diary of an emerging social enterprise

Anyone who has spent any time in a hospital knows that the food there is usually pretty terrible, but what if there were no overcooked carrots or flavorless Jello? Can you imagine traveling a great distance for medical procedure that required hospitalization and having to bring along a cook for your entire hospital stay just so you could eat?

Holy Family Hospital, like the vast majority of comparable hospitals in the region, does not have a cafeteria or regular food service for patients. This means that a community of informal caregivers formed behind every ward with clusters of people sitting together preparing the meals their loved ones would later consume. People laughed and kids played and it seemed a world separated from whatever affliction had brought all these strangers together. I happened to walk up on a lively group of women pounding out some fufu, a local favorite made by beating cassava roots with the end of a six foot stick. One of the women had the most beautiful native fabric wrapped around her and when I non-verbally asked permission to photograph her, she jumped up and ran away. A few minutes later, the young lady returned having replaced the vibrantly patterned local fabric-wrap that had inspired my interest in taking a picture with a pink tank top imported from somewhere in the West. I paused to consider the wardrobe change and was brought back to attention by the young lady now yelling at me to take the picture as her hand danced around the pounding staff that formed the fufu.

Like the families who had come to support their loved ones, John Kelly had a relentless dedication to both Glenda and Isabella. I followed him around as he frequently checked on both ladies. Isabella’s procedure was relatively simple and she started a full recovery almost immediately. Glenda’s post operative status was much less stable. Her surgery had been major and despite having consumed liters of fluid, Glenda’s catheter bag remained empty. Every couple of hours, John would look in on Glenda, and every time her face seemed to get more and more bloated. John picked up the frequency and intensity of his intervention, giving instructions to the nurses and even Glenda’s husband, who didn’t speak English, but seemed to absorb the exact meaning of John’s every word.

Mr. Devotion, the name I gave Glenda’s husband, was far and away her best nurse. He always seemed to be there comforting Glenda at her sickest and he never left her side. In fact, he even chose to spend his nights sleeping on the floor underneath her bed. Unlike many fistula patients, Glenda was never forced to endure her fistula alone because Mr. Devotion stayed with Glenda through her 16 years of leaking urine and feces. After about 30 hours of worry, we found Mr. Devotion giving John the thumbs up sign as he sat next to a full catheter bag.

As Glenda’s condition stabilized, I started looking at and thinking about all the processes that had brought these women to Holy Family Hospital and had finally resulted in their fistulas being repaired. I met with the hospital administrator, Father Ofusu, and reviewed the hospitals cost and operating structure. With all these components, I began hypothesizing ways to cut significant cost out of the process and how we might scale up a treatment and training program to other parts of Ghana. In my research, I realized that Glenda’s Ghanaian insurance covered the cost of her procedure, but that Isabella would have to pay for her procedure out of pocket because she was from the Ivory Coast. I estimated that even with John’s donated surgery Isabella would still need to pay almost $200 – a fortune in her world. I decided to intervene.

I went to the women’s ward and first spoke with Glenda and Mr. Devotion. After discussing how happy we all were about the surgery’s success, I handed Mr. Devotion 10 ceedees (just over $10). This covered all their cooking cost for the entire hospital stay and left them a bit extra. They were both very happy to receive the cash support and thanked me profusely. I snapped a pic, wished them luck and headed across the ward to Isabella and her sister.

With Isabella, I had to speak through two interpreters, so things took a bit longer, but the 10 ceedees had a similar effect. When I told Isabella that OperationOF would be picking up the tab on the surgery, she first didn’t understand. After I confirmed that, like Glenda, Isabella would not have to pay for her procedure, Isabella finally broke her gaze from the floor and hit me with an enormous and radiating smile. After seeing what a brilliant and contagious smile Isabella had, I told her that the surgery was actually not free. Her puzzled look returned. I went on to explain that Isabella had to fulfil two conditions for her side of the deal. The first was to find more women who need the surgery and refer them to us and the second was that she had to smile as often as possible because her smile made the world a happier place. After 30 seconds of translation, Isabella looked me in the eyes and nodded affirmatively with a smile of absolute and pure joy that continues to move me.

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After a fantastic dinner, courtesy of Dr. Lucia Visser, the local OB/GYN who has looked after us brilliantly, I was sure I would sleep like a baby last night. But between the heavy heat, my excitement about the surgeries, and the melodious pre-5am start of the African morning symphony, I barely slept a wink. John Kelly, who runs on some sort of endless supply of high octane enthusiasm was tapping his feet and ready to go before I could pull my sleepless body out of bed. I cleaned up quickly with a very cold shower and hustled to catch John as he peddled towards the operating theatre into the rising sun. My “morning jog” in pursuit of the biking John Kelly had me trying to conceal my huffing and puffing during the pre-op morning staff meeting.

Before I talk about the surgeries, I just want to note that I have changed the names of the patients to protect their privacy. Both have consented to their stories and pictures being used in the blog, but out of respect for these incredible ladies, I have also tried to generalize personal details. Each of the fictitious names starts with the country of origin for the two patients: Glenda from Ghana and Isabella from Ivory Coast. I also want to note that both of the fictitious names I have chosen are the names of women in my own family (my aunt and cousin, respectively). I feel that this personalization is reflective of the deep connection I feel to the millions of women suffering from the indignities caused by OF.

Glenda was definitely the more complicated of the two cases. This forty-something mother of two from a rural part of northern Ghana had had an obstructed birth with her second son that caused both a VVF and an RVF. While a great many babies die in obstructed birth, Glenda’s second son lived and actually just turned 16 years old. This means that Glenda has leaked urine and feces for almost two decades. Yet, despite her dire circumstances, Glenda was a cheerful woman quick to smile and seemingly unfettered by the fairly major surgery before her. I try to imagine what it must be like to have endured such an awful set of circumstances for so long, and its honestly difficult for me to understand such profound strength.

John washed up with the other attending surgeons and assistants and they went right to work, first putting in the local anaesthetic that would keep Glenda from feeling what would be a 4 hour procedure. In addition to closing Glenda’S VVF, John also removed scar tissue obstructing her bladder and then went on to close her RVF with tools that were too short for the procedure. As the rest of the room (myself included) was shifting around in a standing exhaustion, John was doing a very complicated surgery with his fingertips. Incredible.

As soon as John finished, the head nurse suggested we do the next procedure the following day. John refused saying that he would change into dry scrubs (his were drenched in sweat), have a cup of tea and move on to Isabella. And that is almost exactly what Dr. John Kelly did. (Besides the tea, we had crackers, and Kelly chatted with Dr. Ali a bit regarding surgical techniques before we headed back to the OR)

During her examination, Isabella didn’t understand a word of what the interpreter said. This petite woman came from a tribe in Ivory Coast and no one knew how to communicate with her. This meant Isabella had to endure the invasive examination in complete absence of reassurance or even simple information. I can only imagine what an absolutely frightening experience this must have been for her. She sat up after the examination a bit dazed with her feet dangling several feet from the floor. As John helped Isabella off the table, she ruffled a rubber mat on the table and instead of looking where her feet would land, she reached back and tried to right the little wrinkle she had made. This really touched me. Despite her own complete disenfranchisement, Isabella was still incredibly concerned with ruffling this little mat.

Today was the day for Isabella to get her life back. She had been pregnant four times over the years and not one of the children had survived. As if this devastating fate had not been enough, Isabella had lived with urinary incontinence for 10 years. Rare was the instance that you could catch Isabella’s eyes – she almost always stayed completely focused on the floor before her. It was as if her shame disallowed her to even look people in the eyes. But her surgery was over almost before it had even started. It took John Kelly only 45 minutes to close Isabella’s fistula. 45 minutes – that’s literally a morning run on a Tuesday before work. 10 years Isabella had suffered. 10 years she waited to get her dignity back and it only took 45 minutes to do it.

This reminded me of why I left my former life: because years of suffering really can be ended in just minutes.

The driver arrived at our hotel before sunrise this morning and graciously waited as John and I scrambled to gather bread, cheese, and water from the breakfast buffet for the 8 hour ride to Berekum. We would crawl through the sprawling metropolis of Accra and then wind our way north and west to within 20 miles of border with the Ivory Coast. I was excited to see Ghana from the road and was most certainly not disappointed as every town seemed to offer some beautiful surprise. One of my favorites was the explosive flame tree blooming on the side of road that seemed to seamlessly fade from black tarmac to red dirt.

Despite being thoroughly engaged in the passing scenery and thrilled to soon experience my first fistula surgeries, I was quite excited by the prospects of getting to know John better on our day long car trip. I had heard that John traveled around to the most underdeveloped and instable parts of the world to help build fistula capacity, but had no idea he done so on a shoestring budget funded primarily by John himself. I learned that for three decades, John Kelly spent his annual holiday filing in for Reg and Catherine Hamlin at the Addis Ababa Fistula Hospital while they took their annual leave. Since retiring from his Birmingham-based OB/GYN practice in 1996, Kelly has spent more than half of every year contributing and sometimes driving fistula programs in Angola, Sudan (Darfur), Ghana, Pakistan, Zambia, and Uganda.

When we arrived at Holy Family Hospital this afternoon, all I wanted to do was get some food and find some shade, but John was ready to spring directly into action. Without haste, we marched directly from the car to the operating theatre, stopping only to drop off some foodstuffs John had brought that needed refrigeration. On the way, two things caught my attention. The first was this big sign leading people to the parts of the hospital focused on mother and child and the prominence and position of the word “Mortuary” on that sign. The word had top billing with a font that dwarfed anything else on the sign. To me, this sign symbolized the dire situation facing mothers in the developing world.

The second attention-catcher was two women sitting quietly on an out-of-the-way bench. Both women were dressed rather well, in traditional clothes, but neither uttered so much as a word, not even to each other. As we approached I noticed one had her gaze firmly pointed at the ground and the other was curiously watching us. I turned to smile at the woman trying to sneak a peak and she immediately looked at the ground, an unfamiliar response in the ever-friendly Africa I have come to love. We kept walking and only half an hour later would I realize that these lonely two were the patients who so desperately awaited John Kelly’s intervention.

During the examinations, I realized that John Kelly’s determined intensity had an incredibly patient and gentle side as well. Despite multiple language differences, an unfamiliar setting (for everyone save the nurses) and what appeared to be an incredibly uncomfortable examination, Kelly seemed to put the patients at ease as he searched for the small holes that had largely devastated these women’s lives. Throughout the examination, Kelly described the position and characteristics of the fistulas out loud, almost dictating notes to some unseen scribe, while also mixing in questions and reassurance to the patient. I was amazed at how seamlessly Mintah, the head nurse and interpreter, could distinguish between John Kelly’s two dialogs. After the examinations, Kelly sat down and penned a few notes and then we headed home to get a bit of food and some sleep after a very full day.

Dr. John Kelly, or “Kelly“ as he calls himself, is a one of a kind. I was delighted when Steve Arrowsmith introduced me to Kelly and Dr. Maura Lynch of Uganda as they are both fistula legends who have devoted their lives to the cause. John really impressed me with his outspoken advocacy throughout the course of the meetings in Ghana. Never shy to share his opinion with the group, Kelly blended an earnest passion with a sarcastic lightness and always seemed to both educate and entertain whenever he spoke.

Here on the last day of the conference in a side conversation, John told me he was planning to go do some surgeries the next day. For weeks, I have been unsuccessful in my attempts to organize a visit to a working fistula center. John has a relationship with the Holy Family Hospital in Berekum, a town near the boarder with Ivory Coast and planned to leave early the next morning. I asked if I could join him and after John told me that there may not be many patients due to the last minute nature of his visit, he welcomed me to accompany him to Berekum. Kelly even suggested that we share a room on our last night at the hotel in order to save a little money. I like the way this man thinks!

My good impression of John was even further magnified when I got to the room that we shared. John had a huge suitcase half-full of sutures and other medical consumables in excess of what he planned to use at the hospital. The other half of the suitcase was in the minibar refrigerator - John had brought a load of cheese, cookies and other edible goodies with him to hand out to the local staff in Berekum. What a great guy!

“Luck,” the Roman philosopher Seneca said, “is what happens when preparation meets opportunity.”

So far, we have enjoyed considerable luck. All the research that the OperationOF team had been preparing since Christmas collided divinely with an exceptional opportunity to attend three consecutive meetings that occurred on two continents. In just nine days, we had the amazing chance to meet the some of the world’s leaders in fistula repair, share our ideas, and rapidly adjust our strategy to best fit a dynamic and evolving industry.

As much as I love thinking of luck as something that we can influence through preparation, I recognize that shear fortune influences one’s access to opportunity. Our fortune came in the form of two surgeons whose decades of experience helping women with obstetric fistula make them esteemed experts: Dr. Lewis Wall and Dr. Steve Arrowsmith of the Worldwide Fistula Fund. We reached out to Dr. Wall in March after reading his comprehensive research on obstetric fistula. After an enlightening conversation, Lewis introduced us to his partner Dr. Steve Arrowsmith and the two graciously shared their insights and experiences with us. Steve mentioned that he planned to attend a meeting at the World Health Organization (WHO) in Geneva and a meeting in Accra organized by USAID and EngenderHealth. When I expressed interest in the meetings, Dr. Arrowsmith went out of his way to arrange invitations for me to join him on the trip. This is how OperationOF ended up in an expert surgeons meeting at the WHO and at a USAID partners meeting the following week.

As someone with no medical background, I felt slightly unsettled walking through the palatial foyer of the world’s leading health authority en route to an expert surgeons meeting managed by researchers from Johns Hopkins. The purpose of the WHO meeting was to lay out a nine-country, UNFPA-sponsored study intended to improve obstetric fistula prognosis by developing a classification methodology. As I thumbed through the study description and proposed questions, I realized that while I may not have understood the specific detail of some of the questions, I had completed similar exercises as both an academic and a professional. My fading apprehension completely disappeared as I spoke to a few of the surgeons carrying out the study. This delightful group of extremely sensitive men and women from around the world impressed me at nearly every turn. With extensive experience treating fistula patients, these surgeons had some incredible stories. Their deep concern for the women was also quite evident when they passionately debated, reworked and sensitized questions they thought might upset the would-be subjects of the study. Seeing experts devoted to technically improving surgery express such humanitarian concerns and commitment to the whole patient showed me how much these doctors cared about the women.

In Geneva, I met Kate Ramsey, the global coordinator for UNFPA’s Campaign to End Fistula. Besides being impressed with her enthusiasm and breadth of knowledge, I was thrilled when Kate invited me to attend the International Obstetric Fistula Working Group’s (IOFWG) annual meeting scheduled to take place that Sunday in Accra. I had decided to head to Africa a bit early and was overjoyed at the opportunity to participate in these meetings. In a small group setting, the IOFWG meeting really showed me that the areas of prevention, treatment and reintegration should all be included in OperationOF’s mission. We had originally decided to focus all of our efforts on treatment alone, but my experience in Ghana made it very clear that we could contribute significantly to improvement and optimization of prevention and social reintegration services as well.

I started to explore specific ways that we could help the various organizations present at the IOFWG meeting and at the USAID/EngenderHealth’s Fistula Partners meeting that followed it. With a broader focus and some experience communicating OperationOF’s vision, I found the timing of the Fistula Partners meeting could not have been better. The group of attendees was larger than the prior meetings which enabled me to continue some conversations and start many new ones as well. Besides finding solid field-based partners we could help support through fundraising, we also identified organizations that could benefit from our operational services expertise. The discussions enabled us to develop an understanding of critical areas where operations research could help expand capacity and improve efficiency. By the close of the week, OperationOF had an industry-vetted strategy and a swath of potential partners working in countries all over the world. The strides that we made in such a short time were nothing short of miraculous and definitely a testament to some incredible luck.

But the serendipitous fortune fueling OperationOF’s progress surprised us yet again when a conversation on the last day of the conference put us on a path to funding our first surgeries.