A lack of basic health care during pregnancy and delivery in parts of Africa leaves some women with debilitating physical injuries after childbirth. Mary Olive Smith’s new documentary A Walk to Beautiful examines their hardships — and their quest for a cure.

Smith recently spoke with filmmaker and ITF Director Andrew Blackwell about how the documentary came about, the women in the film, and the political implications of her decision to let the camera linger on Ethiopia’s incredible landscapes.

Interviewer: Andrew Blackwell
Interviewee: Mary Olive Smith
What is the story of A Walk to Beautiful?
It’s about five women in Ethiopia who have suffered from serious childbirth injuries, and live in isolation and loneliness as a result. The film follows their journeys to a special hospital in Addis Ababa, where they hope to find a cure.

The real story is one of women who have been shunned by society and who are trying to regain their dignity and their lives, and become whole people again. It’s a human story, a story of personal transformation, not a medical story. The medical problem is the struggle, and we explain that, but the journey is a personal one.

What is the medical problem they are struggling with?
It’s called fistula, and it’s really a hidden problem. Very few people know it exists. The [United Nations] U.N. campaign to deal with it only began five years ago, although the problem has been around as long as humankind.

It’s an injury that is caused by prolonged, unrelieved, obstructed labor. Even in the [United States], obstructed labor occurs in 5 percent of all deliveries, but here the problem is overcome by Caesarean delivery. But in the poorest countries of the world, where there are not enough doctors or hospitals, these women basically need a Caesarean section, but don’t receive it. And there are higher rates of obstructed delivery as well, due to early marriage and pregnancy as well as malnutrition. So these women end up in obstructed labor for days on end, and they either die or they end up with severe injuries. They can be crippled, or get fistula, which causes incontinence.
The reason they’re incontinent is that, after days and days of obstructed labor, they end up with a hole between the vagina and the bladder. And there’s no way to get better without surgery. The bladder doesn’t hold the urine, so it’s constantly coming out. They smell, they are too poor even to have diapers or underwear, and it doesn’t matter how much they wash.

They think they are cursed. They have no idea that it’s a physical injury. Many of them go to hospitals, and the hospitals don’t know what to do with them. And their communities shun them. A lot of the doctors call them modern-day lepers. They are no longer part of society. They just disappear. The response depends on the family, but as a rule, they no longer can hang out at the market or at the well. Some of them are so afraid and ashamed that they go to wash their clothes at night, and their families just leave food out for them.

There are exceptions, in which the family maintains strong support, and it varies from country to country. But in rural Ethiopia, the stigma is very strong. It’s not that they blame the person; they just don’t want to be around them. And the women are too ashamed to go out as well. For the most part, they are rejected by their community. In the case of Ayehu, a young woman who we followed for the film, her siblings were really cruel. Her mother was her only defender. When we met Ayehu, we found her living in a makeshift lean-to that she had put together with sticks against the outside of the back wall of her mother’s house. She would crawl in there and sleep on the floor. Even during the day, she would just sit in there. She would never come in to the house; she wasn’t allowed.

Why is the community and family response so harsh?
The families don’t abandon them at first. I met family after family who took them to the hospital. They’ll sell their goats to raise money to try to get them help. But often they don’t encounter anyone who knows how to deal with fistula, and if they haven’t heard about the Addis Ababa Fistula Hospital, or if it seems too far away, then there’s nothing they can do.

It’s true, women in these areas are second-class citizens: They do most of the work, they don’t have property rights, and they are definitely subordinate. But if a man had the same condition, I think he might not be treated much differently. The smell is very bad; there’s no way to control the flow of urine, and people just don’t want to be around the person. I don’t think you can really point your finger at the culture. The situation comes more from poverty, which creates both the conditions that lead to the injury in the first place, and the circumstances that keep it from being treated.

How did you come to make a film about fistula?
I work for a company called Engel Entertainment, a documentary production house based in [New York City]. I’ve been working there for 12 years. The idea came from an op-ed in the New York Times by Nicholas Kristof in May, 2003, called “Alone and Ashamed,” in which he wrote about women at the hospital suffering from fistula. It was a really moving piece. A friend of Steve Engel, who is the president of our company, brought the idea to him, and Steve took it up as a documentary project. He asked me if I would be interested in directing the film, as I have a longstanding interest in human rights in general, and in Africa in particular. We had always done television in the past, for [stations] like Discovery, PBS, and so on. But this time we wanted to do it as an independent feature documentary.

And so the film follows these women to the hospital?
The first half of the film is that journey to the hospital. Ayehu knew about the hospital before we met her, but she was too afraid to go. Again, it’s a long way away, and they’re unsure if it’s going to be costly, and they’re afraid of going to the city. Going to Addis Ababa can seem like going to the moon for them. But she was convinced to go by another woman who had had the treatment. And so we followed her, as well as two other women, who made the journey separately. The trip means walking for hours and hours, and then a 16-hour bus ride. The treatment itself is free, and they can even get money for the trip home, if they can just get themselves to the hospital.
The middle of the film is at the hospital. When Ayehu gets to the hospital and is given a bed, you see her smile for the first time, as she realizes that she’s not the only one with this problem. … she is amazed that there are 120 women also there who have the same problem as her. And it’s a really open, neat place — very lively — and they can socialize. There’s a real transformation in them as people, even before they get the surgery.

The twist in the film is Wubete, another woman who we met in the hospital. At age eight, she was married off against her will. She was beaten by her husband, became pregnant by him, and had this fistula as a result of the delivery. She’s so beautiful, and her family doesn’t want her. But in her case, the treatment was more complicated, and it was unclear whether or not she would be cured, and we followed her as she dealt with that. In addition to her story, the latter part of the film shows the other women returning to their homes, and becoming part of their community again.

Ethiopia has a lot of stereotypes associated with it, going back at least to the famines of the 1980s, which received so much media coverage. But your film really seems to portray it in a different way.
Some films really show the squalor and hopelessness in African countries, so I really wanted to show how beautiful Ethiopia is. I get tired of the portrayal of Africa as a hell on earth. There is so much beauty and hope there. And there was such a contrast between Ayehu’s situation and the beautiful landscapes. So Ayehu’s leaving her shack and going on this journey through this beautiful environment sort of represents the hope in her poor conditions. Our cinematographer and editor really brought that out.
Although I hadn’t been to Ethiopia before, I wasn’t surprised at how beautiful it was, as I had been to other parts of Africa. And I wanted to bring out the beauty of the country, in a way to represent the dignity of the people there. The women in the film have so much dignity as they go through this process. Ethiopians in general have responded really well to the film. Although it shows a difficult situation in their country, they see the dignity of the people we show, and realize that it’s a personal story, not an indictment of their entire country.
Also, after the devastation of what the film shows — people often describe the film as “devastating” — there’s excitement that comes with realizing that these women can be helped. The Addis Ababa Fistula Hospital is becoming better known, and more women therefore have the possibility of making the journey there. And if you can imagine being a leper of sorts, and then after being treated, being allowed to rejoin the community again, there’s real joy there.

For those who wish to help women suffering from fistula receive restorative surgery and care, visit www.fistulafoundation.org.

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