Suicide prevention Sri Lanka has made best improvements WHO data outdated
By Rathindra Kuruwita
Decisions taken by successive Sri Lankan Governments to control the availability of highly toxic pesticides have led to Sri Lankan suicide rates dropping by 70 per cent from the mid-90s where the number reached an all-time high said Dr. Duleeka Knipe, a researcher from the University of Bristol, who has done extensive work on suicide and self-harm in Sri Lanka, speaking to Ceylon Today.
You have done extensive research on trends in suicides in Sri Lanka. Can you start with an introduction to the work you have done?
A: I am an environmental epidemiologist at the Bristol Medical School and I have been working on suicide variables for the last six years. There have been two main components in my work. One has been looking at national suicide rates in Sri Lanka, over time, and looking at what has changed over the years. The other aspect of my work is looking at data collected as part of a large randomized trial in the North Central Province on introduction of safety storage devices for pesticides and trying to determine whether that can have an effect on reducing suicide rates. This is a large public health trial and the reason why they chose the North Central Province was because it is an area where pesticides are used regularly and where suicides were a particular problem. There is a lot of pesticide use and a historical precedent of suicide rates in the province.
What are the suicide trends in Sri Lanka? Your research seems to indicate that suicide rates here have dropped significantly, which is not the general perception?
A: I have looked at suicide rates in the country from the late 19th century. Up until the 1960s suicide rate was stable, at around 5 per 100,000 people older than 8 years, and then it started picking up from the 1960s. When there has been such dramatic change it's important to see why this has happened. So I looked at key dates in Sri Lankan history like independence and the civil strife, but none of these seem to have a correlation to this sudden increase. I also looked at whether unemployment rates, education, immigration or migration correlated but none of them did either.
What did correlate was the change in the use of pesticides. In the 1960s Sri Lanka was introduced to the green revolution and highly hazardous pesticide (HHP), were introduced for agriculture. With this the suicide rate steadily rose to 24 per 100,000 in 1976. The real rise in suicides began in 1977 when we opened up the economy. It is from then that the highly hazardous pesticide (HHP)were made much more freely available in the country with the relaxation of import restrictions. With this influx of highly hazardous pesticides, the suicide rate increased dramatically between 1983 and 1995 and reached a peak of 57 per 100,000 in 1995. And then Sri Lanka did some amazing things. On banning the most toxic pesticides, in the 1980s and 1990s the suicide rates dropped. When these bans were introduced we saw a dramatic reduction in suicide rates and from the year 1995, when we reached a peak in suicides, we have seen a 70 per cent reduction in suicides. Now that kind of a reduction has not been seen anywhere else in the world but no one talks about this. Most people in Sri Lanka don't even know that we achieved this.
You seem to suggest the main reason for the drop in suicide rates was the ban on the most toxic pesticides. What about the programmes the Government and NGOs carry out on suicide prevention, have they not had an impact?
A: The fact is that there are many factors that determine suicide. One thing we know is that the method people use to self-harm is a significant determining factor whether they will go on to die or not. If someone uses a method that is highly lethal, the person is more likely to die than if that person uses a less lethal method. Most people engage in self, harm with low suicidal intent, that is impulsive action based on an acute sense of distress, and they will often use the most readily available method. In the West, the most readily available method is medicinal products. But in rural Sri Lanka, the most readily available method is pesticides. So, by reducing the availability of highly toxic pesticides you reduce the chance of fatalities and that is one of the best suicide prevention methods, which has been shown worldwide.
Things like helplines, and the work of the Government and the NGOs have an impact, but the greater contribution especially in Sri Lanka, is the removal of the availability of the highly lethal methods. Sri Lanka has banned a number of toxic pesticides and now we might see the impact of improved mental health services and that might help in further reducing suicide rates.
When I heard that our suicide rates have gone down, I was quite surprised; because that's not the impression we have. We feel that things are getting worse and one of the main reasons is that we have got wrong data, for example the WHO Report, which stated Sri Lanka had the 4th highest suicide rate in the world?
A: You are right, Sri Lankan media has been quoting this WHO Report on suicide prevention, released in October 2014, where they have reported that the suicide rate of the country was 28.8 per 100,000 (male rate - 46.4 per 100,000 ; female rate - 12.8 per 100,000). The obvious consequence is that when people rank suicides worldwide they look at this data and say Sri Lanka has the 4th highest suicide rate in the world. That is basically incorrect and I have highlighted this in the articles I have written. When WHO released the Report I looked at how they got to this particular rate.
Now WHO has to use data that has been submitted to its observatory and Sri Lanka for some reason has submitted its last report in 2006. Now in order to calculate the rate for 2012 WHO uses statistical modelling to estimate what the number would be in 2012 based on the data they had previously. Now that would have been alright if the suicide rate in the country remains constant.
But there have been year-on-year declines in the suicide rate since the mid-1990s, so making estimates about the present using historical data means that your guess would be wrong. Unfortunately, the WHO has again estimated that Sri Lanka has the leading suicide rates in the world and that again is wrong. WHO country office in Sri Lanka, are on to it as the problem has been raised at the regional headquarters and the observatory that their estimates need to be reviewed. They need to do it urgently, because they are giving the wrong impression about a country that has made the best improvement on suicide prevention. So, that's one of the issues.
The other reason people feel like suicide rates are up because of the media reportage and social media. That gives an impression that the numbers of suicides are higher than it actually is. But primarily people have a wrong impression because wrong statistics have been used.
What are the most vulnerable groups in Sri Lanka for suicide?
A: In Sri Lanka the youth are vulnerable to suicide. Young women have the highest rate of suicide among youth. For men it's the older men that have a higher rate of suicide. 58 per cent attempts at suicide by women are made by those under the age of 35 and 54 per cent of attempted suicides by men who are less than 50 years of age. So you see that it's much more of an issue among younger women than younger men. When we look at the rate of suicides among young people compared to a higher income country, the rate of suicide is twice as much suggesting that they are more vulnerable. It's good to focus on young people because they are economically active and suicide is one of the most prevalent means of their mortality. But older men, as I mentioned, are also vulnerable and we must not forget about them.
Why are these groups particularly vulnerable?
A: I personally have not done a large-scale research on why young people suicide. You need a lot of detailed data to determine why and how often attempted, to identify why someone has Died by suicide. The researchers have to interview family members but that information might not be the most accurate, because family members most often might not know why a person has died by suicide. They often will report that a person has died by suicide because a romantic relationship has not worked out.
However, suicide is a complex interplay of many reasons. Not everyone who goes through a relationship breakup die by suicide, so you can't just say a person has died by suicide for one particular reason. Jeanne Marecek, of the William R. Kenan Professor of Psychology at Swarthmore College, has done a lot of research on young women on suicide and some of the things she speaks about are that Sri Lankan women are supposed to be more reserved, they are not supposed to express their issues and suicide and self-harming is a way of expressing their emotional distress. She has also highlighted the role of alcohol use of a family member and how that might have a role to play in suicide. So it's a complex interplay and it is very difficult to point out one or two reasons. So it requires a lot more detail and more research needs to be done to understand the causes of having higher rates of suicide among certain groups.
It seems that there are a lot of things that we are not aware of. Are people doing the necessary research to fill the gaps in our knowledge?
A: A lot of people are doing research; I know that there are people doing research in Galle, Kandy, North Central Province, Jaffna and I also assume that students are doing a lot of research.
However, most of this research is not available in the public sphere, which makes gathering evidence difficult. Anecdotally, I know that there are things that people are doing, but the problem is that in places like the North, where there is a high prevalence of suicide there are no recently published data.
There are groups that work to prevent suicides at the grassroots but often they are not in contact with researchers. What benefit can they gain from being in contact or working with researchers?
A: Researchers can and will help them understand whether they are getting the best out of their initiatives. They can also evaluate the work they are doing and if they find that their interventions are having an impact they can push ahead and if they find that their interventions are not having the impact they hoped for, they can rethink their approach.
What can the Sri Lankan media do to play a crucial role in suicide prevention?
A: Media needs to report on suicides but what we have found from research all over the world is that the way media, especially print media, report on the matter has a significant impact on suicides. If you explicitly report on the method, use pictures of the person who died by suicide and if you give suicide a prominent place in the paper, for example in the front page, that makes that attractive to certain vulnerable groups. If you report on suicide you must also include information on, particularly at the beginning or at the end of the article, about help available for people who have suicidal tendencies.
There was this celebrity suicide recently and what we know from research worldwide is that if the celebrity suicide is not reported properly it can lead to an increase in suicides and I am curious to see the rate of suicide after this celebrity death because it was not reported properly at all.
I think what needs to be done mainly is highlight how well Sri Lanka has done in suicide prevention because that is a major achievement. And going forward we need to have a multi sector approach and I would ask the Government to form a Presidential Task Force for Suicide Prevention, something that was there some time ago.
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