ADDIS ABABA -- The best thing, Ajo says, is that soon people won't talk about her any more. She will be just like every other woman, and no one will notice her at all.
At 15, she has the height of a much younger child, and a voice as tiny as her frame. But Ajo has been married and divorced and twice endured childbirth that went on for days and days until she lost consciousness and her babies died, in a small dark house in rural Ethiopia. And with the last baby, Ajo developed a fistula, a hole in her vaginal wall that leaked urine, leaving her with soaked clothes and burns on her legs, plagued by flies and a terrible smell. And so she was not just childless, but abruptly divorced and dumped back with her mother.
"Then everyone started to talk about me," she said. "They said it was evil spirits that caused all this to happen."
A sympathetic uncle mustered the funds to bring her 175 kilometres to the Addis Ababa Fistula Hospital. Earlier this month, she had the simple operation to repair the hole and returned home again in a clean and dry new dress.
For more than 50 years, this hospital has quietly pioneered the treatment of the horrific but little-known problem of obstetric fistula. An estimated two million women worldwide are living with the problem, the World Health Organization says, most of them in Africa. Fistula once occurred in North America and Europe, too, but disappeared more than 100 years ago because of better antenatal care. Today, fistulas affect the poorest women in the most isolated places, and because of that the issue attracts little attention and even fewer resources.
The 1,500 women who get to this hospital each year -- and a few thousand more lucky enough to be seen in other countries by doctors trained here in a procedure hardly taught elsewhere -- receive the simple $350 operation (given free here) that repairs fistula in 93 per cent of cases.
A fistula is, in essence, a hole. More than half of Ethiopian children are stunted by malnourishment; they are more likely to be girls than boys, in this culture that favours male children. In addition, girls do most of the heavy labour and receive fewer calories in family meals. A third of girls are married at age 15 or younger.
Many of these girls have obstructed labour when they try to bear children. They may labour for three, four, as many as nine days to try to push a fetus with a 9.5-centimetre head through a pelvis just 8 centimetres in diameter. The baby invariably dies (and is finally expelled when decomposition softens the bones of its skull), but the pressure of the fetal head has already caused necrosis, or death from lack of blood supply, in the tissue of the mother's vaginal walls.
This dead tissue soon falls away, leaving a hole between the vagina and the bladder or the rectum. Thus urine and feces continually trickle from the girl's vagina, in an uncontrolled flow. This makes her smell foul, but also causes sores on her vulva and legs that never heal. These females are almost all divorced by their husbands, sent back to their families, shunned and end up living on the outskirts of their former communities or, sometimes, are taken in by monasteries.
While surgery to repair a fistula, and postoperative care, is hardly expensive, it costs even less to prevent the problem: a caesarian section costs about $65. But less than half of African women give birth in medical settings or under trained supervision.
In the past few years, campaigners have managed to attract a bit more attention to this unglamorous health-care issue. "We're seeing a lot of positive changes, of facilities being able to handle more cases -- increased awareness and prioritization of the issue," said Kate Ramsey of the Campaign to End Fistula run by the United Nations Fund for Population Activities. Mali now has four times more capacity to do repairs than it did when the campaign started in 2003.
Part of the need is training doctors. Gynecologists are scarce in sub-Saharan Africa, and most were trained where fistula is unknown. Another step, though, is getting word to affected women that there is a simple fix to their shame. In a hospital bed near Ajo's was Almaz Shiferaw: At 50, she lived with her fistula for 30 years. She has given birth to 13 children, only three of whom survived labour. She stopped mixing with other people in her village, kept cloth balled between her legs, used water she hauled from kilometres away to try to wash constantly, and counted her blessings that her husband did not send her away.
A few years ago, she heard of a hospital that fixed women whose babies died in childbirth; two months ago, Ms. Shiferaw made her way to Addis Ababa and asked passersby about the hospital until she made it to its gleaming, whitewashed wards. "Until I stepped in the door, I thought I was the only woman in all of Ethiopia who had this problem," she said.
The fistula hospital was built by two missionary gynecologists from Australia, Reginald and Catherine Hamlin, who came to Ethiopia in 1959. They were told on arrival that they would "see fistula patients and it will break your heart." Rather than sending them away, the Hamlins drew on a method developed on American slave girls in the 1800s, and began operations using techniques they were soon improving with the help of Ethiopian colleagues. They built the hospital with donations in 1974. Her husband died in 1993, but Dr. Catherine Hamlin, at 82, is still operating and still directing the hospital.
Today, all of the nurse's aides and cleaning assistants at the hospital are former patients.
These days, many more of the surgeries are performed by Mamitu Gashe: She came to the hospital 43 years ago, as a 16-year-old village girl who had laboured for days, borne a dead baby, and woken to find her bed wet with urine. After the Hamlins repaired her fistula, she felt she had nowhere to go and so she stayed, at first sweeping the floor and fetching water. Soon she was assisting in surgeries, and then doing them herself.
Today, Ms. Gashe, who this past week bustled between the operating theatre and the ward in a trim set of green scrubs, is one of the foremost experts on fistula repair in the world. And, she says, proud but shy, she has reached Grade 4 in night classes.
The hospital is now in the process of expanding to five outreach centres, one in each corner of the country, where the operations will be performed, sparing some women the weeks-long trek to the hospital.
The Addis hospital has a ward where former patients return to wait for the arrival of their babies, this time delivered -- whole and hearty -- by cesarean section. Ajo, though, says she will not be back: She will not marry again, she will not have more children. "I would be afraid," she said. "I'd be afraid that it would all happen to me again."