Fistula, a birthing injury that leads to incontinence, is practically non-existent in the global North yet it is common in countries of the global South, such as Niger, that boast limited medical infrastructure and poor health outcomes, especially with regard to maternal health. Until recently a relatively unknown condition, obstetric fistula has become the focus of extraordinary attention ever since the humanitarian industry cast fistula patients as ‘superlative sufferers’ (p. 153) – subjects whose complex condition is reduced to a unidimensional (yet universally appealing) image of victimhood. In Fistula Politics, a detailed ethnography based on her doctoral fieldwork, Heller discusses how fistula has captured the imagination of the West, where damaged uteruses symbolize what is supposedly wrong with African cultures. In the simplistic, frequently sensationalistic accounts of fistula peddled by the media, women with leaking bodies are shunned and stigmatized; but if their bodies are repaired via surgery, their problems will be fixed.
Based on in-depth interviews with 100 women, the book offers a persuasive counterweight to narratives of fistula that portray young girls as innocent victims in need of rescue. For one thing, it definitely puts to rest the notion that the incidence of fistula is tied to age. From the diverse sample of women presented, we learn that access to emergency obstetric care plays a larger role than age in determining maternal outcomes. Deeply grounded and densely resonant, the book makes clear that women’s vulnerabilities, the struggles they face, and the lives they lead are not easily captured by statistics, slogans or reductionist typologies.
For starters, fistula is a Western, biomedical category that imperfectly encompasses the myriad postpartum health issues women, especially rural women, face in Niger. By the same token, the notion of stigma – another foreign concept – fails to capture the full spectrum of emotions (shame, loss, longing for children, and so on) experienced by fistula patients. No woman Heller met lived in total isolation, abandoned by all. More often than not, fistula sufferers themselves deliberately limited their social interactions, fearing rejection. And while some women were rejected by their husbands, others enjoyed their full support, although their relationships were inevitably complicated by the presence of co-wives.
What emerges from Heller’s richly textured descriptions is that surgeries are never as physically and socially transformative as is claimed by those who promote and fund them. Not only do surgeries often fail to heal women’s bodies; women are also subjected to long, in some cases interminable, waits. Local clinics exploit women’s hopeful quest for continence: fistula patients are lucrative sources of income. While people tend to see these treatment centres as sites of recovery, they contribute to social estrangement, preventing women from reintegrating the lives they left behind. Heller argues that women are exploited by the very organizations designed to protect them. By framing fistula as passive victimhood, these organizations legitimize interventions that replicate patterns of colonial interference aimed at rescuing African women from harmful cultural practices. Additionally, by uncritically assuming that fistula is part of women’s identity and cannot be concealed, members of the ‘rescue industry’ (p. 187), who use fistula patients as props to promote their own agendas, inadvertently ‘out’ those wishing to hide their condition from the world.
Fistula Politics, Heller writes, is ‘an exploration of the intimate’ (p. 25). One of the strengths of the book is precisely its ability to trace how the diverse birthing injuries classified as ‘fistula’ affect the private lives of women. We learn a great deal about marital sexuality, the love sustaining couples, and the affectionate bond between mother and daughters, while also getting a glimpse of the dynamics of polygyny, divorce and intergenerationality. Niger, a country where the convergence of widespread poverty and pronatalist values directly impacts women’s reproductive health, is a textbook example of how the development industry promotes technical solutions (surgery) to address the consequences of systemic inequality (birthing injuries). But Heller’s account has significance beyond Niger, and, in this sense, it is an important study.
By drawing on ethnography to slow down rapid assessments, revisit taken-for-granted claims and consider multiple causalities, Heller contributes a nuanced account of reproductive health. What is missing is a sense of how the ‘official’ fistula narrative has shaped average Nigeriens’ understanding of fistula. Heller mentions that women who experienced fistula had never heard of it before, but many Nigeriens have. The fistula message of prevention circulates in school, on the radio and via sensitization campaigns. The manuscript is filled with beautiful photographs (some of them in colour) of fistula sufferers taken by the author. While they enliven the book, they also give it the kind of National Geographic flavour that has been rightly criticized for orientalizing difference. It is indeed curious that Heller displays so many photographs of fistula sufferers after noting that local actors who disregard the layers of secrecy maintained by fistula sufferers end up shattering their fragile sense of worth. These slight criticisms do not diminish Heller’s significant contribution to the scholarship on women in Niger. Fistula Politics is written in clear, accessible language. I expect it will be widely read not only by medical anthropologists and gender and sexuality studies specialists but also by the very actors who intervene in preventing and repairing fistula.
