A photographic exhibition presented by Maggie Bangser at her talk upon receiving a honorary doctoral degree from Amherst College in 2009.

2. An unknown problem
An estimated 2 million girls
and women live with fistula
worldwide. Each year
there are an additional
130,000 new cases.
In other words: every four
minutes somewhere in the
world a girl or woman
gets a fistula.
Sources: World Health Organization, 1998
L. Lewis Wall, The Lancet, 2006
I never heard of fistula
before I got one.
I thought I was the only woman in
the world leaking urine and faeces.
Now I know there are so many other
girls and women with fistula!
photos: Mwanzo Millinga

3. 70 percent of the girls
and women in the
’Risk and Resilience’
study got their fistula at
the age of 20 or older.
For many, this was
not their first delivery.
Source: Women’s Dignity, EngenderHealth,
et al., 2006
Don’t think fistula is only
a young girl’s problem.
I got fistula when I was 29 years old.
I am 54 now, and am so happy I will
finally get surgery and be dry.

4. The disgrace of fistula
The majority of the women
in the fistula study isolated
themselves from other
community members,
remaining in their homes
as much as possible and
forgoing public events like
funerals, celebrations and
visiting neighbours.
Source: Women’s Dignity, EngenderHealth,
et. al., 2006
“I feel shame. They laugh at me.
They turn their lips up, and others
leave the moment I enter to take my
tea with them.”
photo: Mwanzo Millinga

5. Alone,
but not neglected
Although fistula makes it
difficult for women to
participate actively in their
community, they are not
abandoned. All the
women in the fistula study
received some form of
help from their family or
community.
Source: Women’s Dignity, EngenderHeallth,
et. al., 2006
My husband has paid for
everything – the bus, the hospital,
the medicines….He saved my life,
but it will take him years to pay
back the loans.

6. Precious water
One out of three
Tanzanians report that
their family did not have
enough clean water over
the past year.
Source: Afrobarometer 2005
“Imagine you have fistula. You have
to walk six hours to get one bucket
of water. Now, you have to decide
how you are going to use the water
– for washing, drinking, bathing, and
cooking, or for yourself.”

7. Being ready
The majority of the
women in the fistula study
wanted to deliver their
baby at a health care
facility of some sort.
However, fewer than half
set aside money – ranging
from USD 3.50 to 50.
Preparing for delivery was
difficult, due to lack of
money and the hospital
being too far away.
Source: Women’s Dignity, EngenderHealth,
et. al., 2006
I was prepared for my baby – I’d
saved some money, I knew where to
go and my husband asked a
neighbour to bring me there on his
bicycle. All women in my village
should have a plan like this.
photo: Mwanzo Millinga

8. photo: Sala Lewis
Theory vs. reality
According to the official guidelines of the Ministry of Health and Social
Welfare in Tanzania, antenatal care services should include: physical
examination from head to toe; check for blood count, blood pressure
and urine; screening for syphilis and HIV; provision of tetanus toxoid
vaccination; anti-malaria medicines and iron supplements; health
education, including information about pregnancy, labour and delivery.
However, reality is often different. For example, out of every ten of the
poorest women in Tanzania, only four have their blood checked during
antenatal care. For the wealthiest women, almost 9 out of 10 receive
this service.
If only I had been told that my blood pressure was
Sources: Ministry of Health (RNC/NMCP) JHPIEGO, 2004 too high, I would have gone to
Demographic and Health Survey 2004/05 the hospital for delivery.

9. Access to
health services
More than half of the
poorest women in
Tanzania say they face big
problems in accessing
health care because the
facility is too far away and
they need to take
transport to get there.
Source: Demographic and Health Survey
2004/05
When my family realized I needed
professional help, I had to walk
four hours to the main road.
There I waited for a bus, but only
one passed and it was already full.

10. Safe delivery
In Tanzania, one woman out of every 66 who give birth,
will die. In the USA, one woman out of 5,882 dies during
childbirth. A caesarean section can save the life of a
woman who has an obstructed labour.
In Tanzania, 65% of government hospitals provide
caesarean section, but no health centres or dispensaries
provide this life-saving service.
The nearest hospital to my village is
Sources: World Development Report 2006 40 kilometers away. I can get to the local health
National Institute of Medical Research, Ministry of Health and Social Welfare, 2006 centre, but it cannot do operations at all.

11. Professional help
In rural areas of Tanzania,
there is usually one
medical officer caring for
45,000 people or more.
In Ruvuma region,
there is just one doctor for
250,000 people. In Dar es
Salaam there is one
doctor for 14,700 people.
In Germany there is one
medical doctor for every
280 people.
Sources: Ministry of Health Personnel
Census 2002, draft
World Development Report 2004
I was lucky.
I got to a hospital with a nurse and
a doctor who took good care of me.
But I know women from my village
who have died during childbirth
because no one could help them.

12. photo: Dorthe Friis Pederson
How healthcare ranks
Tanzania spends $12 per person per year on health.
This compares to approximately $6,000 in USA, $3,100
in Australia, $70 in China, and $33 in India.
The maternity ward was packed with women –
on beds, on the floor, everywhere. There were only five
Source: World Development Report 2004 nurses. I saw one woman deliver without any help.

13. photo: Dorthe Friis Pederson
Money well spent
Spending 8 percent of Tanzania’s annual health budget
on required delivery kits, skilled health workers, and
emergency obstetric care would ensure all pregnant
women a safer childbirth.
What is more important – education, water,
Sources: UNFPA infrastructure, or healthcare? The budget is limited
Tanzania budget estimates, 2006 and we have to make choices. Difficult choices.

14. Less income, more expenses
Almost half of Tanzanians live on less than 1 dollar a day;
almost three quarters live on less than 2 dollar a day.
In poor families, everyone has to contribute to the
household income.
“Our income has decreased because only my
husband is working. There are times when we don’t
have food. Washing daily is costly, you must buy the
Source: World Development Report 2006 soap. This money could be used for other things.”

15. A costly service
Half of the poorest women in Tanzania say that getting
money for treatment is their single biggest obstacle while
seeking health care. Twenty five percent of the
wealthiest women also experience this problem.
Money determines where one gives birth.
I didn’t have enough money to deliver in a health
Source: Demographic and Health Survey 2004/05 facility, so I delivered at home.

16. Unhealthy practices
More than 60 percent of
Tanzanians believe that
the current government is
fighting corruption well.
At the same time, if you
ask 7 Tanzanians if they
paid some kind of bribe to
get medicine or medical
attention in the past
12 months, one person
will say ‘yes’.
Sources: Afrobarometer 2005
“The nurse at the facility told me,
‘If you don’t pay Tshs 15,000 (US$15)
you will never get a blood transfusion.
If you have to die, better die.’ ”

17. photo: Dorthe Friis Pederson
The right to information
Widely disseminated messages about health rights –
including respectful treatment by health workers, and
mechanisms of complaint – can enable citizens to
demand their rights and hold government accountable.
Very few people are aware of their
health rights. It’s important that they
know, so they can demand them.

18. photo: Dorthe Friis Pederson
One man’s voice
Speaking out against bad health services is risky. You will
be remembered. But individual acts of courage can bring
change to thousands.
How can the clinic staff deny
a desperate young woman
transport for the sake of US$ 6?