The world is more aware of the problem of obstetric fistula thanks to the work of Catherine Hamlin. The Australian gynaecologist and obstetrician talks to Fiona Fleck. Q: What is an obstetric fistula? A: This is a condition which occurs when a woman is in labour for four or five days. The bony head of the baby presses on the pelvis for so long that a hole develops between the vagina and the bladder or between the vagina and -the rectum, resulting in urinary or faecal incontinence. possible to prevent this injury by delivering the baby by caesarean section. But in Ethiopia there are not enough doctors in the countryside able to do this operation. Women with this condition are completely ostracized from society, their husbands leave them, they have no friends, because of the smell of urine or faecal matter that leaks. Women who live with this for months, even years, often have suicidal thoughts. Repairing this childbirth injury gives them new hope and new life. Q: When you first arrived in Ethiopia, you had never seen a case of obstetric fistula in your life. How did you learn to perform surgery that had become obsolete in the developed world? A: There were things written about obstetric fistulas. We knew several doctors who had been repairing them. We had a great friend in England who used to go to India to operate and we got in touch with him. We also had manuals, drawings of the actual operation from a wonderful Cairo-based professor Pasha Naguib Marfouz, he was a great help to us. We used to talk to him, we didn't get to meet him, but we learned from his textbooks. We are gynaecologists, so we are used to operating for other things, such as stress incontinence, so we were quite familiar with the anatomy, and we soon learnt. We started with small fistulas which any gynaecologist can fix without much training, and gradually tackled more difficult ones. Q: What was it like to be a fistula surgeon in Ethiopia in the 1960s? What were the challenges in finding qualified staff and adequate medical supplies? A: We were in a hospital that was very similar to the ones in Australia. We did not find it primitive in any way. The Princess Tsehai Memorial hospital had good doctors. These doctors were trained at the American University in Beirut, and we didn't have medical training at the university in Addis Ababa until 1966. We had a good nursing school with tutors from overseas, so we were well equipped with nurses. [ILLUSTRATION OMITTED] Q: At that time, in the 1960s and 1970s, you were innovative in your field, but how did you keep up with medical knowledge before the digital age? A: We had medical journals coming, friends passing through, our doctors had trained overseas. We had Australian gynaecologists who came to work at the Princess Tsehai hospital and several English ones working in other medical fields, including an English physician and a Czech surgeon. Q: Fistula surgery is complex; spanning the boundaries of urology, plastic surgery, colorectal surgery and gynaecology. How did you succeed in providing such sophisticated tertiary care in a developing country, where primary care is often seen as the priority? A: We didn't start with the difficult cases, we started with cases that we could do. Once we were successful in curing these, we gradually took on the difficult ones. As you say, it involves urology and so many other fields in medicine apart from gynaecology, but we were able to talk to our colleagues, the urologists, and they helped us. One urologist used to come regularly from England and we would keep the urological procedures to be done by him. He also trained several of our Ethiopian doctors in this particular operation. We had a lot of visitors passing through. We had a good Ethiopian surgeon who was a great help, he was the godson of the Emperor Haile Selassie and had studied in Edinburgh. Q: One of your colleagues once said: It's difficult to find a surgeon who is highly skilled enough to perform fistula surgery but also has the drive to work in poor countries. …