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Fistulas in the genital area consist of abnormal connections between the bladder and the vagina or between the intestine and the vagina and are the result of injury. The dividing tissue tears or dissolves under pressure, allowing urine and feces to enter the vagina and then exit the body from there.

Rebels returned in 2009. K. was pregnant at the time and begged for mercy, but the four men said they didn't care. Afterward, the neighbors brought her to the hospital. The child in her belly was dead and urine once again flowed out of her body.

This time the fistula was complicated. After four operations, the doctors said they couldn't heal her. She was brought back by ambulance to her village of Likirima, located about an hour's drive from Bukavu. Janet started wearing multiple pairs of pants again, lining the insides with strips of cloth.

Her condition remains unchanged today, and she rarely leaves home. The other people in the village avoid her: "The people say I smell," she says. It has been estimated that several hundred thousand women have been raped in eastern Congo in the past two decades, with rape long since having become a weapon of war. Since the early 1990s, violent conflicts have raged in Congo over mineral resources � substances like coltan, tin, gold and tungsten that are the raw materials required by the digital industry.

New rebel groups are constantly emerging, supplied with weapons and money from abroad with the aim of securing access to the mines. These rebels destroy entire villages, recruit child soldiers and enslave and rape women, abusing them with clubs and bayonets. An estimated 5 million people have died so far in this ongoing conflict.

Fistulas are one of the physical consequences of this brutal violence. "When they rape you, it isn't like having sex," says K. "They want to injure you. When the first one is done, and it's the next one's turn, he wraps your skirt around his hand and sticks it into your vagina. He says he's cleaning you, but he's actually hurting you in the process."

An Age-Old Problem for Women

Fistulas are a problem in many African countries. They can also occur as a result of childbirth, as was the case for 18-year-old Sawara A. of Somalia. She was married at 14, as is customary in her country � and as remained customary, even after her entire village had fled to Ethiopia from the civil war in Somalia.

In Ethiopia, they lived in a lonely desert region near a mountain range. The mothers tilled the fields and the children tended to the goats.

It was also customary to give birth at home on the floor of the hut, with the help of the mother and one of the older women in the village. Sawara A. became pregnant at 16 � and she was only brought to the health station when an overly narrow pelvis prevented her from carrying out childbirth. By then, though, it was already too late. The child was dead and the mother had been left incontinent. Her husband left her, and A. stayed in her parent's hut because she was ashamed of smelling like urine � a desperate 16-year-old without a future.

The World Health Organization estimates that 2 million women suffer from untreated fistulas in sub-Saharan Africa. Each year, an additional 50,000 to 100,000 cases are added. It is an age-old women's problem that already plagued women back in ancient Egypt.

Before the early 20th century, fistulas were also a problem in Europe. But since the introduction of prenatal care, hospital birth and cesarean sections, they have largely become a thing of the past.

Most fistulas arise from complications during childbirth. If the baby doesn't fit through the pelvis, and its head presses against the mother's tissue at the pelvic bone, holes and fissures develop in the walls of the bladder and the intestinal wall.

Fistulas caused by childbirth are a problem faced almost exclusively by poor women. Geographic isolation, a lack of money for medical care and traditions like home births, but also patriarchal social structures in which little value is attached to a woman's life, early marriage and malnutrition can all contribute to the injury's prevalence.

In the world's poorest countries, only every second woman gives birth in a hospital or with the help of a midwife. About 15 percent of all pregnant African women have complications that require emergency care and, when these arise, the nearest clinic is often far away or there aren't enough trained doctors and medical equipment available.

For many women, the injury itself isn't as bad as their loss of social status. Because they smell bad, they become isolated and can no longer go to the market or to church. And because their husbands often reject them, they lose their source of economic support. Poor, stigmatized and robbed of their dignity, some women choose suicide.

Doctor Mukwege Is Tired

Up to 95 percent of childbirth fistulas are treatable. Doctors say that the chance of success with fistulas caused by rape is smaller because the injuries are often more severe. In the case of a very serious injury, even an operation can't do much to help. Making matters worse, despite the large number of women affected, there aren't even a dozen clinics in Africa specialized in the treatment of fistulas.

Doctor Mukwege Is Tired

 

Janet K. was operated on at the Panzi Clinic in the Congolese provincial capital of Bukavu � although the procedure ultimately proved unsuccessful. She is still incontinent. The clinic was founded by Denis Mukwege, a recipient of the European Union's Sakharov Prize for human rights defenders, among other awards, for his advocacy against violence and his accomplishments in promoting women's health.

Mukwege founded Panzi to foster hope for women. He's a large man with a calm face and sage eyes. His clinic is like an oasis in the middle of the chaotic city of Bukavu, with white buildings, abundant flowers and paths surrounded by flower beds. There is also a lecture hall, and doctors from all over Africa come here to learn.

Mukwege has traveled around the world to talk about violence against women in his country. He has spoken with stars like Angelina Jolie and Ben Affleck and has given presentations to the United Nations and dozens of other organizations. Again and again, he has asked the international community to apply pressure on the Congolese government to help to bring the suspects to justice and to help the women of his country.

But 62-year-old Denis Mukwege has grown weary. Not because he is unable to foster any hope � after all, he has managed to operate on 50,000 women in the past 20 years. It's because the international community hasn't helped, or hasn't been able to help � and because the rapes aren't slowing down.

Indeed, the only thing that is changing is the types of victimes. Increasingly, Mukwege has little girls lying on his operating table, girls who have been raped and left to die somewhere. Medical skill, Mukwege says, won't solve the problem of the fistulas. "You can't operate against violence. You can only abolish it."

Hope in Ethiopia

After 18 months of isolation in her parents' hut, Sawara A. of Somalia learned of the existence of Hamlin Fistula Hospital in Addis Ababa. She traveled 760 kilometers in public buses to the Ethiopian capital. "My uncle gave me the money for the bus ticket," she says. "My father didn't want to help me. He said it's not worth it."

Sawara is a shy, beautiful young woman with a narrow face. Before the operation, one of the other women in the clinic gave her a ring with a blue rock. "It was the first present I had received in many years. It brought me luck."

She had to wait to have the operation. She was too thin and had suffered nerve damage in her legs from squatting during labor as well as infected tissue on the inside of her thigh from urine. "I hardly ate or drank because I didn't want everything to flow out of me," she says, full of shame.

Workers at the clinic spent months nursing her back to health: vitamins for her body, physical therapy for the nerve damage in her legs and discussions for her soul. After 12 weeks, she was finally operated on. The fistula was at the top end of the bladder, a relatively uncomplicated procedure for the doctors. They also removed the appendix and then sutured the fistula.

Two days after the operation, Sawara is sitting with the other patients at the entrance to the hospital, where the clinic's only television is positioned in front of several wooden benches. At a humorous moment of the program they are watching, Sawara experiments with a laugh. It's the first time in two years that she's been able to do so without urine leaking out. When a nurse asks her how she feels, she beams: "Like new. I don't stink anymore. And the doctor said I can have children again."

Tens of thousands of patients have been treated at the Hamlin Hospital in Addis Ababa since its founding 40 years ago. But in contrast to Congo, the number of patients here is decreasing every year. At one point, 100 women were coming here every month, but now it is only 10, according to clinic's medical director Fekade Ayenachew.

The number has decreased because the country's health care has improved. The Ethiopian government has been issuing five-year plans for reforming the health care system, which includes training midwives to work in areas located far from the nearest hospital.

Ethiopia has managed to decrease its maternal mortality rate by about 72 percent since 1990. These measures have also had an effect on the fistula cases. More and more women are giving birth in professional health care centers, and more hospitals have well-trained doctors.

The Tranquility Space

Janet K., of Congo, found spiritual healing in a group of 15 women who share her fate. The group is called Simama, which means, "We Stand Up" in their language, Mashi.