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Though Evangel is openly Christian, it ministers to Christian and Muslim patients. "We treat them all the same," Kirschner said. "We try to give them dignity, to say, 'You have value, you have worth.'" The clinic also offers three- to six-month rehabilitation at Fistula Village, a literacy and job-skills training program with a spiritual component, vital to restoring women's lives and self-worth.

Carolyn Kirschner worked at the Evangel VVF Centre until 2004, when the Kirschners moved to Illinois on extended leave. In July, she returned to Evangel to try a new continence surgical procedure that, happily, worked.

Kirschner can understand why husbands bow to strong cultural pressure and abandon wives with fistula. In the poorest countries, governments offer few social services and no pensions. Children tend crops and later support their elderly parents.

"The guy may have every good intention and not want to leave his wife, but … his whole family is saying, 'Get rid of her, she's cursed,'" Kirschner said. Perhaps unspoken is the thought: If this wife cannot provide children, send her away and find another who can.

Yemena Tyewedee of eastern Nigeria's Benue State underwent this experience. In 1990, Yemena's brother sold her to an elderly man as a second wife. At age 13, she became pregnant. Her ten-month pregnancy ended with seven days of labor. She delivered a stillborn baby and became incontinent.

Her husband visited once and left. Her parents wouldn't eat meals she cooked because of her smell. They threw her out of their home. Three years later, after three failed surgeries at regular hospitals, she found Evangel.

Perhaps the hardest part of Kirschner's work is maintaining the hope of patients. Loss of hope could plunge them into suicidal depression. In Yemena's case, her fistula was irreparable. She remains incontinent and barren, which means she likely will never have a husband and children to care for her.

Yet Yemena continues to believe God can heal her. Meanwhile, she works as a clinic housekeeper. "I hope God will do something to change my situation," she said. "But I don't have problems staying here. People have shown love to me. Love I cannot get at home. I've been more loved here than any other place."

Many others are not as hopeful. After Del Fulani's grandmother learned of Evangel's VVF clinic, Del Fulani scraped together funds to go to Jos, 150 miles southeast of her village in Nigeria's northern Kaduna State. After the surgery, she returned to her grandmother and began leaking urine again. After a second unsuccessful surgery, she tried to hang herself.

In Kirschner's near-decade of VVF work, she has heard many stories like Del Fulani's. Additional surgical repairs are common. Complex injuries from hard labor may require six surgeries, some lasting up to eight hours.

Still, Arrowsmith said that 85 to 90 percent of fistulas are "closeable." In some of these cases, there is lasting incontinence due to other injuries. Both Kirschner and Arrowsmith have operated on women who have endured VVF for decades. One Ethiopian woman with a fistula hid for 43 years in a monastery. After Arrowsmith performed a 20-minute surgery, she was continent, though most of her life was gone.

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December 2005, Vol. 49, No. 12