She is lightning, burning like it. She is fire and flame. She is light.
–Yvonne Vera Butterfly Burning
Self-Immolation is the act of offering oneself up as sacrifice, often by burning. This form of self-harm is often linked to Tibetan or Hindu forms of protest: “The immolations in South Vietnam provided a spectacular demonstration of communicative power… After 1963, the global rate of suicide protest increased more than tenfold, and fire became the most common means of death by far.” (1) The choice to commit suicide by setting oneself aflame carries a certain horror that “a scholar based in Washington, D.C., Timothy Dickinson [calls] ‘…an assertion of intolerability and, frankly, of moral superiority. You say ‘I would never have the guts to do that. It’s not that he’s trying to tell me something, but that he’s commanding me.’ This isn’t insanity. It’s a terrible act of reason.’” (1) Self-immolation carries the weight of sacrifice, protest, horror, and awe.
Two weekends ago, I was volunteering at the hospital when a women arrived in Reses with 70% surface area burns. Her boyfriend brought her in after she set herself on fire using petrol gas. The suicide attempt caught my attention because it was truly horrible; the image that remains for me were her earrings, charred black and welded to her ears.
There were two narratives running simultaneously through the brains of doctors, nurses, and students; the first was management and the second was dread. To understand both narratives, I want to first review the management of her case and then, to interrogate the feelings of dread by looking at the act of self-immolation through both sociological and narrative medicine lenses.
Upon arrival we did a rapid assessment:
Vitals were a bit high with a Blood Pressure of 131/73, a Heart Rate of 94, and a Respiratory Rate of 22.
Respiratory: we heard bilateral crackles, which meant that she had inhaled smoke.
Central Nervous System (CNS): Her GCS was 15/15 because she was very responsive even if not she was not well orientated.
Cardiovascular System (CVS): We heard echoes.
We removed her clothes and unwrapped the coating that the EMTs had placed on her burns. She got warm fluids through an IV, to restore intravascular volume and maintain end-organ perfusion, and we put in a catheter. There was blood in her urine, which suggested tissue damage.
After this rapid assessment, we moved to support her airway and breathing. We completed bag-valve-mask ventilation, which involved squeezing oxygen into her lungs with a bag so that she was 100% oxygenated before intubating. I got to practice “bagging a patient,” slowly counting to six as I squeezed air into her lungs.
Then, we intubated. Early intubation is recommended for patients with compromised airways and she had burns all around her throat. First, the young woman received morphine and then a medical student was able to intubate her. Once on the ventilator, the settings were turned to slightly higher respiratory rates (16-20 breaths/min) and smaller tidal volumes (7-8 mL/kg), which meant we gave her a small amount of air but at a fast rate.
Once we had successfully supported her airways, we needed a dipstick to test her urine and an X-Ray to check her chest. The dipstick and urine test showed that she was not pregnant but that she had +4 proteins, which meant that her kidneys were compromised.
Another concept that I learned was escharotomy, which is a surgical procedure that is used to treat full thickness, circumferential burns. The tissue becomes tough and leathery after burning, which can become restrictive, causing compartment syndrome and killing healthy tissue. Surgeons would relieve this pressure by cutting along the burn. The doctors decided that it was not yet time for this measure to be taken.
Now that she was stable, we waited for a surgical follow-up. The surgeons gave her analgesia, fluids and anti-inflammatory medicine. The prognosis, according to the surgeon was not good because of the airway damage and the fact that her body was 70 percent burned.
Now I am going to discuss the act to burn oneself alive from a sociological and narrative medical perspective.
Self-immolation has a long history in the Chinese and Buddhist-Tibetan traditions. These narratives are often around religious renunciation of the body or as a form of political protest.(2) One of the ER doctors also mentioned that self-immolation was the most common way for young black females to kill themselves. These conflicting narratives led me to write this piece.
What I found across multiple studies was that of all the ways to kill oneself “Self-burning (immolation) comprises between 0.37% and 40% of total burn center admissions around the world.” (3) In other words, burning oneself is not the most common way to get very badly burned. Furthermore, in a 2002 study in Durban South Africa, “Self-immolation accounted for 69 (0.6%) of all non-natural deaths and 69 (9.9%) of all suicides. The subjects had a mean age of 31.2 years and were predominantly female (76.8%) and black (81.2%).” (4) So, self-burning is also not a very common way to commit suicide unless you are black and female.
The latter statement corroborates that of the ER doctor. Her burns left us all–doctors, nurses, and students–wondering why. In the studies I read, the subjects were Iranian, South African, and, in one study, the researchers did a global literature review, which suggests that the trend discussed are somewhat universal: “In lower-income countries, the incidence of self-immolation is much higher, and the majority of patients are female.” (5)
Sociologist Emile Durkheim separates “suicides into four types: the egoistic, the altruistic, the anomic (moral confusion), and the fatalistic. Perhaps self-immolation captivates so thoroughly because it wins on all counts. It is the ultimate act of both despair and defiance, a symbol at once of resignation and heroic self-sacrifice.” (1) The complex place that economically disadvantaged women hold in society reflects this “ultimate despair and defiance,” a rebellion against an unyielding system of oppression that echoes female literary protagonists like Antigone from Greek Mythology or Phephelaphi from Butterfly Burning.
I am left to make hypotheses about why young women from low-income settings are committing suicide in this way. There was little to no literature that I could find, which spoke to these astounding statistics. If anyone has come across research responding to these observations please share it in the comments.
Within the act of burning oneself there is an attempt at erasure and moralistic superiority but also an acceptance of intense pain that is, perhaps, related to guilt. I am left deeply puzzled by the act; torn between the protest and total despair. It is also notable that the population most likely to commit this act, low-income women, is one that in South Africa and many other parts of the world goes un-seen. Setting oneself alight is both the ultimate call for recognition and the total erasure of self.
- Verini, James. A Terrible Act of Reason: When Did Self-Immolation Become the Paramount Form of Protest? New Yorker. May 16, 2012. Web. 17, March 2016.
- Ahmadi, Alireza MD. Suicide by Self-Immolation: Comprehensive Overview, Experiences and Suggestions. Journal of Burn Care Research. January/February 2007. Web. 17, March 2016.
- Sukhai, A. E.C.P. (A.D.V.); Harris, C. R.N., E.C.P. (A.D.V.); Moorad, R. G. R. F.C. For. Path. (S.A.); Dada, Mahomed A. M.Med. (Anat. Path.), F.C. For. Path. (S.A.). Suicide by Self-Immolation in Durban, South Africa: A Five-Year Retrospective Review. September 2002. Web. 17, March 2016.
- Poeschla, Brain, Heidi Combsa, Simon Livingstonea, Sharon Romma, Matthew B. Kleinb. Self-immolation: Socioeconomic, cultural and psychiatric patterns. Science Journal. Volume 37, Issue 6, September 2011. Web. 17, March 2016.
- In-text image is Robert Montgomery‘s Great Foster’s fire poem for NYC.
- Cover photo taken from Saigonlocaltours.