RoseCharities Surgery

Rose Charities Rehabilitation Surgery - the '2TS' Principle Since 1997, Rose Charities has been promoting rehabiliation surgery in Cambodia and as a model for developing countries in general. This is a brief synopsis of the founding principles put into the Rose Charities Cambodian projects at that time by Will Grut. The Kien Khleang Center was identified at that time as being a suitable location for the project and Grut successfully obtained permission from the Ministry of Social action to open the Rose Charities Rehab Surgery center there. In 2002 after a horrendous robbery, looting and vandalization, the non ophthalmolgical part of the project was tranferred to Chea Chumneas Hospital and Operation FIRST established with Dr Nous Sarom to run it. This change has been most appropriate as the Kien Khleang Center, not being a proper hospital does not have proper facilities for responsible surgical procedures other than eye surgery (local anaesthetic, no risk of transfusion being necessary) and is not run by the Cambodian Ministry of Health. The following was written in 1997, but applies as much today as it did then in many countries in the developing world as well as to Cambodia

Rose Charities work with victims of land-mine and conflict injury, acid burns, cleft lip and palate, and other surgically treatable conditions ( meningoencephalocel , club foot, slow tumors , congenital malformations and many others ) is now well known all over Cambodia. Dr Nous Sarom , Operation FIRST with RoseCharities have been pivotal in this work and continue today increasing operation spectrum in areas such as micro-surgery , orthopedics, ear surgey etc, as well as training new surgeons, nursing and physical therapy staff . FIRST-Rose has an open door policy, welcoming bona fide students, residents, and other groups, local and international who genuinely and honestly wish to help the people and health system in Cambodia.



Conflict injury

Based in 1992 in Phnom Srouch, a heavily landmined and conflict infected area of Cambodia, Dr.William Grut observed that conflict health problems fell into one or more of three categories

Primary conflict injury / disability : Injury resulting directly from the conflict. Amputees, other land mine injuries, bullet wounds etc.

Secondary conflict injury / disability: Injury, as a result of the disruption of infrastructure of the county. Thus, elimination or serious reduction in health services, and / or access to those services or clinics. Lack of education. Lack of vaccination programs. Lack of health surveillance. Dangerous transport methods over destroyed roads, bridges etc. Polio, post meningitis, cerebral malaria handicaps, effects of measles, shistosomiasis etc.

Tertiary conflict injury / disability. Injury / disability caused by the 'physical conflict mindset' which sees the solution to any problem as being the use of physical violence. Thus, deliberately inflicted acid burns, beatings and other physical cruelty. Forceful control, rape etc. Tertiary conflict problems can be very much accentuated by secondary conflict effects such as the lack of a fair and functioning judicial system and / or corruption in the law enforcement services.


The Rose Charities '2TS' rehabilitation surgery concept

The focus of the Rose rehab surgery model is aimed entirely at two aspects . .. 1) an improvement in quality of life for the sufferer of the disability.... and..... 2) the ability of the country or region to sustain facilities which will lead to such improvements for future suffers.

This is achieved by the paradigm called by Rose '2TS' which stands for ... 'Treatment sustainability & Training Support' ..... and in its most basic form it is this which was defined as the basis of the Rose model based on the following observations, practical experience, and summation, below...


Treatment sustainablity

To be sustainable, health services in any country must be at a cost consistent with what a country can afford and give maximum benefit for the money spent. Since the 1970s the formula to achieve this has focused more on 'Primary Health Care (PHC), elements of vaccinations, mother and child health, sanitation, clean water, education and basic treatment of the most prevalent diseases in the community. PHC continues to give enormous benefits to the health of populations when administered properly. It thus must always be in the front line of the health improvement processes in developing countries.

Due perhaps to the success of PHC however there has sometimes been a tendency to see it as the only health process which can be sustainably implemented at acceptable cost. Surgery, on the other hand is seen as expensive, non cost effective, far to complex and sophisticated and needing inappropriately large resources to sustain a trained level of human resources.

The 'Rose model' however shows both theoretically and (by the work of Rose Charities , www.RoseCharities.org ) and in practice, that surgery too can be cheap, effective in the improvement of quality of life, sustainable, safe and highly desirable.

The Rose model is based on the observations..

Rehab surgical procedures, carried out properly in developing countries by locally trained surgeons can have costs per procedure well equivalent or less than the cost of many of the longer term drug treatments (i.e. for TB, Leprosy etc. etc). Thus a cataract operation which will restore sight to a blind person can cost as little as USD 17 (Rose Charities Cambodia figures for 2005), or a cleft lip or palate, land mine amputation etc, USD 30 - 50)

Rehab surgical procedures often have an enormous benefit, not only for the sufferer of the disability but also for her / his family, village, community. A child who has had a cleft lip or palate repaired is no longer considered 'an idiot'; he/she can go to school, get married, be employed etc. Rehab surgery thus can significantly increase the D.A.L.Y. (Disability adjusted life years ) of an individual, community or even, with nation programs, the whole country.

Populations WANT rehab. surgery. People, wherever they are, want to be cured of or at least helped with their disabilities. If you ask a group of villagers in almost any community whether they would like a clean well, instead of the old muddy stream that they and their animals may be drinking from OR sigh restored to their parents, or their children's cleft lips repaired, or their men to get proper surgical assistance to get a an artificial limb, they will invariably choose the latter. This is not an incitement on PHC, simply a statement of the fact that it is the quality of life perceived by the community itself which should be taken into primary consideration and not just the perceptions of the planners. (who, far more often than not, are not those who live in the villages where the assistance is being made.


Training support.

Support for training - the implementation of cost effective training programs is the crucial element in ensuring treatment sustainablity above. Dr. Grut realized that appropriate training programs....

Need not be expensive. They can be implmentable with the assistance of relatively small international funding agencies and/or national resources. Resources for training can be left within the country in the form of upgrades to existing facilities and or equipment donations

Already have the the basic human resources in place i.e. already qualified physicians, anaesthetic nurses, even nurse-practitioners in outlying areas already in place and interacting with the population in need.

Can be implemented by volunteers from the industrialized or other countries by multiple short term voluntary visits. This has the multiple effects of giving the international trainer a fascinating and enormously appreciated new facet to her / his vocation, making new friendships, linking the trainees into an international network, as well as the main goal of improving health care in the developing country.

Can be linked into a region or nation wide network

Have a multiplying effect, in that once trained, the recipients of training can go out and train others...

Can be linked and integrated with PHC individual or team training to provide the most comprehensive health care 'package' for the country.

NEW ROSECHARITIES NEWS BLOG. RoseCharities News blog is shifting to ...
www.RoseCharitiesNews.blogspot.com .
This blog-site will remain though for general comment, words, thoughts, ideas, non-urgent updates etc, ie. here, on www.RoseCharities.blogspot.com

Acid Violence in Cambodia

Sunday, June 22, 2008

Acid Violence in Cambodia

"Acid violence defies any bounds of comprehension. It is a violation born and nurtured in hell itself, pitiless, hideous evil. It takes away both skin and flesh and the very soul of the victim. And it does so with a finality that is very often absolute.

I saw my first acid violence injury around 10 years ago. I had set up Rose Charities as an extension of my previous organization, Project Iris. Iris dealt with eye injury and sight restoration but so many injuries extended beyond the eye to the face and torso. Rose went beyond the eye to facial and other injuries. Word had gone around that there were ‘foreign doctors’ helping the injured and we had set up a simple operative and treatment clinic on the outskirts of Phnom Penh. I came in in the morning and she was there in the waiting area, led brought in by a friend.

It is hard even now, even as a physician who has seen many physical horrors in a lifetime horrors to think back on that face and body. It was as though the world had brought out a being so alien, so mutated that no other thing would ever recognize it. She just sat there on the hard wooden bench as I took her hand. She could not cry, she had no tear ducts the skin fused tightly over where here eyes may or may not lie underneath. She just sat gazing forward the mottled leather membrane, the shrink-wrapped skin of her face no longer with any elasticity or innervation to display any expression.

She had been beautiful, it was the only possession of value she owned. She had got low paid job in a restaurant. She had a boyfriend. One day it seems she refused the advances of a much older man, a government official of some importance. That evening two men were waiting. They held her down and slowly poured on the acid. And they continued to hold her while it did its work.

That’s the thing. . Simply throwing acid in someone’s face gives the person time to rush to water and prevent much of the damage. Acid will continue working and if the victim is held then it can be poured onto specific areas; the eyes, the genitals, the breasts. There are of course cases where acid is simply flung at the victim, often in a large quantity, like most of a bucket full. If the victim can then get to a source of water very quickly she can limit the amount of damage – though it may still be severe and have irreversibly damaged the eyes.

Now, some 10 years later I have seen victims of acid burn attacks at our Rose Charities Surgical Rehabilitation or Eye Centers. Although statistics are scanty and subject to the inaccuracies of translation (Khmer is a notoriously difficult language to translate into English with the same exact retention of meaning) it would seem that around 50% of attack causes are the consequences of real or perceived extramarital affairs and/or other aspects of life leading to the seeking of revenge, hate, or jealousy. A further 15% are ‘accidental’ in the sense that someone, most usually a child, has gotten in the way of thrown acid. The rest result from disputes such as over land. Cambodia’s history of conflict and successive imposed governments has ensured an enormous uncertainly in land ownership resulting in claims and counter claims.

Cambodia’s conflicts of the last 50 years have been extreme and brutal. Despite attempts to keep neutral, the country became heavily involved in the Vietnam war, its people first being hit by both sides, and before eventually succumbing to one of the most genocidal regimes of human history, that of the Khmer Rouges. In this period, some 2million persons were slaughtered, tortured, starved or worked to death. Women were forcibly married to strangers, forced to watch as their children were taken away or their babies bayoneted in front of them.

The injury and illness of conflict and post conflict zones lies in three broad categories. There is ‘primary’ conflict injury, that which is mostly associated with wars; bullet wounds, blast injuries etc. Then there is ‘secondary’ which is the disease or untreated trauma caused by the conflict induced breakdown of infrastructure and then there is perhaps the most pernicious, the most long term, the ‘tertiary’ injury of the mind where the control of others is linked with violence fear, terror. While sadly the control and abuse of women is not only restricted to post conflict scenarios it may well be one reason why it remains rife in Cambodia.

The throwing of acid is particularly linked with the third and second categories above. A very weak and corrupt legal and law enforcement system (category 2) means that the control by physical abuse (category 3) is rarely punished, or prevented. The direct injuries (category 1) can be inflicted with almost no fear of being apprehended by the legal authorities, and in the event that this does occur, it is easy to buy immunity with an appropriate payment to the right person.

Rose Charities, a partner organization of ‘One in Three Women’ has been dealing with the results of violence against women in Cambodia since 1998. Over this time the range of acid injury has been very wide indeed, ranging from a few superficial covering one or two isolated areas to 60% or more body coverage with deep penetration down to (and even affecting) bone. Scalp eyes, ears and nose may be partially or entirely burned away.

Acid burns create a spectrum of disabilities for the survivor ranging far beyond the terrible disfigurement and physical disability. Livelihoods are ruined; there is social stigmatization, breakup of families, marriages and relationships. Full time care is often needed and this, in a country such as Cambodia is not provided in any way by the state. If the victim has no family or friends to look after them then they will be utterly outcast. So often the attack takes from the victim the only real asset owned in a quagmire of poverty, physical beauty, which in many societies is the only way for a woman to advance. So the damage is also both psychological and social.

Medically and surgically help may be limited. Rose Charities has two operative surgical / medical facilities in the Phnom Penh area to try to assist the victims. One deals specifically in eye care and the other with general rehabilitative surgery. Both facilities are directed by experienced Cambodian surgeons. One of these, Dr Nous Sarom is probably Cambodia’s most experienced maxillofacial surgeon and has trained extensively both with Rose Charities and previously with other organizations including Doctors without Borders. Acid contact with the skin can have an effect akin to ‘melting’. Thus adjacent areas, such as a limb with the trunk, the space between fingers can end up being fused together. There is also a shrinking effect so that the joints can be pulled into horrific distortions. Simple surgery can usually manage to release these adhesions and contractures. but more complex injuries to areas such as ears, eyes, nose or lips ideally need specialized reconstructive surgery, usually beyond the scope of the facilities available in Cambodia. Eyelids are a particular problem. Even if the eyeball itself is spared, a functioning lid is necessary to keep the surface of the eye lubricated: otherwise it will dry out, ulcerate and eye will be destroyed. Often, in the absence of the sophisticated facitlies needed, the most appropriate action is simply to suture up the remaining lids themselves, thus protecting the eye below for some unspecified time in the future when it may be exposed again.

Physiotherapy, preferably with specialized burns therapists are hugely important, but again such personnel are limited and the specialized training is lacking in Cambodia. What is then needed are the facilities for the lengthy rehabilitation process, vocational training, reintegration etc.

Over the years, Rose Charities has done what it can on its budget to improve the situation through training of surgeons, the encouraging of specialized teams to visit Cambodia and occasionally managing to send a particularly bad case for overseas treatment. Such operations however are fund limited, but the work continues.

Cambodia is a small country with a population of warm, artistic people who have a long cultural heritage leading back to roots in the great empires of South Asia. Cambodian lives are full of tradition, ceremony and colour. People smile a lot. I think back to those smiles and my heart goes out again to those who cannot smile. The world can be harsh and cruel, but surely little surpasses the cruelty of the acid attack.

William Grut MD
www.RoseCharities.org

Rose Charities was one of the first organizations to identify and target acid violence in Cambodia. Its treatment center has now been operating since 1998. It has been assisted by several specialist overseas groups who generously provide expertise and resources to help Rose Charities Surgeons deal with the problem

One such wonderful initiative has been that of the Virtue Foundation of New York

"..Led by Dr. Ebby Elahi, an oculoplastic and reconstructive surgeon, Virtue Foundation deployed a team of physicians to Phnom Penh, Cambodia in November 2004 to teach and perform plastic and reconstructive surgery at the Rose Charities Clinic, where many of the patients bear the gut-wrenching scars of callous acid attacks.
Deeply moved by the plight of a young Cambodian mother by the name of Yem and her infant daughter Sophan, who were both burned and disfigured by an acid attack that occurred while the baby was breastfeeding, Dr. Elahi arranged through the Virtue Foundation for mother and baby to travel to the United States in an attempt to prevent their blindness and to alleviate their deformities at the Mount Sinai Medical Center.
The entire cost of the patients’ treatment was donated by the Mount Sinai Medical Center and a team of highly specialized volunteer surgeons, including Dr. Ebby Elahi, Dr. Lester Silver, Dr. Penny Asbell, Dr. Michael Shohet, and Dr. Steven Rosenberg. Multiple surgical procedures on mother and child were followed by three months of intensive rehabilitation and follow-up care.
In January 2006, Dr. Elahi returned to Cambodia with a small team for another round of treatment to acid attack victims and patients in need of critical surgical care. During his visit, Dr. Elahi was heartened to once again see and provide follow-up care to both Yem and Sophan, whose surgeries in the U.S. last year had turned out to be highly successful, with the baby's vision now fully restored. Virtue Foundation hopes to deploy additional teams of physicians to Cambodia to continue the vital tasks of raising awareness of acid violence and training local physicians in surgical and reconstructive procedures."

Donations for any of these works are very gratefully accepted

www.RoseCharities.org

27 June 2008.

Happy Birthday Nelson Mandela from all at RoseCharities. You are an inspiration to us all, and to the whole world !

With appreciation and best wishes
The Rose Charities Volunteers

Pipe Line to Burma. A Musical Fundraiser for the Victims of the Myanmar / Burma Cyclone. Proceeds go to local organizations assisting in the relief work including RoseCharities Organized by Len Walker and 'Tsunami Haven' . Saturday 21st June. Nanaimo. See www.RoseCharities.ca for link to more information. Pipeline to Burma. Donations via www.TsunamiHaven.org or www.CanadaHelps.org (and look under Rose Charities)