Catherine Hamlin – 50 Years in Ethiopia: “The fistula patients will break your heart”

In 1959 Australian doctors Reg and Catherine Hamlin landed in Addis Ababa, Ethiopia. There they encountered patients with a type of injury they’d never seen before: obstetric fistula—a hole in the birth canal caused by a traumatic labour, resulting in permanent leaking of the bladder or bowel. These women lived in seclusion in remote villages, abandoned by families, with no medical support.

Curing obstetric fistula would become the Hamlins’ life work, building the Addis Ababa Fistula Hospital which has treated over 35,000 women to date and trains surgeons from all over the world. After Reg died in 1993, Catherine stayed on in Ethiopia, and was still working at the hospital in her mid 80s when Sheridan Voysey spoke to her in 2009 for Open House.

• Read below or listen in the audio player above.
• Learn about or support the Catherine Hamlin Fistula Foundation at hamlin.org.au.

Yes. My mother was upset. When I rang her from Adelaide she said, ‘I knew Reg would take you to some outlandish country!’

[Laughter]

But most people were encouraging. We didn’t want to just settle down into general practice together or to an obstetrics or gyne practice.

We wanted to help in a developing country. We had both been trained very well in obstetrics and gynaecology, having worked in Crown Street, Sydney, for many years together, and because every abnormality came into that hospital we realised we had special skills. And with our Christian faith we wanted to help in a country that needed doctors.

We had thought of going to New Guinea but then we saw an advertisement in The Lancet medical journal calling for gynaecologists in Addis Ababa. So we applied.

We left by ship for Aiden and then we flew up to Addis Ababa. We sent a cable from the Indian Ocean but it arrived two weeks after we did so there was nobody to meet us!

I believe that when you were deliberating over whether to go to Ethiopia Reg had an interesting experience in a pub.

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He did! My little boy, my only child, was just six. He was at kindergarten and I was doing some work at the children’s hospital so Reg was taking him to school. Reg was wondering what to do and whether we should go to this country of Ethiopia. We had been in touch with several missionaries and the mother of one of them was very negative, telling us it was a ‘dreadful’ place. She made us very depressed.

“Reg said, ‘I’m just wondering whether to take my little boy to Ethiopia.’ And the man sitting next to him said, ‘Oh, I’ve just come back from Ethiopia. It’s a wonderful country! Your boy will love it.’ So Reg came back and said to me, ‘We’re going!’

Reg thought he’d go into this pub, have a beer and sit quietly. He went in and sat down. There was another man at the bar also. The barman said to Reg, ‘You seem to have something on your mind, mate.’ Reg said, ‘Yes, I’m just wondering whether to take my little boy to Ethiopia.’ And the man sitting next to him said, ‘Oh, I’ve just come back from Ethiopia. It’s a wonderful country! There’s a good English school there which all my children went to. You’ll have no problem with schooling. Your boy will love it.’ So Reg was very encouraged by this meeting and came back and said to me, ‘We’re going!’

God speaks through many a pub patron!

Yes! And we never regretted going.

Describe the improvisation you had to do when you first arrived in Addis Ababa.

It was actually a very good hospital. It was run and funded by Britain in those days because it was sort of to do with helping the emperor after the Italian invasion. Apart from several English people it had an all Ethiopian staff; the head surgeon was a very accomplished man called Dr Asrath. The hospital was well run, clean and even better than some of the hospitals are today, although we didn’t have all the facilities.

We had x-rays but we didn’t have ultrasound. We didn’t have a generator. We didn’t have a blood bank, although we did have our own laboratory who would take blood for us and we could cross match the blood and so could give patients blood if necessary. If a women, for instance, had an ectopic pregnancy where the baby is in the tube and it had burst you could bail the blood out of the abdomen, put it through a sieve and put it back into the woman’s blood stream. My husband bought a big soup ladle from the markets, sterilised it and used that to scoop the blood out, put it into the gauze in the funnel and then back into the patients. We saved many women that way.

When you arrived in Ethiopia someone told you that the fistula patients would break your heart. Those were true words in the end.

Yes, they certainly did break our hearts. That was said to us by a woman doctor who had been working as a missionary in the country and was working at the same hospital. She wanted to go back and work in a leprosarium so she had resigned and that’s why we were able to come to this hospital.

We hadn’t come across obstetric fistulas in Australia. We had read all about them. The first man to cure a fistula was in Alabama, America, in 1850. Many slave girls came to him from the South with fistulas; they’d been thrown out because once they’d gotten this injury they couldn’t work. He finally perfected a technique using very fine silver wires as a stitch; he only had horse hair before that and no cat gut or anything like that. He had no anaesthetics or antibiotics then either and his patients were so stoical about the pain. He operated on one little girl thirty times and cured her in the end. He became very famous and travelled all over Europe operating on fistulas. Then when caesarean section came in as a safe procedure, they disappeared from the developed world by the end of that century because there were plenty of hospitals where a safe caesarean section could be done.

In the book that recounts your story, The Hospital by the River, you describe the ‘fistula pilgrims’ that come to your door. Give us some examples.

Well, they wander in to the hospital grounds in their traditional clothes, which are usually very dirty and soaked with urine. They just come with faith and hope that something can be done for them. And they’re pathetic little figures.

Very often the guards at the gate would turn them away because they had no money. They’d tell them they couldn’t come in because it was a paying hospital, so the women would disappear. My husband used to get up early in the morning and go out looking for them. We had a big compound around the hospital and he would find these girls, take them back and get them admitted. So they had problems even just getting into the hospital.

And the stories they have told us… like getting onto a bus in the countryside and trying to hide that they were wet. Some of them had bowel incontinence as well which made their plight much, much worse and they were often turned off the buses. One sat on a tin at the back of the bus, hoping the urine would drip into the tin and nobody would notice. Some just walked to us, taking months to arrive. Two of them in the early days rode on a horse together. They wanted to be done together because they both needed to go back on the horse.

These women are ashamed of this injury. They don’t want to mix with anyone. The other patients in the general hospital despise them because they’re smelling, they’re poor, they’re dressed in dirty clothes soaked in urine. And so they never got a welcome. Nobody loved them.

They’re rejected by everybody.

Yes. We’d have a big clinic each morning with everyone coming to be seen and they would always be sitting away from all the others. My husband was so kind to them and would take them in first. He’d say to them, ‘You’re my special patient, I’m going to look after you’, just to give them a little bit of love…

[Sobbing]

Just to think about them makes me cry…

What they go through, nobody knows… young women that have just gotten married a few years earlier and are having their first baby, thinking to themselves about having a lovely baby and how so happy they’re going to be, and then disaster strikes them. The husband can’t cope with the situation. He’s just a peasant boy. She might be 16 or 17 and he might be in his early 20s and he’ll say he can’t live with her anymore. The girls often ask to be given back to their mother and father. The parents take her back but then they can’t cope with her either because of the smell. They can’t have their relatives or neighbours in to have their little coffee ceremony, which is such an important thing in Ethiopia. And so this little girl will be completely isolated from everything that made her happy. She will be put in some dark shed on her own. There must be thousands of them all over Africa, hiding away because they’re ashamed, because they’re leaking urine, because they’re smelling. They have no underclothes, no pants, no pads; nothing to help soak up the urine. They might have just two dresses to their name. They might have to go out at night and wash the one dress to keep it clean. Their stories are so devastating. You don’t have to be a Christian to feel compassion for such patients.

How have you been able to keep going in such a heartbreaking situation?

Well, it’s so exciting when you cure them. This is the joy that we fistula surgeons get to have. Sometimes it’s a very difficult surgical procedure. Sometimes it’s very easy. It depends on the size of the hole, the scarring that has occurred in the vagina and whether it’s a big double fistula, like a big hole in the rectum and the bladder as well. But when you’ve cured them and they suddenly feel that they’re normal women again, the excitement is so overwhelming that it’s a joy to work there.

Tell me a story of a woman who had her life restored.

My husband was driving in Addis one day. The lights went red, he stopped and a woman put her face through the window and gave him a great big kiss on the cheek. He said, ‘What did you do that for?’ She said, ‘Because you cured my fistula. I’ve had two babies and I love you.’

Another one had been dripping urine for forty years. She was 60 and had had her only baby at 20. She had a very simple fistula to cure and after only about ten days post-operative was quite dry and voiding normally. She said to me, ‘I love you next to God,’ and then added, ‘To think—I could have been cured and had more children. I’ve been sitting alone for forty years.’

We sometimes have a dance in the ward with five or six patients all ready to go home. We give them a new dress, a new head scarf and perhaps a new shawl. We’ve had wonderful people in Australia knitting shawls for us. We give them a present to go home with and encourage them to get another husband and try and have another baby. In fact, we’ve got a ward just for pregnant women who come back to us after a fistula repair. It is so encouraging for the patients to see a woman coming back with a baby inside her waiting for a delivery when they are suffering from this condition. It gives them hope that the same could happen to them.

I bet it does. You’ve briefly mentioned having a Christian faith. When did that become a guiding reality for you? Were you raised in a Christian home?

Yes I was, but I was just a nominal Christian for a long time. I remember one particular occasion when we went to hear a famous preacher in Sydney, a Presbyterian called Mr Paton. He spoke on Jesus telling Peter him three times to ‘feed my lambs, feed my sheep’. Remember?

Indeed.

I was affected by this sermon very much and I remember going home and kneeling and asking God to give me the same encouragement that he gave to Peter. That’s when I really gave my life to Jesus. I think I was a Christian before that, but this was the turning point in my life.

And I know we were called to go to Ethiopia. My husband should have been appointed to Crown Street as an honorary. Crown Street was a very big hospital in Sydney, famous for obstetrics and gynaecology. We had an honorary system in those days. The superintendent of the hospital nearly always got onto the staff as an honorary, which meant that they would be able to use that hospital for their private patients but they had to come and help with the public patients as well.

My husband should have become an honorary because he was a superintendent for over ten years. He’d had some wonderful results from his work, particularly in the condition of toxaemia of pregnancy which he almost eradicated from maternal death. He wrote all this up in a paper and the chief honorary also wrote a paper about a similar condition. My husband’s paper got quite a lot of adulation from medical journals and was put into The Lancet, a very prestigious medical journal, and into the big journal Obstetrics & Gynaecology. The honorary surgeon’s paper wasn’t put in, he became extremely jealous of my husband and said to him one day, ‘While I’m on this staff as an honorary you will never get onto this hospital.’ That was rather a blow. We realised afterwards, of course, that it was God’s will that we shouldn’t get onto that hospital.

You and Reg started working in the government hospital there in Addis Ababa, then started your own ‘hospital by the river’ as it’s come to be known. Resource-wise you really ran that hospital by faith, didn’t you?

Yes. After about ten years we realised we couldn’t cope with the number of patients coming to us [in the government hospital], because we couldn’t get them admitted. We’d already built hostels in the grounds of the general hospital. We had sixty patients waiting there for surgery and there was no way that we could reduce that number quickly because as soon as one came in others came. So we thought about building our own hospital.

We took a long time to decide that because we thought we’d never get permission to build a hospital in a foreign country. We had to get permission from the emperor, who turned out to be wonderfully sympathetic. He came many times to visit the fistula patients and once asked my husband why his women were getting this injury. My husband said, ‘It’s not your women, your majesty. It’s the size of your country and the lack of medical facilities in the provinces.’ The emperor was a wonderful man, was very concerned about these women and looked upon them all as his children. So we got permission very quickly from him to buy land to build the hospital.

Then we had to get permission from the Ministry of Health. We were on good terms with them and they agreed to the hospital as long as we promised not to come to them for money. We told them that we’d raise the money ourselves.

Reg and I went on horseback searching for some land and we found a very nice block on a hillside. There was a factory just behind it that was run by some Italians. Reg went in and said, ‘Where did you get your nice piece of land from? There’s a lovely bit in front of you which we would like to get for a hospital.’ They told us the land was owned by the Arminian Community who might sell it to us if we asked.

We went up to this little Arminian church and sat in the back with the elders—a lot of old men with beards who looked like Abraham—discussing the price. We got the land for a certain price and a few days later we got almost the exact amount from the Kellogg Foundation in America, which my husband had written to. It was a wonderful answer to prayer.

How did you experience God’s provision once the hospital was running?

We had to keep begging, really. My husband was a very good letter writer. I remember him writing to Sir Henry Drake, the head of BP. He said, ‘Sir Henry, while you have been drilling holes in the Middle East and making a profit we have been closing holes in the horn of Africa at a loss. Can you help us?’

[Laughter]

Sir Drake said, ‘I was so touched with your letter that I’m sending you £5,000 from my own pocket.’ So we got the money and gradually got everything together.

Today we have four centres running and the fifth we hope to have finished by the beginning of February [2010]. That one will be way down in Metu, in the south-west corner of Ethiopia, in a province called Illubabor which is very poorly medically supplied. Lots of women suffer with this injury down there. A German organisation has built a good hospital there but no doctors want to stay because it’s so remote and so difficult to educate children or have a family there. They have big grounds and have given us plenty of space to build our centre there, which will be a forty-bed ward with an operating theatre and just the simple facilities that we need.

We’ve got a centre in Bahir Dar in the province of Gojam, where there only three gynaecologists for a population of 28 million people. There’s one up at Tigray in the north and one over in Harer in the east, which is a very big Moslem area so lots of Somalia women come there. Then another down in the south in a place called Yigalem which is on the road going down to Nairobi to Kenya.

Then in 2007 you started a midwifery college.

We’re taking twelfth-grade student girls from the countryside and putting them through a three-year Bachelor of Midwifery course. In the first intake, three years ago, we took twelve students, in the second intake we took another twelve, this year we took on twenty students and we’ll gradually build up. We don’t take anyone from Addis Ababa because they would never stay in the countryside. We take them from the area they’ve grown up in and send them back to that area. We’ll build them a house to live in, they’ll work with a traditional birth attendant and they’ll be attached to a health centre so they’ll have somewhere to refer their patients to. They will become not only birth attendants but diagnosticians, able to tell if a woman is likely to become obstructed. They’ll then get the woman to a facility before she starts her labour.

So often these women wait until the third or fourth day of labour and then try to struggle to a hospital. By then it’s too late and the difficulty they have travelling is so enormous that they often give up and go home to die. The fistula patients are just the survivors. With the college we’ll be able to help [lower] the maternal death rate [in Ethiopia], which is the highest in Africa. Many countries within Africa also want to follow our curriculum. They think it’s the answer to the problem of maternal death from these fistula problems, so we’re very encouraged.

How long do you think you can keep this up?

I love living in Ethiopia. I’ve got a home there, a beautiful garden and beautiful people to look after me if I get ill. I can’t see the point of coming to live in Australia when I’d have to get on trams and buses and things. I haven’t any plans to retire. If I die the work will go on, so that’s very encouraging. And I’m sure that God will keep us going. He loves these women far more than I do and his heart must be broken to see their condition. I know that he will help us as he’s helped us in the past.

One more thing: you and Reg made a fantastic team, didn’t you?

We did. When he died I was devastated, of course. I wondered how I would carry on. And I remember once sitting on the veranda. I think I was reading my Bible, contemplating the future and I must have looked sad. My faithful servant man, who’s been with me since the beginning, came and knelt down beside me, kissed the back of my hand and said, ‘Don’t leave us. We will all help you.’ That touched my heart.