In so many ways, the unique set of challenges surrounding fistula have been
a catalyst for change in the development world. The response to fistula was, along with responses to HIV and AIDS, tuberculosis and other conditions, an early example of a marriage between public health and clinical medicine. Fistula furthered this interface through community-based public-health interventions and institutionally-tied surgical care. Fistula required thought and programmes for both dealing with and preventing the condition, and these were based not in immunization or focus groups, but in institutionally-bound surgery. As a surgical issue, there have been tremendous hurdles to overcome, as fistula repair inconveniently straddles traditional boundaries in pelvic surgery training. Repair involves a mixture of techniques native to gynaecology, urology, general surgery and plastic surgery. It calls for significant capacity-building to conduct highly complex procedures in some of the world’s most resource-poor areas.