Can we prevent rural suicides? Yes, it is possible, says a recent WHO-FAO publication
Almost one in every five suicides in the world is committed by self-poisoning with pesticide, which mostly occur in rural, agricultural areas of low- and middle-income countries (LMICs), states a new publication entitled 'Preventing Suicide: A resource for pesticide registrars and regulators'.
Published jointly by the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO), the booklet says that the adoption of green revolution technology in LMICs (including India) since the 1950s brought with it the practice of intensive application of hazardous chemical pesticides in farming, among other things. The presence of agricultural pesticides in the vicinity (viz. in homes and workplaces) makes it possible for persons with suicidal inclinations to consume such poison impulsively.
Although highly hazardous pesticides in the high-income countries are either banned, restricted or used only by professional sprayers using mechanized approaches, they are readily available in the LMICs thanks to the green revolution.
The recent publication of WHO and FAO indicates that between 1.10 lakh and 1.68 lakh pesticide self-poisoning deaths (suicides) take place every year globally. It has been estimated that close to 14 million premature deaths have happened from pesticide self-poisoning since the 1950s when the green revolution technology was introduced in small-scale farming. More than 95 percent of these deaths from pesticide self-poisoning have taken place in LMICs.
The newly released document has, therefore, called for appropriate action to be taken by pesticide registrars and regulators.
The booklet by WHO and FAO says that there are various risk factors that could trigger suicide including mental illness, acute distress, poverty, breakdown of a marriage or relationship, physical illness, job loss, exposure to violence, being bullied or abused as a child, alcohol or drug abuse, a previous suicide attempt and access to high-lethality suicide methods. Thus, risk factors for committing suicide may include factors that are psychological (e.g. depression), social (e.g. family conflicts), cultural (e.g. religious views about suicide) and economic (e.g. poverty, debt, bankruptcy). Among farming communities, financial difficulties following crop failure could create pressure for taking one’s own life.
The three most common methods of suicide deaths across the world are hanging, pesticide self-poisoning and firearms. The poisons most frequently ingested in high-income countries to commit suicide are pain killers, anti-depressants and tranquillizers, which are relatively non-toxic and have low fatality rate. As opposed to that, high-toxicity pesticides are used to commit suicide in LMICs, and some of these products have case fatality rates like those for suicide attempts by hanging and firearms.
There is a rich literature available, which indicates the ill-effects of chemical pesticides on human health and environment. The recently released booklet of WHO-FAO says that long-term occupational or domestic exposure could cause chronic illnesses – including dermatitis, respiratory problems and cancer apart from reproductive, neurodevelopmental and behavioural disorders. There are some pesticides, which could cause acute poisoning and may result in death.
Instead of using WHO’s classification of toxicity (which is measured on the basis of hazards of acute toxicity in rats after ingestion viz. LD50 value), the 'Preventing Suicide' document has considered case fatality rate of commonly-used pesticides among humans. On the basis of a number of studies, the WHO-FAO resource document has provided the estimated case fatality rate (viz. proportion of people who die following self-poisoning using each product) of commonly-used pesticides. The publication shows that 'paraquat' has a high fatality rate of 43-68 percent, whereas for aluminium phosphide that figure is 60-80 percent. Although the estimated case fatality rate for 'glyphosate'--a herbicide--is 2 percent (which is quite low in comparison to other pesticides, according to the WHO-FAO booklet), a ban on its use in the country is being demanded by several organisations including Swadeshi Jagran Manch (SJM) because it is considered to be carcinogenic. The sale of glyphosate has been banned in the states of Punjab, Kerala, Andhra Pradesh and Telangana.
As opposed to chemical pesticides, there are alternative ways to combat pest attacks such as the integrated pest management (IPM) and integrated vector management (IVM) approaches, which have been promoted by the WHO and FAO, says the recent publication.
According to the resource booklet entitled 'Preventing Suicide', pesticide registrars and regulators of various nations can undertake the following approaches to prevent pesticide related suicides:
* identifying the pesticides most commonly used in fatal self-poisoning;
* identifying highly hazardous pesticides for withdrawal;
* taking regulatory actions to phase out the most hazardous pesticides, along with advice and training about low-risk alternatives;
* requiring data on human risk assessments, particularly in relation to acute toxicity when ingested, for national registration of new pesticide products;
* facilitating the registration and use of low-risk pesticides;
* strengthening inspection and other regulatory control;
* being aware of the conflicting agendas of different stakeholders;
* supporting research into safer alternatives to highly hazardous pesticides.
On the basis of studies done in the past, the latest WHO-FAO publication says that a series of bans on pesticides in Sri Lanka led to 93,000 fewer suicide deaths between 1995 and 2015 along with a 70 percent decline in suicides. Existing literature shows that banning pesticides did not affect crop yields in countries such as Sri Lanka, Bangladesh and the Republic of Korea. On the contrary, banning hazardous pesticides in these countries brought down suicides by self-poisoning.
Availability of cost-effective alternatives is essential prior to banning or severely restricting a pesticide in a country. Otherwise, it may result in illegal importation, production and use of the banned product, cautions the WHO-FAO publication. It suggests that the sale and use of "street pesticides" -- mixed unlabelled cocktails -- should be effectively policed as part of regulatory activity.
The Rotterdam Convention (1998) regulates international trade in hazardous chemicals, including pesticides, whereas the Stockholm Convention forbids or severely restricts the production and use of pollutants (including pesticides), which have been categorized as a persistent organic pollutant.
A recently published factsheet on suicide by WHO shows that a number of measures could be taken up to prevent suicide and suicide attempts, which include:
* reducing access to the means of suicide (e.g. pesticides, firearms, certain medications);
* reporting by media in a responsible way;
* school-based interventions;
* introducing alcohol policies to reduce the harmful use of alcohol;
* early identification, treatment and care of people with mental and substance use disorders, chronic pain and acute emotional distress;
* training of non-specialized health workers in the assessment and management of suicidal behaviour;
* follow-up care for people who attempted suicide and provision of community support.
Age-standardized suicide rate across countries
Chart-1 shows that the age-standardized suicide rate per lakh population (for both sexes) for the country has tapered down from 18.7 in 2000 to 16.5 in 2016. However, as compared to the other 14 countries suicide rate per lakh population in India was higher in 2015 and 2016.
Countries like Bangladesh and Pakistan enjoy lower suicide rate per lakh population (for both sexes) as compared to western countries like France, Germany, Netherlands, Norway, United Kingdom and the United States as well as other neighbouring countries like China, Bhutan, Myanmar, India and Sri Lanka. In some countries, the age-standardized suicide rate per lakh population has risen over the years such as the United States and Netherlands. Please consult chart-1 for details.
Please note that the age-standardized suicide rate is a weighted average of the age-specific suicide rates per lakh persons, where the weights are the proportions of persons in the corresponding age-groups of the WHO standard population.
Table 1: Age-standardized suicide rate (per lakh population) estimates for males, females and both sexes by country
Source: Suicide rate estimates, age-standardized estimates by country, Global Health Observatory data repository, World Health Organization, please click here to access
From table-1 it could be observed that the age-standardized suicide rate (per lakh population) for males has been higher in comparison to that of females in India during 2000, 2010, 2015 and 2016. In countries like Bangladesh, China and Myanmar, the age-standardized suicide rate (per lakh population) for females has been higher in comparison to that of males in the four different time points under discussion. Although suicide rate among females has been greater than that of males in Pakistan, that gap has reduced over the years.
The factsheet on suicide by WHO mentions that the availability and quality of data on suicide and suicide attempts is essential for monitoring purposes and for effective suicide prevention strategies. Since suicide is a sensitive matter and suicidal behaviour is considered illegal in some countries, under-reporting and misclassification are quite common for suicide.
In order to understand differences in the patterns of suicide across nations, and changes in the rates, characteristics and methods of suicide, the factsheet on suicide emphasizes the need for each country to improve the comprehensiveness, quality and timeliness of their suicide-related data. Such data could be gathered through vital registration of suicide, hospital-based registries of suicide attempts and nationally-representative surveys collecting information about self-reported suicide attempts. Most LMICs lack good quality data on suicide mortality, says a press release by WHO dated 9th September, 2019.
In India, suicide data is published by the National Crime Records Bureau (NCRB) in its annual publication ‘Accidental Deaths and Suicides in India’ (ADSI). The latest data on suicide is available for 2015 (which was released in 2016). A study entitled 'Suicide mortality in India: a nationally representative survey' by Vikram Patel and others had shown that the NCRB underestimated suicide deaths in men by at least 25 percent and women by at least 36 percent in 2010. Published in the prestigious Lancet journal in 2012, the study had found that almost 50 percent of suicide deaths were due to poisoning (primarily ingestion of pesticides). In comparison to urban areas, suicide death rates were higher in rural India on account of higher availability of pesticides along with poorer access to emergency medical care in those regions.
It may be noted that suicide mortality rate is an indicator of target 3.4 of the Sustainable Development Goals (SDGs) -- by 2030, to reduce by one-third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and well-being.
Preventing suicide: A resource for pesticide registers and regulators, released on 9th September, 2019, World Health Organization and Food and Agriculture Organization, please click here to access
Press release -- Suicide: one person dies every 40 seconds, World Health Organization, 9 September, 2019, please click here to access
Key facts: Suicides, World Health Organization, 2 September, 2019, please click here to access
Suicide rate estimates, age-standardized estimates by country, Global Health Observatory data repository, World Health Organization, please click here to access
Suicide mortality in India: a nationally representative survey -Vikram Patel, Chinthanie Ramasundarahettige, Lakshmi Vijayakumar, JS Thakur, Vendhan Gajalakshmi, Gopalkrishna Gururaj, Wilson Suraweera, and Prabhat Jha, and for the Million Death Study Collaborators, Lancet. 2012 Jun 23; 379(9834): 2343–2351. doi: 10.1016/S0140-6736(12)60606-0, please click here to access
Pesticide consumption a leading cause of suicides worldwide: Report -Rohan Gupta, Down to Earth, 9 September, 2019, please click here to access
Farm panel chief raises concern over sale of banned glyphosate herbicide, The Times of India, 6 September, 2019, please click here to access
RSS-affiliated body demands ban on glyphosate, PTI, Outlook, 30 June, 2019, please click here to access
Image Courtesy: Inclusive Media for Change/ Himanshu Joshi