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Out of Africa: 'A Walk to Beautiful' Humanizes a Devastating Disease

By Cathleen Rountree

Last December, A Walk to Beautiful won the IDA Award for Best Feature Documentary. Directed by Mary Olive Smith and co-directed by Amy Bucher, Walk chronicles the stories of five Ethiopian women who suffer from devastating childbirth injuries, and their subsequent healing journeys at the obstetric Fistula Hospital in Addis Ababa, where remarkable doctors devote their lives to repairing these women's bodies and hearts.

Obstetric fistula is a rupture that develops between the vagina and the bladder, and sometimes between the vagina and the rectum during obstructed labor. According to UN figures, three million girls and women in developing countries suffer from this chronic condition. In addition to the embarrassment and shame of incontinence, these women are often rejected by their families and driven from their villages because they cannot hold jobs, take public transportation or, due to the fetid odor, even walk in public.

This noteworthy, lovingly rendered film has won audience awards at the San Francisco, Denver and St. Louis International Film Festivals. A Walk to Beautiful opens February 8 in New York City and February 29 in Los Angeles and will air on PBS' NOVA in May. IDA met up with directors Smith and Bucher in April 2007 during the San Francisco International Film Festival.

IDA: What provoked the idea for A Walk to Beautiful?

Mary Olive Smith: We read a column in The New York Times by Nicholas Kristof about obstetric fistula. He was the inspiration for this film. It was the first time he'd written about the Addis Ababa Fistula Hospital; he writes a lot about women's health issues now. We knew it would be a difficult film to make, but we started talking with the Fistula Foundation, which was very small at that time and recently founded.

IDA: Where is the foundation located?

MOS: In New York City. The hospital had been supported for 30 or 40 years by foundations in Australia, New Zealand and the UK, but there had never been a foundation in the US. So it was new and they were supportive of the idea. Then Steve Engel [a producer] asked me to direct it because I'd had previous interest in human rights in Africa.

IDA: When did you first travel to Africa?

MOS: I went to Ethiopia about three years ago on a scouting trip and visited the hospital and met with Dr. Hamlin and Ruth Kennedy. I wooed them and told them how much we loved their hospital and how much we wanted to do this project. And they said OK! I think that was our biggest success, just getting their approval, because they're very protective of the women...

Amy Bucher: They'd had some not so good experiences.

MOS: In fact, when we first arrived, Amy started shooting in the hospital, while I went out to the countryside to find women--we weren't sure we'd find women who would agree to being filmed--so we thought we'd better shoot in the hospital to be safe. But right before we arrived, another film crew had been thrown out.

IDA: What had happened in that situation? 

AB: I think they weren't as sensitive to the women. They may have filmed before asking permission. I think there was an assumption that they could just go where they wanted to go. And that certainly wasn't the way we handled it. I don't think I had known they had been given the boot until we'd been there a couple of days. And then Ruth Kennedy said, "Oh, you guys are such a delight to work with." Then she told me what had happened before we arrived.

IDA: Who is Ruth Kennedy and how did she get connected with the hospital?

AB: Dr. Catherine Hamlin and her husband went to Ethiopia from Australia about 47 years ago-not necessarily to do fistula repair, but to do gynecological obstetric care.

MOS: They were working at a hospital when Haile Sellassie was in power, and they came across fistula patients and, as she says in the film, they were so moved by these women, who were often pushed to the end of the line waiting to get into the hospital because people complained that they "smelled...those wretched women, get them away." So both doctors began specializing in operating on fistulas, and eventually decided to found their own hospital. They've survived through the monarchy, the communist era and now the attempt at democracy. The hospital is still being supported by the government- or tolerated, at least.

AB: And it's growing like crazy. They recently added on a new wing. And Dr. Hamlin appeared on the Oprah Winfrey Show about two years ago, and within days, several million dollars had been raised and they were able to expand. Now their goal is to open five more hospitals in the outlying areas of Ethiopia. Two have already opened. So, that's a big change just since from when we were there.

IDA: Who works in the hospitals? 

MOS: Catherine and her husband Reginald immediately began training Ethiopians. So the hospitals are primarily staffed by Ethiopians, and they are outstanding surgeons. Catherine's goal is for this work to continue after she passes away. She's 83 now, so she can't be here forever.

IDA: Is this is a worldwide problem?

MOS: Yes, in the poorest countries in the world, so there is a direct correlation with endemic poverty. But the highest rates are in sub-Saharan Africa and Central Africa -- Nigeria, I believe, has the highest rate in the world. And then Southeast Asia -- Bangladesh, Pakistan. Latin America has a lower prevalence and they think that's because there are more roads! So the hospital may be far away, but you can get there.

Ethiopia has one of the highest rates, and they think that's because of geography as well. It's mountainous and very diverse geographically, so it's all the harder to get roads in for women to get places.

IDA: Who is affected by this condition? Is it particularly very young women?

MOS: Of all pregnancies, whether in the US or Ethiopia or Sweden or Nigeria, five percent of all pregnant women will have obstructed labor. If they don't get a caesarian, they'll either die or they'll end up with terrible injuries. Maybe there are a few lucky ones who survive without that happening. So you add to that undernourishment. Dr. Ruth Kennedy always likes to remind us that the food in Ethiopia is really healthy, so they get good nourishment, but not enough. And these women work so hard, they burn a lot of calories, so the girls are underdeveloped. But the boys are, too; it's not just the girls.

IDA: But they don't have to push a baby out.

MOS: Right, they don't. Then you add to that early marriage. So there are a lot of complicating factors. But if got rid of the cultural factors and even the undernourishment, there'd still be obstructed labor. And without a caesarian they would still suffer from fistula. We still had fistula in the US until 1895.

AB: But Ethiopia does have one of the highest rates of young marriage in the world. It's a complex picture, but it certainly is a factor that, if you have a ten-year-old-girl, who is as undernourished and works as hard as those girls do, it's very unlikely that she's going to be able to pass a baby through her pelvis.

MOS: One of the girls in the film was 15, but she was married when she was eight. She didn't get pregnant until she was 15, but it's still a big problem.

IDA: How did you locate the young women for the film? 

MOS: I went with a big crew to a region of Ethiopia, a very poor area, and went out beyond the town we were staying in (with just my interpreter and producer and our guide). We worked with the local clinics and the Ethiopian Orthodox Church searching for these women; we went on immunization trips. And we weren't finding any one. I knew it would be hard, and finally on day five...

IDA: There are so many women suffering with fistula, why did you think it would be hard to find them? Because of the shame factor? 

MOS: Well, yes, they hide. I think the villagers may or may not know what kind of sickness they have, or if they know, they're afraid to tell. It's interesting, we were just communicating with women, and really had no luck. And it was our guides, the men, who ended up having a little more luck. We found one young woman and I asked if I could take her picture. She said, "Oh, yes, I've had my picture taken a lot at the fistula hospital" And, lo and behold, she'd already been cured! I was about to cry. I said, "Very nice to meet you, but..." It turned out that she was on her way to her friend Ayehu's house. She was sick and she wanted Ayehu to visit the hospital. So the whole scene in the film is exactly how it happened, how we arrived at Ayehu's.

And then another women we found, thanks to a boy in the marketplace, who admitted that there was a woman in his village who was leaking. But he was so afraid, it took our guides an hour to convince him that he was doing a good thing by telling us how to find her. And then Yenenesh just came to our doorstep at the hospital. She happened to be a maid at a house in the town, and word spread, and the man she worked for heard about us and said, "Come, there are some people who are going to help you." He was so happy. And there she was, two nights before we were leaving. So that's how we found them.

AB: I had the opposite experience and the opposite challenge from Mary Olive. We arrived at the hospital and it was not about finding the women, but the problem of narrowing it down from an enormous selection of candidates. They had about a hundred beds. And every woman's story is compelling and heartbreaking. We asked the hospital if we could interview all the women who had arrived the day before, because we wanted to get their experience from the very beginning of their stay; they hadn't even been examined by the doctors yet. 

We interviewed about 12 women that first day, and I had a set list of questions: How long have you been leaking? How old were you when you got married? What was your husband's reaction? We went through kind of cataloging the stories. It was a day of just crying after hearing these stories. And, too, seeing which women seemed the most comfortable just talking to us. But we certainly didn't bring any cameras in that day. It was a chance to see how they felt about the idea of us following them around.

Out of that first day we found two of the women we followed, one of whom, Almaz, ended up in the film. Her story stood out because she'd had a double fistula, which -- well, urine is one thing, but add feces to that for three years; it's hard to fathom. The next day we actually saw Wubete from across the room, and she was kind of peering around the corner looking at us and her face was so expressive. And as soon as she opened her mouth, there was something about the quality of her childlike hope. She's been there already three times. And I think there was something else interesting about her story because she had already been operated on, but she hadn't been cured yet. So that's how it started at the hospital.

IDA: What was your purpose in making this film?

MOS: Our goal was not to just make an advocacy piece. We felt that we would advocate the best by making a beautiful nonfiction narrative film. The easy sell for the hospital would be: Woman comes in, fistula gets cured, woman goes home. Transformation, she's happy, the end. But you need setbacks and conflict in a good film. And so these stories were, I think, particularly compelling and stood out to Amy. We were a little nervous about having a character who was not completely cured, but the fact that she finds her way--finds a way to grow up and be strong,anyway--is all the more moving. So she ends up having one of the best stories, if not the best story, even though she wasn't cured.

I hope that people see that we were not just making a film about fistula, but about women who just wanted to be whole people again.

AB: That tenacity was important, that they were willing to do whatever it was going to take. Neither of us had any idea about what would transpire with these women, what would happen next. In some cases it was very straightforward and happy; and in other cases it was very complicated and an indirect route to the end product.

MOS: We never thought we would have five characters, but each one seemed to bring something so different.

IDA: How was it for these women after they were cured and they returned home? Were they welcomed back into their society? 

MOS: That's a complicated question. My guess is that for the women who were cured, and who hadn't been sick for that long, they're welcomed back. Zewdie was welcomed back immediately, although she was nervous about reintegrating. Ayehu, the first woman you meet in the film, was sick for six years, and I went back and saw her three months after she was cured. She was still angry because of the way her family had treated her, so she wasn't running out to the well to hang out with the neighbors yet. She's older and doesn't plan on getting married again. For the younger women who get cured, my understanding is that they reintegrate pretty quickly.

It's not that hard to get married again. We found that virginity in an orthodox community is not a big issue. Some of the women had had three or four husbands. If you're married and your husband leaves, you can get married again.

AB: There are so many reasons why girls are married off early. We want to do our next film on early marriage, which we've gotten some interest in.

IDA: Early marriage in Ethiopia?

AB: Yeah, we're going to focus on Ethiopia because it has such a high rate, for a variety of reasons -- from economics to making sure that your daughter is protected and not abducted into marriage as Almaz was: You're abducted, then you're raped, then you're a wife. Almaz's husband treated her well, sold a cow so he could help her, bought soap for her. He never abandoned her, or put her out of the house. But when Almaz was cured and we went home with her to film the homecoming, it all started to come out what her sense of this marriage was. She just had so much spunk, I left thinking, I wonder if she's going to stay with this guy. And, lo and behold, as soon as her body was healed, she was out of there. She left her husband and her village and moved back to Addis Ababa and found a job on a rose farm. So she acquired the strength to leave a marriage she never wanted to be in in the first place. But every story was different.

IDA: How long did you film in Ethiopia?

AB: We were in the hospital for two-and-a-half to three weeks following the women through their surgical procedures and recovery process. Then we went off for a week before we returned. So that first trip was about four weeks. And then a couple months later we went back to film Wubete for a couple of weeks.

MOS: Then I went back again with our composer and we recorded traditional music and a lot of the traditional sounds to include.

But what I didn't do was tour. So, I'm taking some time next fall to travel in Ethiopia, and we're premièring the film then!

Cathleen Rountree is a film journalist and author of nine books, including The Movie Lovers' Club, about the process of creating community through finding meaning in movies. She covers film festivals and writes extensively about films and directors for print and online publications.