FRED DE SAM LAZARO: Saturdays are set aside for funerals in Accra. In the numerous congregations that line the streets and alleys, the air is filled at times with prayer, most times with song blaring at its electronic limits. And nowhere, it seems, is there any outward sign of sorrow or grief.  With few exceptions, like the death of a young person, my host here said that’s the way it is.

NII ADEI KLU: When somebody dies in Christ, or dies a Christian, it’s a good thing because, I mean, he’s going to God, he has died on a good path.  But when somebody dies a pagan or somebody who does not know God, then people cry because his soul is lost.

DE SAM LAZARO: We saw little evidence of any crying on this Saturday. And it would be hard to discern a lost soul. The vast majority of people in this city strongly profess some form of Christianity. About 16% of Ghanaians are Muslim. Most live in the country’s north.

Funerals are major social events that bring together far-flung extended families. Obituary flyers and posters cover neighborhood walls. Often they are anticipated years in advance, and say much about a person’s status. Nowhere is that more evident than in the coffins favored by the Ga ethnic group in southeastern Ghana.

ABLADE (Art Dealer): People who have achieved in their lifetime.

DE SAM LAZARO: The well to do.

ABLADE: Well to do. And usually it has to show your area of achievement. If one were a fisherman, they would show some canoe or fish or things like that. If you are a driver and own transport, they would show some transportation.

DE SAM LAZARO: We saw coffins waiting for the next crab fisherman, hunter — or could this one be for an animal lover? There’s one for the beer lover, farmer, and athlete. Fantasy coffins have gained a reputation for their high art. Many are sold to foreigners and collectors.

At the root of all this is a strong tradition — of honoring, even worshipping ancestors, says Ablade. Grand funerals are a way for the living to please the newly departed elder, to continue the communion with those who went before and to ask for blessings.

ABLADE: The belief is simply that the ancestors are there and if you’re going to meet them, you must meet them properly. I mean, his being there becomes a blessing to the family. They will start calling upon him, “Hey, send us something, this week, things are not so good…”

DE SAM LAZARO: In fact, funerals, even without the expensive fantasy coffins, are a huge financial drain on families: Providing meals and libation for dozens, sometimes hundreds of guests, the musicians, and of course the morticians.

KLU: The family will be paying this money with interest, maybe the person has left children behind, or he has left some properties, sometimes it has to be auctioned or sold to defray the debts which has been incurred.

DE SAM LAZARO: There are calls from time to time from religious leaders to cut out the excess. But funerals are an investment in harmony with one’s ancestors, a true measure of one’s esteem for the departed. How, many families ask, do you put a limit on that?

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Accra, Ghana.

FRED DE SAM LAZARO, correspondent: It’s here at the Ethiopia-Somali border that some 400 refugees arrive every single day, most of them women and children, most of them fleeing not just famine, but fighting.

So far this year, 135,000 mostly women and children have registered here in this harsh but promised land for refugees. They have suffered for months and walked for days to get here. There’s food and some basic medical care — just barely enough.

LINN BIORKLUND (Doctors Without Borders): I think it’s important to point out that the emergency’s not over. It’s ongoing. We continue to see people coming and these people are living here in camps and they are in great need of humanitarian assistance.

DE SAM LAZARO: For humanitarian agencies, the challenge is to sustain the supply pipeline and keep the attention in donor countries focused on this remote region that’s seen hunger and conflict for decades. It’s an ongoing, perennial and at least partially man-made disaster. In the minds of donors, that’s very different from sudden disasters, says Mike Lloyd.  He heads a Minnesota-based group called Kids Against Hunger.

MIKE LLOYD (Kids Against Hunger): When the earthquake struck in Haiti, there was a tremendous outpouring for that event. It went on for several months. We had groups all over country wanting to pack meals, and it was a real scramble for us to meet that demand. Of course, donor dollars followed that demand for packaging the meals. When the Joplin tornado happened, of course we had a similar experience.

DE SAM LAZARO: This year, Kids Against Hunger volunteers will pack some 50 million ready-to-mix meals to be sent to needy regions around the world.  Lloyd says the response to the crisis in East Africa has been much smaller.

LLOYD: Situations like we see in the Horn of Africa are long term, they are political, at least partly political, they’re somewhat related to the drought situation but it’s been a long term political struggle in those areas and that has not excited the packers and the donors in the same way.

DANIEL WORDSWORTH (American Refugee Committee): It’s not so much about compassion fatigue. I think people are as compassionate today as they ever have been. For us, it’s actually more a belief fatigue.

DE SAM LAZARO: Daniel Wordsworth heads another Minnesota-based group, the American Refugee Committee.  ARC also saw a huge response to the Haiti earthquake.  But support for Pakistan, hit by massive floods a few months later, was far weaker.  Initially, Wordsworth says, there also was indifference toward the Horn of Africa.

WORDSWORTH: I think what we see in both Pakistan, and we’re seeing it very strongly in Somalia, is that — and it really is almost confronting to us – is the lack of belief that people have for that country. So it’s not that they don’t feel compassionate. They just can’t make the connection. They don’t believe that either change is possible there or that their money, or their resources, what they give, will actually translate into something different on the ground. That’s the crisis that we’re seeing.

DE SAM LAZARO: Wordsworth says it’s the deeds of one percent of the population that have given Pakistan and Somalia their reputation as hostile terrorist havens.  So in its fundraising campaigns for Somalia, the American Refugee Committee has tried to “de-fang” Somalia’s image, drawing heavily on the fact that the largest Somali-American community is right in its home base in Minneapolis.

WORDSWORTH: Our doctors may be Somali, our local business professionals Somali, our taxi drivers Somali. We actually get to meet the 99% on a regular basis.

Video clip: Hi, I am a star…

DE SAM LAZARO: Somali-Minnesotans — prominent and otherwise — have led a varied media campaign, drawing in the larger local community.

Video clip: We hosted a charity dinner… I’m a star because I donated money that I earned from a car wash… I organized an art show… I collected pennies for Somalia…

WORDSWORTH: It’s a whole different side of Somali culture that people don’t normally see. And then through, I think, that lens, you can see a dynamic, amazing group of people and your ability then to believe that if this country is full of people like this, there’s huge hope for that country.

DE SAM LAZARO: Is it working?

WORDSWORTH: It’s working really well for us.

DE SAM LAZARO: How do you know?

WORDSWORTH: Actually we are seeing the same outpouring of compassion that we saw for Haiti. I think we will be one of the very few organizations in the world that can say that – that we’re tracking about the same.

DE SAM LAZARO: In response to crises, donors fall into two distinct categories, according to Mike Lloyd. He says grassroots campaigns and images of suffering are less effective with large donors and philanthropists than they are with individual givers.

LLOYD: Those gifts are given from the heart. They really react to the emotional sense that they’re making a difference in the individual’s life. And when we talk to corporate givers or large donors, their dollars are usually more intended, in their minds at least, the things that are going to have lasting impact. So they’re less likely to be driven by the emotional aspect of having an impact on an individual and what’s going to happen to my dollars. Are these going to really change anything or is it just going to be the same after the dollars are gone?

DE SAM LAZARO: The American Refugee Committee says it has gotten some major corporate donations, most likely because they’re local, says Wordsworth.

WORDSWORTH: Groups like Best Buy, General Mills, the Mosaic company, U-Care, a health insurance provider. Because they’ve got Somali staff, they can see it more quickly and then the rest of the staff and the rest of the company comes around behind them and shows some solidarity

DE SAM LAZARO: ARC has used its donations to run a hospital in the Somali capital, Mogadishu. The recession at home has not hurt contributions. The group says people tend to be more sympathetic and responsive in tough times. Larger donors, though, need more convincing that their dollars, should they contribute, will bring enduring change over the long term in addition to easing the immediate suffering.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Minneapolis.

FRED DE SAM LAZARO, correspondent: In a region that’s seen civil wars and bloodshed, Ghana has enjoyed years of peace.

Church leader: May somebody leave this service knowing that their tomorrow is better than their today…

DE SAM LAZARO: In its packed churches there’s a palpable sense of optimism about Ghana’s future.

REV. FRED DEEGBE: I wish I could say we’ve reached the Promised Land. We are quite close to it, we believe.

DE SAM LAZARO: The first building block to Ghana’s relative prosperity has been a free press.

Radio announcer: This is your show, the unique breakfast drive….

DE SAM LAZARO: Almost everyone listens to the radio in Ghana and lively political give and take is a breakfast staple. Tempers flared close to boiling point at times in the studios but only until the show was over. All was quickly forgiven. In a continent where long-running dictatorships are the norm, Ghana has enjoyed two decades of thriving democracy. Two incumbent leaders have lost in general elections. In 2008, the margin was less than one percent. Yet on both cases the sitting president stepped aside, and power was transferred peacefully.

PROFESSOR EMMANUEL GYIMAH-BOADI (Executive Director, Ghana Center for Democratic Development): This is the first time we’ve had both economic growth and political stability and freedom.

DE SAM LAZARO: Ghana was the first African colony to gain independence back in 1957, from Britain. It had its share of autocrats and military coups until the early 90s, when long ruling military strongman Jerry Rawlins stepped aside and allowed democratic elections. Ghana has seen steady economic growth ever since. It exports gold, diamonds and cocoa beans, and now new wealth awaits.

Video announcer: In June 2007, Kosmos struck gold…

DE SAM LAZARO: Major offshore oil reserves have been found here and the first oil revenues began to flow last December. Across Africa the discovery of such riches, especially oil, has become known as the “resource curse.”

DEEGBE: Instead of having oil be a source of prosperity and progress for this nation we just allow a few people, very corrupt people, to amass this wealth and flaunt it to all of us, and we want to work towards this not being the story of Ghana.

PATRICK AWUAH: Ghana has been very fortunate to have oil after democracy and not before. Because that democracy is going to influence how Ghana manages its oil wealth.

DE SAM LAZARO: Patrick Awuah is one of a growing number of overseas Ghanaians who’ve returned. He went to college in the US, then worked at Microsoft. He started a university called Ashesi or “beginning.” Ghana’s fledgling democracy needs ethical leaders he says.

AWUAH: We’ve borrowed the model of the liberal arts and sciences as the way to do that, that teaches broad perspectives, a deep ethos, a deep concern for ethics and a specialization.

DE SAM LAZARO: Ashesi has 450 students and will soon triple that number in a new campus being built just outside the capital, Accra, with funds from the World Bank and other investors. Students and alumni we talked to echoed the school’s values

NAA AYELEYSA QUAYNOR-METTLE (Business Major, Ashesi University): You are training ethical leaders, entrepreneurs who are going to take over in terms of the integrity, in terms of sharing the national cake or the national pie among everybody so that the majority of the Ghanaian nationals are not eating the drops or the crumbs from the table, but then they are sharing equally.

DE SAM LAZARO: For now, Ghanaians are hardly sharing equally. There’s still deep poverty in rural areas, where the majority of Ghana’s 22 million people live. Development experts say the best way to attack poverty is to create jobs and improve the rural economy. A number of efforts have begun to do this. For example, shea nuts are a major export. They’re processed in Europe and America into shea butter, used in skin creams or as a food additive. Now several small processing enterprises have been set up in Ghana, supported by private aid groups as well as the US government. Some are mechanized but hundreds of women are employed in traditional processing, kneading a dough that comes from boiling and crushing the nuts to release the prized shea butter.

RITA DAMPSON (Small Business Owner): When you pick the nuts and sell, that is just the end of it, but when you process it into butter, the profit you can get to support your children by paying their school fees.

DE SAM LAZARO: So there is more profit than if you process the nuts?

DAMPSON: Yes, please.

DE SAM LAZARO: There’s a long way to go. Ninety-five percent of Ghana’s shea nuts are still exported raw, and processing is even more difficult with what is still Ghana’s chief export: cocoa beans. Very little chocolate is made anywhere in Africa because of a lack of refrigeration or milk. So the emphasis here instead is on getting a better price. Kojo Aduhene Tano and his neighbors belong to Kuapa Kokoo, Ghana’s largest cooperative. It was set up 20 years ago with the help of British aid group called Twin Trading. Its buyers have pledged to pay higher fair-trade prices. The coop even owns part of a fair trade chocolate line called Divine, sold mostly in Europe and online in the US. Nationwide, the coop has 64,000 members, and its profits have paid for community wells, credit unions, and schools. It’s hardly made anyone rich. Fair trade does not have a fair share of the chocolate market. Kuapa accounts for just five percent of cocoa growers in Ghana.

KOJO ADUHENE TANO: We need more money from you.

DE SAM LAZARO: People in rich countries need to buy more fair trade chocolate, he says, even as I discover that he got his first taste of it very recently.

(speaking to Tano): How old were you when you first tasted chocolate?

TANO: I was 48 years.

DE SAM LAZARO: You were 48 years old?

Life is still tough, but Kojo Tano is much more optimistic about the future. He only went through eighth grade, but his six children are being educated. The two oldest are away in college.

TANO: When I grow old they will look after me.

QUAYNOR-METTLE: This is the best times to be a young person in Ghana.

DE SAM LAZARO: That optimism is echoed in the capital, especially among young people.

QUAYNOR-METTLE: There’s the oil find, Vodafon has just come to settle, there’s KPMG, there’s Price-Waterhouse, there are all the giant multinational companies coming in. The opportunities are just overflowing.

DE SAM LAZARO: Whether it’s in big oil or tiny shea nuts, Ghana’s challenge will be to make the benefits flow more equitably, also to keep its commitment to democracy and freedom of information. Religious leaders in this largely Christian country will have a key role in all of this.

DEEGBE: With the advent of oil, there is a civil society oil and gas platform who are watching, who are keeping vigil over everything. There’s even a faith-based organization, coalition between the Christian Council of Ghana and the Ghana Pentecostal Council. Between those two you have a majority of Ghanaians, and we are extending that a third level to add a coalition that involves the Muslims, and what we want to do is to monitor what comes in.

Radio newsreader: The Ghana National Petroleum Corporation has for the second time lifted a total of 994,691 barrels of Jubilee crude oil …

DE SAM LAZARO: For now, oil revenues are being meticulously reported. How they should be monitored and spent is an on going debate that will escalate as elections approach in 2012.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Accra, Ghana.

KIM LAWTON, correspondent: The famine in East Africa continues to worsen with humanitarian officials now saying that more than 12 million people are in need of emergency food assistance. The United States this week announced an additional $117 million of aid for the region and urged other nations to follow suit. More than 400,000 Somali refugees have flooded into camps in Ethiopia and Kenya seeking help. This week, former US Ambassador to the UN World Food Program Tony Hall was in Kenya visiting one of the largest refugee camps. I spoke with him there via Skype.

Well, Ambassador Hall, tell us about the conditions that you’ve being seeing on the ground there.

AMBASSADOR TONY HALL (Former US Ambassador to the UN World Food Program and Executive Director, Alliance to End Hunger): Well, the situation on the ground, it’s bad and it’s not getting any better. I think that the sheer volume of people that are coming over the border, it’s overwhelming. I must say that the UN and the NGOs that are working on the ground are doing a great job. I think the people that are donating money, I think they, you know, they ought to feel good about the fact that their money is getting through. These programs are working. People are being served. But the volume of people, I mean, and the volume of the problem is amazing. Twenty-nine thousand children have died in the last 90 days. Four-hundred thousand people have been fleeing from Somalia because of the tremendous amount of violence and coupled with the drought—these people have not only been fleeing because of violence, they’ve been fleeing because they’ve lost their livelihood.

LAWTON: What are the biggest challenges the aid groups face right now?

HALL: I think the biggest challenge probably is the sheer volume of people that are coming. Fifteen-hundred people are coming over the border every day. I mean, they’re walking for, you know, a month-and-a-half to two months. I mean, can you imagine? I mean, I can’t imagine this, but they’re walking basically with whatever they can carry over a desert. In some cases they’re walking a hundred to two hundred miles, and they’re fleeing a very violent terrorist group. They have to also be very careful about, you know, these gangs, and they’re out there, thugs that are out there robbing them of whatever they have. The women are very susceptible to being raped along the way. They arrive, and when you see them, I mean, they are exhausted. Many of their children are malnourished, but, you know, they have this tremendous gift of wanting to survive, and, you know, when they get here you see a little bit of hope in their eyes even though they’re exhausted and thin and malnourished, and they think, well, they’ve arrived, and there’s a little bit of hope here, because there’s water and there’s food and there’s a place for them to stay, and that’s pretty neat.

LAWTON: How can you make the case for more aid, more donations coming in in the face of this global economic crisis we’re seeing here in the US, the stock market, and around the world? How can you make the case for people to give?

HALL: Our country has always been generous. Our country is a country that is known for its humanitarian aid, its development assistance, not only in our own country but overseas. That’s what we’re known for, and I think for us to reach out and to, you know, to help the least of these is—it shows moral authority, and it shows what we’re all about.

LAWTON: Ambassador Tony Hall, thank you very much.

FRED DE SAM LAZARO, correspondent: In recent years, thousands of rural communities in Senegal have held extraordinary public rallies they call “declarations,” and they’ve declared an end to a deeply rooted practice, one rarely discussed in public, one commonly known as female circumcision.

MOLLY MELCHING: Never in my wildest dreams could I have imagined that I would be sitting here years later, saying that 4,792 communities in Senegal had abandoned. In the beginning it was just unthought of, unbelievable, because it was so taboo.

DE SAM LAZARO: Molly Melching founded a group called Tostan—“breakthrough” in the local Wolof language—in the early ’90s. She had modest goals: to educate people about health and human rights, especially in rural areas and in local languages. The Illinois native is fluent in the ways of Senegal but she keeps a low profile in the work of Tostan.

Tostan’s work often begins with an ice-breaker, like an old movie. Many in the audience have never watched a film. To overcome the language barrier, the selection is a Buster Keaton silent movie classic from 1923, and it’s a hit. A more serious film followed, on vegetable gardening. It’s all part of seminars on nutrition, health, basic human rights, and other issues—in groups, songs, dances, and drama.

Skit: She needs to be cut. All girls need that.

DE SAM LAZARO: It’s proven to be one of the most promising attempts in history to wipe out what Melching calls female genital cutting [FGC], a practice that dates back 2000 years. Each year, the World Health Organization says up to 3 million girls in Africa are subjected to genital mutilation, and up to 140 million women live with its consequences.

Skit: You can’t have a recognized marriage if she is not cut.

DE SAM LAZARO: That cut is a painful rite of passage for girls across a wide swath of predominantly Islamic African and Middle Eastern countries. However, the practice goes back hundreds of years before Islam or Christianity and is also practiced in both faiths and religions native to this region. It’s thought to have originated in the harems of ancient rulers as a means of controlling women’s fidelity, or as a sign of chastity among those who aspired to be consorts.

MELCHING: Those who were in the rest of society could move up, and you could marry someone who was more prestigious or had more money, more status, if you underwent this practice, because it was a sign of good reputation, and as the years went on, I mean 2,200 years, it became very much a part of what was considered criteria for good marriage.

DE SAM LAZARO: Melching came to this West African nation as a student in the 1970s and later as a Peace Corps volunteer. She stayed on to work on improving health education, which she found sorely lacking.

MELCHING: When you see a friend that you’ve known for several months and you’ve gone to her house for lunch, and then she tells you her child has some problem, that it’s someone who has cast an evil spell on the child, the baby, and that she’s going to take them to a religious leader to get the spell taken off, and you don’t know what to say, and it turns out the baby was dehydrated.

DE SAM LAZARO: But from the health education, women began to understand infection, and Melching says they began to connect the dots.

MELCHING: So suddenly as they started learning germ transmission and the consequences of FGC and how these infections occur and why they had more problems in childbirth than other women who had not been cut, they started saying wait a minute.

Seminar: People used to be afraid to talk about this before. Not anymore.

DE SAM LAZARO: But how did women in conservative, patriarchal societies become able to speak out, especially on a sensitive sexual topic? Melching says it’s because Tostan involves men and religious leaders who’ve confirmed that cutting is not required.

MELCHING: We share our modules with the religious leaders so that they see that everything that we do is for the well-being of the community, the health, and all these things are things that Islam espouses, and so they’re very happy in general, but first of all they’re happy because we start with them. We respect them.

DE SAM LAZARO: And that respect also carries over in the group’s message on genital cutting.

MELCHING: Tostan found that using approaches that shame or blame people really was just the opposite of what would work in changing social norms. When you say to someone, we know you love your daughter and you’re doing things because you love your daughter, but let’s look at this and let’s try to understand together exactly what are the consequences of this practice. But you are the ones who will have to make the decision. Then suddenly people are willing to listen. They don’t get defensive.

DE SAM LAZARO: It’s far more effective than the approach of many aid groups—religious, government, and private, says Princeton University professor Gerry Mackie.

PROFESSOR GERRY MACKIE: Not hectoring and preaching but having pro and con discussions. When we think of an ideal way of making a change, we’d say it’s democratic. We all get together and talk it over and decide what the best thing is to do. Whereas some development approaches would, say, force them to do it, pay them to do it, trick them into doing it.

DE SAM LAZARO: Tostan’s volunteers and staff who conduct its seminars all hail from the local communities. Often they are leaders and elders speaking from personal experience or anecdotes. Diarre Ba used to make a living as a female circumciser.

DIARRE BA: I was part of this process. I felt bad. This is not right. But I didn’t know anything at the time. I had no learning.

DE SAM LAZARO: Others have painful, vivid memories. Ibrahim Sankare was very close to an older sister growing up. He walked into her room one evening.

IBRAHIM SANKARE: I saw her lying in a pool of blood. I thought someone had really hurt her. I screamed. My father explained to me. Since then, even now I get goosebumps thinking about it.

MARIAM BAMBA: It was very painful. I will never—you ask me if I can forget it? I will never forget the pain. So painful.

DE SAM LAZARO: Marieme Bamba is a long-time campaigner against genital cutting, and she’s spared her ten-year-old daughter the trauma. Yet before she became involved with Tostan and early in her marriage, she was determined to keep up the tradition. Even her own husband was opposed to genital cutting.

SULEYMAN TRAORE: She insisted that she had to do it. There were so many problems if you didn’t do it. If you cooked meals, no one would eat your food. It’s because we didn’t know. People told us that it was our religion. If you don’t do it, you’ll be going against your religion. All this is false. But I alone can’t do this in the village.

DE SAM LAZARO: They say Tostan was able to insure they were not alone—that communities in which they intermarried were also thinking alike, that their daughters would still be marriageable. The large declaration ceremonies have been critical.

MACKIE: One part of bringing about a change like this is to get everyone to change at once, what we call “coordinated abandonment.” Everyone has to see that everyone else sees that everyone is changing.

DE SAM LAZARO: Genital cutting is not the only tradition they want to change. Many communities have vowed to end the frequent practice of allowing older men to marry adolescent girls, acknowledging both the health risks and the girls’ human rights. Molly Melching says there’s plenty of historical precedent for abrupt changes in social norms and attitudes. She sees a very current example every time she comes home. That’s in American views about smoking.

MELCHING: People were smoking, and nobody said anything about it much through the ‘50s, the ‘60s, and even the ‘70s. As people became more and more aware of the harm that it causes, more and more people—there was a critical mass of people who started really protesting. It was amazing for me, coming from Senegal to the United States, to see how quickly things turned around.

DE SAM LAZARO: Tostan’s efforts have now expanded to 14 other African nations.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Kaolack, Senegal.

FRED DE SAM LAZARO, correspondent: The patients are often teenagers or barely in their twenties, yet several of them hobble in on walkers to physical therapy. These women suffer from fistulas, ruptures in vaginal, sometime even rectal tissue—a humiliating, even crippling consequence in most cases because of obstructed childbirth.

DR. CATHERINE HAMLIN: They’re leaking urine, and some of them are leaking bowel contents as well.

DE SAM LAZARO: Dr. Catherine Hamlin and her late husband, Reginald, came to Ethiopia in the 1960s as Christian missionaries and founded the Hamlin Fistula Hospital a few years later. A memorial to her husband invokes the Gospel of Matthew.

DR. HAMLIN: “Whatever you did for one of the least of these, my brothers, you did for me.” In the Bible it says my brothers, isn’t it? We say brothers and sisters.

DE SAM LAZARO: The least of the patients the young obstetricians saw were those with fistula. Amid a lot of suffering, Dr. Hamlin says the fistula patients were especially desperate.

DR. HAMLIN: She’s smelling. She’s poor. She’s got nothing, and she’s an outcast from her whole society, from everything that makes her happy. They lie in bed thinking if I keep really still, the urine will dry up. They curl up in bed. They become stiff. Their knees become contracted, their hips become contracted. They get nerve damage to their feet. The sciatic nerve is pressed on by the long labor, and they’ve got paralysis of the feet. They can’t bring the foot up.

DE SAM LAZARO: Fistulas were common across the world until the early 20th century, when prenatal care and modern systems of delivering health care, like cesarian sections, became available. Today fistulas are almost unheard of in richer countries, but two million women endure them in the developing world.

DR. YETNAYET ASFAW: For me as an Ethiopian, the fact that fistula is happening in the 21st century is not something that we are proud of.

DE SAM LAZARO: Dr. Yetnayet Asfaw works with a nongovernment aid group called Engender Health. She says the big issue is access to care in the vast, impoverished rural areas of this land of 82 million people plus myriad cultural practices.

DR. ASFAW: Eight-four percent live in the rural population, so the majority are rural women, and for rural women the issues are many. Women don’t have access to education. There are also several cultural issues, such as harmful traditional practices. Female genital mutilation is one, early marriage is another.

DE SAM LAZARO: Complications from the practice of cutting external female genitalia and other trauma, like rape, are thought to cause about 20 percent of fistulas. But the vast majority are a complication of obstructed labor, which results both in still birth and permanent injury to the young mother.

DR. HAMLIN: The pelvis of the woman is too small for the baby to come through, or the baby’s in a bad position inside the woman. So my husband used to say it’s either the passage or the passenger. The passage is the pelvis that it’s got to negotiate to get out, and the passenger is the baby, which if it’s not lying in the right position can cause the obstruction.

DE SAM LAZARO: Vaginal and rectal fistulas can be repaired surgically, and Dr. Hamlin, who is 87, still performs many of the procedures, like this woman’s case. We were asked not to use patient names.

DR. HAMLIN: Three days of labor, and then she had a stillborn baby, and then she was left with a vaginal fistula in her bladder. And it was quite—it was a reasonably difficult one.

DE SAM LAZARO: What’s the period of convalescence?

DR. HAMLIN: I think in about 10 or 12 days.

DE SAM LAZARO: She’s better off than most women here. Many have lived with their injuries for years, too late to be repaired even with surgery. Hospital services are free, but transportation is often unaffordable—if they can get a ride.

So how far away has this lady traveled to be here?

DR. HAMLIN: It’s about a four-hour drive.

DE SAM LAZARO: Four-hour drive, which for her would mean a bus ride, maybe?

HAMLIN: She would come in a bus, yes.

DE SAM LAZARO: Which sometimes is difficult for them, if they’re…

DR. HAMLIN: Yes, it is difficult, and sometimes the passengers say, “This woman’s smelling. Put her off. She’s got some disease,” and they’ll be thrown off the bus.

DE SAM LAZARO: To offer better access to its services, the Hamlin Hospital created five satellite facilities like this one in the rural countryside. They are funded entirely by donations from governments and private, often church-based donors. Still, only a third of the 10,000 Ethiopian women who develop fistulas every year receive any care for them. That’s why experts say it’s important to shift the focus from repairing fistulas to preventing them. Ethiopia’s minister of health, Dr. Tedros Ghebreyesus says a holistic approach is needed.

DR. TEDROS GHEBREYESUS (Ethiopian Minister of Health): We need to focus more on community-based interventions and on preventing the fistulas. The most important issues, it’s the education part, which will be very important, and also law enforcement, like age of marriage is very important. Girls’ education is very important, and we’re working on that.

DE SAM LAZARO: His ministry has won praise from public health experts for building a network of rural health centers in recent years, with a major focus on maternal and child health. But there’s still a huge shortage of skilled people to staff them.

Midwife students in class: Anterior, posterior ….

DE SAM LAZARO: A few years ago the Hamlin Hospital began a four-year midwifery program. These freshmen were studying plastic models of the female pelvis, learning how to detect abnormalities in the fetus position. So far two dozen graduates have gone on to staff regional health centers in rural areas—a small, promising start, says Dr. Hamlin.

DR. HAMLIN: We just have to keep the next generation of doctors and nurses inspired to help these women until it’s eradicated from the countryside, and it can be eradicated and it will be eradicated. In England, obstetric fistulas no longer occurred after 1920, so it’s not so very long ago that fistulas were occurring in England and in Europe.

DE SAM LAZARO: But Ethiopia, like so many developing countries, has a long way to go. Most Ethiopian women today still deliver their babies without the presence of a skilled birth attendant.

For Religion & Ethics NewsWeekly, his is Fred de Sam Lazaro in Addis Ababa, Ethiopia.

FRED DE SAM LAZARO: It was an unusual sight at Mass last Sunday [January 9] in the dusty regional capital of Bentiu. There were empty seats. But Father Samuel Akoch didn’t seem to mind, because this was an improbable historic day in Southern Sudan. Most of the absentees were around the corner, lining up for the chance to vote for secession, to create their own nation

REV. SAMUEL AKOCH (Saint Martin de Porres Catholic Church): I know that each of you came here to pray. I also know that each one of us is carrying our voting card in our pocket.

DE SAM LAZARO: And as the service concluded, it took on the fever of a campaign rally. Those voting cards came out and Father Samuel led a bee-line to the polling center, joining hundreds already there. Their ballot choice was as simple as the set-up of this polling center under a tree: Stay as one Sudan or separate into a new republic of South Sudan. That was the overwhelming favorite here. Father Samuel imagined that nation.

REV. AKOCH: People will be free to express their own religion, they will use their resources without anybody telling them no, so it is really great help for us to see this day. It was many people have died and they never saw this.

DE SAM LAZARO: The predominantly Christian and traditionalist black African Southern Sudan has seen almost nonstop war with the Arabic-speaking and Muslim North since the country’s independence from Britain in 1956. Two million people are thought to have died in recent years in the battered South, an impoverished land even though rich oil reserves were discovered here in the 1980s. A few feet under this fading sign is a pipeline that conveys crude oil from here in the South north to the port of Port Sudan. It’s a metaphor for the South’s complaint. The pipeline, like the oil wealth, they say, is invisible here in the South.

Oil added a new intensity to the conflict in the ‘90s, a period which also saw the rise of the Islamist regime of Omar al Bashir. He’s since been indicted by the International Criminal Court for his role in the Darfur conflict in Western Sudan. But it’s the enduring North-South war that got the attention of evangelical Protestants in America. They saw it as a religious conflict.

REBECCA HAMILTON (Journalist and Author): The evangelical community has been pivotal in the battle of Southern Sudan for its freedom, and they framed the war with the North as a battle for religious freedom, and in many ways that was true…

DE SAM LAZARO: Religious freedom for Christians.

HAMILTON: Religious freedom for Christians in the South. In many ways it was true, because the Northern government was trying to Islamize the South, but it was also a very useful framing of the conflict for getting the attention of key members of the United States Congress.

JOHN ASHWORTH (Catholic Relief Services): I think in the United States you had the coming together of the right-wing evangelicals, the [Congressional] Black Caucus, and the liberal human rights organizations. There’s probably no other situation in the world where those three groups would have common ground. But I think we also have to say that 9/11 played a role in bringing about the CPA [Comprehensive Peace Agreement]. On 9/11, the United States woke up to the reality that things happening in far-away countries had direct implications for the United States, and from that point we saw a much greater engagement with Sudan—Sudan, of course, having a history of being involved with so-called terrorist movements.

DE SAM LAZARO: Finally, in 2005 an American-brokered peace agreement was reached which called for this week’s referendum and also a sharing of oil revenues. At this church building—destroyed by fighting in the 1980s and now, ironically, a polling center—voters expressed hope that their sad history of slavery and exploitation would soon end.

KAFI ABUSALLAH: We have been mistreated by the Khartoum government, and we will show them that we want to stand firmly alone.

PETER PAL: The Northerners have made us their slaves for a long time, and we are ready to show them that we can lead ourselves. We are looking for good hospitals, good schools, good roads.

MARY DOAR: Our resources have never benefited us. Now we will get the benefit of our own resources.

DE SAM LAZARO: Managing voter expectations will be only one of several daunting tasks for the government of a new South Sudan. Keeping the peace is another immediate priority—not just with the North but within the South.

HAMILTON: South Sudan is itself a hugely divided community, and we haven’t seen for years because it’s been the greater enemy in the North, but I think once that enemy of the North is gone we will see all sorts of ethnic tensions rising inside the South.

DE SAM LAZARO: The Southern churches—Catholic, Presbyterian, Anglican, and others—have held ecumenical services for a peaceful referendum and will play a pivotal role in reconciling the South’s ethnic groups, whose rivalry stems mostly from land, water, and grazing rights for cattle. It’s a familiar role.

ASHWORTH: During the decades of war there was no infrastructure in the South except the church. There was no government, there were no NGOs, no UN, no civil society, and even the traditional leadership of chiefs and elders had been eroded by the coming of the young men with the guns. The church is the only institution which remained here with its infrastructure intact. It remained on the ground with the people. Now because of that we gained huge moral authority.

DE SAM LAZARO: Another key figure is former president Jimmy Carter. With Rosalynn Carter he’s been observing the polls and met with leaders from both North and South. On both sides the former president said he’d received assurances that religious minorities would be protected.

JIMMY CARTER: I met extensively with President Salva Kiir, and he assured me, first of all, that there would be absolutely no restraint on religious freedom in the South, that everybody, Islamic or Christian or Buddhist or whatever, would be free to worship as they chose. In the North, of course, they had had sharia law for many years, and there has been some accommodation for people of other faiths, Christians and others. President Bashir assured me this week that the same guarantees of the rights of other people to worship in different ways would be preserved, and they would not be harassed. He promised me personally that they would protect the churches and other things and protect the right of people to worship as they choose.

DE SAM LAZARO: There remain sensitive issues that could inflame tensions or worse: drawing borders, deciding on the rights of Southerners living in the North and vice versa, and a critical permanent oil-sharing revenue agreement still needs to be negotiated.

The new South Sudan, should that nation emerge, will be one of the poorest on earth. Paved roads, hospitals, and schools are virtually nonexistent, and the peace remains precarious. But all those worries have been cast aside by the euphoria of this moment—the chance, these people say, for the first time in their history for first-class citizenship.

For Religion & Ethics NewsWeekly, this is Fred de Sam Lazaro in Bentiu, Sudan.

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KIM LAWTON, correspondent: There’s been a lot of theorizing about the conflict between Islam and Christianity—what some have called a “clash of civilizations.” Journalist and poet Eliza Griswold wanted to learn about the conflict for herself up close and personal by talking to real people in the midst of it all.

ELIZA GRISWOLD: I wanted to go to where the world is really breaking apart. I wanted to go see what happens when these two religions meet on the ground in villages, mega-slums, floods, droughts. I really feel that I’ve seen that the world is breaking down on tribal lines, and the greatest of those tribes is religion.

LAWTON: Griswold spent the past seven years reporting from what she considers perhaps the biggest faith-based fault line in the world—the tenth parallel, the line of latitude 700 miles north of the equator in Africa and Asia.

GRISWOLD: These are very contested spaces traditionally, and religion has become grafted onto what makes them so contested today.

LAWTON: The area includes Nigeria, Sudan, Somalia, Indonesia, Malaysia and the Philippines—all places of bloody battles between Muslims and Christians. Griswold says geography, climate, wind patterns and human migration have led to clear lines of demarcation.

GRISWOLD: When we think of Islam we think of a billion people around the world. We don’t usually think that four out of five of those people live outside of the Middle East. They’re not Arabs. They live in Africa, and they live in Asia, and then you have about half of the world’s two billion Christians who also live in what we call these days the Global South.

LAWTON: Along the tenth parallel, both Christianity and Islam have been experiencing an explosive growth in numbers and religious fervor. Griswold wanted to examine whether fundamentalism necessarily leads to violence.

GRISWOLD: The belief that there is one and only one way to find God, and the understanding that that leads immediately to an enemy, because everybody else is wrong. That kind of binary division between us and them, the saved and the damned, I wondered if that was inherently violent because you were setting yourself against another person.

LAWTON: Griswold’s explorations were deeply influenced by her personal background. Her father, Frank Griswold, is an Episcopal bishop who from 1998 until 2006 was the top leader, the presiding bishop, of the US Episcopal Church.

GRISWOLD: I grew up with a lot of fear about what God’s will would mean. You know, after being a 12-year-old and watching my dad be consecrated as a bishop in the Episcopal Church, which involved lying face down on a cathedral floor with his arms out in a crucifix shape. That terrified me. If I submitted to God’s will, what would God ask me to do?

LAWTON: Griswold says her family encouraged wrestling over questions of faith and intellect.

GRISWOLD: How does the mind work in relation to God? How do all kinds of people believe in God? And how does intelligence apply to that? That notion very much is at the center of what sent me looking along the tenth parallel. So is the idea that people can believe in God absolutely without necessarily being dangerous or without necessarily there being a way to explain their faith away.

LAWTON: Her journey began in 2003 in Sudan, where nearly two million people had been killed in a civil war between the predominantly Muslim North and the predominantly Christian South. Two years before the war ended, Griswold traveled there to observe a meeting between evangelist Franklin Graham and Sudanese President Omar al-Bashir. She says Bashir was afraid the US would invade Sudan, while Graham wanted permission to do evangelism in the northern part of the country.

GRISWOLD: The trip itself was fascinating to me, because it was what happens when faith and foreign policy become interlinked. And it’s something we’d heard a lot about, certainly during the Bush administration, but both before, because this is a history that dates back to colonialism, and also still today there’s quite a strong religious lobby that works strongly in our foreign policy that we don’t always see.

LAWTON: You talk in your book about many people saying to you this isn’t really a conflict about religion; it’s a conflict about oil, or water, or politics, resources. How much is religion truly a factor in some of these conflicts?

GRISWOLD: It’s almost an impossible question to answer because I have found that each conflict is different. I never saw a conflict that we would see as religious that didn’t have some kind of secular or worldly trigger—whether that’s land, oil, water, even chocolate crops in Indonesia. Now does that mean that religion doesn’t come to bear on these conflicts? It’s more complicated than that.

LAWTON: Adding to the complexity, she says, are clashes within the religions.

GRISWOLD (speaking at bookstore): There is a very profound religious clash that we’re missing. It is not the clash between Christianity and Islam. It is the clash inside of religions. It is the question between Christians over who has the right to speak for God. Those same questions are going on inside Islam today, and yet we don’t hear very much about it.

LAWTON: Griswold saw religion being used to fuel violence, but she also saw it used as a force for reconciliation.

GRISWOLD: One of those places is in northern Nigeria, this town of Kaduna, where a pastor and an imam worked together to really transform one of the most violent fault lines along the tenth parallel into one of the most peaceful ones. How did they do that? Community building.

LAWTON: She says the pastor reminded her that events in the US and other parts of the West can have repercussions around the world.

GRISWOLD: He me told me this quote that I just find so relevant now, which is when the West sneezes Africa and Asia catch the cold. So what does that mean, really? Well, that means quite viscerally, for example, with the cartoon riots, the Danish cartoon riots several years ago, more people died in Nigeria than any other country around the world.

LAWTON: After seven years of talking to people on the front lines, Griswold says she didn’t discover any easy answers about the volatile mix of religion, politics, and violence.

GRISWOLD: What I probably took away is certainly empathy, but also—it’s a hard word to use because it comes with so much baggage—but a lot of humility, I guess. Because I didn’t feel myself in a place to intellectually judge people’s lives, although I began thinking—I didn’t even question that I would be able to sort of assess what people were up to by assessing their sociology, and in truth I couldn’t.

LAWTON: But she did come to see, as she writes in her book, that “religions, like the weather, link us to one another, whether we like it or not.”

I’m Kim Lawton in Washington.