinese are all over Rwanda, laying electrical cable, engineering mountainside roads, investing in agribusiness…

Today’s drive from Kigali to the bordertown of Cyangugu was painless except for the usual money headache. Everyone here wants brand new USD, no tears, no wrinkles, 2006 mint. In Congo, the cash (and you can only use cash) needs to be small, and apparently, now in Rwanda, the USD cash needs to be big. I was ready for small – did not bring any big – inducing a polite, understated, sotto-voce full on caniption from the Rwandan driver about his tiny-tender, brand new USD $5’s fee. Thank goodness the Congolese relay driver had Benjamin in his wallet or I would have been driving halfway back to Kigali to wait for a bank to open on Monday.

Now on my 3rd return to Panzi Hospital www.panzihospitalbukavu.org, this time I am here to facilitate the regional needs assessment for a newly minted joint venture between Harvard Humanitarian Initiative www.hhi.harvard.edu and the Engender Health division of USAID www.engenderhealth.org designed to improve fistula care in this difficult and lately recognized disaster zone.

I’ll leave you with this quote from a 2007 treatise published by Dr. K. Ramsey of the United Nations Population Fund in the international journal of Gynecology and Obstetrics:

“Women in most developing countries still risk their lives and their health in childbirth despite the existence of life-saving interventions (the most obvious being cesarean section). In regions such as Africa and Asia, where approximately 95% of annual (worldwide) deaths occur, at least 20 women experience an obstetric morbidity (injurious complication of pregnancy that does not cause the mother to die) for every woman who dies…. The most devastating of these injuries is probably obstetric fistula, a condition that was virtually eliminated in industrialized countries nearly a century (A CENTURY) ago.”

International Journal of Gynecology and Obstetrics (2007) 99, 5130-5136.

Doesn’t that make you sad and furious and wanting to make it stop? Does me.

(c) 2010 Lauri Romanzi

For the latest on vaginal dryness in your 40’s and beyond,  enjoy this guest-blogger interview with PHIT’s medical director from  Sweet Talk on the Spot. I’m talking user-friendly vaginal estrogens, over-the-counter lubricants, kitchen myths and the latest from Europe.

WD-40

Dr. Romanzi Talks Lubrication After 40Wednesday, April 21, 2010 by SweetTalk on the Spot

Our resident Vaginal Phitness expert, Dr. Lauri Romanzi, educates the SweetTalk community with answers to your most pressing, personal questions.

Q: Dear Dr. Romanzi, Why do women experience pronounced vaginal dryness after 40, and what lubricants do you recommend for women over 40?

A: Aaaah, the Magic of Estrogen.

First, a little background: Before puberty, estrogen levels in girls circulate at a tiny fraction of normal adult levels. At puberty, the ovaries start cranking out estrogen to full – range, grown woman levels, and stay that way til about age 35, when the slippery slope toward menopause goes gently into first gear.

By age 40-45, fertility, skin integrity, bone density, cardiovascular resilience and even memory can be affected as the reduction in estrogen production accelerates into third gear.  For many women this “Change before the Change” is confusing, because they continue to menstruate, and may even become pregnant, as these menopausal symptoms cavort erratically around the edges of their lives. One month is “normal”, the next nutty with late menses, heavy flow or light spotting, hot flashes, night sweats, aches and pains, insomnia and mood swings in a rollercoaster of unpredictability that heralds the life cycle book-end mate to the process of puberty. My New York City colleague, Dr. Laura Corio, coined this phrase, “The Change Before The Change”, and used it as the title of her book on health in the decade before menopause.

Regarding vaginal dryness and lubrication: The vulva, vagina, clitoris and lower urinary tract skin surfaces contain a high density of estrogen receptors, and as these receptors undergo peri-menopausal deprivation in the early to mid-40’s, many women report uro-genital symptoms.  In the vagina, these may include dryness, poor spontaneous sexual lubrication, reduced clitoral sensitivity, difficulty achieving orgasm, and muted orgasm intensity. And here’s the ironic truth – overweight women tend to fare better because body fat makes its own estrogen, called estrone, that, when present in high levels, minimizes the impact of reduced ovarian estrogen production, called estradiol. Skinny women make very little estrone, overweight women make a lot of estrone. Both skinny and overweight women’s ovaries run out of estradiol between age 35-ish and menopause.

A woman who is sensitive to reduced estrogen production in the 40’s and beyond, sex may be plagued by painful dryness that is often frustrating and confusing, both for her and her sexual partner. With reduced estrogen production, the exquisitely estrogen- sensitive skin of the vulva, vagina, and clitoris literally becomes thin, dry, and brittle. As a doctor, I’ve taken care of many women over the years in stable, happy, sexually active relationships who come in to the office utterly mystified by these symptoms, with partners convinced that the women don’t love them any more or accuse them of having an affair. so abrupt and intense can be the sexual impact of estrogen deprivation.

My favorite treatment option for hormone-related vaginal dryness is … hormones: Recoil not, as this does not mean total-body-dose (a.k.a. systemic) hormones. You can use ultra-low-dose vaginal estrogen therapy that rejuvenates the vaginal skin to youthful elasticity, sensitivity, and lubrication. It does this by making those poor, deprived estrogen receptors in the vagina, vulva and clitoris happy.  There is not enough estrogen in these local estrogen treatments to increase estrogen blood levels, and there is no evidence that they increase cancer risks, as some total-body hormone regimens might. Ultra-low-dose vaginal estrogen therapies come in cream (fingertip application), suppository (vaginal insertion) and ring (vaginal insertion 4 times per year) form.  I shared this low dose vaginal estrogen information on the Dr. Oz show a few weeks ago.

Lubricants help with dryness, but will not improve elasticity or sensitivity. The best lubricants are water soluble and paraben free. Glycerin-free lubricants are best for women who cannot tolerate this additive, and silicone based lubricants require less re-application. Lubricants contain no hormones.

Oils and herbs are purported to reduce vaginal dryness, however clinical trials thus far fail to demonstrate efficacy, and oils may throw off vaginal pH or turn rancid, ultimately causing vaginal irritation and possible increased risk of vaginitis.

Several of my European patients are using hyaluronic acid vaginal suppositories, which are not available in the U.S.  These novel vaginal ovules help maintain cellular hydration, and are marketed both for post-operation healing and menopausal dryness.  Given that these ovules contain no hormones, it is likely that this product will not improve sensitivity, but would restore lubrication and thereby improve elasticity.  Catch the red-eye to Paris and let us know if it works for you!

Back to lubricants before I finish: The shop shelves buckle under the voluminous assortment of 21^st century sexy lubricants with additives designed to improve blood flow, enhance sensitivity and super-charge orgasm intensity.  Marketing trials are not the same as scientific, clinical trials published in peer-reviewed medical journals, and it is not clear that the robust marketing claims are born out in the bedroom. That said, if these pumped-up lubricants rock your world, are paraben free and water soluble, have at it!

Content courtesy Alan Fogel

(c) 2010 Lauri Romanzi