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14 May 2011

Acid Violence (Cambodia)

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

As a physician, 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 had set up a simple operative and treatment clinic on the outskirts of Phnom Penh.

My First Case of Acid Violence.

My first experience with this heinous manifestation of acid violane remains seared in my memory. I came in in the morning and she was there in the waiting area, brought in by a friend. She sat there on the hard wooden bench. I took her hand. She could not cry, she had no tear ducts since the skin fused tightly over where here eyes may or may not lie underneath. She just gazed forward; her skin mottled leather membrane, shrink-wrapped; her face no longer with any elasticity or ability to display any expression. Her name is Vanna.

Vanna had been beautiful, and for many poor, oppressed Cambodian women it is their only possession of value. Before becoming a victim, she had a low paying job in a restaurant. She had a boyfriend. The story goes: One day Vanna refused the advances of a much older man, a government official of some importance. Later that evening two men were waiting for her. They held her down and slowly poured the acid on her beautiful face. And then they continued to hold her while it did its work.

That’s the thing. Simply throwing acid in someone’s face might give the person time to rush to water and prevent much of the damage. But when the victim is held, the acid will continue working. It can be poured onto specific areas; the eyes, the genitals, the breasts and there are cases where large quantities, like a bucket-full, of acid is simply flung at the victim. 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, irreversibly damaging her eyes.

It is hard even now, even as a physician who has seen many physical horrors in a lifetime to think back on Vanna’s face and body. It was as though the world had brought out a being so alien, so mutated that no one would ever recognize it.

What We Know About the Problem

Now, some 12 years later I have seen so many victims of acid burn attacks at our Rose Charities Surgery and Sight  Centers. Although statistics are scanty and subject to the inaccuracies of translation  it would seem that around 50% of attacks are the consequence of real or perceived extramarital affairs or other aspects of life leading to seeking of revenge. This is an extreme and tragic consequence of men seeking to control women. But attacks in Cambodia are not restricted to women. Some 15 - 20% of attacks are of men on men, or women (with or without the assistance of a male collaborator).And there are more victims. An additional 15% are secondary victims, usually a child, who have gotten in the way of thrown acid. The rest, not the result of gender-based violence but rather arise from civil disputes, such as over land and other property. Cambodia’s history of conflict and succession of imposed governments has ensured an enormous uncertainty in land ownership, resulting in claims and counter claims.

Historical Influence

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, before eventually succumbing to one of the most genocidal regimes of human history, that of the Khmer Rouge. In this period, some 2 million 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 can be discussed in three broad categories; primary, secondary, and tertiary. There is ‘primary’ injury that is mostly associated with wars; bullet wounds, blast injuries, etc. Then there is ‘secondary’ victimization, which is the disease or untreated trauma caused by the conflict and the induced breakdown of infrastructure. Third, there is the ‘tertiary’ category, perhaps the most pernicious, the most long-term, and an injury of the mind where the control of others is linked with violence, fear, and terror. While sadly, as we know from global prevalence data,  control and abuse of the vulnerable  is not only restricted to post-conflict scenarios, however, it may well be one reason why it remains rife in Cambodia.

The throwing of acid is particularly linked with the second and third categories above. A very weak and allegedly corrupt legal and law enforcement system means that the control by physical abuse is rarely punished, or prevented. The direct injuries 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.

Long-term Consequences and How Rose Charities is Helping

Rose Charities 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, from a few superficial injuries covering one or two isolated areas to up to 60% or more of the body covered with deep penetration, even down to bone. The 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, and breakup of families, marriages and relationships. Full time care is often needed and in a country such as Cambodia, this care is not provided in any way by the state. If the victims have 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, her physical beauty, which in many societies is the only way for a woman to advance. So the damage is also both psychological and social.

Dr Nous Sarom of the Cambodia Surgical Center (Operation First & Rose Charities) is now one of Cambodia's leading rehab surgeons having had years of experience working in the area both on his own and with various generous international organizations and specialists who have come to assist.  Donations and gifts of equipment and transfer of expertise have improved treatment ability but there is still a long way to go.  Rose Charities employs many treatment specialties in its arsenal, from direct eye and body surgery through physio and other therapies to give a 'holistic' approach to each case.  Where possible specialized education and vocational training may also be provided.  Counseling is always needed, though sadly can be hard to find.

The injuries are often so severe that complete recovery is impossible, even with the most sophisticated methods of treatment. Thus the aim is rather to alleviate as much of the trauma as possible both mentally and physically and then lead on to try to help the victim return to life with quality.

Male acid victim
William Grut, MD, Rose Charities

(Revision and update of an original article written 2008)

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