Elsevier

Burns

Volume 40, Issue 8, December 2014, Pages 1799-1804
Burns

Acid violence in Cambodia: The human, medical and surgical implications

https://doi.org/10.1016/j.burns.2014.04.012Get rights and content

Abstract

Introduction

Acid violence is the deliberate use of acid to attack another human being. Such attacks leave a terrible human, medical and surgical legacy. This study, from one of the largest cohorts of acid attack victims to date, provides insights into Cambodia's unique demographics of such attacks, as well as the human cost and necessary surgical interventions.

Methods

A retrospective cohort consisting of all patients presenting to the Children's Surgical Centre, Phnom Penh with acid burns from 1 January 2000 to 1 January 2013 was identified and information retrieved from their hospital records.

Results

254 patients were identified. Males and females were almost equally likely to be victims of an acid attack (48.4% and 51.6% respectively). There was no significant association between victim and assailant gender (p = 0.475). The face (78.0%), neck (51.5%) and chest (49.0%) were the most frequently affected body areas. The median total surface body area affected by acid burns was 7.0%. The mortality rate from acid assault was 2.0%. Patients required an average of 2.0 operations, ranging from 0 to 18.

Conclusions

Acid violence in Cambodia has a complex demographic which is different to many other developing countries and requires more investigation. Tougher legislation is required to reduce the incidence of these horrific crimes.

Introduction

Acid violence, or an acid attack, is defined as “the deliberate use of acid to attack another human being.” [1] The face is the most frequently targeted area in chemical assault [2], with the intention to maim and disfigure. The physical effects of such chemical burns are devastating, with blindness due to corneal perforation [3], nasal deformity, microstomia, and debilitating contractures amongst the complications documented [4]. In addition, the long term social and psychological impact for sufferers is huge, with impaired ability to find employment, social isolation and depression all common in the aftermath of an attack [5].

The worldwide epidemiology of acid attacks has been well delineated, with greater incidences reported in the developing than in the developed world [6], [7]. For example, the percentage of chemical burns caused by assault in a study from London, UK was 8% [8], contrasted with 83% in a Cambodian study [9] and 92% in Bangladesh [10]. Broadly speaking, there appears to be two epidemiological categories of acid assault in the developing world. In countries such as Bangladesh, India and Colombia, females are almost exclusively the victims of acid assault, and the motives are often to do with refusal of a lover or marriage proposal [11], [12], [13]. In other countries though, such as Uganda and Jamaica, the most common motivation for acid assault is as part of a robbery, and males are more likely to be victims than females [14], [15].

As if the tragic human cost of these assaults was not enough, given the constraints on healthcare resources in developing nations, the surgical, medical and economic burden is considerable. To date, however, most studies of acid attacks have focussed on demographics of victims and assailants, motives, and location and extent of burns [8], [9], [10]. Reporting of necessary interventions is sparse.

In the current study from within Cambodia, we present the findings from one of the largest cohorts of acid attack victims to date. We document the demographics, clinical features, and surgical interventions neccessitated by acid assaults. In so doing, we give not only another poignant reminder of how personally devastating and disfiguring these attacks are, but also a unique insight how acid attacks in Cambodia differ from other developing nations.

Section snippets

Methods

A retrospective review was carried out of all patients’ charts presenting to the Children's Surgical Centre (CSC), Phnom Penh, with acid burns between 1 January 2000 and 1 January 2013. CSC works closely with the Cambodian Acid Survivors Charity (CASC), and many patients are referred for treatment by this charity. Data on demographics, clinical features, surgical burden and complications were collected.

Study population and timeframe

In total, 254 acid burn patients were identified as presenting to CSC between 1 January 2000 and 1 January 2013, with the actual incidents occurring between 1964 and 2012. In six cases no information about the date of the acid burn was available. In 14 cases only demographic data was available. Fifty patients presented to CSC with incidents that had actually occurred between 1964 and 2000 (20.2% of the total). Between 2000 and 2012 there were 198 reported incidents (79.8%). The number of

Discussion

There are no comprehensive statistics for the overall incidence of burns in Cambodia and limited evidence on acid violence within the country. However, as a nation with an under resourced healthcare system, the management of acid violence and its complications remains a significant challenge. This study, although limited from a single centre, represents one of the largest series of acid violence reported to date. It is hard to draw definitive conclusions about the precise nationwide incidence

Conclusions/outstanding questions

The present study demonstrates that, in Cambodia, acid attacks continue to not only destroy and disfigure at the individual level, with debilitating physical complications, but likely consume precious healthcare resources in a country with a developing healthcare system. A study which could produce an economic costing model for acid burn care would be useful in being able to quantify the surgical and medical cost. The evidence presented here provides impetus to the recommendations made by CASC

Conflict of interest

The authors all declare they have no conflict of interest in regard to this manuscript.

Acknowledgements

The first author was only able to travel to Cambodia thanks to a donation from The Hospital Saturday Fund. The Hospital Saturday Fund was not in any way involved in the study design, data collection, data analysis, or preparation of this manuscript.

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    In several cases, the eyes and mouth of the victims melted away or had to be opened by skin contractures. Various researchers have highlighted the horrendous physical impact of acid on the victims where acid has been found to cause pulmonary disorders, vomiting of blood, swelling in the throat (McBroom & Wilson, 2014), and damage to organs (Waldron et al., 2014). However, very few researchers have explored the psychological impact resulting from acid attacks.

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