You are a 14-year-old girl. You've never been to school. You were married to a man in a neighboring village at age 13—before your first menstrual period—and six months later, you became pregnant. Now you are in labor with your first child.
Labor has already lasted for three days, but still the baby has not come. You are exhausted. You have lost a lot of blood and are running a fever. You haven't passed urine in over two days, and your genitals are horribly swollen and bruised from the constant pushing. Why won't the baby come out? you wonder. You dread the long, bony fingers of the old woman who is attending your birth. Nothing she does brings relief.
Soon the sun is rising on the morning of your fourth day of labor. At midday, with agony, you manage to pass the child from your body. The baby is stillborn. It has been dead for nearly three days and has started to decay. The softening of its tissues finally allowed it to pass through your vagina.
Thank God, you sigh. It's finally over. But it's not.
On the morning of the fifth day, you pass more dead tissue. And then it starts. Urine is running out of your vagina, onto your thighs, onto the floor. What is going on? The urine does not stop. You find some rags and stuff them between your thighs.
There, that ought to take care of it, you think. But it doesn't.
In an hour or two, the rags are soaked. In six hours, you have run out of rags. In 12 hours you notice—to your horror—that feces are also coming out. No matter how much you try, no matter how much you wash, you cannot get rid of it.
The odor and wetness are constant. Your husband is disgusted. He cannot stand to have you around. Your presence is unendurable.
"What has happened to you? What did you do?" he demands. You were supposed to have become a woman, the mother of his first-born son, but instead you have turned into a human cesspit. This all must be punishment for something you did.
He turns you out of the house. Your family takes you back, but you are not fit to live in their dwelling, so they put you in a shack on the edge of the family compound, where you sit day after day—alone, wretched, and stinking—until your family finally has had enough of you and casts you out.
You are 14. You are illiterate and have no money. You have no skills with which to earn a livelihood. You reek of urine and feces. And you want to die.
You don't know that your condition has a name; all you know is that you are cursed for reasons you don't understand. As far as you can tell, you are the only woman who has ever been afflicted in this way. You don't know that 3 to 4 million other women currently share your fate of having a fistula. Neither do you know that tens of thousands more join this sisterhood of suffering every year. As the lonely months roll by, you understand that this condition will not go away, that your injury will not heal on its own, and that nothing you can do will change your condition.
Most importantly, perhaps, you do not know that fistulas are both curable and preventable. You do not know that 150 years ago, thousands of American and European women suffered from this. You do not know that for only a few hundred dollars, a surgical operation could repair your injuries and restore your whole life.
The fifth chapter of Mark's gospel, verses 25 to 34, contains a story of the healing of a woman with a chronic bleeding problem:
Now there was a woman who had been suffering from hemorrhages for twelve years. She had endured much under many physicians, and had spent all that she had; and she was no better, but rather grew worse. She had heard about Jesus, and came up behind him in the crowd and touched his cloak, for she said, "If I but touch his clothes, I will be made well." Immediately her hemorrhage stopped; and she felt in her body that she was healed of her disease. Immediately aware that power had gone forth from him, Jesus turned about in the crowd and said, "Who touched my clothes?" And his disciples said to him, "You see the crowd pressing in on you; how can you say, 'Who touched me?'" He looked all around to see who had done it. But the woman, knowing what had happened to her, came in fear and trembling, fell down before him, and told him the whole truth. He said to her, "Daughter, your faith has made you well; go in peace, and be healed of your disease." (NRSV)
When I read this passage as a child, I was amazed that someone could hemorrhage for 12 years and still be alive—that in itself seemed miraculous to me. English versions of this passage usually use the word hemorrhage to translate the Greek, but modern readers are likely to interpret hemorrhage as the sudden bursting of a blood vessel that leads to uncontrollable, life-threatening bleeding. That is certainly not the case here. In Mark's gospel, the Greek phrase is ousa en rhusei haimatos, meaning "in a state of blood flow"—a steady ooze rather than a dam burst of bleeding. The King James Version appropriately translates the phrase as "an issue of blood."
What this passage refers to is menstrual bleeding. The woman who touched Jesus' garment had what gynecologists call meno-metrorrhagia: heavy, irregular, and unpredictable menstrual periods. There are a number of potential causes of menometrorrhagia, including uterine tumors and polyps of the tissue that lines the uterus. But the most likely reason this woman bled chronically is anovulation: her hormonal rhythms were badly off balance, and as a result, she was not maturing an egg in her ovary and releasing it on a regular basis.
Menstrual periods are triggered by ovulation. If an ovulated egg is fertilized, a pregnancy ensues, and menstruation will stop until after the baby is born, when the hormonal cycle resumes. If ovulation does not occur regularly, the affected woman will not have a regular, predictable menstrual cycle.
As a woman's hormonal signals become more unsynchronized, her bleeding gets worse. Her uterine lining becomes thick and shaggy, with unpredictable spotting and bleeding. More irregular periods with heavier bleeding follow, and her life steadily becomes more miserable. If the bleeding continues for long, the lining of the uterus can become thin, raw, and denuded, a chronic weeping sore. The common medical term for this condition—dysfunctional uterine bleeding—gives some sense of the reproductive disruption that it often causes.
In noting this woman's medical condition, what is Mark the evangelist suggesting about her larger condition in life?
First, because regular cyclic menstrual bleeding is the sign of regular ovulation (a prerequisite for conception), this woman was probably infertile. Since Mark says she has had this discharge of blood for 12 years, we can be pretty sure she has not been pregnant during this time. A 12-year stretch without a pregnancy would have been very unusual in ancient Galilee, as it would be today in rural societies where fertility is unregulated by effective contraception. For healthy, sexually active couples, where the woman ovulates regularly and contraception is not used, an annual pregnancy is commonplace. It would be almost unheard of to go 12 years without a pregnancy under these circumstances. Something was definitely wrong with this woman's ability to conceive. This lies at the heart of her problem.
It wasn't so much that the woman had been suffering from hemorrhages as that she was infertile—she was unable to "be fruitful and multiply" as God commanded. She was thus cut off from something that gave her life meaning and provided her acceptable social status: motherhood.
She was also probably anemic from her bleeding, especially in a society with an iron-poor diet, and was likely chronically tired from the resulting decrease in her stamina. As a result, this woman's general health was probably poor.
But the real reason that she had "endured much under many physicians and had spent all that she had" was not her unpredictable and prolonged menstrual periods. Her desperation came from the fact that she could not have children. To be infertile in a culture where motherhood was the supreme female virtue hung a cloud not only over her current life, but also over her future prospects. In such societies, one's security in old age came from one's family. To be childless was to confront, on a daily basis, the likelihood of a very grim and lonely future.
The second devastating consequence for this woman was that she was perpetually unclean according to the rules of ritual purity. Even though most Americans don't talk about menstruation in polite company, we do not regard menstruating women as impure persons. We do not categorize them as "unclean" and banish them from our company. We do not exclude them from Sunday worship and other religious events.
In first-century Palestine, however, other rules applied: social behavior was controlled by rules of cleanliness that were deeply embedded in religious practice and belief. These rules were particularly important—and particularly strict—for cultic practices at the temple in Jerusalem.
Leviticus 15:19-28 describes in detail the ritual status of menstruating women. A normally menstruating woman (niddah) was regarded as impure for the seven days that her period was said to last. Persons who touched her were also unclean until they had bathed and purified themselves. Everything that the menstruating woman sat or laid on was also unclean. Should a man have intercourse with a menstruating woman, or allow her blood to fall on him, he was unclean for a week, and everything that he sat or laid on was also unclean.
It was dangerous for such women to enter the presence of holy things. Normal female physiology made women periodically impure and thus separated them from the most important cultic practices. Women could not, therefore, officiate at the temple.
In his treatise Against Apion, first-century Jewish historian Flavius Josephus described the architectural layout of the temple in Jerusalem, which consisted of four courts surrounding the inner sanctum, the holy of holies. The outer court was open to all, even foreigners and Gentiles; the only persons excluded from entry were menstruating women. If a woman was not contaminated by menstruation, she could enter the second court, but could go no further. The third court was open only to Jewish men, the fourth court, only to male members of the priesthood, and the inner sanctuary, only to the high priests clad in their ritual garments.
In Jesus' time, the rules of ritual purity were tightening, not loosening, in response to the presence of a dominating Roman military occupation. The group that regarded itself as the purest of the pure—the Essenes of the Qumran community, which produced the Dead Sea Scrolls—were celibate men who believed that the law of priestly cleanliness should apply to everyone, not just Levites and high priests. The Temple Scroll from Qumran actually recommended that menstruating women be quarantined in special sections of the cities, separated from the rest of society.
To be sure, many and perhaps most women accepted the purity laws laid out for them in the Torah, abided by them scrupulously, and found fulfillment in living what they regarded to be properly regulated religious lives. But when menstruation became irregular and unpredictable, the purity restrictions became more constricting. The irregular bleeder had a more precarious ritual status. She was a zabah, not a niddah, which meant she was impure not only during her bleeding, but also for a week after each episode of bleeding, after which she had to make offerings through a priest to expiate her sinful, unclean discharge (Lev. 15:25-28).
To have near-constant bleeding for 12 years in a society where such rules were rigorously enforced would be awful. You would be constantly unclean. Those who knew about your condition would not welcome you. You could not participate in religious services or activities. An accident of menstrual hygiene could disrupt your household at great inconvenience to those living with you. The burden of 12 years of such uncleanness would have been overwhelming. The woman of Mark 5 must have wondered why such a thing had been visited upon her.
Furthermore, if her husband was a righteous man, he wouldn't have come near her due to her impurity—which was virtually all of the time—so the likelihood of her being permanently childless would have been certain.
We now understand why the woman was desperate to find Jesus. We also understand why she wasn't eager to explain her problem to him face-to-face and to ask for healing; to do so would have been embarrassing and ritually dangerous. How much simpler to avoid all of this by sneaking up and grabbing hold of his clothes, making off with just a bit of his healing power. The plan assumes the woman would be able to catch Jesus in a crowd, with lots of people pushing in on him, trying to hear him, to catch a glimpse of him, to get his blessing, or to ask for some form of healing.
But imagine her horror when, after having stealthily accomplished her task and melting back into the crowd, Jesus turns and asks, "Who touched me?" The reason Mark says the woman "came in fear and trembling" was that she had just done an unconscionable thing. She had approached a holy person willfully, knowingly, and in the flood of her impurity. According to the rules of purity, she had just rendered Jesus unclean. She had been exposed in public in the middle of this shameful, embarrassing, and defiling act.
Instead of castigating and humiliating her, Jesus approaches her directly. We can even imagine him touching her himself. Taking hold of her in such circumstances would have been typical of Jesus, for by doing so, he would have been deliberately violating a ritual restriction in order to perform an act of compassion. "Daughter," he says, using a term that indicates a familial relationship, even though he cannot have been much older than she, "your faith has made you well; go in peace, and be healed of your disease."
This sudden reversal of expectations—this expression of forgiveness, restoration, and healing—is the moment when the kingdom of heaven breaks forth in the life of this suffering woman.
A Simple Operation
Three to four million women in Africa today are shunned by their communities because they are victims of disordered reproductive physiology. But the shame of these women is deeper, their suffering more intense, and their need for healing even greater than that of the unclean woman in Mark's gospel. Like her, these women try to hide themselves in the crowd, but they are less able to do so because their affliction is more obvious to those around them. These young women have vesicovaginal fistulas, a catastrophic complication of childbirth in which the base of the bladder is destroyed during labor, making the women totally and continuously incontinent.
A vesicovaginal fistula results when labor becomes obstructed and is not reversed with timely surgical intervention. Obstructed labor occurs when a fetus does not fit through its mother's birth canal during labor. Unless the woman receives an emergency cesarean section, her labor may last for several days before it reaches its inevitably disastrous ending. The rate of C-section deliveries in the United States has reached 30 percent—probably higher than it should be. But in West Africa alone, the rate of C-sections is only 1.3 percent of all births, far below what's needed to meet the most basic obstetric needs of pregnant women.
As a result, many African women die in childbirth, because they do not have access to the surgical care they need. Although Africa accounts for only 20 percent of the world's births, 40 percent of the world's maternal deaths take place there. For women who survive the ordeal of obstructed labor, living with a fistula often seems worse than death.
Labor is an involuntary process. Once started, it continues until delivery is achieved or it ends in one of several catastrophic ways. The pregnant woman whose pelvis is too small for childbirth may be in hard labor for days, suffering severe, unrelenting uterine contractions without achieving delivery until—exhausted, weak from blood loss, and probably infected because of the long labor—she dies without ever delivering her child. Sometimes the uterus will rupture, killing both the woman and her baby in a sudden cataclysm in which the fetus and the afterbirth are thrown into her abdomen through the burst wall of her womb.
Women who do not succumb eventually pass a stillborn infant who is asphyxiated during the long birth process. After death, the entrapped baby starts to decay, eventually macerating and sliding out of the mother's body.
And as if this were not terrible enough, the worst is yet to come. A few days later, the base of the woman's bladder sloughs away due to her injuries, and a torrent of urine floods through her vagina. In obstructed labor, the woman's bladder is trapped between the fetal skull and her pelvic bones. The skull is forced relentlessly downward by the contractions, but the unyielding bones of her pelvis refuse to let it pass. As her pelvis's soft tissues are crushed, they die and slough away, forming a fistula. Once this happens, the fistula will not heal without a surgical operation.
Because surgery is so scarce in this part of the world, most of these women never receive help. They become "incurables," wet, miserable, stinking, and friendless—the outcasts of society. Many of these women are teenagers, sometimes barely even of reproductive age, when this event destroys their lives.
The woman in Mark's gospel could hide her shame with a discrete padding of cloth, but the woman with a fistula is not so fortunate. The constant trickle of urine saturates whatever absorbent material she can find, and the odor emanating from rags soaked in urine is unmistakable to those around her. Unlike the woman in Mark 5, she can't hide in a crowd. Unfit for close companionship, these women are frequently divorced by their husbands and abandoned by their families. They are seen as hopeless, drifting to the margins of society where they live lives of misery, isolation, worsening poverty and malnutrition, unloved, unwanted, and alone.
The vast majority of women with fistulas can be cured by an operation that costs only three or four hundred dollars. The surgical cure of a fistula is life-transforming, almost miraculous. A successful surgery pulls these women back from the edge of the abyss of hopelessness and restores their social personhood. It creates a stunning moment when the kingdom of heaven breaks forth in their lives in ways they never could have dreamed of or anticipated.
L. Lewis Wall is professor of obstetrics/gynecology in the School of Medicine and professor of anthropology in the College of Arts and Sciences at Washington University in St. Louis.
Copyright © 2010 Christianity Today. Click for reprint information.
Christianity Today also posted a story on how human rights lawyer, a Pulitzer Prizewinning journalist, and two world-class surgeons are rallying evangelicals to defeat fistula.
CT also wrote about fistula in 2005.
For more information on the Worldwide Fistula Fund, visit WorldwideFistulaFund.org.
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