Monday, December 20, 2010

Beauty and the Beast

During the boom years in Ireland, while many were indulging in a frenzy of empire expansion, an industry that specialised in nipping, tucking and tightening flourished. The cosmetic surgery business experienced a massive surge in clients eager to satisfy fantasies of designer bodies and ageless beauty.

In 2006, one Dublin clinic reported a 200 per cent leap in patient numbers over a 12-month period. That year, the cosmetic surgery market in Ireland was worth about €25 million. By the beginning of 2009, this extraordinary growth industry was estimated at almost €50 million. 
Despite a recent reversal of this trend as the economic belt tightens – one industry source tells Scope that the decrease in procedures could be more than 30 per cent in Ireland over the past 12 to 24 months – the market for cosmetic surgery remains high. And according to leading specialists in the field, the industry is badly in need of a facelift of its own.
Plastic and cosmetic surgeons in Ireland are concerned about the worrying lack of formal regulations to ensure uniform standards are maintained in facilities and practices throughout the country. Within this unregulated environment, unscrupulous opportunists are free to target vulnerable members of society, aggressively marketing their trade at deflated prices with no guarantee of adequate service or after-care.
However, this gravy train may be about to derail for disreputable cosmetic surgery clinics. After years of lobbying by members of the Irish Association of Plastic Surgeons (IAPS), the Medical Council and a small number of professionals and clinics, the Government is poised to clean up the unregulated mess that is the Irish cosmetic surgery market. 

Corrective work
While the majority of clinics operating in Ireland are reputable, and several have secured or are seeking international accreditation for their facilities, clinics offering cosmetic surgery are not regulated and practitioners may have neither adequate credentials nor training to carry out these invasive surgical procedures.
The Department of Health has just announced plans to push through a mandatory licensing system for public and private healthcare facilities, including cosmetic surgery clinics. Scope has learned that the Department aims to have these legislative proposals ready for the Health Minister’s consideration by the end of this year.
And not before time, according to the IAPS, which in 2007 submitted a document, The Regulation of Private Clinics, to the Government, the Medical Council, the RCSI and the Commission on Patient Safety and Quality Assurance. 
“People in Ireland, who, for one reason or another seek cosmetic surgery, have been left unprotected for far too long,” IAPS president Mr Michael Earley tells Scope. “Most of our members have seen patients who come to them for corrective work to repair badly done cosmetic surgery. 
Mr Michael Earley
“These patients were lured in by glossy advertisements promising unrealistic results and end up with bad or disfiguring surgery and, in some cases, complications that may risk their physical and mental well being.”
Under current Irish law, even a recently qualified doctor with a basic degree and no further training or specialisation is permitted to perform cosmetic surgical procedures, as long as they receive patient consent. 
A common practice in a small number of cosmetic surgery clinics in Ireland is to fly in ‘visiting surgeons’, who are then not around when the patient requires post-operative care.
“There are definitely a few clinics around which have what we call ‘FIFO’ – fly in, fly out – surgeons who come in to the country and operate and then leave the same day,” says Mr Kevin Cronin, a consultant plastic surgeon who shares a private aesthetic surgery practice with five colleagues, each a fully accredited and registered plastic surgeon living in Ireland. “The patients are then looked after in other hospitals by nursing staff. If there is a problem like haematoma, for example, or bleeding, that surgeon is not in the country to deal with the problem.”
Conversely, while doctors fly into Ireland to perform procedures, ‘cosmetic tourists’ continue to travel abroad for plastic surgery that costs a fraction of the price here. But this can also be a risky business.
“All of us have seen the fall-out from cosmetic tourism,” Mr Cronin remarks. “We don’t know how widespread this practice is or how many people are travelling abroad for cosmetic surgery, so we can’t say how much of it turns out badly, but we do know that we end up repairing the damage when the procedure goes awry. I would say 10 to 15 per cent of my work is corrective – repairing the bad work of others.”

Tightening up on practices
Mr Jack Kelly, consultant plastic and reconstructive surgeon at the Galway Clinic and IAPS secretary, points out that he and his colleagues have met and operated on many cosmetic surgery patients who have been delighted with their outcome. 
Mr Jack Kelly
“There are certainly patients who have a poor result and who are dissatisfied with cosmetic surgery, as there are with any type of surgery, but the vast majority are happy and pleased as a consequence,” Mr Kelly adds.
While there are no official statistics available in Ireland to indicate the level of referrals to correct poor cosmetic surgery, a recent survey of 155 GPs in the UK found that over 60 per cent of them have been consulted by distraught patients following unsatisfactory invasive cosmetic procedures.
In 2009, nearly 40 per cent of surgeons in the UK said they had seen patients who had suffered complications from permanent filler operations, and over 25 per cent had to perform corrective surgery.
The Medical Defence Union, which provides indemnity cover to doctors in the UK and Ireland, issued a statement in 2006 estimating that £8.5 million had been paid out for claims over poor cosmetic surgery in the previous 10 years. Breast and facial surgery accounted for the most claims. The size of settlements ranged from £200 to £305,000.
“This area has a significant rate of litigation and this is attributable to both the high expectations of patients undergoing these procedures and the nature of the risks involved. 
“In light of all of these factors, there is a very high duty of care on surgeons performing cosmetic surgery and it is important that patients give fully informed consent. The unregulated landscape does not assist matters from the perspective of patient or doctor,” says Aoife Nally, a solicitor at Hayes Solicitors in Dublin.
However, as the concept of cosmetic surgery becomes increasingly mainstream, fuelled in part by the reality TV ‘make-over’ phenomenon, prospective ‘customers’ are being hit with a hard sell. Even a cursory shuffle through the many websites managed by Irish cosmetic surgery facilities reveals a forest of ‘leggy babes’ who have obviously never seen the sharp end of a surgeon’s knife. Images of perfect breasts and tight abs, plump lips and sculpted features are seducing the gullible into believing that improbable results are possible.
“It’s the age-old problem of advertising cosmetic surgery, showing people who have very definitely never had or needed to see a cosmetic surgeon. All of these perfect bodies are utterly misleading,” says Mr Earley. “In an ideal world, we would ban all advertising for cosmetic surgery but at the very least there should be no photographs or illustrations allowed and the ads should not be misleading and should carry health warnings because there is a risk involved in all surgery.”
The Medical Council’s Guide to Professional Conduct and Ethics recommends that doctors “avoid using photographic or other illustrations of the human body to promote cosmetic or plastic surgery procedures, as they may raise unrealistic expectations amongst potential patients”. But clearly, in some cases, these guidelines are being ignored. The IAPS’s 2007 report on the regulation of cosmetic surgery calls for the legal enforcement of these advertising restrictions.

A new code
The IAPS document also recommends the introduction of a ‘code of practice’ that would require the surgeon to meet with the patient for a private consultation prior to the procedure. During this meeting factual and not promotional information should be given. 
The issue of payment is also highlighted. It should be illegal for money to change hands prior to the patient’s consultation with the surgeon, and there should be a 14-day ‘cooling-off’ period between agreeing to undertake surgery and doing so.
Importantly, recognised specialist training in cosmetic surgery should be established and surgeons who have been suspended for clinical reasons should not be permitted to work in the private healthcare sector.
“There is no reason why the private sector should not be regulated in a similar fashion to the public in order to ensure fair standards for both private patients and public patients,” the report states. “We would recommend the establishment of a new regulatory body for the private healthcare sector. This body should be made up of individuals; half of whom should be elected by the professionals and half of whom should be recommended by the Department of Health.” 
This industry watchdog would be paid for by the private healthcare sector and would oversee all regulatory matters related to private clinics. 
Dr Labros Chatzis
Many of the association’s recommendations were echoed in a recent submission to the Department of Health by Dr Labros Chatzis, a consultant plastic surgeon and Medical Director of the River Medical cosmetic surgery clinic in Dublin.
He concurs that only a qualified surgeon on a specialist register with the Medical Council, permanently resident in Ireland with 24-hour, seven-day-a-week medical and nursing back-up and performing all operations in a regulated medical environment, should be allowed to practise here.
Dr Chatzis further recommends that all doctors seeking to perform specific non-surgical cosmetic procedures must first receive a certificate of competence from the Medical Council. This provision is also espoused by members of the Irish Association of Cosmetic Doctors, which has been lobbying since 2008 for proper regulation of the non-surgical cosmetic medicine business in Ireland.

UK findings
There is no clear picture of how many private cosmetic surgery businesses operate in Ireland, if their surgeons are suitably qualified and screened, or whether their facilities are adequately equipped.
UK authorities have addressed a similar information deficit there in a new nationwide review of the organisational structures surrounding the practice of cosmetic surgery. The findings, which were published in September this year, are truly alarming. 
Although there was a statutory obligation to take part in the review, a mere 20 per cent of cosmetic surgery clinics participated. Shockingly, more than one in 10 clinics “ceased to exist” between being identified and being approached by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which conducted the review. The remaining 69 per cent of clinics either did not answer or refused to take part.
One would imagine that those clinics that complied with this investigation would have facilities ranking among the top in the industry. But the report authors discovered “an alarming lack of equipment in the theatre, in proper recovery facilities, in HDU facilities and in out-of-hours surgical cover”.
Less than half (44 per cent) of operating theatres were fully equipped to carry out cosmetic surgery and 30 per cent of sites performing cosmetic surgery did not have a Level 2 care unit. Almost 20 per cent had no emergency re-admission policy. 
Many cosmetic surgery sites were offering a menu of procedures, some of which were only performed infrequently, and surgical training was only available on 16 per cent of the sites. “In one sense this may be just as well: what sort of training can be offered in a centre that performs most of its procedures once a month?” the authors remarked.
Among its recommendations, the NCEPOD said that regulatory bodies should ensure national requirements for audit and scrutiny of sites under licence are adhered to. More formal training programmes must be established, leading to a certificate of competence. Cosmetic surgical practice should also be subject to the same level of regulation as any other branch of surgery. 
Mr Nigel Mercer
British Association of Aesthetic Plastic Surgery president, Mr Nigel Mercer, agrees: “These figures present a distressing picture, but one which is sadly not surprising to us as they only confirm what we have been saying for years – that there is an absolute need for statutory regulation in this sector.
“Aesthetic surgery needs to be recognised as the multi-million pound specialty it is and not just a fragmented cottage industry.”
Mr Earley says that the HSE should conduct a similar investigation into cosmetic surgery in Ireland. “If it’s anything similar to the UK, we have a lot of work to do,” he warns. 
The NCEPOD review may be informally discussed at the IAPS annual winter meeting in Dublin on November 25 and 26, as will the Department of Health’s drawn-out efforts to regulate private healthcare clinics in Ireland. This is a hugely complex, multi-layered issue and considerable uncertainty abounds. To what degree will any new legislation tackle the problems unique to the cosmetic surgery sector? Who will grasp the nettle in enforcing these regulations? When will this long-awaited legislation be introduced and will the Government get it right this time or will corrective work be required?    



Not without complications


Several prominent cases in recent years have highlighted the dangers of the lucrative but unregulated cosmetic surgery industry. Plastic surgeon Marco Loiacono, 34, was found guilty earlier this year of six out of 12 counts of misconduct by the Medical Council. In June, the High Court confirmed the Council’s decision to suspend Mr Loiacono for six months and he was ordered to undergo further education. However, an Irish national newspaper recently revealed that despite this ban, he has since returned to his native Italy where he is still working in plastic surgery.
In May this year, a Co Limerick man was awarded $3.1 million in compensation over the death of his wife following cosmetic surgery in the US in 2005. The cosmetic surgeon at the core of the case, Dr Michael Sachs, settled without admission of liability for $2.1 million.
Dr Jerome Manuceau
In 2007, Bernadette Reid, a mother of six, died from a cardiac problem after an aborted procedure to have a gastric band fitted at the now defunct Advanced Cosmetic Surgery (ACS) clinic in Dublin. Paris-based surgeon Jerome Manuceau did not complete the operation after he discovered a tumour in Mrs Reid’s stomach. The Arklow woman died the next day. The coroner recorded a verdict of death by natural causes. 
Dr Manuceau has since been struck off the register of medical practitioners following a Medical Council inquiry. It said the surgeon was guilty of “professional misconduct”, a claim confirmed by the High Court on September 10, 2008.
Mr Michael Earley, consultant plastic surgeon at the Mater Misericordiae Hospital and president of the IAPS, has been called on as an expert witness in a number of court cases when legal action is being taken against cosmetic surgeons. 
“That is not rare in Ireland. Usually the examples revolve around the post-operative care and lack of it. Unfortunately you also come across errors of judgment on the part of the surgeon, they would usually revolve around breast implants and basically taking the easy option,” he says.
“I can only say that these patients are very traumatised by their surgery experience. If someone is willing to chase after a surgeon from a legal viewpoint they certainly are filled with both dissatisfaction and anger. It is often quite difficult to secure a finding against a surgeon because you have to prove that someone is actually negligent. And proving negligence is quite different to saying ‘that wasn’t a very good job’.”


The long road to legislation

It’s hard to blame the sceptics when they scoff at news that the Government is poised to introduce new legislation to regulate all healthcare facilities, including cosmetic surgery clinics. It has been a lengthy journey and there is no definite end in sight.
The task to devise these tighter controls began in earnest in 2007 when Health Minister Mary Harney established the Commission on Patient Safety and Quality Assurance to make recommendations ensuring quality and safety of patients. 
Nineteen months later, in August 2008, the recommendations were published. Most notably they called for the introduction of a licensing system for public and private health services. Indeed, the Commission singled out cosmetic surgery clinics in its list of facilities that urgently require mandatory licensing and audit.
The Government deliberated on these recommendations for a further six months before finally announcing in February 2009 that they had decided to draw up legislation for the licensing of healthcare providers.
To facilitate this, the Government approved “the immediate establishment” of a steering group to drive implementation of the Commission’s recommendations. This group was launched four months later, in June 2009, and set about dividing the 134 recommendations into 13 separate projects, including legislation, standards, education and training, and clinical audit. 
In its September 2009 progress report – the only one published to date – the group stated that legislative provisions regarding open disclosure, adverse event reporting and clinical audit were to be included in heads for the Health Information Bill. This Bill was enacted in July this year. It is concerned with the transfer of information from the HSE to the Health Minister; it does not relate to private facilities and makes no mention of clinical audit. The Commission also recommended that the Health Information and Quality Authority (HIQA) “progress urgently” the development of safety and quality standards to be applied to hospitals and all future licensed healthcare facilities, in advance of the introduction of licensing legislation.
In September 2010, HIQA launched a six-week public consultation process on draft national standards for better, safer healthcare. “It is proposed that these national standards will provide the basis of a mandatory licensing system for private and independent healthcare facilities, including cosmetic surgery clinics,” a Department spokesperson told Scope. 
He added that the Department “is now developing legislative proposals for a mandatory licensing system covering both public and private healthcare facilities in line with the Commission’s recommendations. The Department aims to have these legislative proposals ready for the Minister’s consideration by the end of this year.”

Wednesday, December 15, 2010

The Burning Question


What motivates a person to start fires? Dr Theresa Gannon is the head of a new project that aims to answer this question and to develop a treatment programme for arsonists and fire-setters internationally.

A petty criminal is imprisoned for trying to kill a doctor and his family in an arson attack at their Belfast home. A teenager dresses up as ‘The Joker’ and sets fire to his Clondalkin school to teach staff a lesson for treating students as ‘sub-human’. A homeless man with a severe speech impediment is convicted of arson after he lights numerous fires around Dublin city “to get the upset out”. An alcoholic caretaker kills two promising young jockeys  - including Galway-born Jamie Kyne - in a fire attack fuelled by envy, anger and drugs.
These four incidences of arson - as diverse in motive as they are in severity of outcome - were reported recently in Irish newspapers, and they are only the tip of the iceberg. Irish fire fighters tackled over 12,000 ‘malicious’ fires in 2006 – more than half of these were in Dublin City. The following year this figures dropped to less than 5,000 but only because the breakdown on cause was not available from Dublin City Council.
The latest recorded crime figures confirm that arson attacks are steadily increasing. According to the Central Statistics Office, arson offences have risen year-on-year from about 1,400 in 2005 to more than 3,000 in 2009.
Yet, astonishingly, professionals hold very little knowledge of the types of arsonists who exist, or of their key characteristics and treatment needs. This is extremely worrying given that arsonists are highly likely to repeat their behaviour when released into the community. A widely cited Irish research paper on this subject estimates that at least 35 percent of known arsonists re-offend.
But in the UK, where deliberate fire-setting costs society in excess of £42 million every week, authorities are attempting to address this intervention deficit. A grant of more than £560,000 was recently awarded to Dr Theresa Gannon, a Chartered Forensic Psychologist and Senior Lecturer in Forensic Psychology at the University of Kent, to develop and oversee the very first standardised treatment programme for fire-setters internationally.
With these Economic and Social Research Council funds, Dr Gannon, who has a long held academic interest in arson and fire setting, will fully examine the types of arsonists who exist and their treatment needs.
Using this information, she will then develop, implement and evaluate the very first specialised, standardised treatment programme for arsonists worldwide. Each stage of the treatment programme will be designed to build upon the previous one, and, taken together, the results will change the way in which both academics and practitioners view, conceptualise and treat this group.
Dr Gannon, whose grandfather hails from Mayo, is one of the world’s leading authorities in both male and female sexual offending. However, she has noticed that a significant number of these offenders also had fire-setting tendencies in their history.
Dr Theresa Gannon
“I was very curious about the fact that I was treating these people for their sexual offence but not necessarily for their fire-setting and that peaked my interested initially,” Dr Gannon tells Scope. “I realised that there was not much in the form of treatment protocols for arsonists or fire setters, certainly nothing standardised. Perhaps there are a handful of people with their own devised treatment plans for these offenders, normally in mental health settings, but there is nothing specific available.”
This conspicuous service gap was also recorded in a UK Government-funded survey in 2005 to evaluate interventions with arsonists and young fire-setters. The study found that most interventions were educational in nature and provided by Fire and Rescue Services for children and adolescents; few forensic NHS services provided specialist interventions for mentally disordered or learning disabled adult arsonists; and there was no provision by the Prison Service or Probation Areas for offenders serving prison or community sentences.
Dr Gannon’s research is funded for three years and will be conducted in four phases. Initially, her team will empirically validate the characteristics and deficits associated with personalities who deliberately set fires. This information will provide the groundwork for phase two – the development of a structured treatment programme for arsonists and fire-setters.
Armed with this treatment blueprint, 10 forensic psychologists and assistants in the UK will be enlisted to provide the intervention for well over 100 fire-setters. At present, the facilities that have agreed to take part in the pilot programme are secure prison establishments, but Dr Gannon says the intervention could also be introduced in mental health settings if they express an interest in participating.
Outcomes for the treatment group will then be compared to a matched group of fire-setters who don’t receive treatment. Finally, participants will be followed-up at a later date to gauge the sustained effectiveness of the treatment programme and its impact on fire-setting recidivism rates.
“Our objective is to develop a kind of manual that guides therapists through what they should be doing and who should go on the programme, as well as what we should be treating. Then we can assess how effective the programme is, relative to having no treatment at all, or more generic treatment which is typically what happens to fire-setters at present,” says Dr Gannon.
“One of the common traits that many people say characterises the fire-setters is mental disorder, however, we’re not sure how valid that is because there is an over-representation of mental disorder classifications as these people tend to get channelled towards those facilities.
“But I would say that arsonists and fire-setters are more likely to be male, the ratio of male to female fire-setters is estimated to be 6 to 1. There are a number of different motives as to why someone might set a fire but the one feature that seems to set them apart from other offenders is their inability to communicate or express themselves, or their anger, directly. A violent person would approach his or her victim directly and use a knife, for example, whereas using fire is a very indirect way of communicating your anger towards someone or that you need help from society.
“Obviously there are many different types of fire-setters - it’s a very heterogeneous group - but there is a sub-type who are particularly interested in fire. I’d say fire is an innate interest for all of us, so I’m talking about someone who is very inappropriately interested in fire. Perhaps they gain a lot of sensory reinforcement from the fire; intense pleasure, gratification or release at the time of lighting fires. The term is pyromania and the diagnosis is extremely rare and only when certain strict criteria are met.
“Certainly, developing a treatment plan for arsonists and fire setters is going to be quite challenging and new. We need to establish, for example, which types of fire-setters need treatment. Do we give fire-setting treatment to a young man who has just set fire to a notice board in a hospital or a prison, but the majority of his other offences have nothing to do with fire-setting? The answer, perhaps, it that it is not appropriate for them, and this is what the first part of our research will be concerned with: identifying which factors really exist in those who show very problematic or repetitive fire-setting and are they different to offenders who don’t fire set? From there we can develop a suite of criteria for who should be on the programme,” says Dr Gannon.
Towards the end of the first year Dr Ganon and her team will begin selecting people for the treatment programme and the intervention will be provided over the following two years. The programme involves 25 weeks of group therapy and, in parallel, the participating psychologists will provide individual support work to ensure that each person works on their own particular areas of need.
“This flexible approach is essential,” Dr Gannon explains. “In any treatment programme, the people running it need to be experienced enough to know that one size does not fit all; they must develop a formulation for each person in the treatment group - an individualised treatment plan.
“In our third year, we will be following up their treatment progress and seeing whether there have been any improvements since the programme ended and whether any of these improvements have actually stuck with them.
“This will tell us whether or not the new treatment is effective for meeting the needs of arsonists and how we should deal with arsonists in the future so that we can stop them from re-offending.”
Several international studies have suggested a wide range of recidivism levels for arsonists, depending on the methodology and sample used. A 2006 study using a criminal justice sample of 34 court reports from arson cases in England and Wales between 1999 and 2003 found two-thirds of arsonists (67.6 percent) had a previous history of fire setting, although not necessarily a conviction. Fire-setting behaviour among the sample had begun as early as seven years of age.
A study of fire-setters in the south west of Ireland in 1987 examined a non-random convenience sample (n=54) of fire-setters from prisons and psychiatric hospitals in Ireland. It found that 35 percent of the sample were recidivists, and 11 percent engaged in repeated episodes of fire setting. The recurrent fire-setters were all lower socioeconomic status males, all of whom had a psychiatric diagnosis.
Meanwhile, a study in West Germany of convicted arsonists found that recidivism rates ranged from only 4 to 10 percent over a ten-year period.
Another fundamental difficulty exists in attempting to estimate the prevalence of deliberate fire-setting acts in society, as not all perpetrators register on the criminal justice radar or even attract the attention of the police force.
“The reason we use the term fire-setting at times is because often you encounter someone who is setting problematic fires in hospitals or in their cells and it never gets to the courts, so it never gets counted as an arson offence for one reason or another.
“In the UK, you might get over 100,000 incidents of deliberate fire setting recorded by the fire service in a year, but only half of those would be recorded as arson by the police, because they have a different burden of proof or other facts might take precedence, such as a stolen car that is destroyed by fire would be recorded as car theft, not arson. In fact only about 8 percent of deliberate fire settings acts will come before the court and approximately 2,500 people in a year would be convicted for arson, in England and Wales.
 “So our treatment programme will not only be targeting people who have been convicted of arson, we will also be including people who may have fire setting in their offence or in their background and is deemed to be a problem, but they may not have been convicted of it.”
The Arson Prevention Bureau in the UK has compiled some disturbing statistics: every week, arson attacks result in 2,213 deliberately started primary fires, 63 injuries, 2 deaths and a cost to society of over £42 million. In the last decade, there have been around 2.4 million deliberate fires in the UK, resulting in 1,250 deaths and 32,000 injuries. A similar breakdown is not available for intentional fire setting or arson in Ireland.
Despite the seriousness of the crime, arson has traditionally received little attention from academics. Dr Gannon admits her surprise that a research project such as hers was not commissioned years ago.
“When you see the enormous cost to our society that arson produce, in terms of cost to the economy and the incalculable cost to human welfare - loss of life or injury. I’m surprised a formal and specific treatment programme hasn’t been devised already. “The fact is, the recidivism rates for arsonists are very similar to those of sexual offenders, but no one would ever say to a sexual offender, we’re not going to treat your specific problem but we can offer you something general. But that’s what we’re doing for fire-setters. If we stand any chance of tackling this problem and of helping these people we have to do develop an specialised and effective treatment programme.”


Australia’s burning

Every hour of every day in Australia at least one arson fire is lit. The deliberate setting of bushfires is one of the most costly crimes committed in Australia, yet police, fire-fighters and researchers agree that little is known about the motivation of arsonists and how to tackle the crime.
Earlier this year, at the first conference of its kind in Australia, experts across several disciplines gathered to discuss developing a plan to cut down the number of deliberately lit fires.
Prof James R P Ogloff
Addressing the two-day meeting, Prof James R P Ogloff, director of the Centre for Forensic Behavioural Science at Monash University’s School of Psychology and Psychiatry in Victoria, revealed his plans to develop a comprehensive research project on the psychology of fire setting, including the validation of assessment, intervention, and risk prediction strategies. 
He stressed that the task will be a tough one: “It is generally accepted at least 30% of arsonists will go on to subsequently set fires. Some fire setters, light hundreds of fires over time. Given the nature of their fire setting, such individuals have a great deal of difficulty simply refraining from thinking about and setting fires. 
“An area that requires more concerted research is how we can identify which fire setters are at greatest risk for re-offending. We need to know more about risk factors for those who repeatedly set bushfires.”


Profiling arsonists

Although deliberate fire setting is one of the least understood and infrequently studied problematic behaviours, data gathered over the previous years have increased our knowledge surrounding various aspects of the arsonist.
Dr Tom O’Connor, renowned comparative criminologist and Associate Professor of Criminal Justice at Austin Peay State University, Tennessee, summarises the emerging profiling characteristics for arsonists as follows:
AGE: 10-14 (26 percent), majority under 18 (51 percent) if adult, late 20s, never over 35 if adult, revenge or profit motive

SEX: 9 out of 10 times (90 percent) a male; if female, revenge type

RACE: 3 out of 4 times (75 percent) a white; black (20 percent) of time if first-timer;
CLASS: majority from lower to working class; middle class if vandalism or excitement

IQ: vast majority subnormal (70-90) with 22 percent in retarded range (below 70), rare genius

FAMILY: absent or abusive father, history of emotional problems with family/mother

SCHOOL: learning problems and usually held back a grade in school, normally in 10th grade; younger (grades 6-8) if vandalism

PEERS: social misfit, interpersonal problems with opposite sex, appears physically and emotionally weak compared to peers

WORK: usually chooses subservient position and then resents it (both ambivalent and resentful toward authority-repressed); unemployed if vandal, excite, or profit

CRIMINAL HISTORY: numerous status offences as juvenile, property crimes, almost all have arrest records

DRUG/ALCOHOL: no problem, but involvement with

MENTAL: lack of remorse may appear as psychopathy, but more typically result of obsessive-compulsive disassociative trance-like state during fire setting

ARREST: majority remain at crime scene except revenge, conceal, profit types; some attempt suicide in lockup; most easily confess through cooperation.

Types of arson 



ARSON FOR REVENGE (41 percent) - precipitating factor is a real or imagined affront that occurred months or years ago; attack is focused on individual rivals, a business chain, schools, or some facilities connected with offender

ARSON FOR EXCITEMENT (30 percent) - precipitating factor is boredom, (sexual) thrill cycle, or need for attention; attack is focused on large or outdoor targets, like parks, construction sites, arenas, as well as residential areas

ARSON FOR VANDALISM (7 percent) - precipitating factor is family disturbance or peer pressure; attack if usually focused on educational facility as well as residences and outdoors

ARSON FOR PROFIT (5 percent) & ARSON FOR CRIME CONCEALMENT (17 percent) 

Modern-day Methuselahs

How long can humans live? It's an age-old question but one that may now be obsolete as there appears to be no upper limit to life expectancy in sight. That’s according to an international team of age researchers, who have for the first time gathered a database of the oldest people in the world - those who lived beyond their 110th birthday. 
The Supercentenarians.
This new scientific data shows that records are being broken every year. Today, there is not only a dramatically increasing number of centenarians, but also more and more men and women who live to 110 years or older.
Age researchers in 15 nations have spent the last ten years scouting their countries for people who reached the extremes of old age. Together they found over 600 genuine supercentenarians in the USA, Canada, Japan, Australia, France, Italy, Spain, Germany, Switzerland, Belgium, the United Kingdom and in the Nordic countries. Of the 600, nearly 20 lived beyond 115 and - no real surprises here - the vast majority (almost 90 percent) were women.
Although Ireland was not one of the countries investigated, a UK researcher identified an Irish woman as one of the first carefully validated supercentenarians - Katherine Plunket, the oldest person in Irish history. She was born on November 20, 1820, and died on October 14, 1932, at the age of 111. She therefore became a supercentenarian in 1930, which is “very early for the appearance of a genuine supercentenarian in any country,” the researchers declared.
While searching for these ”supercentenarians“ and trying to find accurate documentation of their age, the researchers not only collected data for scientific purposes, but also documented the fascinating personal histories and wisdom of those who lived more than a century. They have now published their findings and the stories of many of their subjects in the book “Supercentenarians” which was coordinated by the Max Planck Institute for Demographic Research (MPIDR) in Rostock, Germany.
“Investigating very old age has always been difficult for demographers," says Heiner Maier from the MPIDR. "Science has been plagued by myths and fairy tales."
He explains that most claims of modern-day Methuselahs appear promising at first glance, but usually turn out to be unverifiable. Entries in the Guinness Book of World Records aren't reliable either; their validation is often based solely on documents provided by the families of those who reached an advanced age and are not independently confirmed by scientists.
“A fundamental question in aging research concerns the trajectory of mortality at the highest ages. Until recently it was uncertain whether human mortality after age 110 is slowly increasing, level, slowly decreasing, or rapidly decreasing,” Heiner, who is Dean of the Max Planck School, tells Scope.
“This uncertainty arose because reliable data on mortality after age 110 had not yet been collected. Almost a decade ago, an international group of researchers decided to establish a database that would allow the best possible description of the mortality trajectory beyond the age of 110.”
Specifically, the objective of this concerted effort was to gather complete lists of validated supercentenarians in as many countries as possible. The new data was used to create the International Database on Longevity (IDL, http://www.supercentenarians.org), which contains exhaustive information on validated cases of supercentenarians and permits unbiased estimates of mortality after age 110.
"The IDL is the first reliable record of scientifically verified data about supercentenarians on an international scope. It is the best existing account of mortality beyond the age of 110."
Heiner describes their main finding as remarkable: human mortality levels off at a probability of death of 50 percent per year after age 110. It appears the older we get, the more our mortality increase slows down. One study even raises the possibility that mortality may fall after age 115.
“Life expectancy is lengthening almost linearly in most developed countries, with no sign of deceleration. Extrapolating these trends would suggest that life expectancy will continue to increase in future years,” Heiner remarks.
However, he adds that, even though life expectancy at birth is steadily increasing, it is unlikely that we will see dramatic increases in maximum age in the near future – “barring major breakthroughs”.
Finding the supercentenarians was an unusual task for the demographers, as they could not rely on standard statistical methods. As most countries didn't have a central birth register in the late 19th century, when the supercentenarians were born, the scientists faced significant challenges to prove their age and often had to search through a massive amount of certificates, census lists, death registers and the paper files of universities and health and security administrations to identify supercentenarians.
The findings varied between countries. In the United States, 341 supercententarians were eventually verified (309 women and 32 men), whereas, in the much smaller country of Denmark, only two women were verified as being over 110.
Some researchers got lucky. In Germany, for instance, the researchers found a much faster method - they asked the Office of the German President for help. The President keeps a directory of residents older than 100, in order to send birthday congratulations. With the list in hand the researchers easily tracked down 17 supercentenarians.
Jeanne Calment
The record holder in longevity is still the French woman, Jeanne Calment, who died in 1997 at the age of 122. The book "Supercentenarians" celebrates her life - how she met the painter Vincent van Gogh when she was 13 and how she took up fencing at age 87. She allowed herself one glass of port and one cigarette a day, and she enjoyed good food and wine, including cakes and chocolate, which she ate every day.
Apparently, Jeanne smoked until she was 117. The only reason she quit is because she got tired of asking people to light her cigarettes for her. She couldn't see well enough to do it herself.
When the demographers James Vaupel and Bernard Jeune, two of the authors of "Supercentenarians", visited her at age 120, she remarked that the most important thing in her long life was that "I had fun. I am having fun”.
Chris Mortensen's long life is also detailed in the book. Born in Denmark, he died at 115 in the United States. Currently the record holder as the world's oldest living man, at his advanced age he still enjoyed smoked cigars.
The Dutch woman Hendrikje van Andel-Schipper also reached the remarkable age of 115. Despite being born prematurely with a weight of only three pounds, she nevertheless avoided major life-threatening diseases until her nineties, when she was diagnosed with a breast cancer, and ultimately died of stomach cancer.
The African American woman Bettie Wilson, who died at the age of 115, even survived gall bladder surgery at age 114. And Elizabeth Bolden, also an African American woman, who was deeply religious and had ten great-great-great grandchildren, was allegedly completely mentally fit and was able to recount all the major details of her life on her 112th birthday.
“I was struck by the finding that there is apparently no secret of longevity,” says Heiner. “Supercentenarians appear to be almost as diverse as individuals at younger ages, albeit almost all are women, most enjoyed comparatively good health until advanced old age and none were heavy cigarette smokers. The number who did not marry or who had fewer children than average appears high compared with marriage and childbearing patterns for people who died younger,” he adds.
What is striking, he notes, is that many of the super old avoided dementia, at least until shortly before they died. This provides evidence that dementia is not an inevitable corollary even of extreme old age. Now researchers want to expand the use of the IDL and its data to investigate mortality at advanced age and the reasons for an extra long life.
Happy Birthday!!!!
In one of the book’s chapters, researchers Bernard Jeune et al, report that while the super old retained their youthful personalities and were able to live on their memories, none of them could escape the effects of extreme old age.
“Their physical functions declined markedly, especially after their 105th birthdays. They walked very slowly and had increasing difficulty in performing daily tasks. Their sight and hearing weakened, so that in the last years of their lives they were virtually blind and very hard of hearing. They spent their last years confined to wheelchairs and slept most of the time,” the authors wrote.
However, it was observed that, despite their advancing frailty, they did not fear death, and they appeared to be reconciled to the fact that they were approaching the end of life.
“They never expressed any wish to recover their youth.  'Enjoying and living are two different things,' as Chris Mortensen put it."
Heiner reiterates that the key to longevity is still elusive. So far the only thing for certain is that being a woman is clearly advantageous, since 90 percent of those celebrating their 115th birthday were women. Having ancestors who lived exceptionally long played as little a role as economic background, and half of the supercentenarians had no children. It is unclear, however, whether this evidence will remain constant with future supercentenarians. The search for the secret of super old age has only just begun.

The Irish supercentenarian

Katherine Plunket was 102 when she contracted bronchitis – her only serious health problem in her remarkable 115 years. Until then, she actively oversaw the upkeep of the home and gardens of Ballymascanlon House near Dundalk, one of her distinguished family's ancestral homes.
The longest-lived person in Ireland (1820 – 1932), Katherine was a member of the Anglo-Irish aristocracy. Her grandfather was a Lord Chancellor of Ireland. Her father became a Bishop and inherited the title of Baron Plunket.
She never married, but Katherine and her sisters travelled widely and visited almost every capital in Europe. She also made many sketches of flowers in France, Italy, Spain, Germany, and Ireland, which were bound in a volume and were presented in 1903 to the Royal College of Science. The collection is now in the Irish National Botanic Gardens at Glasnevin.
Katherine was included in the first ever Guinness Book of Records in 1955 and was also the last living person who had met Sir Walter Scott, when he stayed at her grandfather’s house in while she was visiting.
She credited her longevity to a carefree aspect of life.

Can we live forever?

Aubrey de Grey
Cambridge University geneticist, Aubrey de Grey, drew jeers of disbelief from many of his peers when he declared: “The first person to live to be 1,000 years old is certainly alive today; indeed, he or she may be about to turn 60. Whether they realise it or not, barring accidents and suicide, most people now 40 years or younger can expect to live for centuries.”
Aubrey may be wildly optimistic but he is not alone in the search for a virtual fountain of youth. In fact, a growing number of scientists, doctors, geneticists and nanotech experts - many with impeccable academic credentials - are insisting that there is no hard reason why ageing can’t be dramatically slowed or prevented altogether.
Scientists have been successful in prolonging the life of some animals. On a near-starvation diet rodents can live up to 40 percent longer, once they have the required vitamins and minerals. In addition, some of the genes related to ageing have been identified. Modifying these genes can lengthen the life of yeast, worms, mice and fruit flies. Yet, would these longer-living or slower-ageing animals prosper in the real world? Evolutionary theory predicts that longevity would come at a cost. Many of these mutants have been infertile.
But Robert Freitas at the Institute for Molecular Manufacturing, a non-profit, nanotech group in Palo Alto, California, is up-beat: “It will take time and, if you put it in terms of the big developments of modern technology, say the telephone, we are still about 10 years off from Alexander Graham Bell shouting to his assistant through that first device. Still, in the near future, say the next two to four decades, the disease of ageing will be cured.”


People are living longer and healthier - now what? 

People in developed nations are living in good health as much as a decade longer than their parents did, not because aging has been slowed or reversed, but because they are staying healthy to a more advanced age.
James Vaupel
"We're living longer because people are reaching old age in better health," said demographer James Vaupel, author of a review article which was published in the March 25 edition of Nature. The better health in older age stems from public health efforts to improve living conditions and prevent disease, and from improved medical interventions,
Over the past 170 years, in the countries with the highest life expectancies, the average life span has grown at a rate of 2.5 years per decade, or about 6 hours per day.
"It is possible, if we continue to make progress in reducing mortality, that most children born since the year 2000 will live to see their 100th birthday in the 22nd century," says James, who heads Duke University's Center on the Demography of Aging in the US, and holds academic appointments at the Max Planck Institute for Demographic Research in Rostock, Germany, and the institute of Public Health at the University of Southern Demark.
He ponders that it may be time to rethink how we structure our lives. "If young people realize they might live past 100 and be in good shape to 90 or 95, it might make more sense to mix education, work and child-rearing across more years of life instead of devoting the first two decades exclusively to education, the next three or four decades to career and parenting, and the last four solely to leisure."

The Wisdom of Women


Imagine having all the women in the world to lean on when you need advice. Dublin-based doctor and author Juliet Bressan and co-author Michelle Jackson have tapped into that fountain of knowledge and produced a unique and inspiring book that shares tips, thoughts and advice from ordinary women on a myriad of issues.

“The most common way people give up their power is by thinking they don't have any.” This pearl of wisdom from African American author, Alice Walker is a tenet that rings true for Dr Juliet Bressan and Michelle Jackson.
Earlier this year, while despairing at Ireland’s economic tailspin, the two friends and best-selling authors were maddened that half of our society appear powerless to influence our recovery.
They felt that the main institutions of wisdom are governed by men, and are articulated by men: women's wisdom is ignored by the institutions of society. The opinions of women were irrelevant in what President Mary McAleese branded a “testosterone driven” crisis.
“Not one woman caused this disastrous situation and not one woman’s opinion was being sought on how to repair it. We thought this is nonsense because women are managing financial crises every day of their lives; they’re managing emotional crises, family crises, death, bereavement; you name it, women manage it. We are the gender that keeps everything going on a daily basis,” says Juliet, who alternates her life between writing novels, working as a GP specialist in addiction and HIV-related health, running a Performing Arts Medicine clinic for musicians, and writing a popular column for Scope.
She and Michelle, a fellow-author and friend, decided to restore some of the balance of power by giving women back their voice. The end result is a new book celebrating the knowledge and wisdom of women for women, with more than 1,000 contributions from women all over the world.
The authors confide that when they first conceived the idea for this book, they had no idea where to start. They wanted to write a book of wisdom for women, and they needed to find a way of getting at what was in women's heads, and collecting their shared experiences into a book.
The answer was Facebook, an online social community that connects people throughout the world.
Juliet Bressan and Michelle Jackson
The friends set up a page on Facebook called “What Women Know” and within a few months they had registered more than 1,200 fans of all ages, from all backgrounds and from many different countries.
“The Facebook page got the book going very quickly. I believe this is the first book written entirely on Facebook. There were well over a thousand women who were contributing to the questions or problems that we posted on our status updates,” explains Juliet. “Every day we’d post a new question and ask the women for their advice. It was very interesting because what we noticed was that women were so pleased to be asked about what they thought on an issue.
“Some of the answers are just amazing. A lot of it was quite empowering and inspiring. Sometimes I’d read a response and cry because I couldn’t believe that a woman was sharing a story that was so heartbreaking; women wrote about death and abortion, loss and tragedy, and domestic violence came up a lot.
“But one very strong theme that came across I felt was that a lot of women are very lonely; they don’t have any real power in society and yet they are doing a very powerful job, whether it’s looking after kids or elderly parents or whatever their responsibility, they are contributing hugely to society in a very quiet and undervalued way.”
Through the Facebook page, Juliet and Michelle reached out to women everywhere, encouraging them to join in discussions and share ideas, stories, knowledge and wisdom about money, love, friendship, work, health, spirituality, everything that matters in our lives.
“Women tend to be collaborative and cooperative, we don’t tend to be competitive. We are inclined to solve problems by asking each other for advice, and often we give that advice by sharing our own stories or personal experiences. That’s what this book is all about,” Juliet tells Scope.
“From my point of view, writing this book and the Facebook interactions very much helped me in my job as a GP. None of this is aimed at academics, it’s aimed at everyday women and those are my patients.
“A patient of mine, who joined the Facebook page, is one of the most active contributors. Her posts are lovely. It gave me a bond with her and other women that I wouldn’t necessarily have bonded with at that level.
“Also, it’s astonishing what people will actually come up with when you ask them for an opinion. I think that is something that is missing in the world today is actually asking ordinary people for their opinion. We have all these experts getting it wrong. We need to ask the people who are at the real coalface, the people all around us.”

What Women Know is published in hardback by Hachette and is available in all good booksellers or on www.amazon.co.uk/books

Monday, September 13, 2010

Fighting Fistula

©Alixandra Fazzina/ Noor

Obstetric fistula is the most devastating of all childbirth injuries, although many may never have even heard of it. Constantly in pain, leaking urine or faeces, bearing a heavy burden of sadness in discovering their child stillborn, outcasts because of their offensive smell; ashamed, these young women live on the periphery of their former existence, without friends and without hope.

Although once common in western countries, the obstetric fistula is virtually unknown in the developed world today. During prolonged, obstructed labour, sometimes lasting several days, the pressure from the trapped foetus cuts off the blood supply to tissue between the mother's vagina and her bladder or rectum, causing that tissue to die away and creating a hole, or fistula.
Eradicated in western countries at the end of the 19th century when caesarean section became widely available, obstetric fistula continues to plague an estimated two million women worldwide, according to the United Nations Population Fund.
Reconstructive surgery can often heal these women, returning to them their dignity and their lives. However, with an estimated 100,000 new fistula cases each year and the international capacity to treat fistula remaining at only 6,500 per year, the suffering and isolation is life-long for an incalculable number of desperate women, who can’t access treatment.
The specialist surgery skills to treat fistulas must be learned in those countries where women and girls suffer from this debilitating and humiliating condition, primarily in Africa and Southeast Asia. A handful of international humanitarian groups and charities are working to eliminate obstetric fistula, among them Médecins Sans Frontières (Doctors Without Boarders), which has provided fistula repair in numerous countries including Liberia, Somalia, Sierra Leone, Central African Republic, Burundi, Nigeria, Ivory Coast, Chad and, more recently, the Democratic Republic of the Congo (DRC).
This year, due to the numbers of patients identified as needing this specialised reconstructive surgery in MSF’s ongoing programmes, it was agreed to run three camps in the DRC, the first of which was in May, another was held in August and an third is planned for September.
Helen O'Neill, a Dublin-born nurse, is MSF's Operational Advisor for the DRC, India and Sri Lanka, and is based in Holland. She explains to Scope that a month-long MSF camp last year in the village of Dubie in Katanga, DRC, during which 78 young women were surgically treated, identified many, many more fistula sufferers.
“We’ve generated some awareness about the fact that there’s a possibility to treat this condition, and hundreds of ladies have been identified. We don’t have the capacity to do that many, so we will do one camp now [May] and put on an extra in August but in another location. It means some people won’t get treated, but this problem is not going to go away. It’s a life long affliction unless it’s repaired, so maybe next year we will be able to offer them help,” Helen adds, all to aware that she and her team of surgical and nursing volunteers may never be able to keep pace with the numbers who need treatment.
“In 1997, I was in Sierra Leone and we identified a number of women with this problem and I was really lobbying hard, it was so difficult to get anything done. The nearest place that any of them could get repaired, at that time, was in Nigeria. And I think that there were only two surgeons in the world with the expertise to do this specialised surgery at that time, and they were in Nigeria and Ethiopia.
“So we started doing it ourselves in Sierra Leone. We did the first 100 ladies or so and that’s a small volume but it’s still a very small select group of people who have the expertise. It’s quite specialised, but once you learn it, you can repeat it.”
Since then, several MSF surgeons have mastered the techniques and train others through MSF. Dr Volker Herzog, an experienced MSF obstetric fistula specialist, has participated in numerous fistula camps over the years throughout Africa, including this latest programme in the Congo.
“MSF organised the first vesico-vaginal fistula (VVF) camp in Katanga, DRC, three years ago, in the town of Dubie. We operated on about 70 patients and, when we finished the session, the patients who were operated successfully wrote a letter and asked that we return to treat the women who had not yet been operated on. Since then MSF has organised a special VVF camp every year for the past two years. This year it is in Shamwana,” Volker tells Scope.
Helen remarks that this rural village is hard to find on a map. It lies northwest of Dubie. “It’s a very basic bush place, when we started working there we built a hospital and that’s where this fistula camp is, on the hospital grounds. We use the hospital lab facilities and the staff are the same but with two extra – the surgeon and one nurse.”
A Congolese surgeon was scrubbed in alongside Volker to assist and train in fistula repairs during the camp last May. The second camp in August helped to hone the local doctor’s skill in this specialised surgery so that, should MSF ever have to pull out of that region in the future, for whatever reason, there is someone there who knows how to do these repairs.
“We started by raising awareness of the condition among the population in the district via local radio and over 230 potential patients were identified. Of course it is not possible to operate on so many patients in one session so it was planned to start with 80 patients, and that is what we did,” Volker recounts, adding that it is an immense logistical task to install 80 beds, toilets, water supply and food for so many patients and their care takers, and this in addition to running a hospital with about 70 beds.
“MSF operates on about 15 patients a week and at the end we hope that we will have operated on about 70 patients. Not all of the 80 patients we examined had a fistula. Some of them have urethra incontinence so that they are treated with physiotherapy, and some have a urinary tract infection, which can produce symptoms similar to those of a fistula, but can be treated by antibiotics.
“In about 8 percent of operations, the first attempt is not completely successful and the patient requires a second operation. Sometimes the damage in the vagina is too extensive and the patient is inoperable. But usually the outcome is very successful with a cure rate of 90 percent,” the German surgeon notes.
The surgeons, indigenous and foreign, who train to perform reconstructive obstetric fistula repair, are not drawn to this specialised area because of monetary reward - $300 covers the cost of surgery, post-operative care and rehabilitation support - indeed, many offer their services for free. It is the complete transformation of personality in those women successfully treated that spurs these doctors on; the joy that they see in the eyes of patients on the day of discharge, these women are re-animated in the knowledge that their lives can begin again.
“I was confronted with the condition for the first time during the war in Mauritania/Liberia in 2003, where I operated on a woman with a perforated appendicitis and noticed the dreadful smell of urine.
“I was so concerned about the fate of this woman that I decided to learn to repair fistulas. So, I joined the most experienced fistula surgeon, Dr Kees Waaldijk, who has operated on 25,000 VVF patients. I trained with him on three occasions at his hospital in North Nigeria,” recalls Volker.
“The constant leaking of urine out of their bladder wets their clothes and due to the accompanying smell, many communities consider these women outcasts and often they are abandoned by their families and husbands. With a successful operation these women are not only healed of their condition they have had their dignity returned to them - they are no longer outcasts from society and can look forward to their new lives.
“The estimated number of VVF patients in Africa is about 2 million so it is obvious that we need more VVF camps like ours and more surgeons who can operate the obstetric fistulas. More importantly there needs to be more maternal services for pregnant women to prevent obstetric fistulas from occurring in the first place and to avoid unnecessary maternal deaths,” he stresses.

The UNPFA agrees that the key to ending fistula is to prevent it from happening in the first place. Skilled attendance at birth, including swift surgical intervention if obstructed labour occurs, can prevent a fistula.
©Alixandra Fazzina/ Noor
At present, many women in sub-Saharan Africa have little or no access to such services. Births are traditionally at home with untrained people, and even when health care is available nearby, social mores can take precedence over the health of the mother.
A large number of those who die from obstructed labour or who survive with fistulas are between the ages of 10 and 18 and are of small stature. They might have been made to marry and become pregnant quite young, and because their bodies have not fully developed, they cannot deliver the baby. These are the women and girls who are at risk of such complications, and huge numbers of them die.
Helen describes the overall health services not only in this DRC region where MSF operates, but also many other rural areas of Africa, as abysmal. “In theory, or maybe on paper, it doesn’t look too bad but in practice it isn’t good. There are a lot of people that don’t have any healthcare at all. They are extremely poor, yet they are expected to pay for healthcare. They can’t manage that so they will not bother to seek it out. There’s no point in taking a sick child to the hospital if it’s going to die because you can’t afford to pay for the hospital. It’s very sad,” she says.
“For women with an obstetric fistula - some of them may have been suffering with it for decades - this surgery changes their lives completely. Suddenly, they are allowed back into society; they do not smell anymore. They are young women and most of them would be able to have children again.
“I met three women together recently, and the difference before and after surgery is extraordinary. They were all aged between 18 and 30; they were cowed, quiet, miserable, afraid, ashamed – all of these things – when you met them at the beginning. And when you meet them post-surgery, they are laughing, smiling, “bonjour Monsieur le Docteur”, happy women. It’s quite extraordinary.”
The eradication of obstetric fistulas in Africa is decades away at least. But these doctors and nurses with MSF, and other humanitarian groups, are taking crucial first steps toward that goal.


The Campaign to End Fistula

©Alixandra Fazzina/ Noor
During most of the 20th century obstetric fistula was largely missing from the international global health agenda. This is reflected by the fact that obstetric fistula was not included as a topic at the landmark United Nations 1994 International Conference on Population and Development (ICPD).
However, since 2003 obstetric fistula has been gaining awareness amongst the general and medical public and has received critical attention from the United Nations Population Fund (UNFPA), which is spearheading the first-ever global campaign to "End Fistula". Its overall goal is to make the condition as rare in the developing world as it is elsewhere.
The Campaign, launched in 2003, has already brought fistula to the attention of a wide audience, including the general public, policy-makers, health officials and women with fistula. More than $25 million in funding has been mobilised from a variety of donors and activities are underway or being planned in more than 40 countries.
In each country, the Campaign proceeds in three phases:
  • First, needs assessments are undertaken to determine the extent of the problem and the resources to treat fistula.
  • Second, each country that completes a needs assessment receives financial support for planning, including raising awareness of the issue, developing appropriate national strategies and building capacity.
  • Finally, a multi-year implementation phase begins, which includes interventions to prevent and treat fistula, such as improving obstetric care; training health providers; creating or expanding and equipping fistula treatment centres; and helping women reintegrate into their communities.

What can be done to help?

Skilled surgeons can repair obstetric fistula. A simple repair may take only 45 minutes to complete, but many cases are more complex and require several operations. After the operation, the woman will need a bladder catheter for a couple of weeks and will be taught pelvic floor exercises to strengthen their muscles.
Women who have had a fistula repaired are able to have a healthy child, if they receive appropriate antenatal care.
Training local midwives to help mothers give birth safely is vital. They can spot when a mother is in difficulty with the labour and arrange help before it is too late.