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JSM Burns and Trauma

Cite this article: Bhate-Deosthali P (2018) Implications of Poor Clinical and Forensic Burns Care on Burn Outcomes and Access to Justice: Study of hospitals in Mumbai. JSM Burns Trauma 3(2): 1041.

*Corresponding authorPadma Bhate-Deosthali, Independent Researcher, Former Coordinator -CEHAT, India, Email: padma.

Submitted: 11 July 2018

Accepted: 08 August 2018

Published: 10 August 2018

ISSN: 2475-9406

Copyright© 2018 Bhate-Deosthali

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Keywords•Burns•Injuries•Hospitals•Clinical

Review Article

Implications of Poor Clinical and Forensic Burns Care on Burn Outcomes and Access to Justice: Study of hospitals in MumbaiPadma Bhate-Deosthali*Independent Researcher, Former Coordinator-CEHAT, India

Abstract

This paper unravels the circumstances surrounding the incident of burns, the reporting of cause of burns, the pathway to care, the response of health system and the role of the family in care and recovery. By using gender analysis and a gender sensitive public health approach the study uncovers critical gaps in information gathering at a hospital setting, lack of will to enquire into the manner of burns and poor treatment and care compounding the matter. Most importantly the links between burns injuries and experience of domestic violence are established through this work. But the health system has no mechanism for documenting experiences of domestic violence. Most often than not, domestic violence is considered as a personal issue that no one wants to address. It makes important contribution through informing the Haddon Matrix used for Burns Prevention (WHO, 2011) by deconstructing ‘kitchen accident’ and uncovering the socio cultural factors contributing to the incidence. The findings underscore the need to focus on socio-cultural problems versus non-human agents/hazards thus making a critical contribution to the field of burns prevention. It provides an evidence base for developing a gender sensitive public health approach to preventing burns by focusing on changing gender norms, recognizing and detecting domestic violence cases within health settings, providing intervention services for survivors of domestic violence and improving the medico legal and clinical response to burns.

INTRODUCTIONBurns is reportedly the third cause of death for women aged

15–44 years in Southeast Asia, followed by self-inflicted injuries [1]. Burns is a major challenge causing deaths, disability, and disfigurement. Globally, there are about 300,000 deaths due to burns every year (WHO, 2008). Of these, 95% take place in developing countries with South East Asia recording nearly 57% of these deaths. Extrapolation of data from major hospitals in India indicates an estimation of 7 million burn incidents and 140000 burn deaths every year, making burn injuries the second largest group of injuries after road accidents [2]. Of the 140000 burn deaths per year in India, 91000 are women which are much higher than the number of maternal deaths [3]. Sanghavi et al., estimated 163,000 fire related deaths in India based on medically certified causes of death in urban areas and a verbal autopsy based sample survey for rural populations for the year 2001 [4]. Of these fire related deaths, 65% were female deaths, with 57% of these female deaths occurring in women between 15-34 years. Incidentally, for the age group 15-34 years, 15% of all deaths were found to be fire related. Women were on average three times more likely to die of fire related injuries than men.

There is, however, no data available to make a definitive conclusion on causes. There is some evidence that suggests that

domestic violence could have an important role. There is sufficient evidence from India that domestic violence is widespread.

The health systems response to burns injuries is crucial in terms of preventing death, reducing morbidity, assisting access to justice through its medico-legal documentation and rehabilitation. The burns outcomes in India are very poor for all burn patients, especially for women. It is reported that there is a remarkable difference in burn outcomes in low middle and income countries and high income countries. In Australia, even those with more than 80% burns survive whereas in Nepal even 40% burns may not survive. The type of burn care that is routinely available in high-income countries is currently beyond the reach of those in the LMIC. What this means is that someone with moderate burns would most probably die in a LMIC but will be saved in HIC and someone with even low degree burns in LMIC is more likely to suffer significant disability due to limited availability of rehabilitation and care including reconstructive surgery [5,6].

The medico-legal response to deaths caused by burns is well entrenched in the existing criminal justice system in India. The existing laws make investigation mandatory for all unnatural deaths of married women within seven years of marriage. Doctors play an important role in the recording of dying declarations, determining whether injuries were ante-

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mortem (preceding death) or post-mortem, whether the deaths were homicidal, suicidal or accidental and whether they were self-inflicted. As observed in the literature based on hospitals records, most cases are recorded as ‘accidental burns’ as this is what women and their families report. Certain patterns in these histories, such as reporting a ‘stove burst’ when most households use LPG (Liquefied petroleum gas) for cooking, reported time of stove burst at unusual hours at night, manner of burns akin to burns when kerosene is poured on the body vs a stove burst, and discrepancy between history given by the patient and the patterns of burns, point towards the need for further investigation. However, health professionals often fail to document such details, or ask about domestic violence and limit their role to treating physical signs and symptoms. There is an overwhelming association of this injury/death with one gender, namely women. The paper is based on doctoral work carried out in Mumbai, India and focuses on the issues emerging in the study of clinical and forensic response of hospitals to women reporting with burn injuries.

METHODOLOGYUsing a qualitative research design, the study took a public

health approach to uncover the social dimensions of occurrence of burns among young women, the modes of information gathering in the hospital setting, means of enquiry to identify the causes of burning and the circumstances preceding the episode of burning on the one hand, and current management of such cases. The issue has been neglected both by the medical as well as social sciences and therefore using qualitative research tools to uncover the phenomenon from the perspective of health care providers and the survivors/victims was found apt. The study was conducted in two public hospitals and one private hospital. The objectives of the study were as follows:

• To review the response of hospital providers to the burns injuries including review of existing protocols and documentation in cases of burns

• To understand burns survivors/families perspectives on their experience with hospitals Twenty six interviews with health providers in burns care across the three hospitals under study were conducted; they included medical officers, surgeons, resident doctors, and nurses, labour staff (wardboys and ayahbais). Survivors/victims were approached and twenty two of them agreed to participate and eight key informants included experts from the fields of forensic medicine, burns surgery, and law, and women activists.

1RESULTS

Association of burn injuries with domestic violence

18 of 20 married women reported that they experienced domestic violence of various forms- physical, emotional and financial. Of these 18 women suffering domestic violence, 11 women reported suicidal burns and 3 reported homicidal burns. 1 The Haddon Matrix is used as a tool in Injury Research to understand the risk factors associated with various injuries and has been found effective in reducing road traffic accidents and other injuries. The framework for this research was in-formed by this matrix and specific questions were included in order to understand what happens pre event, event and post event.

Of those who reported suicidal burns, 5 recorded the intent as suicide in medical and police statements but 6 recorded this as an accident. In the homicidal burns, all three recorded intent as accidents. None of the women had been asked about the experience of domestic violence by the hospital or police. But all of them spoke without much hesitation about their lives after marriage, how they have been tolerating the abuse and accepting it as their fate. Most of them were living in nuclear families and so the abuser was their husband.

Four women maintained that the incident was an accident. Their narratives raise several concerns about whether this was a genuine accident. The other important concern that arises is about the impact of experiencing domestic violence, living under immense stress and whether or not that could make them vulnerable to such ‘lapses’ or lack of safety measures. Three of them were currently married and one had been deserted by her husband. He was currently living with another woman. They spoke freely about emotional abuse from mother in law (MIL), physical and economical violence by husband, and neglect by natal family. They also reported feeling tensed, anxious, loss of appetite amongst physical and mental health consequences. They had suffered 40-50% burns but all had survived.

18 of the 22 women interviewed were experiencing domestic violence thus indicating the widespread occurrence of domestic violence (DV) and its linkages to burns injuries. Women reported domestic violence in all its forms physical, emotional, sexual and financial. Experiencing domestic violence was one the most significant risk factors to suffering burn injuries contrary to the reported stove and/or cylinder blasts or the perception of saris and dupattas that are likely to cause burn injuries. Women are conditioned not to speak about domestic violence to preserve the honor of the home, caste, and community. The strong link between burn injuries in women and experience of domestic violence is established through the study.

Differing histories- busting the ‘kitchen accident’ myth

The manner of burns is an indicator to understand the cause of burns and is critical from the perspective of prevention and justice. The manner of burns is recorded in hospitals based on the history provided by the victim or relative. Based on the hospital records, 15 of the 22 women had recorded the cause of burns as an accident in the kitchen, six reported suicide and one reported homicide. These kitchen accidents were reported either as “stove burst” or “cylinder blast” or ‘clothes caught fire while cooking” on the medical reports. These reasons are identical to that mentioned in most of the medical literature on burns published by forensic scientists and surgeons.

However, as part of the research process, when the patients were asked to describe the incident in some detail in terms of who was at home, how the blast/burst occurred, who saved her, was anyone else injured, how was the fire doused which are essential elements from a public health as well as injury prevention perspective, women provided a different history about the manner of burns. These kitchen accidents were not accidents in most cases. Women also spoke about their tensions and worries and disclosed experiencing violence from their husband and/or

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marital family. The following table depicts the difference between what was stated in medical records and what the woman told the researcher as the manner of burns. The arrows indicate the shift in causative factors based on the interviews. What emerges from the narratives of women is the clear gap between what is reported and the facts. Eight women honestly told the researcher the reasons for not revealing the actual cause of burns at the admission to the doctor and police (Table 1).

What emerges from the narratives of women are the societal compulsions that made them record what was clearly the consequence of domestic violence as ‘accidents’. The looming fear of arrest of husband and fear of police investigation pushes the facts under cover and the story of ‘kitchen accidents” became the dominant narrative. Women said that they deliberately reported incidents of homicide and suicide as accidents as they did not want any police investigation lest their partners are arrested. Even those who reported suicide did not mention domestic violence to the hospital or police for the same reasons.

Belur et al., report based on a study conducted in Delhi and Mumbai that women state the cause of burns as kitchen accidents when they are brought to the hospital as their marital family usually accompanies them [7]. It is only after their natal family arrives that women gather up the courage, to tell the truth about the incident. Rao’s study found that in 29% of cases the cause of death was reported as the bursting of kerosene stove while there was not even a stove in the kitchen (1989). A CEHAT study in the state of Madhya Pradesh 2014 found the substantial difference (>60%) between the history provided by a burns patient to the

doctor (mostly accidents) and that given to a counselor. Women succumb to family pressure and their concern for their children prevents them from speaking out against the abuse faced by them. Most cases, therefore, remain ‘accidents’ only. There is evidence of women changing their statements from direct work with burns victims as well as research.

CLINICAL RESPONSE OF HOSPITALSThere were several issues plaguing the clinical response of

hospitals. The routinely available care is fraught with apathy, poor standards, and ill-informed practice of categorizing patients as “non-salvageable” /’non-survivable”, thus leaving them to die. Such a practice is not just unethical but gross violation of the right to treatment for women suffering moderate and severe burns.

A senior burns surgeon called out this practice as inhuman and said “Who are we to decide this?” Once a patient is categorized as non-salvageable, he or she is given ‘comfort care or no care. This categorization may vary from 40% and above to 60% above burns injuries depending on the infrastructure of that unit. The problem with this is that the treatment is withheld for such patients; the patient dies because the doctors have decided that he or she is not likely to live even if treated. There is need to stop this practice and actively treat patients irrespective of this categorization based on a calculation of ‘percentage of burns’. She also cited the consequence of this undesirable practice. As the general surgery department received severe burns cases that eventually died, they had little interest in treating burns they also felt demoralized and the state of mind then is “everyone here is going to die, why I should try?

Table 2: Gaps in current medico-legal practice in burns care.

Expected role Existing practice Gaps

Assessment of percentage of burns, degree By treating doctors The % documented were different in the records trailConnect to causative agents – dry flame or

scalds or chemical burns or electrical or petroleum product- kerosene or diesel.

As reported by victims,The protocol has no section for recording any gap in

observation. No recording on Position of or when patients fell, whether she fell on front or back

Assess whether the person sustaining these burn injuries was fit enough to give a

statement OR whether the person is in compos mentis to give dying declaration.

Awareness about this role, police called as a routine matter.

Dying declarations recorded only when asked for by the police and not on a routine basis.

No information to the patient that she may die.

Assess Cause of death Done by a forensic expert as part of PM.

The time lapse between death and post mortem, the victim has been under treatment for many days. Signs such as the smell of kerosene, burnt clothes etc. lost. Examples of how

injuries on body missed due to severe burns,

Assess the time since injury and manner of injury As reported by patient

No mention of-Circumstances under which the incident occurred

-Fuel or vehicle for burning-Position of or when patients fell-Smell of kerosene from the body-Whether she fell on front or back

To assess whether the burn injuries are sustained Ante mortem or Postmortem Done in case of PM only, The gap between incident and PM. No clear protocol for

documentation

Table 1: Medical records vs researcher’s records: cause of burns.

Accidents Suicide Homicide Accident but experience of DV Total

Medical records 15 6 1 - 22

As told to researcher 3 13 2 4 22

Source: Interviews with survivors/victims. The arrow depicts the change in reported cause of burns.

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There is no uniform protocol for management and referral of burns cases across various levels of the health facility. As observed in the study, the hospitals follow different protocols for acute care that comprises of fluid management, dressing, excision of burnt tissue and psychological care. Clear surgical protocols have been found to improve burn outcomes and this is well documented. This is mainly related to immediate care or acute care which consists of immediate resuscitation, dressing, early excision and skin grafting. The existence of such protocols also ensures audit and standardization of care. However as most experts said these do not exist in India, if they exist in few places it is due to the initiative of few doctors there. Within the same hospital too, each surgical unit may follow its own protocol. The Sion hospital is a good example, where a separate burns unit has been set up for better management of burns cases but it can accommodate only 14 patients. The others are then admitted in other surgical units. When it was found that the units were following their own protocol for management of burns, the hospital issued a policy for a uniform protocol for all burns care irrespective of the ward in which the patient has been admitted. The adherence of uniform protocol in the hospital has improved the burn outcomes as reported by Gore and Kumar in 2013.

All underscored the need for clinical protocols for resuscitation, treatment, and referral. Experience in other countries has been that introduction of clear protocols for resuscitation, quick and effective management of burn injuries with latest surgical interventions has resulted in survival for those with severe burns and reduction in post burns morbidity. The protocol led patient care (both nursing and medical) in

Australia has facilitated clinical audit and standardization of care. The specialized centres provided services such as special diet, physiotherapy, and counselling [8]. The long term impact of burns as shared by the three survivors makes it imperative for general hospitals to also provide these services so that women are able to easily access them. Success in these areas involves a multidisciplinary team trained in current state-of-the-art interventions and therapies, with the ultimate goal of restoring function and allowing psychosocial reintegration.

It is commendable that there has been a massive improvement in chronic care, which is largely plastic surgery where contractures are being treated very well, but acute care is poor. Burn outcomes, therefore, are miserably low and many deaths are preventable if the acute care improves. Burns care requires huge resources in terms of dressing material, dedicated nursing and medical staff, ancillary services and the treatment is long drawn. The high mortality acts as a dampener. Systemic problems such as resource availability, rationing of material that ails the public system makes it challenging for hospitals to priorities burns care which resource intensive is.

Another issue plaguing burns care is who should treat and where burn cases should be treated. The hierarchy of specialization and “whose’ job it is-whether that of a general surgeon or a plastic surgeon - was found to significantly affect the quality of care. This issue needs to be understood in the context of availability of human resources across various levels of the health system. Plastic surgeons are available only in tertiary and specialized centres as opposed to general surgeons who are

Table 3: Engendering the Haddon Matrix to prevent burn injuries in women.Host (individual

factors) Agent/vehicle Physical environment Social environment-Gender roles and cultural norms

Pre event

• Age and early years of marriage

• Experiencing DV• Lack of awareness

about DV services to stop abuse and self-harm

• Reduced kitchen safety as a mental health consequence of DV

• Easy availability of kerosene for women at home

• Small living space • Uninterrupted access to gas/stoves for women due to gender roles

• Social norms that accept domestic violence as normal including dowry

• Acceptance of DV as private matter so no intervention by neighbours and community

• Lack of support from natal family for married women experiencing DV

Event

• Lack of knowledge about what to do in case of burns

• Stored water in houses the only first aid available

• Alone so no one to intervene to stop fire

• Time lapse for others to intervene

• Lack of knowledge about intervening in a burns incident

• Reluctance to intervene due to fear of getting into “police case”.

• Lack of facilities for transfer to burns care facility• Lack of policy or law on prevention of kitchen

accidents

Post event

• Poor knowledge of first aid& services for burn care

• Access to treatment is gendered as seen in discharged against medical advice (DAMA), low follow up for ancillary care

• Fear of arrest if the husband

• No report of damage in the house

• No investigation into malfunction of stove/gas

• Low level of care in general- first aid, acute care and chronic care.

• Access to acute care not uniform for all but based on percentage of burns

• High cost of care

• Actual cause and history of domestic violence not registered in the health system

• Conspiracy of silence over domestic violence by a woman, family, police, and hospital--

• Disability caused by Burn injuries not recognized in the Disability Law

• No compensation for “kitchen accidents”

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relatively more accessible at district levels. Providers and key informants further reiterated this and what emerges clearly is the need to equip the primary and secondary levels of health care system to “treat” burns and not “manage” or give “comfort care”.

The currently available clinical care to burns point to serious gaps in the provision of these services. It is important to note that this is based on health facilities in the city of Mumbai which is endowed with best health care. The state of burns care at district levels is expected to be worse. The implications are huge in terms of increasing allocation of financial and human resources for burns care considering the huge burden that is 70 to 80 lakh persons suffering burn injury in a year.

FORENSIC RESPONSE OF HOSPITALSThe existing gaps in current medico-legal practice in

responding to women reporting burn injuries are summed up in the table below. The expected role of the health professionals is to assess the percentage of burns, connect to causative agents, record or ensure DD is recorded as per procedure, assess the cause of death, assess nature of injuries [9,10] (Table 2).

The study found that there is no clear protocol for documenting the history, evidence collection and medical opinion in the case of burns injuries. Despite it being a clear issue for medico legal procedure, the response is routine and does not dwell on the principle of justice. It all operates based on what the woman says. The normalcy with which providers said that women hide the true cause of burns and that they can do nothing about it makes them responsible too for the conspiracy of silence. Their attitude that this is not their role thereby stating that their role is limited to clinical care, is rooted in the lack of understanding and sensitivity to gender and power relations affecting health. It also clearly shows apathy to existing legal obligations. Providers not only accepted the ‘false story of kitchen accidents’ but also seemed to justify them. They were able to list the various reasons that may prevent women from speaking the truth and also recognize this as an issue of domestic violence but most of them felt that they have no role in the prevention or in seeking justice for her. The interviews with hospital staff give specific identifiers for the manner of burns based on their experience of working with such patients for several years and the histories shared with them in confidence. They were able to recognize the gap between the history provided by the woman and the injuries she had suffered. This was based on the severity of burns, parts of the body that were burnt, the pattern in which the body was burnt and so on [11-15].

The access to justice for survivors/victims of burn injuries can begin at the hospital level by recording the history of violence, documenting and collecting evidence, corroborating the history and clinical findings and interfacing with the police and courts. This would require a clear medico-legal protocol to be developed with clarity on how and where to seek such information [16,17]. Despite over three decades of focus and advocacy on VAW by women’s movements, textbooks on medical jurisprudence followed in medical schools in India still do not provide any systematic guidelines for examination of burn injuries or the links between burn injuries and experience of domestic violence. The review of the textbooks highlights the

lack of scientific information, missing data on incidence and epidemiology of burns, the absence of guidance on dowry deaths and domestic violence as underlying causes of burn injuries. There is no guidance on the role and responsibility of medical professionals to investigate the cause of burns in order to inform prevention strategies and assist women’s access to justice [18-20]. These contribute to the mindset “it is not our job” “we record what she says” ‘getting into the true cause of injury is not our job but that of the police”. The forensic role of health professionals in burns care needs to be recognized and integrated into burn care in India [20,21].

ENGENDERING THE HADDON MATRIXThe WHO (2011), a document on Burns Prevention presents

the epidemiology of burns and also presents the Haddon Matrix� to indicate the focus on prevention. In this document, kitchen accidents assumed as an outcome of constrained cooking space or hazards endemic to cooking have not been deconstructed and thus the socio cultural factors contributing to the incidence do not find a mention. The research findings found different factors operating at the individual, agent, physical and social environment in the pre-event, event and post-event phases of incidents of burn injuries reported by women. The engendered Haddon Matrix shown in Table (3) provides a perspective on preventing burn injuries in women and for improving response of the health system [22-26].

Pre-vent phase

This refers to factors that need intervention in order to prevent the occurrence of burns. The research highlights the factors such as age and early years of marriage, the experience of domestic violence (DV) at the individual level that made women susceptible to burn injuries. The lack of awareness about DV services of what to do and where to report DV was also a risk factor to burn injuries [27,28]. Also, women had no positive coping mechanisms as there was a lack of awareness about what to do when one feels suicidal. With regard to agenda/vehicle of burns, the research identified only one single factor which is easy availability of kerosene for women at home. With regard to the physical environment, what was found was that women were alone in the domestic space when the incident took place due to their gendered roles that define domestic role especially cooking as their primary responsibility. With regard to the social environment, the WHO lists poverty, unemployment, lack of fire safety in buildings and the acceptance of acid throwing. The research has highlighted several additional factors in the social environment such as social norms that accept DV as normal including dowry, acceptance of DV as private, the cultural of silence around reporting of DV, lack of support from natal family post marriage (Table 3)[29,30].

Event phase

In the Event phase, the research uncovered several additional factors at various levels. At the individual level, the lack of knowledge about what to do in case of burns was found to delay the immediate first aid. At the level of vehicle/agent of burns, it was found that most households could access the limited stored water as first aid or a blanket to stop the fire. This is important to note as most are reportedly occurring in kitchens/ domestic

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space. In most of the cases, there was no one at home at the time of the incident and so no one to intervene or stop the fire, there was a time lapse between the incident and intervention to stop the fire by neighbors. But what emerged from the research were several factors at the social environment level that hindered an intervention such as reluctance to intervene due to fear of getting into a police case, lack of emergency service to reach burn care facility and a complete lack of policy or law on prevention of kitchen accidents [31-33].

Post-event phase

In the post event phase, the research found the gendered access to treatment as seen in women leaving the hospital against medical advice (DAMA) from the hospital, low follow up for ancillary care, and not revealing the actual cause of burns due to fear of arrest of husband as factors at the individual level. At the level of the vehicle/host, it was found that there was neither any report on damage in the house due to the incident nor any report of the investigation into malfunction of stove/gas. At the level of physical environment, the low standards of care in acute and chronic care, access to acute care not uniform but based on a percentage of burns. At the social environment level, the high cost of care, the actual cause and history of domestic violence not registered in the health system, conspiracy of silence over DV by woman, family, police and hospital, the lack of compensation by state for “kitchen accidents’ and the Persons with Disabilities Act 2016 not recognizing flame burn injuries as disability. Thus, bringing in a gender perspective can go a long way in preventing burn injuries and effectively responding to them [34-37].

CONCLUSIONThe research was carried out in the city of Mumbai which is

known to have one of the best health care facilities. The findings of the research are therefore most significant in terms of improving the clinical and forensic care for women survivors/victims of burn injuries as the situation at the district level in other parts of the country is likely to be far worse. It is essential to create an ecosystem that is alert to VAW within the health system to be able to identify violence at an early stage, create an enabling environment for victims/survivors to speak up and create a comprehensive multi-sectoral response. Such an ecosystem will act as a deterrent to VAW. The critical role that the health system and health-care providers can play in terms of identification, assessment, treatment, crisis intervention, documentation, referral, and follow-up, needs to be integrated within the national health programmes and policies in India.

RECOMMENDATIONNeed for injury documentation and national registry

There is an urgent need to document and collect accurate data on burn injuries and deaths from health facilities, police records, and cause of death registers. Currently, there is no mechanism to collate this data. The national injuries registry that has been proposed under the NPPBI (National Programme for Prevention of Burn Injuries) must include critical information about circumstances of the burns incident and history of domestic violence so that a better public health response is developed.

Investigate

There is a need to investigate the abnormally high number of accidental burns amongst young women. Issues such as the role of family members when such accidents take place, and immediate medical care, need to be explored and documented.

Clinical protocols for acute and chronic care

Need to implement protocols for management of burns care, increase the allocation of resources and conduct research on burn injury management. The psychosocial care also needs to be included within these guidelines.

The MoHFW (Ministry of Health and Family Welfare) needs to recognize flame burns as an issue of gender based violence, thus going beyond acid attacks. Gender sensitivity needs to be integrated in hospital systems. The training on this should be part of in-service training and also in medical and nursing education

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