Where do beggars come from?

I am 30 years old, I am Rohingya and I escaped from the genocide in Myanmar to Bangladesh in 2017. I live in Cox Bazar, about 400 km south of Dhaka, in one of the largest refugee camps in the world. There are about a million of us here, maybe more. What might my problems be?

Your pregnancy may be at risk, you may become ill during the pregnancy, you may not be covered by prenatal care. You may have ill children or be at constant risk of gender-based violence.

And you are definitely experiencing some kind of deprivation. You probably have mental health problems, depression, and constant anxiety like almost 100% of women in the camp. You have experienced torture, mental and physical violence at home. This is why our foundation, apart from the field hospital for pregnant women and mothers, and several small maternity centres that operate in the camp 24 hours a day, introduced a mental health programme.

Are women the majority in the camp?

More than half of Cox Bazar residents are women and girls. Almost all of them are of reproductive age, were or want to become pregnant, and about 30-40 thousand are pregnant. This means that 30-40 thousand children are born here every year.

Some pregnant women who report to you prefer to give birth at home, i.e. in a tent. It struck me because there is probably not much space in one, it is difficult to take care of comfort and hygiene.

The Rohingya is a very conservative and religious nation, women follow the instructions and wishes of their husbands, other elderly men or women – mothers-in-law, mothers. Culturally, they do not feel comfortable in hospitals, because they know that a woman will not always take care of them there, sometimes there are only men on duty. They feel embarrassed to show them their intimate body parts. They are also not used to hospitals.

Many are very young, they do not speak out loud about their needs, and they do what society expects of them. So they usually have a lot of children. This is why we introduce them to family planning issues that men are often opposed to.

What are their options?

We provide them with birth control pills, injections, implants, any possible options. Sometimes it’s about changing their behaviour, knowing when to be sexually active. We talk to women and their husbands.

I saw a lot of photos of cradles suspended from the ceiling of tents on four strings. They are made from rice bags stretched out on four bamboo sticks. They look comfortable and practical, but when I look at them, I think to myself that whatever the context, parenting comes with a lot of anxiety. Will I raise my child well? How will I provide them with what they need? I have a two-year-old child and I can’t imagine what it’s like to be pregnant in a place with no prospects. How do these mums manage not to break down?

It’s a very philosophical question. Well, I’m a man, but there are women in my life: my sisters, my mum, my wife, and I know being pregnant was the most important desire for most of them. I don’t think the women in the camp differ from those in the US in this respect. It’s just part of their essence.

When we talk, they tell me that they want their children to be educated, to have a good life. However, every society has different expectations – the expectations of my mother or my Bangladesh-born sisters differ from those of my US-born wife. The women in the camp do not think about their children becoming doctors or lawyers, they just want them to be healthy and happy, and God willing, to have a job – poor people have a rich spiritual life, they strongly believe in God, destiny.

What will happen when they grow up? Before the escape, there weren’t many options either – the Rohingya worked in shops, doing odd jobs. Their expectations are very low.

Can they work outside the camp now?

They can’t leave it. Some of the women have been trained and perform field work. In Myanmar, most of them were housewives, took care of children and cooked. Few have an education.

What is their menstrual reality?

Almost 90 percent of them have access to hygiene products distributed by various NGOs. But sanitary pads don’t always arrive on time, and women often don’t have the money to buy them on their own. The sets are usually picked up by men, only 27 percent of women and girls pick them up in person. Organisations also build toilets where women can wash themselves, wash reusable products or discreetly dispose of used sanitary pads.

There are taboos and myths around menstruation – many women believe that contact with used hygiene products is a sin that can harm others, especially children and men. Menstruating women are considered unclean, some are isolated – they sleep and eat separately, they are not allowed to leave the house.

In Bangladesh, abortion is legal until the third month. Do you help women in this aspect?

Yes, we do. This is how we save women’s lives – illegal abortion is a common cause of death.

You mentioned that the refugees are traumatised. Shortly after their arrival, many of them became pregnant as a result of rape – some did not admit it to their husbands so that they would not reject them, others did not want these children. Still, other, young, unmarried women, had to give their children to their relatives, even though they wanted to keep them; otherwise, they would not be able to find a husband. I wonder how you can help them recover from this?

We should start with the fact that this is not Florida or Krakow, it’s a refugee camp. There is no avenue here that people can walk down, they cannot go on holiday or to the cinema, and they have nowhere to play sports. The number of their activities is very limited: women cook, talk to their neighbours, and are at home all the time. They don’t even have space to use the toilet, sometimes they wait all day until it gets dark to go to it. They have seen their husband or their own children killed in front of their eyes. They have been raped and have seen other women being raped. They came to a new country, Bangladesh, where there are lots of poor people. Sometimes it’s just too much.

Exactly.

That’s why we recruit people from the area who understand what they’ve been through and speak their language. The idea is to support them and make their lives a little bit better. Every pregnant woman who visits her GP is questioned and she receives regular therapeutic support. We want to expand the team of specialists and introduce cognitive-behavioural therapy. Women know that they have a safe space at our points where they can talk about their feelings. Our midwives visit them at home, and so do our field workers – we are just trying to create an application that will help them with their work.

In your 2019 report, I read that you accommodated over 1,000 natural births, 157 caesarean sections, 40,000 prenatal visits, 13 thousand family planning consultations, you have cured over 25 thousand children under 5 years of age. Impressive, but a drop in the ocean compared to the needs. Doesn’t it overwhelm you?

I have a lot of resources – I use my knowledge, skills, and network of contacts to put together various aid programmes. For me, it’s not an overwhelming problem. It’s overwhelming for them. I just help a little.

I would like to do more, but I feel happy that we have managed to build hospitals, run them, train midwives. About 650 people work on our projects, we manage to find people who leave their nine-to-five jobs to help.

I have to confess to you: before our interview, I had no idea that obstetric fistula – the flagship disease that the HOPE Foundation deals with – even exists. Even though I was pregnant and I was prepared for various birth scenarios, no one even mentioned this to me. When I read what fistula does to the lives of 3 million women in the world, I felt ashamed of my ignorance.

Before I started dealing with it myself 10 years ago, I didn’t know much about it, and I studied medicine! Why do Polish and American women not know about fistula? Because it’s a disease of poor women.

Overall, one or two pregnancies in 10 are high-risk pregnancies. So eight women will give birth without any problems, be it at home or in hospital. But these 10-20 percent have some kind of problem: the baby is too big, the mother has too small a pelvis, she has diabetes, the baby is handicapped or simply badly positioned – head up, bottom down. In developed countries, we learn about these problems during prenatal care, and we can take care of women and children early enough. In poor countries, millions of women live in remote places – on islands, in the jungle, in the mountains, where they do not have access to midwives and doctors. They learn that their pregnancy is at risk when labour begins.

Then what?

They hope that God and the midwife will help them give birth. Childbirth lasts 12, 18 hours, a day or two, the literature even mentions six-day cases. The woman is sick, suffering, and 24 hours after the onset of labour, the child dies. But the mother still pushes. The tissues in the genital area are destroyed because circulation stops under pressure. A deceased child is taken out by midwives or they go to hospital together for a caesarean section. However, damaged tissues are not repaired.

Women are convinced that it cannot be helped, and in many places there are indeed no doctors who can repair the damage. So they live with a fistula until the end of their lives. Most of the time, this happens to very young girls, teenagers, in rural sub-Saharan Africa and South Asia, where they get married young because no one has any other plans for them.

Child marriages are a significant cause of fistula. The pelvis may be too small for many reasons: because a woman is too short, because she is still very young, or because she is not well-nourished.

In Bangladesh, although theoretically marriage for women is legal from the age of 18, UNICEF estimates that about 20 percent of girls get married before the age of 15, and almost 60 percent – before the age of 18. Girls Not Brides reports that Bangladesh has the third highest child marriage rate.

My oldest patient suffered over 40 years, but before the fistula, she had children who grew up, her husband did not leave her, and so she managed to live with it.

But wait, I still haven’t explained what a fistula is. It’s just a channel that connects the vagina to the bladder or the anus, or both. In most women, the anus is intact, so only urine leaks from the vagina. Those whose tissues are damaged in both places suffer the most, experience great pain, they stink, and have infections, ulceration on the skin.

These women did not start out as beggars – they were just born into a poor family and married young. Suddenly they become unwanted, cannot bear children, cannot form families, they stink. And there is no treatment for them.

On your website, we have the story of Ziddka, who was sent to the family home three days after giving birth because urine was leaking from her vagina. As if she were a broken vessel. Of course, the child died in childbirth. She came back to life only 5 years later, when you operated on her. I cannot imagine this kind of suffering and the feeling of shame.

That is why we are building a specialised hospital. Before my doctors were trained, there was only one fistula surgeon in Bangladesh. I got funding, trained doctors, we have great midwives who work in the field. We run clubs for mothers living in small villages where we talk about pregnancy and how we can take care of these women, we identify patients at risk of fistula. And we run an awareness campaign to get other doctors to pay attention to the fistula. And in a year or two I plan to conduct surgery training for doctors from all over the country.

Is it an expensive operation?

The world's average amount is $500-600.

Why are there so few specialists?

Because these women can’t pay for the operation. And medical students are looking for a specialisation that will allow them to support their family. To learn obstetric fistula surgery, you need to be affiliated with some kind of foundation or organisation that deals with it and organises training, e.g. HOPE Foundation, Fistula Foundation, Every Mother Counts. Our surgeons do not work for free.

The surgery itself is not complicated, is it? Reportedly, over 90 percent procedures end well.

Many cases can be repaired even without surgery, and after a slight intervention, the fistula heals itself. If a surgery is needed and it’s performed early, they are 90 percent effective. But after many years it becomes extremely difficult, because many tissues around it undergo necrosis and fibrosis. Sometimes three, four or five surgeries are needed. Some women cannot be helped, but luckily there aren’t many of them. We have cured over 500 women and failed only in two cases. I started with 15 patients a year in 2011, now we operate on 100, and when we open the hospital, there will be between 300 and 500 patients a year.

And why women, after all you are a paediatrician?

Because a long time ago in a hospital I realised that if I wanted to help children, I had to help mothers first.

I come from a simple, not very educated family, but I was talented, I managed to go to the medical school in Chittagong, where I worked for a year in a small children’s hospital. 20-30 beds, usually night shifts, there were only three of us doctors. On every night duty, parents would bring their dead or dying children, it was too late for us to do anything.

My father was very spiritual, sensitive, he said, “You are a doctor, you should help people.” But until then, I hadn’t thought much of it. I went to study medicine because I wanted to ensure myself abundance, money, a good image, and power – like many colleagues who thought about professorship, running clinics, working in government. That year changed me completely.

Why did you go to America?

Because I wanted to experience a different world. And I knew it was a land of opportunities, I would educate myself better and be better off there. Back then it was really nice in the US, I worked hard, got my diploma quickly, became a doctor.

As soon as I reached the basic level of comfort, I started the HOPE Foundation. I even wanted to return to Bangladesh after specialising, but at the time the political situation there was not very stable. I thought that maybe I should stay, become a US citizen, thanks to which I would have more connections, a network of friends.

How do you reconcile going to Bangladesh with living in the States? You have three children, you run a medical practice in Miami.

My wife and I both sacrificed something – she has given up her career to take care of the children, and I have sacrificed mine to run the Foundation. It’s teamwork. Since my sons are in college, I go to Bangladesh four or six times a year, previously once or twice. I practice with my partner when I’m in Bangladesh, he works, and then we switch over. I am a paediatric endocrinologist, but I practice as a general paediatrician, because if you are a narrow specialist, you have too many obligations, and others cannot replace you.

Are you proud of yourself? Because you should be.

Now I am very happy with my success. My practice in Miami allows me to pay my bills, buy clothes for my children and books for myself. I have always had enough income to support my family and my personal needs are very small. I invested everything else in the HOPE Foundation.

Many people dream of something like this, but cannot do it. I didn’t focus on my career, building a great house, my image, practice, but on the Foundation, and at the same time I took care of my personal and family needs. I am still quite young and I feel that I have achieved a lot.

 

Maria Hawranek talks to Iftikher Mahmood

Dominika Kulczyk and Dr. Iftikher Mahmood in front of the HOPE field hospital
for women co-financed by the Kulczyk Foundation.
Photo: Tatiana Jachyra

• Dr. Iftikher Mahmood – physician and founder of the HOPE Foundation supporting pregnant women and their children in Bangladesh. He has also been helping the Rohingya since the beginning of the humanitarian crisis in Bangladesh.

The text was published in „Wolna Sobota” on 13 February 2021.