An Ethiopian Hogarth: “The Fistula Patient’s Progress” — March 12, 2014

One of my favorite artists is the Englishman William Hogarth (1697 – 1764). Hogarth was a satirist, cartoonist, printmaker, painter and social critic who is credited with creating what has been called “Western sequential art:” a series of paintings or prints that tell a story, particularly a story that depicts a moral tale of some kind. His best-known works are a series of “modern moral subjects” which compare and contrast social styles or behaviors. Typically his sequential tales follow a character through a series of life stages (often from happy initial circumstances to a bad ending as the result of poor choices or bad behavior). His best-known series are “Beer Street and Gin Lane,” “The Rake’s Progress,” “The Four Stages of Cruelty,” “Marriage a-la-mode,” “The Harlot’s Progress,” and “Industry and Idleness.”

Hogarth’s works were extremely popular during his lifetime. He converted many of his paintings into etchings which were printed cheaply and widely distributed as popular art in 18th Century Britain. These works were huge commercial successes, and in many ways he may have been the first major “modern” artist with a devoted popular public following.

There is a series of paintings on the wall of the corridor at the Addis Ababa Fistula Hospital leading to the operating theater. These paintings are truly “Hogarthian” in their conception and execution. The paintings depict the life-course of a young woman who develops a fistula from obstructed labor but who ultimately finds relief at the fistula hospital and eventually returns to her family. The paintings are the work of a remarkable young Ethiopian artist named Dawit Bagegn who was tremendously moved by the life’s work of Catherine Hamlin and her staff. His paintings tell the same kind of story that engaged William Hogarth– simply, visually, and movingly. Needless to say, unlike Hogarth’s “Rake” or “Harlot,” women who develop an obstetric fistula are morally blameless. Their condition is only the tragic result of faulty obstetrical mechanics—a big baby, a small pelvis, a fetal malposition during labor–rather than any moral fault of their own.

Enjoy this remarkable example of modern Ethiopian folk art.

Scene One:  A Child Marriage

Scene One: A Child Marriage

Scene One:  A Child Marriage

The first painting is a marriage scene.  The wedding has been concluded and the bride—herself still a child—is wrapped up in a cloth on her new husband’s horse to be taken away.  Family members seem sad and reluctant at the departure of their daughter, but this is life as it is lived.

Scene Two:  Hard Work for a New Bride

Scene Two: Hard Work for a New Bride

Scene Two:  Hard Work for a New Bride

The joys of girlhood have vanished, suddenly and abruptly.  As is the case for many young African brides, the abrupt transition from child to adult comes suddenly and sometimes shockingly.  She has moved to her husband’s home, where she is the most junior member of the family.  Her mother-in-law may regard her merely as “cheap labor,” at least until she has proven herself by bearing children.  Now she must do heavy labor–hauling firewood, fetching large pots of water from remote locations, and grinding grain.

Scene Three:  A Difficult Labor

Scene Three: A Difficult Labor

Scene Three:  A Difficult Labor

Her wish has been granted:  she is pregnant!  But as is often the case, be careful what you wish for.  In most African societies, a girl does not really become a woman until she has given birth to a child, but in societies where marriage takes place shortly after puberty, there is an increased risk of difficult labor.  While growth in height stops shortly after menstruation (and reproductive potential) begins, the pelvis continues to grow until the late teenage years.  This means that young adolescents have smaller pelves in spite of being able to conceive, and adolescent pregnancy is one of the recognized risk factors for obstructed labor.  Alas, this is the case with this young woman.  She has been in labor for days.  She is utterly exhausted.  The traditional birth attendants lack the necessary obstetric skills to achieve a delivery and because she lives in a remote area, she cannot reach a hospital where emergency obstetric care is available.  This is still a common problem in Ethiopia when obstetric complications arise, as 85% of deliveries still occur at home without the presence of a skilled birth attendant.

The sad looks on the woman supporting her tell the story:  the baby is dead and she is exhausted, virtually comatose from the agony of days in labor.

Scene Four:  The Misery of an Obstetric Fistula

Scene Four: The Misery of an Obstetric Fistula

Scene Four:  The Misery of an Obstetric Fistula

She has recovered from her labor, but to her horror and dismay, she has developed an obstetric vesico-vaginal fistula.  The prolonged pressure of the baby’s head in her pelvis—unable to negotiate the bony obstruction in her birth canal–has crushed the soft tissues between the bladder and the vagina, opening a hole (a fistula) through which urine pours in a constant torrent.

If you look carefully at her left leg, you will see the urine running down onto the floor, where it is pooling.  The dejection in her face is obvious.  In the upper left corner of the picture, a family member is passing her a basket with food in it, but she covers her nose and face in disgust at the overwhelming odor of urine that pervades the hut.  Life is truly miserable.

Scene Five:  Rejection

Scene Five: Rejection

Scene five:  Rejection

It is finally more than her family can bear.  The constant wetness, urine soaking everything in the house, the awful stench of urine that can never been removed, has finally gotten to be too much.  Her family rejects her and sends her away.  In the picture you see her husband (and probably her father-in-law) casting her out of the house.  She looks back in anger and regret, but has no choice.  Both men are holding their noses and covering their faces.  At the bottom of the picture you can still see the trail of urine running down her legs.

Scene Six:  Compassionate Care at the Fistula Hospital

Scene Six: Compassionate Care at the Fistula Hospital

Scene Six:  Compassionate Care at the Addis Ababa Fistula Hospital

She has made her way to Addis Ababa, where she found the Addis Ababa Fistula Hospital, devoted to the care of women with childbirth injuries like hers.  In contrast to the other paintings, here she is surrounded by love and compassion.  In contrast to the previous paintings, she is surrounded by care and attention.  She is depicted in her hospital bed, recovering from fistula repair surgery.

Scene Seven:  Redemption and Return

Scene Seven: Redemption and Return

Scene Seven:  Redemption and Return

Her surgery was successful!  The fistula has been closed and she is continent again!  With the stigma of her injury removed, she can return to her family.  She is warmly embraced.  Her husband takes off his hat in gratitude and casts his glance upward to thank God for the miracle that has occurred.

You will also note that the ragged old dress she was wearing in previous pictures is gone, replaced by a new dress given to her by the hospital to mark the transition to her new joyful status.

The paintings depict a fictional story, but one that resonates with every fistula patient who goes through the doors of Dr. Hamlin’s fistula hospital in Addis Ababa.  This scene has been replayed nearly 40,000 times since Catherine Hamlin and her late husband Reg began their work with fistula patients over 55 years ago.


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