KATSINA, Nigeria - Dr. Kees Waaldijk began surgery shortly before 10 a.m. one recent Saturday in a cement-walled operating room in this city near Nigeria's northern border. More than five hours later, orderlies carried the last of four girls to the recovery ward. In the near-90 degree heat, Dr. Waaldijk's light blue surgical garb had turned dark with sweat.
Michael Kamber for The New York Times
Inno Usman, 25, waited for surgery this month in Babbar Ruga Hospital in Nigeria. She suffered from an obstetric fistula, an injury, suffered by many African women, that can be prevented with a Caesarean section.
"We are finished for the day," he barked.
It was the last thing the dozen girls who squatted in the open-air corridor outside wanted to hear. Leaping up, tracking wet footprints and soaked skirts across the floor, they besieged the towering, white-haired surgeon, holding out orange case files, their names scrawled on them in black marker.
"Big eyes, with a question mark: 'When is it my turn?' " he said later in his office, filled with medical books, suture-filled suitcases and damp socks and T-shirts hung on chairs to dry. He held up his hands. "The eyes are following you everywhere you go. I tell them it is one man, two hands and many women."
What brings the girls to Dr. Waaldijk - and him to Nigeria - is the obstetric nightmare of fistulas, unknown in the West for nearly a century. Mostly teenagers who tried to deliver their first child at home, the girls failed at labor. Their babies were lodged in their narrow birth canals, and the resulting pressure cut off blood to vital tissues and ripped holes in their bowels or urethras, or both.
Now their babies were dead. And the would-be mothers, their insides wrecked, were utterly incontinent. Many had become outcasts in their own communities - rejected by their husbands, shunned by neighbors, too ashamed even to step out of their huts.
Until this decade, outside nations that might be able to help effectively ignored the problem. The last global study, in which the World Health Organization estimated that more than two million women were living with obstetric fistulas, was conducted 16 years ago.
Nor has a recent spate of international attention set off an outpouring of aid. Two years of global fundraising by the United Nations Population Fund, an agency devoted in part to improving women's health, has netted only $11 million for the problem.
The number of new cases is far outpacing repairs - not just here, but in other sub-Saharan nations like Kenya, Malawi and Uganda. Despite recent strides, said Thoraya Ahmed Obaid, the Population Fund's executive director, "at the current rate of action it will take decades to end fistula."
Few doubt that the problem is most concentrated in sub-Saharan Africa, where poverty and rudimentary health care combine with traditions of home birth and early pregnancy to make women especially vulnerable. In Nigeria alone, perhaps 400,000 to 800,000 women suffer untreated fistulas, says the United Nations.
Dr. Waaldijk, a 6-foot-4, 64-year-old Dutchman who rides a circuit nine months each year from his home in the Netherlands to Babbar Ruga Hospital here and others in rural Nigeria, says he has operated on 15,000 fistulas in 22 years here, repairing nearly all of them.
Obstetric fistulas are easily prevented by Caesarean sections. But in sub-Saharan Africa - excluding the region's richest nation, South Africa - the average doctor serves 6,666 patients and villages are often linked by little more than dirt paths. Many rural women labor fruitlessly for days before being taken, sometimes in a cow-pulled cart, to a road leading to a hospital.
Dr. Waaldijk remembers one patient well. She managed to push out only her baby's head before collapsing from exhaustion in her hut, he said. Her brother carried her, balanced on a donkey, to a road, where a bus driver demanded 10 times the usual fare to take her to a hospital. She half-stood, half-sat for the trip, her dead baby's head between her legs, her urethra ripped open.
"This is what is happening," the doctor said. "Nobody will believe it." The fistulas point to the broader plight of millions of African women: poverty; early marriage; maternal deaths; a lack of rights, independence and education; a generally low standing. One in 18 Nigerian women dies during childbirth, compared with one in 2,400 in Europe, the Population Fund says. A larger share of African women die in childbirth than anywhere else in the world.
Were it widely available, the United Nations agency states, a $300 operation could repair most fistulas. But Mozambique, with 17 million people, has just three surgeons who consistently perform those operations. Niger, population 11 million, has but six, the organization reported in 2002.
Nigeria, Africa's most populous country with 137 million people, has eight fistula repair centers, and Dr. Waaldijk, a Health Ministry employee, said he had trained 300 doctors in fistula surgery. Once trained, though, many leave for better paid jobs in wealthier nations.