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The Cry of Alice

One of the best stories in Africa today is linked to one of the worst stories in America’s past

Coca-Cola has been cashing in on women’s bodies for more than a hundred years now. I don’t want to get into a whole big debate about it, but suffice it to say that the shape of the classic Coke bottle looks nothing at all like a cocoa pod (the official origin), and more or less exactly like a headless woman in a hobble skirt (what everyone else thinks the origin is). So there is a bit of irony to the fact that Coca-Cola was out in force this past August 16, at the grand opening of Uganda’s new Terrewode Women’s Community Hospital, a facility that represents a dramatic leap forward in the evolution of the treatment of vesicovaginal fistula, a condition that results from so-called “accidents” of childbirth and is one of the worst things that can happen to a woman’s body.

The corporate colonialism of the Coca-Cola Company has never been particularly subtle. Teaching the world to sing in perfect harmony is sweet euphemism for the white man’s burden. Coke-logo building materials form the architecture of shops and kiosks across Africa, and in Uganda there are entire villages that are Coke-themed, every building painted red, the swoopy white logo ubiquitous—towns as daunting as the fiery, red-slathered hellscape of Clint Eastwood’s High Plains Drifter.

Which is to say that Coke never misses a trick. At the hospital opening, Coke provided tents, chairs, and a mobile sound booth, and in exchange the logo was everywhere, along with profile images of the hobble skirt bottle. As the day-long celebration began with announcers heralding the arrival of prominent officials and religious and community leaders, I, for one, couldn’t help thinking that it was about time Coke came clean about the century’s worth of bank they’ve been making off the female form.

And, actually, the world’s largest soft drink company is not alone in this. The Terrewode Women’s Community Hospital is the happy ending of a story that harkens back to a time when women’s bodies were a frontier and a commodity, and when obstetric vesicovaginal fistula spelled opportunity for at least one unscrupulous physician.

As a schoolgirl in Soroti, a small city in northern Uganda, Terrewode founder Alice Emasu had six girlfriends, all slightly older, young women who took under their wings a precocious girl destined to become a visionary.

Political unrest in northern Uganda in the late 1980s compelled Emasu’s family to relocate south. She completed her schooling in Kampala. After five years, negotiations brought peace to Soroti, and Emasu returned home on a school break to visit her friends. Four of them were dead. Two died while giving birth, another died during labor, and one more died of complications of birth a short time later. The other two friends were a mystery. People referred to them using very rude terms—the women were mad, or dirty, or cursed. They avoided other people, did not care for their bodies, ran off whenever they saw others. Emasu came to learn that both women were suffering from fistula.

Obstetric fistula is so disturbing to describe that even Oprah Winfrey, after doing two shows about an important fistula hospital in Ethiopia in 2004-05, admitted to hesitance in having even taken on the subject. “[A] fistula is a—a hole that’s left in a woman’s body? And she’s dripping urine? Oh yeah, let me try to humanize that. Let’s make that palatable to ten million viewers.”

An obstetric fistula forms like this. The passenger, as is said, is too large for the passage, and labor becomes protracted: two days, three days, five days, more. Most often, the baby dies early in the process, and the woman must endure relentless contractions that press the infant skull against her pubic bone until the baby’s corpse has softened enough to at last pass out of her body. The fistula opens inside, at the site where the skull has impacted against bone. The tissue in between is pulverized and dies and the dead flesh sloughs away. This is not a cut or a tear, but a crush wound. Most often, the location of the slough is the septum that separates the vaginal canal from the bladder. Women with fistula are left with a perpetual leak of urine from their vaginas.

I’ve come across no better description of the plight of fistula sufferers in Africa than that of Reginald Hamlin, founder along with his wife, Catherine Hamlin, of the Addis Ababa Fistula Hospital, the institution that Oprah profiled:

Constantly in pain, incontinent of urine or feces, bearing a heavy burden of sadness in discovering their child stillborn, ashamed of a rank personal offensiveness, abandoned therefore by their husbands, outcasts of society, unemployable except in the fields, they live, they exist, without friends and without hope.

Emasu’s two surviving friends had been left like this. She was unable to locate them on her journey home, but it was the predicament of these women that inspired her to investigation, action, and ultimately a calling.

What became clear at once was that fistula wasn’t really an “accident” of childbirth at all. Rather, it was an inevitable outcome in a society that was plagued by a host of factors associated with high incidence of obstructed labor: prevalent child marriage, zero antenatal care, age old traditional beliefs, unjust laws limiting the rights of women, poor medical facilities, ragged infrastructure—and on and on. Furthermore, the simple cure of a fistula, the stitching closed of a hole, was only the beginning for women who were likely to suffer ongoing ostracization and stigmatization at home, even if they were “cured.”

A glimmer of Emasu’s vision sparked even then, in the early 1990s. She went on to become a journalist and activist, inspiration flickering all the while, and in 1999 she founded The Association for the Rehabilitation and Re-Orientation of Women for Development (TERREWODE).

Terrewode identified fistula sufferers, assisted them in seeking out what medical treatment was available, and then aided in their reintegration into their home communities. By 2002, Emasu was working closely with what she called “flying doctors,” drawing on the Flying Doctors Society of Africa—Western physicians who flew to Uganda once or twice per year to treat fistula sufferers assembly line-style. Western aid organizations and Catholic missionary nuns had been offering this “camp model” of care for years, and it was hard to fault these efforts when there was no better option. At the same time, Emasu recognized that the camp model sometimes used fistulous women as fodder for surgical training. When the flying doctors flew out of the country again, they left behind no equipment, and there was little follow-up for a procedure that required weeks of aftercare.

The Terrewode Women’s Community Hospital is the happy ending of a story that harkens back to a time when women’s bodies were a frontier and a commodity.

Emasu began to feel the call to a leadership role when she wrote a story about child marriage and her editor tore it up right in front of her. The problem of fistula was systemic, but few were willing to even think about the underlying causes that created an atmosphere ripe for obstructed labor.

In 2005, Emasu found her two old friends and arranged for them to be cured. By then, Terrewode had identified more than three-hundred cases waiting for an opportunity for treatment, but over the next two years foreign fistula aid in Uganda began to dry up. The government gave Terrewode six beds in a state-run hospital, but physicians complained that there was never enough money for treatment. Soon, everyone from local leaders to fistula sufferers themselves were clamoring for a hospital dedicated to obstetric fistula.

Emasu had once heard a rumor: fistula had first been cured in some kind of clinic in the United States in the 1850s. She wondered what strategies had been used to eliminate fistula in the West—today, obstetric fistula is unknown outside the developing world. Could those practices be replicated? To further this goal, a colleague attached to the Uganda Media Women’s Association suggested that Emasu apply to study in the United States, at the Brown School of Social Work at Washington University in St. Louis.

It’s tempting to credit providence for this suggestion. Also at Washington University was Dr. Lewis Wall, a skilled fistula surgeon, founder of the Worldwide Fistula Fund, co-founder of a dedicated fistula hospital in Niger, and author of Tears for My Sisters: The Tragedy of Obstetric Fistula and dozens of papers on fistula in Africa, including impassioned pieces boldly asserting the medical ethics that should attend the treatment of fistula in the developing world, and announcing via fiat the rights that every fistula patient should enjoy.

In Spring 2008, transported to St. Louis, Emasu found herself at Wall’s office door.

“I am here, but I am bleeding,” she said. “I left behind three-hundred women, and my country cannot help them.”

Her vision was two-fold, she explained. In the short term, she wanted funding for women in existing facilities. In the long term, she hoped to build a hospital of her own.

More than ten years later, Dr. Wall sat in a Coke-provided chair, watching the opening festivities of the Terrewode Women’s Community Hospital. Wall is an unassuming presence, projecting an air of kindness that is nicked at spots by the scars of a lifetime battling bureaucracy and corruption to do good work. I watched as he cast a wry eye at Coke banners seizing the day to advertise a “carbonated coffee-flavored drink” with “added coffee from coffee beans.”

I asked at what point he thought Emasu’s hospital might actually come to pass.

“I thought it was possible the first time I sat down with Alice,” Wall said. “She’s an intelligent, determined woman. There is a passion that burns inside of her. Now, she’s poised to become the face of fistula for the entire continent.”

COCA-Cola displays at the opening ceremony at the Terrewode Women’s Hospital in Soroti, Uganda. | Susan Stava

The rumors Emasu had heard of a cure for fistula in America in the 1850s are almost true—and you might have heard them too.

In August 2017, in the aftermath of the deadly Confederate monument protests in Charlottesville, Virginia, protestors in New York staged an event at the site of the Central Park statue of controversial surgeon, J. Marion Sims, the so-called “Father of Gynecology.” Sims is infamous for performing surgical experiments on enslaved women, without the use of anesthesia, in an attempt to become known as the physician who cured fistula. An image from the New York protest was shared on social media more than 250,000 times. Mayor Bill de Blasio immediately called for a ninety-day period of reevaluation of the city’s policy on monuments, and several months later the city’s Public Design Commission voted unanimously to remove the Sims statue.

I’d been immersed in the Sims story for almost two years by then. Sims’s legacy, I had found, and even the story of his statue, was encrusted with a host of calcified falsehoods, the simultaneous result of generations of medical hagiographers straining to create a rhetorical façade to match Sims’s bronze statue, and, on the flip side of the debate, unfortunate errors and exaggerations that cropped up in otherwise unimpeachable scholarly publications, and snowballed as they bounced from source to source. In terms of medical history, Sims’s Alabama fistula experiments, lasting from 1846 to 1849, are a “perfect storm” of timing. The American Medical Association adopted its first Code of Ethics in 1847. Chloroform and ether had begun to be experimented with at approximately the same time. In short, one could not design a more perfect conundrum to illustrate the thorny issues of medical ethics and consent.

Until a reevaluation of Sims’s career began a few decades ago, the three-and-a-half years of fistula experiments were uniformly described as a trying period—though not for the women undergoing the experiments. Rather, historians lauded Sims’s temerity and perseverance, and showered him with praise for the financial sacrifice he endured in the name of medical progress. That’s far from the full story. A complete examination of Sims’s record reveals that even as he was encountering his first fistula sufferers (initially he “hated” diseases of the female pelvic region), he was also performing radical jaw surgeries on enslaved men to enhance his surgical reputation, and forming and testing extravagant theories about infant lockjaw in enslaved babies in yet another premature lurch for medical glory. Details of these episodes read like snippets lifted from the pages of a horror story, and belie any claims of Sims’s altruism.

In Sims’s day, women’s bodies were a frontier for adventurous doctors keen on immortalizing their names in books of medical history. Your fallopian tubes are named for sixteenth-century Italian physician Gabriele Falloppio. Behind your uterus and in front of your rectum is the pouch of Douglas, named for eighteenth-century Scottish anatomist, James Douglas. The glands of Montgomery on your nipples are named for Irish obstetrician William Fetherstone Montgomery, and the episiotomy that you may have received during childbirth traces back to the Schuchardt Incision of German gynecologist Karl August Schuchardt.

Sims’s Alabama fistula experiments were a halting and often desperate attempt to perfect a “clamp suture”: small metals bars that were positioned on either side of the fistulous wound, and were meant to absorb the tension of the tightened sutures. Sims believed his clamp suture mechanism was essential to a cure. It was not. Although his first cure on the young enslaved woman known as Anarcha, who endured as many as thirty experimental procedures, was performed with the clamp suture, it was a scant eight years later that Sims abandoned the device entirely. That didn’t stop him from grabbing what credit he could, and the “Sims position” and the “Sims speculum” carry his name even today, though variations on both were being used in Europe long before him. In 1879, Sims’s closest associate, Dr. Thomas Addis Emmet, admitted that every aspect of Sims’s fistula cure had been anticipated by others.

The later period of the Alabama fistula experiments witnessed the first example of fistula sufferers living together, forming community and sisterhoods, learning the procedures of aftercare, and eventually becoming skilled assistants in the experiments themselves.

For the purposes of this article, what is most important about the Alabama fistula experiments is the milieu that Sims created to enable them at all. Anarcha was the first fistula sufferer he encountered, and she was quickly followed by women he later identified as Betsey and Lucy. After some initial hesitance, Sims recognized the potential value of becoming known as the physician who cured a condition that had stymied the medical world for hundreds of years. His assistants discovered six or seven other fistula sufferers in areas around Montgomery, and to enable the experiments Sims gathered them all in a small “Negro Hospital” behind his downtown office.

There are many hotly debated aspects of the Alabama fistula experiments—just one is the extent to which Sims’s subjects eventually became his nurses and assistants. I hold with scholars such as Deirdre Cooper Owens and Nicole Ivy, who allow that after repeated failures made it difficult for Sims to enlist colleagues or medical students to assist him, he called on the enslaved women themselves to assist in the procedures. The later period of the Alabama fistula experiments witnessed the first example of fistula sufferers living together, forming community and sisterhoods, learning the procedures of aftercare, and eventually becoming skilled assistants in the experiments themselves. In the end, it is this—much more accident than plan—that is the true lasting innovation to emerge from the Alabama fistula experiments.

I first visited Uganda to study Terrewode and the work of Alice Emasu in early 2018. Emasu is a commanding presence. She wears a steely professional mien that is likely born of the struggle to establish herself as a leader inside an ancient patriarchy. Occasionally, a smile cracks the polished mask.

“I got into the fistula world because of my passion for women’s emancipation,” she told me. “Women were doing so much—yet they were treated almost like slaves. The deaths of my girlfriends brought this inequality home to me. It became live for me. It was not skills that created passion in me, it was passion that inspired the skills. Christians would say it’s a miracle. I had very little knowledge. I was not prepared for what came.”

What distinguished Terrewode from the camp models, and from the work of lone, crusading doctors and nuns, and even from hospitals and clinics that have now spattered the African continent for decades—curing women, yes, but barely making a dent in the backlog of extant cases hiding in rural areas, and doing nothing at all to effectively stem the flow of new cases[*]—was that Emasu started with community activism and reintegration, and worked backward from there to the medicine.

There was a predominant model of care. Beginning in the 1970s, Reginald and Catherine Hamline’s Addis Ababa Fistula Hospital in Ethiopia had pioneered pairing vocational training with the aftercare of fistula surgery. After weeks or months of rest and educational programs, fistula survivors returned to their home communities with a trade (seamstressing, fattening sheep, running a shop, craft-making) and perhaps some seed money to establish themselves. After thirty years of operation, the Addis Ababa Fistula Hospital had added a College of Midwives, along with a comfortable campus for so-called incurables—women whose fistulae were inoperable, and who could not hope to return home.

The Addis Ababa model had inspired dozens of hospitals and clinics to follow its lead. To the extent that funding permitted, the template of a successful surgery plus vocational training had spread across the continent. Emasu, however, recognized that it wasn’t enough. A line of sutures and a gift of a manual sewing machine might cure a single woman, but it would do little bring about the eradication of fistula. What was required was a fundamental shift in the legal and cultural identity of the nation. Before and after Emasu traveled to the United States to study, she set about implementing an additional layer of fistula survivorhood. Beyond identifying fistula sufferers and shepherding them to medical resources, Terrewode invited certain fistula survivors to participate in a further round of training as community organizers and activists. A sad criteria determined who would be invited into the program, including: those who lived on $1 per day or less; those who were homeless, or had slipped into begging and penury; those who had effectively become slave labor, working twelve hours per day slaughtering chickens and being paid with their legs; those who were at risk of sexual abuse.

After training, these survivors returned to their home communities, where they merged with other community groups or form their own fistula survivor and solidarity groups. Fistula solidarity groups were not limited to fistula survivors as members, though survivors would always be among their leaders. These groups worked on a variety of fronts to spread awareness not only of the existence of fistula, but also to teach local communities of the underlying causes of obstructed labor, and of the obstacles that would confront survivors as they attempted to reintegrate into their communities. Often, the work of fistula solidarity groups takes the form of performance, including drama and dance. In Uganda, dance is a storytelling medium, and the groups’ dances were not exclusively celebratory but often allegorical. They were morality plays delivered in the language of the body, and they told the story of fistula sufferers.

At the opening of the Terrewode Women’s Community Hospital, speakers came one after the other, delivering short speeches into Coke microphones. A religious leader invoked a gospel story from Matthew, Mark, and Luke: a woman who was bleeding approached Christ, and the savior touched her and restored her to her community. Another community leader spoke proudly of those who had answered the “Cry of Alice.” Earlier in the day, there had been rumors that the festivities’ “Chief Guest” would be Ugandan president, Yoweri Museveni. Relief spread through the crowd, however, when it was revealed that instead the Chief Guest would be the Right Honourable Speaker of Parliament, Rebecca Kadaga. Kadaga is the Nancy Pelosi of Uganda, and she had been a consistent supporter of Terrewode since 2013, when the fundraising campaign for the hospital began.

Between the speakers, Terrewode’s Fistula Solidarity Groups performed their kinetic tales in a language of rhythm, mime, and movement. The dances were a jazz of the body, oscillating between narrative and ritual, and before and after the performances, the women of the groups let out piercing ululations. To a Western ear, these sounded like war cries or alarms—or rather, the ululations cracked the air like shrieks of pain transformed into cries of joy.

Fistula was never J. Marion Sims’s life ambition, yet he parlayed the cure that he claimed to have achieved on Anarcha in 1849 into a historic career. Today, Anarcha’s cure stands as the creation myth of modern gynecology.

It was an excellent story. In a now classic medical paper from 1852, Sims described his years of effort in the face of financial woe, and his perseverance resulted in cures not only for Anarcha, but for all the other women he had gathered for the experiments. This, like almost everything else in Sims’s legacy, was false. Just at the moment when Sims cured Anarcha, he took on an assistant, Dr. Nathan Bozeman. After a few years of working for Sims, Bozeman publicly announced that Sims’s clamp mechanism was suited only for perfectly situated fistulae, and then it was successful only about fifty percent of the time. It was a far cry from Sims’s claim of a perfect cure.

In 1853, Sims moved to New York. Almost immediately, he advertised a public lecture (medical advertising was an ethical violation at the time; Sims would crusade against medical ethics for the rest of his life) to propose “Woman’s Hospital,” which would become one of the first institutions in the world dedicated solely to women’s health. Woman’s Hospital was sold in two ways. First, Sims pitched it to the male medical establishment as a training facility for a new generation of surgeons, and as a laboratory for new surgeries that could be tested on populations like Irish immigrants (an extremely vulnerable population not racially considered white). Second, Sims told a much different story to the high society women—Mrs. William B. Astor, Sarah Platt Doremus, and others—who would sign on to raise funds for the hospital. For this audience, Sims described the small community of enslaved women who had lived together and formed community in his backyard in Alabama. Woman’s Hospital would be a similar institution devoted to conditions peculiar to women—fistula in particular.

Clinically, Sims’s role in the history of fistula ends there. Not long after Woman’s Hospital opened in 1855, he handed off a great deal of the fistula work to Thomas Addis Emmet, and for the most part it was Emmet who would further refine the procedure. Sims went on to champion or pioneer a variety of horrific surgeries: incision of the cervical os for sterility and painful menses; a surgical cure for hysterical vaginal pain; and female castration or “normal ovariotomy” (the removal of one or both healthy ovaries) for epilepsy and mental illness. All of these procedures were discredited within Sims’s lifetime or soon thereafter, but not before thousands of women, by his hand or others imitating him, were left disfigured—and in some cases, dead.

From the start, tensions brewed between Sims and the “Board of Lady Managers,” the Woman’s Hospital administrative body that was comprised of the society ladies that Sims wooed with stories of Anarcha and the others. In the first year, Sims juked around the Managers’ requirement that Woman’s Hospital’s first assistant be a woman. Later, after the Civil War (during which, incidentally, Sims acted as an agent on behalf of the Confederacy in Paris), Sims openly defied two rules that had been in place for some time, but were not enforced until now. First, the Managers placed a limit on the number of visitors that could attend surgeries. Second, the Managers took a hard line on prohibiting the treatment of cancer patients in what was supposed to be a fistula hospital. Sims’s defiance of both rules resulted in a dramatic confrontation, and in 1874 he was effectively forced out of the hospital he had founded.

The hospital had succeeded in becoming an institution dedicated to the treatment of women—one that had been imagined by a woman, fostered by women, and was now run almost entirely by women.

It was only a few years later that Thomas Addis Emmet, among others, acknowledged that the true solution to the problem of fistula would not be a clamp suture, or the silver suture that Sims managed to convince the world was his innovation (it was not). The cure was prevention, in the form of safe cesarean sections. Cesarean sections had been performed successfully in the United States since at least the 1790s, but it had taken nearly a century for the procedure to become common and linked with sound obstetric practices. Of course, Sims had done nothing to advance cesarean section, nor did he lift a finger to ensure that the fistula cure that had made him famous reached the population that had provided him with his experimental fodder—Africans.

In 1894, the same year that Sims’s statue was dedicated—the one was that pulled down in 2018—Howard Kelly, one of four founders of Johns Hopkins University School of Medicine and one of the first historians of vesicovaginal fistula, gave a speech before a prominent medical society. Kelly lamented the fact that a single man had been given sole credit for the cure of fistula. Sims’s work was erratic and spasmodic, Kelly said, and the accolades granted to him distracted from the work of many others who had come before him, or were contemporary with him. Four decades later , famed Egyptian gynecologist Naguib Pasha Mahfouz—who is the reason a cure for fistula finally reached Africa—produced a comprehensive history of fistula that agreed with Thomas Addis Emmet: Sims helped to popularize fistula surgery, but despite every claim he made no aspect of the cure began with him.

Between Kelly and Mahfouz, generations of enthused medical historians worked to apply thick layers of biographical varnish to Sims’s rhetorical façade. In this same period, two additional statues to Sims were erected: one in Columbia, South Carolina, and another in Montgomery, Alabama. These monuments are still in place today.

In 1959, a young gynecologist couple from New Zealand and Australia answered an ad to open a new hospital in Addis Ababa. Reginald and Catherine Hamlin’s lifelong mission of curing fistula in Ethiopia began then, though it would be another fifteen years before the Addis Ababa Fistula Hospital formally opened. Reginald Hamlin was the first to identify the problem of “fistula tourism” in Africa—what Alice Emasu would later call “flying doctors.” Under the guise of goodwill, Western physicians were providing themselves with surgical experience, medical appliance companies were seizing the chance to experiment with new procedures and devices, and charitable organizations were funding poorly planned relief efforts with sometimes disastrous results. (As recently as 2005, “Fistula Fortnight,” an effort that set out to cure more than five-hundred Nigerian women in two weeks’ time—funded in part by Richard Branson’s Virgin Group and Johnson & Johnson—resulted in four deaths, even though mortality in fistula surgery is extremely rare. The deaths were blamed on illness; no autopsies were performed.) In short, the opportunistic atmosphere that J. Marion Sims had enjoyed and exploited in America in the nineteenth century repeated in Africa in the twentieth century.

There is no small dose of irony, then, to the fact that Reginald and Catherine Hamlin, in preparing their own hospital, visited Naguib Mahfouz in Egypt for advice, and, more notably, studied The Story of My Life, J. Marion Sims’s posthumously published autobiography. The Hamlins took particular interest, it would seem, in Sims’s description of his backyard clinic in Alabama, and in particular his use of his experimental subjects as nurses and assistants. Almost immediately, the Hamlins began training fistula sufferers as nurses, and at least one fistula patient, Mamitu Gashe, went on to become a fistula surgeon herself.

The Hamlins considered the Addis Ababa Fistula Hospital to be the second dedicated fistula clinic in the world. Today, a plaque on the wall of the hospital’s main ward makes the influence clear, as they understood it:

the Addis Ababa Fistula Hospital, the founding of which was inspired by the historic and noble example set by J. Marion Sims and thereby linking inseparably together the only two hospitals in the world founded for the same purpose, the cure of fistula in women.

Reginald Hamlin died in 1993; Catherine Hamlin continued the work of the Addis Ababa Fistula Hospital without him. Oprah Winfrey’s shows a decade later ensured that Catherine Hamlin would appear on shortlists for the Nobel Peace Prize. Yet for all the good work the Hamlins did—increasing the success of fistula surgery from 70% to more than 90%, offering training to doctors who are now curing women across the developing world, and employing 150 fistula survivors as nurse aids in Addis Ababa today—they had the history completely wrong. The role that Sims’s enslaved subjects played in creating the template upon which Woman’s Hospital would be based was a byproduct of J. Marion Sims’s lust for fame. Woman’s Hospital remained committed to fistula not because of Sims, but in spite of him. In both Alabama and New York, the mission of fistula stayed true thanks to the bravery, sacrifice, and dedication of women who have long since vanished into the abyss of history.

When I met Alice Emasu in 2018, the Terrewode Women’s Community Hospital was little more than a few trenches dug into a field, and Emasu told me that she wasn’t certain she was going to be able to hire a medical staff made up entirely of African women. When I returned in August 2019, traveling with a group of Western doctors, fistula aid administrators, and donors who had been championing Emasu’s work for years—virtually all of us white—Emasu had done almost precisely that.

The opening ceremony ground to a halt when the Chief Guest arrived. Rebecca Kadaga emerged from a heavily armored SUV in a flourish of color and taffeta. Suddenly, soldiers who had been lurking behind the Coke tents, dragging their machine guns behind them like sacks of potatoes, made themselves all too present and erect, and even a drone that had been noisily swooping past the Fistula Survivor Groups in the midst of their frantic reveries, assumed a quiet hover twenty meters over the celebration grounds.

The ceremony stopped so that the Chief Guest could tour the pristine hospital grounds.

Surgeries for fistula and a few related conditions had begun some days before. In the main ward, a large open space of thirty beds, there were nine women who had already been operated on successfully. We’d been told to avoid taking pictures of the women’s faces, but when the Chief Guest came swooping through the ward, she brought with her a long royal train of photographers, and for a time no one cared about the anonymity of the cured women.

Kadaga was accompanied by Emasu and by Dr. Josephine Namugenyi, who a few months earlier had been hired as the hospital’s medical director, in charge of a staff of fifteen, all but one native African women. Namugenyi had studied general medicine in Volgograd, Russia, interned in Uganda, and worked as a general practitioner for a year before returning to school to study surgery and become a member of the College of Surgeons of East, Central, and Southern Africa. As the entourage moved through the hospital, authority shifted from the medical director to the nurses who were in charge of the main ward and the surgical theatre. Kadaga asked questions of the Chief Nurse, Elizabeth Atiang, and the Deputy Chief Nurse, Agnes Amidiong, and what was most striking about watching these exchanges was how unremarkable it was in real time. Men had played roles as advisors and assistants as the Terrewode Women’s Community Hospital was planned and built, but now they weren’t needed. The hospital had succeeded in becoming an institution dedicated to the treatment of women—one that had been imagined by a woman, fostered by women, and now it was run almost entirely by women.

Several weeks before the hospital opened, the medical staff traveled to Addis Ababa to study best clinical practices. In literature associated with Terrewode, and even on the walls of the hospital itself, it was emphasized that Terrewode was “replicating” the Hamlin model of care. That’s not a complete story, either. First, it leaves out the fact that the Hamlin model of care was a variation on the model of care that had been championed by the Board of Lady Managers at Woman’s Hospital in New York. And the Woman’s Hospital model of care was a variation on the model of care that had been spontaneously devised by a group of enslaved women—teenagers, really—in a tiny clinic in Alabama in the 1840s.

Second, the most crucial feature of the Terrewode model of care—the reintegration and training programs that empowered fistula survivors as activists and community leaders—went well beyond what Hamlin or anyone else had imagined. This was Alice Emasu’s vision, and when the Chief Guest’s tour was complete and everyone returned to the Coke pavilions, it was at last Alice Emasu’s time to speak.

She took up a Coke microphone, and stood before the Coke tents and the Coke sound booth. She thanked us all for treasuring her cause. She thanked the mamas who had mentored her at crucial moments. She explained that the hospital opening today was but the baby of the mother of Terrewode, and she insisted that Terrewode focus not only on curing women, but on educating men who were clan leaders, and decision makers, and who controlled family resources. The hospital was the realization of a dream—one that made them independent of sometimes dubious Western surgeons—but it was a dream that was still in need of a budget. Terrewode was free in every sense except money, and her speech became a plea for her own government to step in where, until now, foreign aid had paid the bills. Her dream was for her country to be independent, too.

Emasu was followed by Rebecca Kadaga, but as Kadaga began to speak—an extemporaneous delivery that began, as all politicians’ speeches do, with a defense against some sleight she had lately received—I got up and walked around the Coke pavilions to where the fistula survivors, and the Fistula Solidarity Groups, and their families, had been seated. There was much milling and chatting here, and you could barely hear anything of the proceedings, the Coke speakers having been aimed at the community leaders, the religious leaders, the group of foreign dignitaries and doctors I’d been traveling with, and of course the Chief Guest. It seemed that for the actual women that Terrewode served the ceremony was simply a period of waiting for the meal that would come after it.

That’s precisely what happened when the Chief Guest was done talking. Kadaga climbed back into her SUV and was swooshed away, and the dignitaries filed into a makeshift cafeteria for lunch. The fistula survivors and their families queued up for meals taken al fresco, in waves. The Coke people began stacking chairs, the tents came down. After we ate, the group I was traveling with gathered in the parking lot in a mood of anticlimax. We were confused. The ceremony was over, yet many people remained, as though waiting for something. We shrugged and boarded our bus for the return trip to our hotel.

It wasn’t until the next day that we learned the true festivities began after dark. At dusk, the Coke sound booth turned to music, and the dances now were not stories, but ecstasy. The celebration lasted well into the night, without us.

[*] Fistula data is notoriously difficult to come by, but estimates claim that Uganda has 85,000 extant fistula cases, with 1,900 new cases every year. Continent-wide, fistula sufferers number more than a million, and estimates of new cases annually range from 30,000 to more than 100,000.