Una Jeanie Lee, MD
Reflections on Empowering Women and Surgeons in Uganda
In November of 2021, Dr. Una Jeanie Lee from Virginia Mason Franciscan Health Urology, Seattle, WA served as teaching faculty with nonprofit organization Medicine for Humanity (MFH), a group she has been volunteering with for over 10 years. This year, after careful COVID-19 risk mitigation planning, 9 team members including urologists, urogynecologists, anesthesiologists, nurses, and surgical technicians successfully completed the annual MFH surgical educational program at Mbarara University of Science and Technology (MUST) in Mbarara, Uganda. 45 surgeries were performed with Ugandan and American surgeons working side by side. In addition to the surgical care provided, the education of Ugandan and American residents and fellows was one of the program’s main goals. “I’m most proud of being part of an organization that has committed to empowering the surgeons of Mbarara and building their capacity to help women with obstetric fistula.” Dr. Lee commented, “Medicine for Humanity and MUST has established the second Urogynecology Fellowship in East Africa, and now their team of trained surgeons and nurses does outreach fistula surgery in other parts of Uganda with unmet need. We help teach the Ugandan doctors to “fish” and these doctors are teaching others to “fish,” and these surgeries have downstream positive impacts as changing women’s lives lifts up families and communities.”
“Another personal highlight was teaching vesico-vaginal fistula surgery and ureteral reimplant surgery. One of the patients was a 47-year-old peasant farmer who had been leaking urine continuously for 18 years without resources for repair. Another young woman named Jenifer had been leaking urine for 8 years due to a ureteral-vaginal fistula. I’m humbled by their resilience and their courage in the face of hardship. They each taught me about gratitude, what really matters in this world, and how connected we all are.” The AUA Foundation support was invaluable for this program given the multifactorial challenges related to COVID in low-income countries and the tremendous need for surgery, education, and training on urologic and urogynecologic women's health and repair of childbirth injury.
Assistant Professor, University of Washington (Seattle) and Associate Program Director of Fellowship in Female Pelvic Medicine and Reconstructive Surgery of the Fellowship at Virginia Mason Urology
Related Org.: Medicine for Humanity
Primary Area Served: Uganda
Dr. Lee completed medical school at the Stanford University School of Medicine, residency training at the Glickman Urological and Kidney Institute in Cleveland, Ohio. She went on to complete a Fellowship in Female Pelvic Medicine and Reconstructive Surgery at the UCLA Department of Urology.
Dr. Lee’s collaboration with Medicine for Humanity (MFH) and Mbarara University of Science and Technology began in 2011 as a fellow, then in 2013 as an attending surgeon, and more recently in 2019 as trip medical director for MFH.
Support through the UCF/AUA Humanitarian endowment will help develop the care model for obstetrical fistula into a self-sufficient, year-round repair, recovery, and reintegration program for low-income East African women. Our deepest appreciation to the American Urological Association for establishing this grant support.
An obstetric fistula is a heartbreaking condition in which prolonged, obstructed labor causes severe childbirth injury to the mother. It most commonly occurs among women who live in developing countries, who give birth without adequate access to advanced obstetric care. The fistula develops at the end of pregnancy when labor is obstructed and lasts many hours or days. The pressure of the baby’s head against the mother’s pelvis cuts off blood supply to the surrounding tissues in the birth canal, resulting in urinary and/or bowel incontinence due to obstetric fistula. Two million women suffer from fistula worldwide. The World Health Organization (WHO) estimates that in Uganda alone there are over 100,000 women enduring life with fistula, and nearly 2,000 women develop this condition each year. For every woman who gets treatment, over 50 women go without. In Uganda, the magnitude of the problem overwhelms the local capacity and resources.
My surgical humanitarian activities with Medicine for Humanity and Mbarara University of Science and Technology (MUST) have contributed to:
- Alleviating the burden of obstetric fistulas in East African women from impoverished communities. Obstetric fistulas are preventable and correctable. The lack of timely medical intervention produces tragic consequences: the baby often dies in utero from prolonged lack of oxygen, and the mother is left with severe physical injuries, causing uncontrollable, chronic incontinence that leads to social stigmatization. These women are often abandoned by husbands and outcast from society and work. They suffer kidney disorders, skin infections, severe depression, neurological problems like foot drop and even death if left untreated. To date, Medicine for Humanity has performed over 800 surgeries, directly impacting the lives of these patients.
- Empowering women through patient education. Affecting the most vulnerable members of society, obstetric fistula touches issues related to reproductive health and rights, gender equality, poverty and adolescent reproductive health. Educated patients are able to better care for themselves and also serve as a conduit of information for young girls, other women, and the larger community to destigmatize obstetric fistulas and focus on prevention measures.
- Bringing much needed expertise in urologic care and training to Uganda. There is a great need for urologic training and resources in this medically underserved region. There are very few urologists in the entire country, and most are located in the capital city, Kampala, which is several hours from Mbarara. As a urologist who is Board-certified in Female Pelvic Medicine and Reconstructive Surgery, with extensive experience in mentoring residents and fellows, I have provided clinical education at MUST to trainees to build skills and train Ugandan surgeons, nurses, and medical students.
- Capacity building to strengthen the existing program and create opportunities for further development. By engaging in educational and training programs for providers and trainees, we significantly strengthen the ability to provide surgical care and build capacity for future opportunities. This application builds upon our model of care for low-income East African women suffering from obstetrical fistula for further development into a self-sufficient, year-round repair, recovery, and reintegration program.
- Clinical and research advocacy. I am humbled by the privilege to help Ugandan women in their path to healing and the Ugandan surgeons in their path to gain these specialized skills. My commitment to health care equity also runs through my clinical research work in patient-centered care and health disparities in women’s urological health. I am honored to advocate for this humanitarian work with next generation surgeons coming through our residency and fellowship programs at Virginia Mason, and through funding opportunities to support this important area of global health research.
The long-term contributions directly impact the physical and societal well-being of the Ugandan community, the growth of Mbarara University of Science and Technology, and the global health efforts to address childbirth injuries in underserved areas:
- By helping to improve women’s health, we are creating healthier families, communities, and countries. Women in Uganda cope with challenged access to healthcare, particularly basic obstetrical services. Our current goal is to reduce the societal burden of fistula in this part of the world. We are healing women by providing life-altering surgical care. Our surgical programs, staffed by volunteer doctors and nurses, provide surgery, transportation, food, housing, medical support, and postoperative care at no cost to our patients. In the process, we are restoring dignity, hope, and quality of life to these women, their families, and their communities.
- We are creating life-long impact by training doctors. Medicine for Humanity’s recurring presence has served to transform Mbarara into a true center of excellence in the care of obstetrical fistula, including building the Center for Gynecologic and Fistula Care. Medicine for Humanity collaborates with the Obstetrics and Gynecology residency program at Mbarara University Teaching Hospital to offer a training track for our high-volume fistula program to Ugandan Ob/Gyn residents.
- We are supporting local champions. Dr. Musa Kayondo serves as Chair of Obstetrics and Gynecology and head of the Fistula plus Female Pelvic Medicine & Reconstructive Surgery (FPMRS) Division at Mbarara University of Science and Technology (MUST). As a young resident doctor in 2009, Dr. Kayondo was the first graduate of Medicine for Humanity’s collaborative FPMRS program at MUST. Currently, Dr. Kayondo, in his role as Chair, leads the Obstetrics and Gynecology residency program and serves as Head of our newly developed clinical Urogynecology Leadership Fellowship. Dr. Kayondo is dedicated to maintaining the integrity of Medicine for Humanity’s established fistula training programs year-round. His commitment to the women we heal and the doctors we train is the reason that our work in Uganda is so successful.
- We are developing new leaders. Medicine for Humanity created an annual Urogynecology Leadership Fellowship Program to train a Ugandan Obstetrician Gynecologist and future leader in the field of women’s health. Specialty training of a physician in Urogynecology will contribute to women’s health and empowerment in Uganda and East Africa. This is a powerful investment in professionals, such as Dr. Paul Kato Kalyebara, a first-year fellow in Urogynecology at MUST, who can increase access to health care throughout the nation.
- We are building a patient-centered holistic program. Prior literature has demonstrated success of postoperative programs aimed at physical, psychosocial, and economic rehabilitation individually, however there is a lack of data regarding programs combining all of these components (El Ayadi et al, Int J Gynaecol Obstet 2020). The implementation of a patient-centered holistic reintegration program will help to provide critical data about long-term fistula outcomes following obstetric fistula surgery and further elucidate gaps in the current understanding of how to care for this vulnerable population.
- 6. We are sharing our findings to reach other regions in need. We plan to disseminate our findings through national and international presentations and through publications in medical journals. We hope that our program will serve as a model for obstetric fistula repair, recovery, and reintegration programs worldwide. With the acquisition of global health research skills obtained from this experience, our young leaders, including Dr. Kato, will be well-equipped to follow their passions to lead future programs and research in women’s health globally.
"We know helping to improve women’s health creates healthier families, communities and countries.”
– Dr. Leo Lagasse, Medicine for Humanity Founder
Local community service has been an integral part of my life. However, going to East Africa with the Medicine for Humanity (MFH) team in 2011 changed the trajectory of my life by opening my eyes to the chasm of global need. While obstetric fistula is the downstream effect of poverty and maternal morbidity is a measure of the health of country, I have had firsthand observations of the positive change that can occur through a humanitarian partnership with a shared mission and purpose. The success of the MFH program can be attributed to the strong relationships with the local doctors and the commitment to this common purpose - a commitment to training and educating doctors, nurses, students, and helping the women heal and live with dignity.
Leading the 2019 trip as the MFH medical director deepened my resolve to dedicate myself to the advancement of urologic women’s health and heath disparities in my own community, regionally, nationally, and globally. My role as a urologist in the MFH program is key, as teaching the surgeons urologic skills and principles is integral to their training in the repair of uro-genital fistula and FPMRS, and is a current gap in their training. I approach this role with humility as we have much we can learn from each other, and this interconnectedness lifts up both our communities in powerful ways. The value of our cross-cultural program is multifold and includes the benefit from the hands-on surgical training and educational didactics as well as a deeper understanding of the complexities of medicine in low resource settings. This deeper understanding is foundational to performing patient care, education, and research to address health disparities nationally and globally.
The strong relationships and personal growth are fundamental to the sustainability of the program. Our team travels to Uganda to help heal women but ultimately the interaction with the Ugandan people heals me. Experiencing the courage and strength of these resilient Ugandan women allows me to feel the true joy of being a surgeon and teacher, and I carry this inspiration with me every day. My time and learnings from Uganda make me a better doctor, a better person, and a better citizen of our global community.
David E. Rapp, MD
In November 2021, Dr. David Rapp, University of Virginia, and founder of Global Surgical Expendition (GSE), led a surgical trip to Belize where combined mission teams treated 37 patients and provided 31 surgeries and procedures to patients coming from all regions of the country. In an effort to reach more patients, separate surgical teams were organized to provide focus on both general urology and FPMRS surgeries. Care was provided at Corozal Community Hospital in the Corozal region. A total of eight members participated in the trip, including surgical, anesthesia, and nursing professionals. Combined, GSE teams performed surgeries to correct vesicovaginal fistula, BPH, urethral stricture disease, pelvic organ prolapse, urinary incontinence, and bladder stones, as well as provided surgical training to local Belizean surgeons and gynecologists. Also as part of the trip, over $1,000 in surgical supplies was provided to facilitate future surgery by Belizean surgeons. Dr. Rapp commented: “Our group of medical volunteers continues to be both humbled and thankful for the support we have received to conduct our ongoing surgical trips. The work of our team during our most recent mission included treatments of urogenital fistula, pelvic organ prolapse, urinary incontinence, prostrate obstruction, urethral strictures, and numerous other debilitating illnesses. We are truly excited about continuing to provide care and develop the surgical infrastructure in Belize during future missions.”
Associate Professor, University of Virginia
Related Org.: Global Surgical Expedition (Founder)
Primary Area Served: Belize
Dr. Rapp completed medical school at the George Washington School of Medicine, residency training at the University of Chicago and a Fellowship at the Virginia Mason Medical Center, specializing in urinary incontinence and pelvic floor reconstruction.
Founded in 2012 by Dr. Rapp, Global Surgical Expedition (GSE) is a global charity that delivers urologic care to underserved nations. Presently, GSE organizes and sends five surgical teams annually for week-long surgical trips to sites in Belize and Rwanda. GSE has a long-standing history of comprehensive initiatives to not only provide surgeries, but also make a greater impact through research, education, and infrastructure growth. The UCF grant will support work in conjunction with GSE, specifically to support the delivery of urologic surgeries in Belize.
Support through the UCF/Richard J. Fox Humanitarian Endowment will contribute significantly to the career of Dr. Rapp and is an investment in improving the lives of patients suffering from urologic diseases. Our deepest appreciation to the Fox Family for supporting the critical need to enhance urologic patient care for the underserved.
- GSE has maintained a commitment to providing urologic surgeries to men and women in underserved nations. To date, GSE has treated over 1,000 patients and performed over 350 surgeries. Dr. Rapp and GSE have provided a diverse range of surgeries to treat cancer (renal, penile, bladder), urethral stricture disease, urolithiasis, and female pelvic medicine. GSE has also placed focus on providing education to local surgeons to improve access to care. This collaboration with local urologists and gynecologists in Belize and Africa has expanded delivery of a greater number of surgeries and safer approaches to surgical care. In addition, GSE has intermittently undertaken the organization of out-of-country surgery, where patients were transported to the US for more complex care and recovery (e.g., cystectomy).
- GSE has sought to increase care infrastructure with its partner communities. GSE has donated extensive surgical equipment to allow for care delivery by local surgeons. In Belize, for example, GSE undertook the setup of necessary equipment and related training to allow for TURP procedures. In Rwanda, GSE provided a pelvic and vaginal ultrasound machine and maintenance required to facilitate better obstetric care and uro-gynecologic surgery. GSE was also proud to organize the first laparoscopic renal surgery in Belize to introduce this technique locally. Additional examples include the donation of surgical retractor systems, surgical lighting equipment, and surgical instrumentation to facilitate safer surgery.
- GSE has placed focus on providing educational experiences for students and residents. In doing so, GSE seeks to inspire the next generation of global surgery leaders. GSE has provided many residents scholarships to support resident experiences during a week-long surgical trip. More recently, in collaboration with the University of Virginia through Dr. Rapp’s involvement in the Center for Global Health and International Programs Council, Dr. Rapp has developed formal curriculum to help train residents with career interests in global surgery. This includes the formal Global Health Leadership Tract and separate curriculum developed and overseen by Dr. Rapp.
- GSE has emphasized research activities to help better understand surgical disease and poverty in the countries it visits. This research has been published and also presented at society meetings to include the Society for Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU), the American Urogynecologic Society (AUGS), and AUA Mid-Atlantic Section. Ongoing projects include assessing the impact of urological conditions on job and caretaking responsibilities in developing countries. This project has provided insight into the impact of urologic disease not only clinically but also its relationship with poverty.
- Among other awards and distinctions, Dr. Rapp was awarded the Global Program of Distinction grant by the UVA Center for Global Inquiry and Innovation to begin development of a pelvic floor exercise treatment program in Belize.