The World Health Organization defines health inequity as avoidable inequalities in health between groups of people within countries and between countries. Obstetric fistula is one such example—a truly devastating but preventable and largely treatable condition. It is estimated that between 50,000 and 100,000 women develop fistulas each year in low- and middle-income countries, often leading to ostracism from communities and their families, separation or divorce, infertility, and depression.¹ In 2003, the United Nations Population Fund launched a global Campaign to End Fistula, with United Nations resolution 73/147 intensifying efforts stressing the interlinkages between poverty, malnutrition, lack of or inadequate or inaccessible health care services, early childbearing, early and forced child marriage, violence against young women and girls, sociocultural barriers, marginalization, illiteracy, and gender inequality as root causes of obstetric fistula, and that poverty remains the main social risk factor.² Despite these efforts and focus, fistula continues to be a devastating disease in low- and middle-income countries.

The International Organization for Women and Development (IOWD) is a nonprofit, nongovernmental organization founded in 2003 for the treatment of fistula, initially working in Niger, then Vietnam, and since 2010 in Kigali, Rwanda. Nongovernmental organizations are recognized and necessary partners, providing not only surgical treatment and expertise, but also partnering with local training to assist the unmet surgical needs of developing countries (Lancet Commission on Global Surgery).³ IOWD has been conducting 3 missions per year in Kigali, Rwanda, working closely with local medical students, anesthetists, residents, physicians, and the Rwandan Ministry of Health. IOWD teams not only continue to treat fistula, but also have worked tirelessly in capacity building with fistula prevention strategies, including obstetric training programs, cesarian section training programs, developing a cervical cancer screening program, training anesthesia specialists, and a surgical nursing training program. Our mission in October 2022 also allowed an outstanding group of Rwandan surgeons to spend the entire mission learning fistula evaluation and surgical management (Figure 1). These efforts, combined with our obstetric training programs, are in alignment with the United Nations Population Fund’s Campaign to End Fistula (Figure 2). I have been working with IOWD since 2012 and sit on the medical director’s board, serve as a mission leader in our spring mission, and serve as the mission urologist during our fall mission. As a mission leader, I have taken pride in working through unexpected situations, which can arise running surgical missions in a low-resource setting, and have enormous respect for local physicians, nurses, medical students, and staff in Rwanda and the selfless dedication they embody every day (Figure 3). A Humanitarian Grant Award from the AUA Urology Care Foundation™ helped support our last mission, an award for which I am most thankful. I can honestly say I have gotten more out of these missions than I can ever give back, and I am truly honored to work with such a fantastic organization as IOWD.

Figure 1. Dr Stephanie Kielb and the Rwandan medical students’ team from October 2022.

Figure 2. Surgical skills training with medical students.

Figure 3. Dr Stephanie Kielb and other members from the surgical team.

With the support of the Robert J. Havey Institute for Global Health at Northwestern University, undergraduate students, medical students, and urology residents have been able to accompany us on several missions, allowing the development of the next generation of global health leaders to engage in a humble manner, grounded in equity and social justice. We always also involve Rwandan students and physicians in our research, and have published on trends in fistula type in Rwanda.⁴

My current efforts in Rwanda also involve resident educational initiatives, putting my 14-plus years of experience as a urology residency program director to use. There are only 5 urology residents currently in training in Rwanda (and you thought your call schedule was hard) and 10 practicing urologists in a country with a population of around 12 million people. As I’ve researched, there are no urologists or gynecologists surgically treating female stress incontinence. I am currently developing a fascial sling training curriculum with remote didactics and an in-person skills lab to coincide with our next mission (a Catalyzer Grant from the Havey Institute for Global Health is supporting these efforts). The goal is to train current residents in the evaluation of incontinence and help them become proficient in fascial slings. If this initial pilot program is successful, my goal is to expand this resident education collaboration into other areas of urology and develop a sustainable model to expand urological surgical care in Rwanda.

Figure 4. Dr Stephanie Kielb and patients in preop.

Figure 5. Rwandan woman and baby.

I feel privileged to be a part of the IOWD team, am honored to work with the dedicated health care team in Rwanda, and am thankful to the Rwandan Ministry of Health for allowing us to continue this work. Most of all, I am thankful for all the wonderful people of Rwanda who have trusted me to contribute to their care (Figures 4 and 5).