The high suicide rate in India has been discussed in medical literature and the media. The divergent frameworks employed to address the problem have resulted in a polarised debate and in a weak and disjointed response. The issues need to be re-examined and alternatives suggested.
The suicide rates in the western world are low compared to India. Western evidence argues for a high prevalence of mental illness in those who kill themselves, while Indian data suggest that many suicides are impulsive and related to stress, socio-economic circumstances, and interpersonal, social and cultural conflicts. Consequently, the proportion of people with mental illness contributing to the high suicide rate is small compared to the number of suicides secondary to stress and conflict. While distress secondary to life events and social circumstances can be re-labelled as depression using the medical model, it does not reflect severe mental illness. Ecological studies also show that the suicide rate may be linked to increased consumer price index, gross domestic product and to economic inequality.
Misery and mortality
The survival of the human body is best explained by the material explanation which locates the variation in health and longevity to tangible resources, property, income, housing and eligibility for government services. There is a direct association between material disadvantage and various indices of adverse psychosocial exposure. Consequently, both misery and material disadvantage are associated with poor health and they lie on the final pathway to suicide. However, changing psychosocial adversity without any change in material disadvantage is ineffective, and this fact mandates the need to address both issues simultaneously. The current lower rates of suicide in the west are due to better material resources, social security and health services which provide improved living conditions and better access to care, even for the poor and the marginalised.
Much of the suicide data examine univariate causal relationships without regard to the complex interaction between multiple etiological factors. Many of the risk factors associated with suicide are neither sufficient nor necessary for death by such methods. The search for simple answers has included recent strategies for pesticide storage where farmers in Sri Lanka have been given locked boxes to store pesticides. Preliminary results document unsafe storage practices at home and report poisoning and death. Pesticide storage approaches without regard to the basic economic issues related to globalisation, economic growth, livelihoods, personal, social and cultural aspects of the lives of the people, will be superficial and inadequate.
Prevention programmes will have to be eclectic as no single theory or framework can explain or provide effective interventions for all potential suicides. The challenge would then be to identify priority interventions.
The immediate interventions which could have a major impact on the current high rates of suicide include certain population interventions.
* Macroeconomic policies which protect sectors of the economy which are not able to face the sudden opening up of markets are mandatory. A phased and carefully planned changeover, keeping in mind the social costs, will be necessary.
* Schemes to meet the basic needs, which are basic human rights (for example, employment guarantee, health care, education, housing, water, sanitation) would be essential.
* Psychosocial interventions for communities aimed at organising local support groups within vulnerable sections of society for providing social support, advice on alternative approaches and on changing the culture which accepts suicide as an option out of personal misery, are needed.
* Capitalism, urbanisation, and migration have led to a breakdown in traditional support mechanisms, which need to be revived or replaced.
* India needs to develop and implement an essential pesticide list that excludes extremely lethal compounds, and regulate their formulation, packaging and sale.
* Addressing gender justice, violence, changing the culture which undervalues women and providing legal recourse for such problems on a national scale are required.
* The media should be recruited to fight stigma and discrimination related to mental illness and suicide and to argue for social justice. Responsible reporting of suicide is also necessary.
All these options will have to be applied simultaneously and with urgency to have any impact on the current suicide rates.
Interventions aimed at individuals, although useful in preventing individual deaths, may not have a major impact on national and population suicide rates. While strategies to manage people in distress should be pursued, their effect on reducing the overall suicide rate will be much less than any reductions that are achieved through population-based approaches, which should receive the significant proportion of funding.
Prevention and public health
Population-based interventions should form the core of all suicide prevention programmes. However, the list suggests programmes that raise the health of populations rather than being specific to preventing suicide. This fact supports the argument that an improvement in the general health and living standards of people will result in the lowering of suicide rates, in addition to meeting their basic needs and rights. There is little proof that “suicide prevention programmes” that target individuals have a major impact on population rates of suicide. Reductions in suicide rates reported in some countries have more to do with secular trends and improvements in living standards than specific prevention programmes.
In the developing world
National programmes for suicide prevention in the west usually argue for multifactorial approaches. Specific actions to be taken include the provision of employment and housing for people with mental health problems, mental health services for people with substance misuse and high risk groups. The high rates of suicide in India due to economic difficulties and social, cultural and interpersonal conflicts among people without known mental illness mandates a much broader approach involving whole populations. Macro-economic policies, social interventions, approaches to reduce gender injustice, a national pesticide list, and revised public education strategies using the mass media targeting the general population are necessary. Much broader approaches to suicide prevention are required in the developing world.
Public health agenda
The public health revolution in the west was part of a social reform movement. It occurred before medical interventions were invented. Progressive groups within the public health movement advocated reform on political, economic, humanitarian and scientific grounds. It involved many disciplines including engineering, economics, law, politics, sociology and religion. Viewing public health in general, and suicide in particular, as an individual or medical issue and suggesting individual interventions and psychiatric treatment reflects a poor understanding of issues. Employing urgency-driven curative solutions, mistaking primary care solutions for public health, and reducing public health to a biomedical perspective are the errors of the public health movement in the developing world.
Individual vs community
The current approaches tend to fix the responsibility for suicides on individuals. For example, in Sri Lanka companies that manufacture pesticides refuse to reformulate their compounds in order to reduce their concentration and lethality as this may interfere with their sales and profits. Multinational corporations sell in developing countries lethal compounds that are banned in the developed world. On the other hand, they are willing to fund programmes that encourage safe storage of pesticides in individual households.
Nations need to consider policies which regulate the formulation and sale of pesticides, rather than place the burden of safe storage and the entire responsibility of preventing suicide on individuals and the general population. Similarly, governments should review and reconsider policies which result in high suicide rates and poor health of populations. Restructuring economies are particularly vulnerable and demand protection. While such protection may be viewed as a financially retrograde measure in the short term, it will meet basic needs and human rights and will result in improvement in the health and longevity of populations.
Viewing suicide as a single phenomenon or even as a single final pathway is simplistic. Many diverse approaches, focussing on population interventions and tailored to the regional context, will have to be implemented simultaneously in order to produce any reduction in suicide rates for populations.
There is a need for formulations that clearly state the context, personality factors and vulnerability at the individual level, and social support, culture, and economics at the population level. De-emphasising medicalisation of personal and social distress and focussing on other underlying causes of human misery including poverty, unmet needs and the lack of rights is equally important. More pragmatic approaches, which move beyond the specific models of suicide and the narrow disciplinary perspectives, are called for.
(K.S. Jacob is on the faculty of Christian Medical College, Vellore. This article is based on a paper he recently published in Crisis, the journal of the International Association of Suicide Prevention.)