Announcing our new Executive Director!

Please welcome IMR's new Executive Director, Dr. Ambereen Sleemi.

Ambereen is a co-founder and  Surgical Director of International Medical Response. She has been a crucial figure at IMR since inception and has led our projects in Puerto Rico, Malawi, Liberia and Haiti. Her passion for quality care has fueled her to treat women with fistulas and other pelvic floor disorders all over the world. 

As a female pelvic medicine reconstructive surgeon (Urogynecologist) and trained obstetric fistula surgeon, Ambereen serves as an obstetric fistula surgeon for the Eritrean Women’s Project in Mendefera, Eritrea since 2007, and as a surgical team co-leader for Medicine In Action’s spring trip to Kingston, Jamaica as well as on the medical board. She spent 6 years on the executive committee of the International Society for Obstetric Fistula Surgeons (ISOFS) and is still an active member. In January, 2013, she developed the Haitian Women’s Heath Collaborative in partnership with the Department of Ob/Gyn at the National Hospital in Port-au-Prince, Haiti. This project has expanded to a partnership with St. Boniface Hospital in the southern part of the country, continuing our pledge to increase safe surgical capacity in Haiti. 

She holds an MD/MPH from George Washington University School of Medicine, and is currently pursuing her M.S. in Epidemiology at Columbia University’s Mailman School of Public Health. She trained in Ob/Gyn at Louisiana State University in New Orleans, LA, in Female Pelvic Medicine and Reconstructive Surgery at Maimonides Medical Center and in obstetric fistula surgery in Northern Nigeria. 

We are thrilled to have Ambereen lead us through this new chapter!

Healing in Malawi: An Update on our Surgical Obstetric Fistula Program

Photo: L. Santaniello

In December 2016, we launched a partnership with the UNFPA Malawi, the Malawi Ministry of Health, and local district hospitals to help treat women in the southern region who are suffering with obstetric fistula and to train surgeons in fistula surgery. It is estimated that over 2 million women suffer with this condition and for every 1 woman treated, 50 remain untreated. IMR is committed to treat the women affected, often the poorest and most marginalized, for free. Importantly, our commitment goes beyond surgery and extends to training surgeons and nurses in this field. This includes pre- and post- operative care and patient safety.

Last April, Liz Santaniello, MSN, FNP-BC and I worked at the Mulanje District hospital. We evaluated 30 women with fistula and treated over 25 with very successful outcomes. IMR held a day-long training workshop for surgeons and nurses in Mulanje.

WHAT IS AN OBSTETRIC FISTULA? Obstetric fistula is a debilitating child birth injury that results from prolonged obstructed labor (it can often be several days) and the inability to obtain a timely and safe operative delivery, in almost all cases, a cesarean section. These injuries have severe complications, leading to a hole between the bladder and vagina, or the rectum and vagina, resulting in constant urine or stool leakage, and in some cases, 15-20%, incontinence of both. Since the injury is vast, leading to tissue death and scarring, we often see damage to pelvic organs, infertility, leg paralysis (footdrop), skin ulcers and more. This injury also leads to social isolation and depression.

Over 90% women lose their babies during birth. This was true in Mulanje also. Some are fortunate, as were Emily and Christine, in Mulanje, both were healed after we repaired severe birth trauma in the form of a fistula and ruptured anal sphincter. They both were able to continue to breastfeed their babies. They’ll return home to family once  healed and  counseled on ways to prevent this from recurring in next pregnancies: good prenatal care and delivery in a hospital, preferably by cesarean section.

Photo: A. Sleemi

WHAT DO WE DO IMR has surgeons who have advanced specialty training in how to repair these devastating and often extensive pelvic injuries. Our surgeons have spent years training in the best centers in the world with the most experienced fistula surgeons. Our fistula surgeons return frequently to work with the world’s experts to continue advance their surgical skills to help women. We are also educators, with decades of teaching students, residents and fellows worldwide. Patient care and teaching are our passion.

WAYS TO HELP We’ll be returning to Malawi later this year to continue training local surgeons and transforming women’s lives with surgical repairs of fistulas. None of our work in Malawi, Liberia, Haiti or Puerto Rico could happen without your support. Please make a tax-deductible donation here.

-Ambereen Sleemi, MD, MPH, FACOG
Executive Director, Surgical Director

IMR in Vieques

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Last week, we traveled to Vieques, Puerto Rico to help care for the population on the island that is still suffering from the aftermath of Hurricane Maria. We partnered with other organizations on the ground as well as Jordan Aid International to care for over 200 people on the island of Vieques. Vieques was particularly hard hit by Maria and has had a long-standing history of health disparities for the last few decades. The need for medical care on Vieques was glaringly obvious. Chronic conditions such as diabetes, high blood pressure, asthma and mental health issue such as depression and anxiety remain. 

Puerto Rican physician Manuel Betancourt triages patients

Since Maria, the public hospital had not opened to its full functioning capacity and currently there’s an urgent care center but all emergencies and obstetric care has to be obtained on the main island of Puerto Rico. This means that someone in need has to take a boat or plane to get to the main island for urgent medical care. IMR worked with a dedicated team of internal medicine, pediatrics, family medicine, gynecology, and many nurses and non-medical volunteers who made this three day clinic a tremendous success.

Thanks in part to the generosity of our donors we were able to provide medications, medical care, therapy, and disease management for the people of Vieques. We would like to especially thank MAP International for their medical supply donation. There’s a lot to learn about the history of Vieques, some of it can be found here.

IMR volunteer, Angela Baumeister, RPAC, listens intently to her young patient

As the need continues, IMR will continue to return to the island work with our partners to provide the best medical care we can. It’s unclear when the current medical crisis will be over, however we are committed to being able to help as long as we can. Our supporters donations and support can help us have a long-term presence in Vieques and Puerto Rico for as long as needed. Please consider making a tax-deductible donation below to help us continue our work. We are grateful for your support.

Thank you,

Ambereen Sleemi, MD, MPH

IMR team in Vieques

Learning from a Master Surgeon: The Northern Nigerian Realm of Dr. Waaldijk

Documenting all

I was in Northern Nigeria at the end of January for a couple of weeks to visit with one of the world’s most experienced fistula surgeons and see the centers he has established over the last few decades. Dr. Kees Waaldijk is a surgical mentor of mine for over the last 10 years. He single-handedly has done the most fistula repairs of anyone in the world, over 25,000. Dr. Waaldijk is one of the best vaginal and fistula surgeons I have ever worked with. The execution of expertly placed suture, the precision of an incision and the economy of motion (as I teach it to my residents and trainees) is a beautiful thing to witness. That, coupled with meticulous documentation of each operation and outcome, is a good as it gets.

Notes on instruments and inventory

As IMR is preparing to help launch a new fistula ward in southern Malawi in April, it was important to visit with him and see how these centers were planned and how they are run. Over 2 weeks and 1500 km we went to 4 centers in Sokoto, Zaria, Kano and Katsina. All have served as training centers for 100’s of nurses and surgeons, all have high volumes of patients with obstetric trauma and fistulas. It was important to see how these centers have set up the operating rooms, the rehabilitation centers and importantly, training of surgeons and nurses.

Sokoto’s only fistula center

Thoughtful post op ward design

What is the best way to train surgeons in a highly complex surgery like fistula surgery, where the best shot a success is on the 1st attempt? How do you prepare trainees in the anatomy and surgical techniques needed for a vaginal approach.  Much of the same questions are asked when trainees are learning other surgical operations. Focusing on providing the best care and best training possible is our goal. Looking forward to April when we launch the project. Stay tuned.

-Ambereen Sleemi, MD

Urogynecology Seminar in Montego Bay

By: Ambereen Sleemi, MD, Surgical Director

At the end of October, IMR was invited to be on a panel of physicians who presented “Current Trends in Urogynecology”. This conference we sponsored by the Western Gynecology Association of Jamaica and Medicine in Action. I presented on genitourinary fistulas in developed and under-resourced healthcare systems, expanding on IMR’s work in Malawi, Liberia and Haiti. IMR has projects in these regions focusing in on surgical training in pelvic reconstruction and fistula repairs. Our work over the last few years in Liberia has been to work with the Liberian National Fistula Project, the Ministry of Health and the College of Physicians and Surgeons to train the Ob/Gyn residents in pelvic reconstruction and basic obstetric fistula repairs. I also spoke about urogynecology issues that arise during pregnancy, ranging from the commonly seen complaint of urinary incontinence and the less frequent condition of prolapse in pregnancy. 

Update: IMR in Puerto Rico

Municipal water trucks delivering water to mountain towns in Lajas

Water is life everywhere

Homes destroyed, bits and pieces of a family’s home strewn down the mountainside in Morovis

Home visits, like this one to a 90- year old in Lajas, to the most elderly and infirm. Her severe arthritis in arms and legs makes walking impossible

Commonly seen sights along roads all over the island

The profound intimacy of home visits. Home bound seniors like Rosa, 97 years old, still have no running water

We have just returned from a week in Puerto Rice working with the Department of Health and the Puerto Rican College of Physicians and Surgeons. Each day, the DOH identified municipalities in need. This was done in cooperation with local mayors and community workers. Liz Santaniello, a family nurse practitioner joined me for the week long trip.

Our first day was spent in Canovanas and Loiza, one of the hardest hit areas on the island and the one with hundreds of people in refugee centers. We set up a clinic in town and saw dozen’s of people who needed care. None had electricity or running potable water. Over the week, we traveled to the south to Lajas, the mountains of Morovis, refugee's shelters in Salinas, and the hardest hit areas of San Juan, including Hill Brothers. Home visits to the elderly and frail, as support and reassurance that they will not be forgotten, were much needed.

Everywhere, we saw old and young alike in need of medicines, water and electricity. And everywhere we saw Puerto Ricans from all walks of life rise to this need and do the work that needed to be done to care for people. We were able to deliver 8 large bags of medicines, syringes, pain relievers, water purification tablets, bug spray and more to 100’s of people. 

Working with the local doctors and authorities ensured our efforts were directed to the most needy areas of the island.  IMR has committed to return to work with local Puerto Rican doctors to provide care, supply medical goods as well as technical support as long as the need exists.

- Ambereen Sleemi, MD, MPH

Surgical Director 

IMR begins assisting physicians in Puerto Rico

Approximately a month after Hurricane Maria devastated Puerto Rico, a team from IMR will travel to work with physicians and nurses at the Medical Center in San Juan. The Medical Center and Department of Health have been key local responders to the medical crisis in nearby towns.

Blue tarps over homes damaged by Hurricane Maria

Puerto Rican physicians we’ve spoken to report widespread illnesses such as infectious diseases like scabies and conjunctivitis, as well as untreated chronic disease like diabetes, asthma, and high blood pressure. All these left diseases left untreated can lead to severe complications. The fear of water-borne diseases exists and cases of Leptospirosis have been reported. Due to the continued lack of clean, potable water, there’s real concern of widespread infections.

We’ll spend a week working with the Medical Center teams. Thanks to the many who donated supplies and funding to help make this happen. Thanks to JetBlue and MAP International for in-kind donations.

This will be the first of many trips to help healthcare workers and the patients they care for. We’ll continue to return as long as we are able to help fulfill a need. 

Summer Update: Building more partnerships in Haiti

Christie Louis, WHNP, talks to healthcare workers and medical students about hypertensive emergencies in obstetrics

In June, IMR was invited again to present at "World Health: Special Focus on Haiti", a medical conference in Limonade, Haiti in collaboration with NOAH-NY, Healthfirst, and Howard University Hospital. We gave lectures on Pelvic Floor Disorders and held a workshop on Ob/Gyn emergencies including postpartum hemorrhage, hypertensive disorders of pregnancy and ectopic pregnancy to a room full of Haitian medical and nursing students. We were joined by Christie Louis, WHNP, first-time volunteer with IMR. 

After the conference, Dr. Sleemi traveled to southern Haiti to begin a partnership with St. Boniface Hospital in Fond-des- Blancs. St Boniface is located in a remote mountain region about a 3 hours drive from Port- au-Prince. It’s remote area lends to a very large patient cachement area, treating over 100,000 patients per year with over 200 surgeries per month. The Department of Ob/Gyn invited IMR to come and work with the 2 staff physicians, Chairman Dr. Guerrier and Dr. Germinal. Enhancing the vaginal surgical approach in pelvic reconstructive techniques for prolapse and incontinence will be the focus.

Dr. Meyer working with Dr. Guerrier, Chief of Ob/Gyn, to repair an obstetric fistula at St Boniface

Clinically, Dr. Sleemi and IMR volunteer Dr. Bill Meyer saw many patients with complete prolapse that had been untreated for years, leading to extreme discomfort and bleeding. We treated pelvic organ prolapse, genital fistula and a few congenital vaginal abnormalities.

We look forward to continuing our growing relationship with St. Boniface Hospital and improving care for women with devastating childbirth injuries and other debilitating gynecologic conditions.

“My experience at the conference in Haiti was beyond my expectation... Interacting with individuals that are passionate about teaching and helping those who are not as fortunate as us is a rewarding feeling. Living in a country where medical technology is so far in advance you easily forget about the basics. This trip has changed my perspective in life and how I will practice as a Clinician. I’m more determine then ever to master my craft and learning alternative ways to practice preventive care and treatment. ”

— Christie Louis, WHNP

Staff and faculty of "World Health: Special Focus on Haiti"

Unite for Sight's Global Health and Innovation Conference

By: Nicole Turturro, Development Intern

This past month, I had the pleasure of going to Unite For Sight’s Global Health and Innovation Conference.  Every year students and professionals convene at Yale University to discuss the current situation in global health and to exchange ideas on how to move forward in everyone’s respective field.  Much of this year’s conference focused on cultural humility and how we, as a Western country, can humbly serve the communities we work with.  Vanessa Kerry, the first keynote speaker, talked much about how listening to the communities we work with and learning to conduct our work in the context of their cultures greatly improves patient and program outcomes.  One of the first panels I attended was the “Thinking Outside of the Box:  Careers in Global Health Panel.”  Although I will be pursuing an MD degree, this panel showed me the various paths to a career in global health and the various niches within the global health sector.  Those on the panel included a global health consultant, a professor, and a photographer!  

The next keynote speaker was perhaps the most interesting talk of the day.  Jeffrey Sachs, a professor at Columbia University, gave a talk on universal health coverage in the US and what the current situation is in this country.  Although the US spends the most on healthcare, it has a shorter life expectancy than most high-income countries.  The United States is also the only country that treats healthcare as a business.  The US has the second highest relative poverty rate and the most income inequality among high-income countries.  As a young person, this talk was extremely enlightening and demonstrated the amount of work that my generation and future generations need to do.  

Throughout the day, I also learned about the role of surgical care in global health and experts’ opinions on different healthcare systems, such as customer-centered and value-based healthcare.  One of the most interesting talks was about MEDSINC, an app developed by two pediatricians that enables the user to triage patients and make treatment recommendations.  This allows clinics that are mainly run by nurses and secondary healthcare workers to more efficiently treat their patients.  

Attending the Global Health and Innovation Conference was a wonderfully cerebral and inspiring experience.  Thank you so much to IMR for asking me to attend.

Royal College of Obstetrician and Gynecologist Annual Congress

by: Dr. Ambereen Sleemi, IMR Surgical Director

I was invited to talk to members of the Royal College of Obstetricians and Gynecologists (RCOG) at their annual Congress in Cape Town this past month.. A full-day workshop focused on current topics in Obstetric Fistula repair was offered as a pre-Congress event. I was honored to speak about IMR’s work and to join expert surgeons from Zambia and Tanzania and representatives from FIGO’s ( International Federation of Gynecologist and Obstetricians) Fistula Training Initiative. Travel was made possible through generous funding from the RCOG and a grant from the Polan-Bennack Foundation.

Topics ranged from current practices, urologic abdominal approaches to VVF, vaginal stenosis, and how to approach RVF’s. I spoke on training the next generation of VVF surgeons, using IMR’s work in Liberia and now Malawi as examples of how post-graduate training programs are now incorporating fistula training into the teaching curriculum. I’ve relied on my experience as a surgeon with the Eritrean Women’s Project over the last 9 years to help shape our teaching.

The surgical burden of fistula cases is enormous. The actual numbers are elusive given the nature of the condition, but an estimated 2 million women are currently suffering with fistula. We have been able to markedly increase the number of cases we do, but it is not nearly enough to decrease the incredible backlog that exists. Add to it a new 50-100,000 cases per year and it will take over a century to even catch up.

Table Mountain, Cape Town

There are many thoughts on how best to train the next generation of fistula surgeons, including vetting candidates to find the best fit for this type of work. Our patients are the poorest, most marginalized people on earth. The pay is low and the surgeries are extremely complex and challenging. Even in the most expert hands, no one has 100% success with repairs. We’re hoping with early introduction to obstetric fistula training, some will make it their life’s work and others will incorporate it into their practice.

Well into our 2nd year of training residents in Liberia and a few months from launching fistula and training services in Malawi, IMR continues to strive to bring best practices in surgical work to areas with great need. We are fortunate to partner with WAHA (Women’s and Health Alliance) , the Liberian College of Surgeon’s and Physicians and UNFPA Liberia and UNFPA Malawi to treat women who suffer with obstetric fistula.