Interview with Christopher Tarnay, MD
Raffi Djenderedjian interviewed Dr. Christopher Tarnay as he prepared to leave for Uganda to celebrate the opening of the Center for Gynecologic and Fistula Care
“These are going on the plane with us,” Dr. Christopher Tarnay says, referring to the dozen or more boxes of heavy medical supplies stacked in his office. Dr. Tarnay, a urogynecologist and professor at the David Geffen School of Medicine at UCLA, is preparing for a surgical trip—one he takes every year—to Uganda. Since 2009, he and a team of mainly UCLA doctors, residents, nurses, and medical students have worked with the nonprofit organization Medicine for Humanity to conduct annual, two-week trips to perform and teach obstetrical fistula repair at Mbarara University of Science and Technology [MUST] in Mbarara, a town of 200,000 near the border of Rwanda and the Democratic Republic of the Congo.
Obstetrical fistula, a passage between the vagina and bladder and/or rectum, often develops at the end of pregnancy when obstructed labor lasts hours or days without Caesarian delivery. The condition is endemic in sub-Saharan Africa, where “the women laboring don’t have easy access or transport to a hospital,” according to Tarnay. Complications include permanent urinary and/or fecal incontinence, which frequently leads to extreme social ostracization in the local community, limiting the ability to work or attend school.
Medicine for Humanity was founded by UCLA gynecologic oncologist Dr. Leo Lagasse in the 1990s to address disparities in women’s reproductive health in the developing world and to help provide medical education. Dr. Tarnay became involved in 2009 and now serves as the organization’s medical director and president. Since 2008, Medicine for Humanity has performed over 1,000 surgeries and has worked with over 159 Ugandan resident physicians, seven of whom have successfully matriculated through its training program. At this time, Uganda has just twenty-six skilled surgeons to treat obstetrical fistula; Medicine for Humanity’s training program is aiming to improve capacity by adding to this cadre year by year.
This year’s trip marks a milestone for Dr. Tarnay and his team. Medicine for Humanity will be celebrating the opening of the Center for Gynecologic and Fistula Care, a dedicated surgical and recovery center for which the organization raised all of funding. Previously, a lack of space meant that fistula patients convalesced in cramped conditions. Before he left for Uganda for the center’s opening ceremony, I had the chance to speak to Dr. Tarnay about the new center, obstetric fistula care in Uganda, and his vision for the future of Medicine for Humanity.
What are some of the logistical challenges your team faces and how does the new center [Center for Gynecologic and Fistula Care] help to resolve those challenges?
The chronic challenge to caring for these women with fistula has been a lack of space in the hospital. Another challenge has been the need to keep patients convalescing for two weeks after surgery–you can’t–there is limited capacity to fill their hospital with an additional 40+ patients requiring prolonged care. In years past, we had done transient convalescence housing with tents from the World Health Organization, then we moved to a transitional space that we built onto the side of an existing building with a tin corrugated roof. We also used unoccupied operating theaters for a couple of years to house the patients. These were all makeshift and functional, but in the end just rudimentary solutions. We ultimately decided there was some unused space on the grounds we could use that would expand the existing gynecological ward, which only had twelve beds.
By building this center, we are increasing our ability to take care of the women who have fistula and to do so in a more dignified manner. It will be year-round, instead of our prior “surge” model of flying in, taking care of patients, leaving, and coming back again—by creating a space where the hospital can have an increased capacity to actually house these patients properly. Another challenge, as with many surgical issues in global health, has been that these elective conditions—ones not medically required in order to save a life or lengthen life—tend to be prioritized below life-threatening conditions. At the hospital we were going to, these elective procedures were done very sporadically. However, this center will increase capacity to care for quality of life conditions as it is all focused on—designated for—women’s health.
What are some of the local/cultural challenges faced by not just the patients but your team of surgeons as well?
As Westerners flying in, it has been critical for us to acknowledge, recognize, and honor the work being done there on a day-to-day basis. The staff live and work in these places every day to take care of overwhelming numbers of patients, with limited resources. An egregious break in what we would consider the norms of taking care of patients is usually borne out of the fact that, at times, the hospital doesn’t have the capacity or the ability because of resource restriction. Instead of viewing what they do as uncaring or neglecting, we have to recognize limitations in a realistic manner and what is being done is the best within those limitations. That being said, we still can strive to practice as we would practice here, in terms of patient autonomy, privacy, informed consent—all these things, with effort, can be translatable over there.
I’ve always felt that our best ambassadors for what we’ve been doing over the years have been the UCLA residents, because they come in with a sense of wanting to learn as much as they can. Our Ugandan partner doctors there do amazing things without all the devices and tools we have in the US, and are able to take care of patients in a completely fundamental way. As a result, our residents and fellows learn how to take good care of patients without technology and gadgetry we tend to believe is required to do a job. The art of medicine is alive and well. Mbarara is a university town, so people really value learning there. The community recognizes us as people who are helping with that learning process, so we have always felt welcome and respected.
Can you talk about the some of the success stories you’ve had with training surgeons there?
Dr. Musa Kayondo, now the Chairman of the Department Obstetrics and Gynecology at MUST, was our first successfully trained and certified fistula surgeon. He was a resident when I first starting coming in, took an interest in minimally invasive gynecologic surgery and fistula care, and wanted to stay in Mbarara—which takes a special kind of person. Even though he has a home in Kampala and his wife and children are in Kampala, he decided to stay in Mbarara because he is dedicated to fistula care. He has been one of the constant fixtures there.
With his presence, the local residency program has grown considerably. When we first started, there were only five OB/GYN residents to take care of the entire population; now there are twenty-five. What we’ve been able to do is create a training track for this high-volume fistula program that we have a couple times a year. The Ugandan ObGyn residents participate in at least three surgical programs—that’s fifty to sixty cases per program. In combination with their regular training, they come out after these training experiences completing cases and autonomously caring for patients with fistula. To date we have seven graduates of the residency. In a country that has only twenty-five trained fistula surgeons, adding seven to the mix over the last several years has really increased capacity. In addition, Mbarara borders Rwanda and the Democratic Republic of the Congo [DRC], and we have residents who come from these countries because the Ugandan Ministry of Health has offered to train residents in conflict-torn countries where infrastructure and medical training has broken down.
In 2017, one resident drove seven hours from the DRC to come to Mbarara to observe and work during our fistula care, and now he’s the only doctor in his town who can perform fistula repair. He came back after having just done his first fistula case and was eager to tell us. We were excited because he was excited. It’s very gratifying to see not only our effect on the local community in southwest Uganda but the ripple effect that’s hopefully spreading across more of East Africa. We’re hoping ultimately to provide the training, support, and care so that one day our presence isn’t needed—that’s my sincere hope.
In an article from 2015, you said that your team completes around fifty cases per two-week trip. Has that number increased since then?
That’s about as much as we can do. We strain the system when we’re there. We only have two theaters to work out of. There’s a balance between expediency and the ability to train doctors in a way that they will understand the steps. We do four to five cases in a room per day, and that is still tremendous turnover. At UCLA, we do two to three cases at most in a room per day. Any more than that starts to provide too much strain and has diminishing return for everyone. But now that we have this new space, who knows?
Do you typically have more than one surgery happening at a time?
We have two rooms being used at the same time. The MUST hospital has four functioning operating rooms, and we take two of them during the trip.
What are some of the steps being taken for prevention or reduction of fistula?
The tenet of fistula is that it’s caused by obstructed labor—the baby is stuck in the birth canal—but fistula fundamentally is a result of obstructed access to healthcare. So there are infrastructure issues and there are health education outreach issues. Our small organization is very challenged to create large population-based health education awareness, or to do outreach—having healthcare workers go out to communities and talk to traditional birth attendants about the importance of getting laboring women to a hospital or near a hospital and how to identify obstructed labor at an earlier point. The Ugandan Ministry of Health, several years ago, put out a national campaign to end fistula, and a part of that included these preventive strategies I just outlined.
In addition, the women that undergo fistula care convalesce in a group. We’ve learned—and we’ve studied this—that there is a tremendous benefit to patients healing with other patients. These women come in believing they are alone with this condition until they come to a community where they see they are not alone. They share stories and share experiences. After surgical correction they tend to be enthusiastic to go back to their communities to share their experience and evangelize about the importance of fistula prevention.
We have nurses that specialize in fistula care who do group education sessions with these women. We have numerous examples of women who go on to tell their communities about the importance of avoiding fistula. Last year, for the first time, we had one of our repaired fistula patients independently return the following year because she felt so connected to the community. She came back to share her experiences with the women and served as an impromptu counselor who encouraged all the women to let others who are afflicted with fistula know about this problem.
What initially drew you to doing this work? I imagine there are many opportunities for someone like yourself.
Actually it’s the converse. This was serendipity. About 10 years ago, Dr. Amy Stenson, my colleague, went to Mbarara, where she was doing work on reducing post-partum hemorrhage. While there, she was seeing all these women with fistula, yet there was no one to treat this condition. However, in the US we don’t have obstetrical fistula like they do over there—this condition doesn’t exist in developed countries. I went to Uganda and worked with a doctor who had experience; in doing so, I added the skills to become proficient in fistula surgery. Hundreds of cases later, I am still learning. Ultimately, it is the courage and grace of these women that inspire me. I realized if we don’t go, these women don’t get cared for. So that’s what keeps drawing me back.