“They come in as victims and leave as leaders” - Salamatou Traoré (Niger) - 3/4

Our conversation with Mrs Salamatou Traoré continues and gets even more interesting with each new part. We have discussed what inspired her choice to build a career in healthcare (Part 1),and her experience in public health (Part 2)

You just told me that you founded your NGO. Let’s start with its name, “DIMOL”. What does it mean?

“DIMOL” means “dignity” in Fulani. I founded the DIMOL Centre because of the fistula issue that is still ongoing.

Please tell me more about the DIMOL Centre and your work there with women diagnosed with obstetric fistula?

The women we accommodate come to the Centre in bad shape because of fistula. First, their wrappers are always wet with urine. They are stressed and embarrassed. As soon as they arrive, they’re given two pairs of underpants and two bars of soap per week. They get to clean themselves. When we see the women again the next day, there’s neither the smell nor the stress. We don’t see them constantly touching their clothes to make sure they’re not wet.

Then, the Centre’s midwife does the examination and determines if a woman has a case of fistula or not. The registration period is important for collecting quantitative data. If the patient does indeed have a fistula, the midwife refers her to the surgery center for another examination and a follow-up on her case, to know if it requires surgery or checkups.

While the woman is being observed and even during her recovery after the operation, she stays with us at the Centre. This waiting period is used to help the woman understand the causes and consequences of her illness. We teach her environmental hygiene, the importance of not defecating out in the open, the importance of going to school, and the use of contraceptives. All of this is preventive work, to avoid future infections.

Most importantly, we explain to the women the reasons that brought them here. Now, from that moment on, patients understand better that it is not a curse.

Oh I see, some of them think that it’s a curse?

Yes indeed. Many think that they’ve been cursed. At DIMOL, they learn that the fistula is due to delayed treatment of their health condition: not going to prenatal examination, not giving birth in sanitary health facilities. So, once they understand, it becomes a repetitive process. We repeat the same topics each week: environmental hygiene, sanitation, education for girls, family planning, and so on. We spend all our time explaining to them but when they become aware of what has happened and are more receptive, we take action.

And what is the “action” phase?

The women usually spend between three and six months with us. They have their first surgery after three months. Then, after the surgery, we give them appointments and they go back and forth between the DIMOL Centre and the hospital until they fully recover. Some of them have had up to five surgeries.

Meanwhile, at DIMOL, they acquire skills in sewing, embroidery, basketry, knitting, weaving…whatever they can learn. The patient chooses what she wants to learn. Once she is healed, we reinforce the training on the skill chosen by the patient. If she has chosen sewing, we focus on that. If we see that she has not mastered cutting, or if she has not mastered certain patterns, we strengthen the training.

At DIMOL, the women acquire skills in sewing, embroidery, basketry, knitting, weaving…whatever they can learn.

And she goes back home with the possibility of teaching a skill? That’s amazing!

Once she is ready to return to the village, she is given the task of teaching her fellow women in the village the skill she learned at the DIMOL Centre. She will also conduct awareness-raising activities for her colleagues, guiding women to health services if they have problems. She can look for cases of fistula in the village, by word of mouth, to tell them that fistula is curable.

She is given money to start cultivating the skill in her home. She can buy the materials she needs for the skill as well as for her fistula awareness sessions: a bench, a table, everything she needs. It helps people take what she is doing seriously.

By word of mouth, former patients raise awareness. They also refer or accompany women who need access to fistula care. They become ambassadors for the DIMOL Centre, and they sometimes bring in new patients. There are even former patients who have become health care workers.

And the cycle goes on. Actually, it’s a virtuous one. Is there a woman whose journey made a lasting impression on you? I’m sure there are many.

We have Oumou, who has already brought us 14 new patients. She just brought two new women yesterday. Oumou spends all her time on market days raising awareness and asking questions: "Do you have cases of fistula in your home? Women who smell of urine? If you do, I have someone who treats it for free”. And she gets the message across.

During her time here, Oumou chose to learn sewing. She received reintegration funds, and a machine. She taught her husband how to sew, and he taught others as well.

What’s interesting about the DIMOL Centre’s model is that women come in almost as victims, and they leave as game-changers. They are empowered personally but also make a change in the community. It’s very transformative.

Patients enter the DIMOL Centre as victims and leave as leaders. Sometimes their families don’t even recognise them anymore because they have changed so much. When a patient returns to the village, she is healed, clean, and well-dressed, with knowledge that others do not have, and with funds and materials or livestock that others do not have.

She is accompanied by members of the DIMOL Center who explain that she is cured and that they must accept her and stop stigmatising her. They explain in front of everyone that the money and materials she has are for cultivating her skill, and to finance future cesarean sections or other operations, so they should not be taken from her.

And the women usually do not face hardship when they go back because you provide guidance? You said that you talked to the community, to leaders and the families.

Yes, raising awareness first starts with the family. The health agent comes with us to the authorities to tell them that the NGO is going to intervene in a certain way and that’s what is bringing us there. For patients who have been cured of obstetric fistula, the nurse accompanies us to the village. Sometimes the nurses discover the localities that they are used to writing down as "common" when they have never been in the field. And when they realise how far away these women are, how far they must travel, they now take the cases of women who come from these villages seriously. Once they arrive in the village, the women share their experiences. But the health worker also must speak. He also makes his plea. He says that he expects the people of these villages or this community to come quickly for care so that they can heal quickly rather than being evacuated because it is expensive.

When it comes to the families, we also speak to the men. We tell them that fistula is not easily curable. It requires a lot of money, and it stigmatises and traumatises the girls. So, if they avoid child marriage and give children the chance to go to school…if they avoid girls having to wait before going for care and allow them to go for consultations and assisted deliveries instead, they will not have any more cases of fistula.

And finally, we make the village chiefs aware of their responsibilities as well, telling them: “if there is a case of fistula in this village, you are responsible because you have been warned. You will have asked for it because we have warned you. And it works. As soon as a woman is sick, they say: go quickly to the dispensary and another woman must accompany you. So, they have all the information at hand, and they respect it.

If they avoid girls having to wait before going for care, and allow them to go for consultations and assisted deliveries instead, they will not have any more cases of fistula.

It’s great to see success in that way. You still face some challenges, I suppose. What’s the biggest one?

The great difficulty is the lack of understanding of others about fistula. Fistula is found in remote or isolated areas. If you don't go there, they don't listen to you and they don't take the fight seriously. To fight fistula, people only talk about operations, over and over. I say it is not operations that will eradicate fistula. Fistula can only be eradicated through prevention. First, child marriage must be banned and access to basic social services must be promoted. Second, parents must understand the risks of not providing prenatal care and assisted childbirth.

The DIMOL Centre can accommodate about 50 women, but fistula affects thousands of women in Niger. What do you need to support more women?

We need more space. We need to be able to accommodate more women, organise the treatment of cases better and ensure a better follow-up.

We also need more space for the training we do in sewing, basketry, weaving, knitting, etc. This training is not only for fistula victims. We have women from various women’s groups who come to acquire skills to fight against poverty. We think that fistula is also a poverty issue. To avoid complications for these women, if they can access training for financial empowerment, they can also cure their health issues. And it works, because they come for empowerment, they can listen to the conversations, and it strengthens the women. We need the space to do all that.

We need more resources to create a centre where we can offer training for women, for NGOs or organisations, community decision-makers and others… We have a lot to share… but where?

We’d also like to work beyond the fistula issue. We want to help women who have experienced gender-based violence. We want to support more women's economic empowerment. To increase our impact, we need more space and more resources.

Despite the challenges, your pride and joy are visible. When we arrived at the Centre earlier, I saw how your face lit up. How do you feel each time you walk in here?

Yes, when I visit and I see a healthy and clean environment, when I see that the women are all clean, when I see the systems that I have organised in place, it gives me pride. It gives me even more pride since I say to myself that at least some of them listen to what they are told. They are present. This is what we wanted for the women that are there and need us.

It is also a responsibility. Everything you do, everything they hear, they take at face value. And so, we avoid saying things that are not feasible.

Oh, you avoid making promises you can’t keep?

Yes. And when we translate what visitors say, we translate the exact words the person said. Because they memorise everything. They don't write but they record everything we say. They call us back afterward. That makes me feel better. For me, it's an honour to see that women are expecting us to help them.

Has the prevalence of fistula changed in Niger over the course of your career? What changes have you observed?

There are fewer fistulas, and the cases are less severe today. Before, we had multiple fistulas. Now the type of fistula is less serious, it is the bladder fistula. Before, we had many cases of recto-vaginal fistula. There were many deaths in Niger. The latest statistics are not yet available, but there has been a decrease in deaths. It is already something to see that even if a fistula is present, at least there is a reduction in maternal mortality and mortality following childbirth.

One of our great successes is that thanks to DIMOL's strong advocacy, today, fistula is no longer a secret to anyone. First, there is a network that is created, the Fistula Eradication Network or REF. In the mother-child centres throughout Niger, the topic of fistula is discussed. This is a result for us, fistula has been identified as a public health problem, which is an honour for us.

And it is not only in Niger. I remember in 1998 or 1999, when I spoke about fistula at a conference, there was one country whose representative said: “Fistula does not exist in my country”. He didn't even know what fistula was. But today that country is receiving hundreds of millions to fight against fistula. In nearby Burkina, they took the example of everything I said. It's like a consultation. There is even a lady who has created a foundation on fistula. And when she saw me, she said: “Mrs. Traoré, I respect you because if it wasn’t for you, I wouldn’t have had my ideas for creating the Foundation in Burkina”. The foundation is called the RAMA Foundation. I am very happy about that. Moreover, we did our workshop on the fight against fistula with a professor from Nigeria, and they founded a center for fistula based on the Dimol model.

In part four, we’ll talk about the women who inspire her and the changes she sees in regards to women, as a participant of the 1995 World Conference on Women in Beijing and a decades-long advocate against the stigma around fistula. Read it here.

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