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A prospective study of suicidal burns admitted to the Harare burns unit
Burns 26 (2000) 460±464
www.elsevier.com/locate/burns
A prospective study of suicidal burns admitted to the Harare burns unit S. Mzezewa a, K. Jonsson a, M. AÊberg b, L. Salemark b,* a
Department of Surgery, University of Zimbabwe, Harare, Zimbabwe Department of Plastic and Reconstructive Surgery, MalmoÈ University Hospital, SE-205 02, University of Lund, MalmoÈ, Sweden
b
Accepted 17 January 2000
Abstract The aim of this study was to obtain prospective information on suicidal (attempted suicide) burns patients admitted to the Harare burns unit during 1995±1998. Forty-seven patients, 42 females (89%) and ®ve males (11%), evenly distributed throughout the period of study, were included. The median age was 25 years, range 13 to 50 years. Thirty were housewives (64%). Women married according to customary law were the group most at risk. All patients were burnt by ¯ame after dousing themselves with paran or petrol. Con¯ict in love relationships was the most common circumstance leading to attempted suicide. The median Total Body Surface Area (TBSA) burnt was 60%, range 10±90%, for all patients, 25%, range 10±40%, for those who survived and 65%, range 20±95%, for those who died. Surgery was performed on 16 patients (34%). Mortality was 68%. The overall median hospital stay for all patients was 10 days, range 0±322 days, and 5 days, range 0±322 days, for those who died. 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Self-in¯icted burns; Attempted suicide; Burns; Customary marriage; Mortality
1. Introduction In a previous study on the epidemiology of burns conducted at this burns unit, it was noted that 22% of adult patients had burns due to attempted suicide [1]. These self-in¯icted burns were associated with very high mortality. From an international perspective, these patients formed an unusual group. The aim of this study was to collect information on this speci®c group of patients prospectively.
included. Data on age, sex, occupation, marital status, ospring, cause and the circumstances leading to the attempted suicide were recorded. Information on the burn wound, the date and time of the burn, treatment, length of hospital stay and outcome was recorded. All patients were interviewed by the same nursing sister who used a structured questionnaire throughout the study. To compare the frequencies of dierent modes of suicide, admission statistics on suicides during 1998 were obtained from the health database started in 1998 at Harare Central Hospital.
2. Materials and methods Patients admitted to the Harare burns unit during the period September 1995 to April 1998 with burns after attempting to commit suicide were prospectively
2.1. Statistical methods
* Corresponding author. Tel.: +46-40-33-1000; fax: +46-40-336271..
The Epi-Info statistical package was used to calculate medians and ranges.
0305-4179/00/$20.00 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 0 ) 0 0 0 1 9 - X
S. Mzezewa et al. / Burns 26 (2000) 460±464
461
3.4. Circumstances leading to attempted suicide
Fig. 1. The preponderance of young females in the material is obvious.
3. Results 3.1. Age and sex (Fig. 1) Forty-seven patients with median age 25 years, range 13±50 years, were included. Forty-two (89%) were female and ®ve (11%) male. 3.2. Occupation Housewives were the largest group at 30 (64%). Six of the remaining 17 (13%) were unemployed, ®ve (11%) self employed, three (6%) students and the others a gardener, a waiter and a manager. 3.2.1. Marital status and ospring (Table 1) Women married in accordance with Zimbabwean tribal law were the largest group (72%) with the largest number of children (median one child, range zero±seven children). 3.3. Cause of burn Patients were burnt by ¯ame after dousing themselves with paran (46 cases) and petrol (one case). Two patients had previously attempted suicide by taking overdoses of anti-malaria tablets.
Table 1 Marital status and numbers of ospring Marital status
Patients (n )
%
Ospring (n )
%
Customary Eloped Single Widow Divorcee
34 5 3 3 2 47
72 11 6.5 6.5 4 100
61 0 0 7 3 71
86 0 0 10 4 100
3.4.1. Marital and love relationships (23 females) There was a wide range of causes. Six women realized that their husbands had mistresses, four were beaten by their husbands, three husbands wanted the wife to stay in the country and not in the town, two husbands had lost interest in the ®rst wife after taking a second one and one wife became pregnant while breast-feeding and was afraid to tell her husband. One wife was unfaithful as was one husband and another wife found herself relegated to the ¯oor while her husband shared the bed with girlfriends. One woman was jilted by her boyfriend and another became angry when she found out her husband was still seeing a former wife. One woman was harassed by a jealous former boyfriend and another had an argument with her husband after being patted on the buttock by another man. 3.4.2. Problem with in-laws (®ve females) Three mothers in-law were dissatis®ed with their daughters-in-law, one quarreled with her sisters-in-law and one sister-in-law took away groceries meant for the mother-in-law [1]. 3.4.3. Financial (two males, six females) One male was involved in fraud and another got involved in a dispute with a nephew over an inheritance. Three women had disputes with their husbands about money and the husbands of the three others spent their bonus money on other people and not on their families. 3.4.4. Psychiatric illness (one male, two females) All were schizophrenic. The male heard voices ordering him to go and burn himself. 3.4.5. Possessed by spirits (one case) This was a male patient who thought himself to be protected from burning. 3.4.6. Other causes (one male, three females) One female was beaten by her brother for going out with boys, another was accused of prostitution and the
Table 2 Type of accommodation Home set up
Patients (n )
%
Own home Rented home Lodger
13 7 27 47
28 15 57 100
462
S. Mzezewa et al. / Burns 26 (2000) 460±464
third harassed by her husband over a damaged bicycle. The male was a minor who stole a packet of biscuits. 3.4.7. Unknown causes (two females) One was a patient too ill to communicate. 3.5. Type of accommodation (Table 2) The largest group of patients was lodgers (a lodger is here a tenant who rents one room, usually with its door giving direct access to the street). 3.6. Time of burn In 10 cases (21%) the time of burn could not be established. Eight patients (17%) were burnt at around 8 p.m. The rest of the burns were evenly distributed in time. 3.7. Total body surface area burnt The median TBSA was 60%, range 10±95%, for all patients and 25%, range 10±40%, for those who survived. The median TBSA burnt for the patients who died was 65%, range 20±95%. 3.8. Types of treatment Non-operative treatment was rendered to 31 patients (66%). Of the others, 15 (32%) had delayed split skin grafting and one (2%) primary excision and skin grafting. 3.9. Lengths of hospital stay The median hospital stay was 10 days, range 0±322 days, for all patients and 5 days, range 0±322 days, for those who died. 3.10. Outcome and mortality (Table 3) Ten (21%) patients healed well, ®ve (11%) healed with sequelae and 32 (68%) died. The total number of attempted suicides admitted to Harare General Hospital during 1998 is shown in Table 4 and includes those who were brought in dead, those who died in casualty and those admitted to the general surgical wards Table 3 Outcome and mortality Sex
Healed well (n )
Healed with sequelae (n )
Died (n )
%
Male Female Total
1 9 10
1 4 5
3 29 32
11 89 100
because they had minor injuries or the burns unit was full. Organo-phosphate poisoning was the most frequent cause of suicide (51%). Burns accounted for 11% of all suicides in 1998. 4. Discussion In a previously-reported epidemiology study, 22% of the total number of adult patients attempted to commit suicide by burning themselves [1]. Since in other recent studies, the percentages of similar burns range from 1 [2] to 7.6% [3], the suicidal burn patients in our study constitute a major subgroup with a very high mortality. Even in relation to other modes of attempted suicide, self-in¯icted burns constituted a major group, as illustrated in Table 4, amounting to 11% of the attempted suicides admitted to Harare Central Hospital in 1998. 4.1. Age and sex distribution The median age of 25 years is much lower than that reported in other studies [4,5]. Furthermore, our typical patient is a young female (89%) in contrast to most other studies where no sex dierence [6±8], or even male preponderance [2,9,10], is reported. Only a few studies report a majority of females [3,11,17]. In a study 11 years ago, the same male-to-female ratio of 1:9 was found [12]. In the statistics of attempted suicide patients at Harare Central Hospital, the male-to-female ratio was 1:2 (Table 4). In the Harare region, attempting suicide by burning seems to be a method preferred by females. 4.2. Marital status Most women (3/4) were married in the customary way. It was not possible to ®nd out how many of them lived in rural areas while their husbands worked and lived in urban areas, nor if they were ®nancially dependent on their husbands. However, when rural wives visited their husbands and found
Table 4 Suicide admissions at Harare Central Hospital in 1998 Cause
Male
Female
Total
%
Organo-phosphate poisoning Antimalarial poisoning Burns Analgesics and barbiturate poisoning Other
82 23 7 3 12 127
103 74 34 11 15 237
185 97 41 14 27 364
51 27 11 4 7 100
S. Mzezewa et al. / Burns 26 (2000) 460±464
them in the company of other women or having spent all their money on beer, etc., some burnt themselves. At admission, they were registered at the addresses of their husbands. In the circumstances mentioned above, women married in the customary way often do not have anyone to turn to for advice, support and counselling. In the traditional setting, this is the role of the father-in-law's sister (Vatete). The Vatete is expected to make sure that her brother's children have successful marriages. She thus plays the role of the counsellor for the couple and the incoming bride is supposed to con®de freely in her. The Vatete is also expected to exert pressure on the husband and be rather protective of the bride. In the traditional setting, failed marriages are either blamed on the Vatete or regarded as a failure on her part. Although marriage partners are not speci®cally picked by relatives, they guide selection to the extent that one is advised which families to avoid. In addition, the prospective husband's sisters or cousins are actively involved in the courtship. As a result, a cordial marriage environment is established before marriage and con¯icts are less likely to occur. In Zimbabwean church or civil marriages, wives generally live with their husbands. In the event of problems, the couple may go to a marriage counsellor. In addition, wives can sue husbands for polygamy and extramarital aairs. Traditional courts whose members include tribal chiefs, headmen and elders with jurisdiction over customary marriage are to be found in rural areas. The decisions of these courts are binding and recognized by the national legal system. Depending on the severity of the oence, they can impose ®nes ranging from cattle, goats and chickens to money on any oender, male or female. Underutilisation of the traditional courts for solving marital and ®nancial problems might contribute to the attempted suicides. Although discouraged, polygamy is still legal and girlfriends are therefore regarded as a ®rst step towards polygamy. In the traditional setting, however, the subsequent wife has to be approved of by the ®rst wife through the Vatete. The preponderance of young women married according to traditional law in our material might therefore re¯ect a reduced role of the Vatete, particularly in urban areas, and dicult marital circumstances. It is worth pointing out that the occurrence of a signi®cant suicidal burns group is limited to the Harare region and is not observed in others parts of Zimbabwe (private communications). In addition, one of us (LS) worked for 3 years during the 1980s in neighbouring Mozambique and treated hundreds of burns patients without a single case of attempted suicide.
463
Why such numbers of patients are observed at Harare remains a mystery. 4.3. Cause of burn All patients doused themselves with ¯ammable liquids and then set ®re to themselves. Being widely used for lighting and cooking by the majority of residents in the densely-populated suburbs, paran is readily available. In other studies, the methods of in¯icting burns vary from electricity to scalding and ®re, but burns from ¯ammable liquids are overall the most frequent [4,6,9]. In the traditional setting, people have been known to commit suicide by hanging or by taking poisonous substances. The availability of ¯ammable liquids may have led to a shift in the methods of committing suicide. 4.4. Circumstances leading to attempted suicide The predominant causes in our study were marital and love relationships 23/47 (49%), ®nancial hardships (17%) and problems with in-laws, 5/47 (11%). These causes are seldom found in other studies [5,6]. Domestic violence (wife beating) and con¯icts between mother- and daughter-in-law might be explained by the breakdown of the social role of the extended family. In the latter, the father-in-law's sister plays a crucial role in preventing and solving con¯icts. There were only three cases of psychiatric illness, and none of drug addiction or alcoholism. In other studies, psychiatric illness, drug addiction and alcoholism were diagnosed in the majority of cases [3±11,13,14]. On the Indian subcontinent, failure to pay the bride's dowry is a major cause of suicidal burns. In addition, these newly-wed young housewives are either killed or tortured by their in-laws or husbands to burn themselves if their parents or guardians fail to pay their dowries [15,16]. In Zimbabwe, the dowry is paid by the groom. More suicidal patients were noted in Indian joint families [17]. In Zimbabwe on the other hand, the joint family has a role in resolving family con¯icts as well as preventing suicides. Some people in dierent regions in Zimbabwe believe that if a breast-feeding woman becomes pregnant, her milk will harm the unborn baby. Hence, one of our patients burnt herself because she was pregnant and afraid to tell her husband. The intervention of a traditional healer through the father-in-law's sister might have prevented this situation. Employees get a 13th cheque (bonus salary) in November or December and most families look forward to this. Con¯icts can arise if the husbands spend the money elsewhere as happened with three of our patients. People possessed by spirits can believe them-
464
S. Mzezewa et al. / Burns 26 (2000) 460±464
selves to be protected from burning as did one of our patients.
References
4.5. Outcome and mortality
[1] Mzezewa S, Jonsson K, Aberg M, Salemark L. A prospective study on the epidemiology of burns in patients admitted to the Harare Burn units. Burns 1999;25:499±504. [2] Krummen DM, James K, Klein RL. Suicide by burning: a retrospective review of the Akron Regional Burn center. Burns 1998;24:147±9. [3] Marchesan WG, Ferreira da Silva F, Canalli JE, Ferreira E. Suicide attempted by burning in Brazil. Burns 1997;23:270±1. [4] O'Donoghue JM, Panchal JL, O'Sullivan ST, et al. A study of suicide and attempted suicide by self-immolation in an Irish psychiatric population: an increasing problem. Burns 1998;24:144±6. [5] Suk JH, Han CH, Yeon BK. Suicide by burning in Korea. Int J Soc Psychiat 1991;37:141±5. [6] Hadjiiski O, Todorov P. Suicide by self-in¯icted burns. Burns 1996;22:381±3. [7] Castellani G, Beghini D, Barisoni D, Marigo M. Suicide attempted by burning: a 10-year study of self-immolation deaths. Burns 1995;21:607±9. [8] Klasen HJ, van der Tempel GL, Hekert J, Sauer EW. Attempted suicide by means of burns. Burns 1989;15:88±92. [9] Garcia-Sanchez V, Palao R, Legarre F. Self-in¯icted burns. Burns 1994;20:537±8. [10] Shkrum MJ, Johnston KA. Fire and suicide; a three-year study of self-immolation deaths. J Forensic Sci 1992;37:208±21. [11] Sheth H, Dziewulski P, Settle JAD. Self-in¯icted burns: a common way of suicide in the Asian population. A 10-year retrospective study. Burns 1994;20:334±5. [12] Mzezewa S. Burns Management: The Harare Central Hospital Experience. University of Zimbabwe, Harare, Zimbabwe. Thesis 1988. [13] Ben Meir P, Sagi A, Ben Yakar Y, Rosenberg L. Suicide attempts by self-immolation Ð our experience. Burns 1990;16:257±8. [14] Cameron DR, Pegg SP, Muller M. Self-in¯icted burns. Burns 1997;23:519±21. [15] Gupta Das SM, Tripathi CB. Burnt wife syndrome. Ann Acad Med Singapore 1984;13(1):37±42. [16] Satpathy DK. Burning brides. . .a medicolegal study. Med law 1995;14(78):547±52. [17] Wagle SA, Wagle AC, Apte JS. Patients with suicidal burns and accidental burns: a comparative study of socio-demographic pro®le in India. Burns 1999;25(2):158±61.
Most of our patients had severe burns. Limited resources in terms of the availabilities of blood for infusion and intensive care facilities made these patients unsuitable for primary excision and skin grafting. Surgical treatment was therefore only given to 34% of the patients. In consequence, mortality was very high, 68%, consistent with results found in other studies [4,5,7,13,14]. The majority of these patients were very dicult to resuscitate because they removed intravenous lines, were generally uncooperative and determined to die. Among the survivors were some who attempted suicide merely to draw the attention of the husband and others who wanted to get him punished by their relatives. 5. Conclusion In the area served by this burns unit, the majority of suicidal burns patients were young women married according to customary law, who doused themselves with paran after con¯icts in marital or love relationship. These extensive burns resulted in very high mortality. Acknowledgements This study was supported ®nancially by the Swedish International Development Cooperation Agency (Sida) and their department for research cooperation (SAREC Ð the Swedish Agency for Research and Economic Co-operation). Mr Rusakanoko assisted with the statistical analyses.
www.elsevier.com/locate/burns
A prospective study of suicidal burns admitted to the Harare burns unit S. Mzezewa a, K. Jonsson a, M. AÊberg b, L. Salemark b,* a
Department of Surgery, University of Zimbabwe, Harare, Zimbabwe Department of Plastic and Reconstructive Surgery, MalmoÈ University Hospital, SE-205 02, University of Lund, MalmoÈ, Sweden
b
Accepted 17 January 2000
Abstract The aim of this study was to obtain prospective information on suicidal (attempted suicide) burns patients admitted to the Harare burns unit during 1995±1998. Forty-seven patients, 42 females (89%) and ®ve males (11%), evenly distributed throughout the period of study, were included. The median age was 25 years, range 13 to 50 years. Thirty were housewives (64%). Women married according to customary law were the group most at risk. All patients were burnt by ¯ame after dousing themselves with paran or petrol. Con¯ict in love relationships was the most common circumstance leading to attempted suicide. The median Total Body Surface Area (TBSA) burnt was 60%, range 10±90%, for all patients, 25%, range 10±40%, for those who survived and 65%, range 20±95%, for those who died. Surgery was performed on 16 patients (34%). Mortality was 68%. The overall median hospital stay for all patients was 10 days, range 0±322 days, and 5 days, range 0±322 days, for those who died. 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Self-in¯icted burns; Attempted suicide; Burns; Customary marriage; Mortality
1. Introduction In a previous study on the epidemiology of burns conducted at this burns unit, it was noted that 22% of adult patients had burns due to attempted suicide [1]. These self-in¯icted burns were associated with very high mortality. From an international perspective, these patients formed an unusual group. The aim of this study was to collect information on this speci®c group of patients prospectively.
included. Data on age, sex, occupation, marital status, ospring, cause and the circumstances leading to the attempted suicide were recorded. Information on the burn wound, the date and time of the burn, treatment, length of hospital stay and outcome was recorded. All patients were interviewed by the same nursing sister who used a structured questionnaire throughout the study. To compare the frequencies of dierent modes of suicide, admission statistics on suicides during 1998 were obtained from the health database started in 1998 at Harare Central Hospital.
2. Materials and methods Patients admitted to the Harare burns unit during the period September 1995 to April 1998 with burns after attempting to commit suicide were prospectively
2.1. Statistical methods
* Corresponding author. Tel.: +46-40-33-1000; fax: +46-40-336271..
The Epi-Info statistical package was used to calculate medians and ranges.
0305-4179/00/$20.00 7 2000 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 0 ) 0 0 0 1 9 - X
S. Mzezewa et al. / Burns 26 (2000) 460±464
461
3.4. Circumstances leading to attempted suicide
Fig. 1. The preponderance of young females in the material is obvious.
3. Results 3.1. Age and sex (Fig. 1) Forty-seven patients with median age 25 years, range 13±50 years, were included. Forty-two (89%) were female and ®ve (11%) male. 3.2. Occupation Housewives were the largest group at 30 (64%). Six of the remaining 17 (13%) were unemployed, ®ve (11%) self employed, three (6%) students and the others a gardener, a waiter and a manager. 3.2.1. Marital status and ospring (Table 1) Women married in accordance with Zimbabwean tribal law were the largest group (72%) with the largest number of children (median one child, range zero±seven children). 3.3. Cause of burn Patients were burnt by ¯ame after dousing themselves with paran (46 cases) and petrol (one case). Two patients had previously attempted suicide by taking overdoses of anti-malaria tablets.
Table 1 Marital status and numbers of ospring Marital status
Patients (n )
%
Ospring (n )
%
Customary Eloped Single Widow Divorcee
34 5 3 3 2 47
72 11 6.5 6.5 4 100
61 0 0 7 3 71
86 0 0 10 4 100
3.4.1. Marital and love relationships (23 females) There was a wide range of causes. Six women realized that their husbands had mistresses, four were beaten by their husbands, three husbands wanted the wife to stay in the country and not in the town, two husbands had lost interest in the ®rst wife after taking a second one and one wife became pregnant while breast-feeding and was afraid to tell her husband. One wife was unfaithful as was one husband and another wife found herself relegated to the ¯oor while her husband shared the bed with girlfriends. One woman was jilted by her boyfriend and another became angry when she found out her husband was still seeing a former wife. One woman was harassed by a jealous former boyfriend and another had an argument with her husband after being patted on the buttock by another man. 3.4.2. Problem with in-laws (®ve females) Three mothers in-law were dissatis®ed with their daughters-in-law, one quarreled with her sisters-in-law and one sister-in-law took away groceries meant for the mother-in-law [1]. 3.4.3. Financial (two males, six females) One male was involved in fraud and another got involved in a dispute with a nephew over an inheritance. Three women had disputes with their husbands about money and the husbands of the three others spent their bonus money on other people and not on their families. 3.4.4. Psychiatric illness (one male, two females) All were schizophrenic. The male heard voices ordering him to go and burn himself. 3.4.5. Possessed by spirits (one case) This was a male patient who thought himself to be protected from burning. 3.4.6. Other causes (one male, three females) One female was beaten by her brother for going out with boys, another was accused of prostitution and the
Table 2 Type of accommodation Home set up
Patients (n )
%
Own home Rented home Lodger
13 7 27 47
28 15 57 100
462
S. Mzezewa et al. / Burns 26 (2000) 460±464
third harassed by her husband over a damaged bicycle. The male was a minor who stole a packet of biscuits. 3.4.7. Unknown causes (two females) One was a patient too ill to communicate. 3.5. Type of accommodation (Table 2) The largest group of patients was lodgers (a lodger is here a tenant who rents one room, usually with its door giving direct access to the street). 3.6. Time of burn In 10 cases (21%) the time of burn could not be established. Eight patients (17%) were burnt at around 8 p.m. The rest of the burns were evenly distributed in time. 3.7. Total body surface area burnt The median TBSA was 60%, range 10±95%, for all patients and 25%, range 10±40%, for those who survived. The median TBSA burnt for the patients who died was 65%, range 20±95%. 3.8. Types of treatment Non-operative treatment was rendered to 31 patients (66%). Of the others, 15 (32%) had delayed split skin grafting and one (2%) primary excision and skin grafting. 3.9. Lengths of hospital stay The median hospital stay was 10 days, range 0±322 days, for all patients and 5 days, range 0±322 days, for those who died. 3.10. Outcome and mortality (Table 3) Ten (21%) patients healed well, ®ve (11%) healed with sequelae and 32 (68%) died. The total number of attempted suicides admitted to Harare General Hospital during 1998 is shown in Table 4 and includes those who were brought in dead, those who died in casualty and those admitted to the general surgical wards Table 3 Outcome and mortality Sex
Healed well (n )
Healed with sequelae (n )
Died (n )
%
Male Female Total
1 9 10
1 4 5
3 29 32
11 89 100
because they had minor injuries or the burns unit was full. Organo-phosphate poisoning was the most frequent cause of suicide (51%). Burns accounted for 11% of all suicides in 1998. 4. Discussion In a previously-reported epidemiology study, 22% of the total number of adult patients attempted to commit suicide by burning themselves [1]. Since in other recent studies, the percentages of similar burns range from 1 [2] to 7.6% [3], the suicidal burn patients in our study constitute a major subgroup with a very high mortality. Even in relation to other modes of attempted suicide, self-in¯icted burns constituted a major group, as illustrated in Table 4, amounting to 11% of the attempted suicides admitted to Harare Central Hospital in 1998. 4.1. Age and sex distribution The median age of 25 years is much lower than that reported in other studies [4,5]. Furthermore, our typical patient is a young female (89%) in contrast to most other studies where no sex dierence [6±8], or even male preponderance [2,9,10], is reported. Only a few studies report a majority of females [3,11,17]. In a study 11 years ago, the same male-to-female ratio of 1:9 was found [12]. In the statistics of attempted suicide patients at Harare Central Hospital, the male-to-female ratio was 1:2 (Table 4). In the Harare region, attempting suicide by burning seems to be a method preferred by females. 4.2. Marital status Most women (3/4) were married in the customary way. It was not possible to ®nd out how many of them lived in rural areas while their husbands worked and lived in urban areas, nor if they were ®nancially dependent on their husbands. However, when rural wives visited their husbands and found
Table 4 Suicide admissions at Harare Central Hospital in 1998 Cause
Male
Female
Total
%
Organo-phosphate poisoning Antimalarial poisoning Burns Analgesics and barbiturate poisoning Other
82 23 7 3 12 127
103 74 34 11 15 237
185 97 41 14 27 364
51 27 11 4 7 100
S. Mzezewa et al. / Burns 26 (2000) 460±464
them in the company of other women or having spent all their money on beer, etc., some burnt themselves. At admission, they were registered at the addresses of their husbands. In the circumstances mentioned above, women married in the customary way often do not have anyone to turn to for advice, support and counselling. In the traditional setting, this is the role of the father-in-law's sister (Vatete). The Vatete is expected to make sure that her brother's children have successful marriages. She thus plays the role of the counsellor for the couple and the incoming bride is supposed to con®de freely in her. The Vatete is also expected to exert pressure on the husband and be rather protective of the bride. In the traditional setting, failed marriages are either blamed on the Vatete or regarded as a failure on her part. Although marriage partners are not speci®cally picked by relatives, they guide selection to the extent that one is advised which families to avoid. In addition, the prospective husband's sisters or cousins are actively involved in the courtship. As a result, a cordial marriage environment is established before marriage and con¯icts are less likely to occur. In Zimbabwean church or civil marriages, wives generally live with their husbands. In the event of problems, the couple may go to a marriage counsellor. In addition, wives can sue husbands for polygamy and extramarital aairs. Traditional courts whose members include tribal chiefs, headmen and elders with jurisdiction over customary marriage are to be found in rural areas. The decisions of these courts are binding and recognized by the national legal system. Depending on the severity of the oence, they can impose ®nes ranging from cattle, goats and chickens to money on any oender, male or female. Underutilisation of the traditional courts for solving marital and ®nancial problems might contribute to the attempted suicides. Although discouraged, polygamy is still legal and girlfriends are therefore regarded as a ®rst step towards polygamy. In the traditional setting, however, the subsequent wife has to be approved of by the ®rst wife through the Vatete. The preponderance of young women married according to traditional law in our material might therefore re¯ect a reduced role of the Vatete, particularly in urban areas, and dicult marital circumstances. It is worth pointing out that the occurrence of a signi®cant suicidal burns group is limited to the Harare region and is not observed in others parts of Zimbabwe (private communications). In addition, one of us (LS) worked for 3 years during the 1980s in neighbouring Mozambique and treated hundreds of burns patients without a single case of attempted suicide.
463
Why such numbers of patients are observed at Harare remains a mystery. 4.3. Cause of burn All patients doused themselves with ¯ammable liquids and then set ®re to themselves. Being widely used for lighting and cooking by the majority of residents in the densely-populated suburbs, paran is readily available. In other studies, the methods of in¯icting burns vary from electricity to scalding and ®re, but burns from ¯ammable liquids are overall the most frequent [4,6,9]. In the traditional setting, people have been known to commit suicide by hanging or by taking poisonous substances. The availability of ¯ammable liquids may have led to a shift in the methods of committing suicide. 4.4. Circumstances leading to attempted suicide The predominant causes in our study were marital and love relationships 23/47 (49%), ®nancial hardships (17%) and problems with in-laws, 5/47 (11%). These causes are seldom found in other studies [5,6]. Domestic violence (wife beating) and con¯icts between mother- and daughter-in-law might be explained by the breakdown of the social role of the extended family. In the latter, the father-in-law's sister plays a crucial role in preventing and solving con¯icts. There were only three cases of psychiatric illness, and none of drug addiction or alcoholism. In other studies, psychiatric illness, drug addiction and alcoholism were diagnosed in the majority of cases [3±11,13,14]. On the Indian subcontinent, failure to pay the bride's dowry is a major cause of suicidal burns. In addition, these newly-wed young housewives are either killed or tortured by their in-laws or husbands to burn themselves if their parents or guardians fail to pay their dowries [15,16]. In Zimbabwe, the dowry is paid by the groom. More suicidal patients were noted in Indian joint families [17]. In Zimbabwe on the other hand, the joint family has a role in resolving family con¯icts as well as preventing suicides. Some people in dierent regions in Zimbabwe believe that if a breast-feeding woman becomes pregnant, her milk will harm the unborn baby. Hence, one of our patients burnt herself because she was pregnant and afraid to tell her husband. The intervention of a traditional healer through the father-in-law's sister might have prevented this situation. Employees get a 13th cheque (bonus salary) in November or December and most families look forward to this. Con¯icts can arise if the husbands spend the money elsewhere as happened with three of our patients. People possessed by spirits can believe them-
464
S. Mzezewa et al. / Burns 26 (2000) 460±464
selves to be protected from burning as did one of our patients.
References
4.5. Outcome and mortality
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Most of our patients had severe burns. Limited resources in terms of the availabilities of blood for infusion and intensive care facilities made these patients unsuitable for primary excision and skin grafting. Surgical treatment was therefore only given to 34% of the patients. In consequence, mortality was very high, 68%, consistent with results found in other studies [4,5,7,13,14]. The majority of these patients were very dicult to resuscitate because they removed intravenous lines, were generally uncooperative and determined to die. Among the survivors were some who attempted suicide merely to draw the attention of the husband and others who wanted to get him punished by their relatives. 5. Conclusion In the area served by this burns unit, the majority of suicidal burns patients were young women married according to customary law, who doused themselves with paran after con¯icts in marital or love relationship. These extensive burns resulted in very high mortality. Acknowledgements This study was supported ®nancially by the Swedish International Development Cooperation Agency (Sida) and their department for research cooperation (SAREC Ð the Swedish Agency for Research and Economic Co-operation). Mr Rusakanoko assisted with the statistical analyses.