Deliberate self-harm (DSH) is
defined as intentional self-injury or self-poisoning, irrespective of type of
motivation or degree of suicidal intent. This definition, which is used widely
in a similar way in countries in Europe and elsewhere, thus encompasses both
‘suicide attempts’ and acts with other motives or intentions.
Written
by Dr. Dipankar Chatterjee1
Introduction
Suicidal
behaviour, which encompasses non-fatal deliberate self-harm (DSH) and fatal
suicides, are serious public health problems in many countries of the world. In
2002, an estimated 873,000 people died by suicide, which represents 1.5% of
global mortalities and together with non-fatal deliberate self-harm (DSH),
intentional self-injury comprises 1.4% of the global disease burden.
Approximately 86% of the global suicides occur in low-and-middle income
countries particularly with pesticides. Deliberate
self-harm (DSH) is defined as intentional self-injury or self-poisoning,
irrespective of type of motivation or degree of suicidal intent. This
definition, which is used widely in a similar way in countries in Europe and
elsewhere, thus encompasses both ‘suicide attempts’ and acts with other motives
or intentions. This reflects the often mixed nature of intentions associated with
self-harm and
also the fact that suicidal intent is a dimensional rather than unitary
phenomenon. Self-poisoning is defined as
the intentional self-administration of more than the prescribed or recommended
dose of any drug (e.g. analgesics, antidepressants), and includes poisoning
with non-ingestible substances (e.g. household bleach), overdoses of
‘recreational drugs’, and severe alcohol intoxication where clinical staff
consider such cases to be acts of deliberate self-harm. Self-injury is defined as
any injury that has been deliberately self-inflicted (e.g. self-cutting,
jumping from a height).
Community
mental health research in the Sundarban region of India previously identified
widespread concerns about DSH and suicide, mainly because of pesticide
ingestion and the lack of effective treatment to prevent avoidable mortality.
Acknowledging the problem, a research for preventing suicidal behaviour was
carried out in the Sundarban region with a special focus on Namkhana block.
Context and Methods
The Sundarban is an area of active delta of the
river Hooghly at its confluence in the Bay of Bengal. It is the southern most
part of the state of West Bengal. The region is demarcated by the river Hooghly
on the west, the Bay of Bengal in the south, the Ichamati-Kalindi-Ramganga
rivers in the east and the Dampier-Hodges line on the north. Sundarban has been
declared as ‘World’s Heritage Site’. It is the largest delta on the globe in
the estuarine phase of the river Ganges and is a unique bio-climatic zone in the
coastal Bay of Bengal. But a state of chronic stress becomes the part of daily
life in Sundarban and in the struggle for survival. The blessings of goddess Banabibi (queen of forest) and Dakshin Rai (God of the tiger) are the
only available ethnic coping options to the people against these life
threatening ecological stresses.
A community cross-sectional study was conducted among 240
households in three villages of Namkhana to identify agriculture-related
pesticide practice, DSH and suicide in the community and the interactions
between pesticides and self-harm. The researcher made visits to Block Primary
Health Centres between January and April 2014. Information on DSH was collected
from admission from admission and emergency registers. Data on suicides and
accidental poisoning was also collected which have been reported elsewhere. FGD
were conducted with the selected gram
panchayat samity. Their
opinions about socio-cultural dynamics of DSH and pesticide use were collected.
Social Darwinism in Agriculture
Inaccessibility, poor-yield agriculture, constant
changing landmasses and hostile climatic conditions make this area one of the
most backward regions of the state. Lack of industry and very slow pace of
socio-economic development kept the majority of its inhabitants are land or
water dependent for their livelihood. Almost 89% of the people are agriculture
dependent on reclaimed land, which bears mostly single crop of paddy. Steady
decreases of landmass due to global warming by the tidal waves, inflow of saline
water into the fields and concomitant steady increase of population in
Sundarban makes agriculture a hard task of great endurance (Bandopadhyay,
1996). Decrement of effective land area, steady soil erosion by tidal rivers or
estuarines and creeks, the pressure of spreading human habitation and the
vanishing of forest area at remarkable speed – all have a cumulative delirious
influence on the agricultural climate of the region. Two facts of psychiatric
importance are apparent from this agricultural perspective.
Maximum crop production is a vital aim of the every farmer. To
increase the soil fertility and to protect the crops from different types of
insects (there are over 150 different species of insects in this region), heavy
use of fertilizers and insecticides is very common in this area. The deadly
poisonous pesticides (organophosphate, carbamates etc), dinitrophenolic
compound, bipyridiliums and anticoagulant rodenticides is available in
sufficient quantity in almost every households and this easy availability of
poison makes the impulsive suicidal attempts fatal specially in females. The
main reasons of familial disorder are husband’s alcoholism, husband’s
extra-marital relations and disputes over incestual relation in the family,
economic hardship, quarrel over land or land products or familial disputes etc.
Easy availability of lethal agents as a positive catalyst for deliberate
self-harm (DSH) in vulnerable subjects (Nandi et al., 1979). DSH mortality is
alarmingly high in this region and the data presented in the tables from
selected Block Primary Health Center (BPCH) of the region speaks the truth.
The
proportion between cultivable land area and adult earnable member in the family
is gradually decreasing and thereby all the member are engaged in the same plot
and thus causing unemployment. This no doubt a key factor in generating
economic status and coupled with a motivation of same members for equal sharing
of task act as a common factor that cause familial disputes of severe nature in
families.
Result and Discussion
In many Asian
countries, hanging, self-immolation and jumping from heights are common methods
of self-harm acts. However in the present study, deliberate pesticide poisoning
was found to be the most frequent method. This study and the concurrent
participatory observations in this region revealed some interesting findings
that are presented in the tables below.
Table 1: DSH data
from BPHC.
DSH Case
|
Male
|
Female
|
Total
|
Brought dead
|
5
|
10
|
15
|
Died at hospital
|
3
|
7
|
10
|
Discharged
|
40
|
74
|
114
|
Total
|
48
|
91
|
139
|
Table 2: Nature of DSH.
DSH methods of poisoning
|
Male
|
Female
|
Total
|
Insecticide
|
37
|
46
|
83
|
Rat-killer poison
|
1
|
5
|
6
|
Indigenous poison
(Yellow oleander seeds)
|
1
|
5
|
6
|
Copper Sulphate
|
2
|
--
|
2
|
Kerosene oil
|
1
|
--
|
1
|
Total
|
42
|
56
|
98
|
Table 3: Causes
of Death
Causes of death
|
Male
|
Female
|
Total
|
Burning
|
1
|
3
|
4
|
Hanging
|
2
|
1
|
3
|
Grand Total
|
45
|
60
|
105
|
The available
data suggest that acute pesticide poisoning is a major health concern in the
region. Still it is a wasteful and unnecessary to embark on activities which
purely seek to blame the agrochemical industry. It is recognized that
pesticides are primarily used for their beneficial effects but responsible
action must be taken to eliminate or minimize this DSH.
Factors Affecting DSH
Socio-demographic factors: Male commits
more suicide than female by self-poisoning. It was found that the
self-poisoning rate is high among the young (15-35 yrs) and the elderly (over
75 years). Divorced, Widowed and single people are at a higher risk than the
married one. Loss of job is positively associated with self-poisoning for
suicide. People who have moved from a rural to an urban area or to a different
region or country are more vulnerable to self-poisoning behavior.
Environmental factors: There are two
important environmental factors found to be highly related with such behavior –
Life stressors and easy availability of methods.
Life Stressors:
The majority of
those who commit self poisoning have experienced a number of stressful events
prior to suicide such as’
1.
Interpersonal problems (quarrels with spouse, family, friends, lovers).
2.
Rejection, separation from family and friends.
3.
Los events (financial loss, bereavement).
4.
Work and financial problems (job loss, retirement, financial stress).
5.
Social change (rapid political and economic changes).
6.
Threat to social prestige (shame and treat of being found guilty).
Easy availability of methods:
The immediate
availability of a method to commit self-poisoning is an important factor in
determining whether or not an individual will commit self poisoning. A glaring
example is easy availability of firearms in developed countries and
insecticides and pesticides in any developing countries like India. Reducing
access to the means of committing suicide by self poisoning is an effective
prevention strategy.
Health Seeking Behavior
In spite of quite a few government rural
hospitals in this region, people follow different types of health seeking
hierarchy according to their traditional mode of beliefs. The local medicine
man, ojha, magic healer, herbal
healer or the fortune teller makes the first line of health consultants and the
quakes (non-medical man who prescribe medicine) stand next. Obviously many of
the cases visit government clinics at a very late stage of the illness.
Ignorance, illiteracy, distance, lack of suitable alternative system and
poverty helps to flourish different categories of traditional healers including
quacks in the region who enjoy a good grip over the community in health and
distress. It is also evident that people never seek help to government clinic
without consulting them first.
Recommendations and Conclusion
The entire
sundarban area needs comprehensive psycho-social intervention coverage. A
community psychiatric approach addressing the community participatory technique
and field study should be launched to explore the different aspects of health
seeking behavior of the people, their illness condition, the stress generating
area and their modes of operation to tackle mental illness. A strong drive for
a preventive programme against self-poisoning and deliberate self harm, gender
exposition and alcoholism is an urgent agenda for this region. This research recommends the development of an
intersectoral programme linking the interests of the agriculture department,
local administrative bodies, the health sector and the community at large.
This
conjoint approach - by promoting awareness about safe pesticide practice,
developing alternative methods of pesticide use, sensitizing and encouraging
community supports to those vulnerable to DSH and suicide and improving medial
management of pesticide poisoning - would help to reduce morbidity and
mortality due to pesticide-related DSH and suicide in not only Namkhana but
also in similar settings in India and the world.
The available
data suggest that acute pesticide poisoning is a major health concern in the
region. Still it is a wasteful and unnecessary to embark on activities which
purely seek to blame the agrochemical industry. It is recognized that
pesticides are primarily used for their beneficial effects but responsible
action must be taken to eliminate or minimize this DSH.
Factors Affecting DSH
Socio-demographic factors: Male commits
more suicide than female by self-poisoning. It was found that the
self-poisoning rate is high among the young (15-35 yrs) and the elderly (over
75 years). Divorced, Widowed and single people are at a higher risk than the
married one. Loss of job is positively associated with self-poisoning for
suicide. People who have moved from a rural to an urban area or to a different
region or country are more vulnerable to self-poisoning behavior.
Environmental factors: There are two
important environmental factors found to be highly related with such behavior –
Life stressors and easy availability of methods.
Life Stressors:
The majority of
those who commit self poisoning have experienced a number of stressful events
prior to suicide such as’
1.
Interpersonal problems (quarrels with spouse, family, friends, lovers).
2.
Rejection, separation from family and friends.
3.
Los events (financial loss, bereavement).
4.
Work and financial problems (job loss, retirement, financial stress).
5.
Social change (rapid political and economic changes).
6.
Threat to social prestige (shame and treat of being found guilty).
Easy availability of methods:
The immediate
availability of a method to commit self-poisoning is an important factor in
determining whether or not an individual will commit self poisoning. A glaring
example is easy availability of firearms in developed countries and insecticides
and pesticides in any developing countries like India. Reducing access to the
means of committing suicide by self poisoning is an effective prevention
strategy.
Health Seeking Behavior
In spite of quite a few government rural
hospitals in this region, people follow different types of health seeking
hierarchy according to their traditional mode of beliefs. The local medicine
man, ojha, magic healer, herbal
healer or the fortune teller makes the first line of health consultants and the
quakes (non-medical man who prescribe medicine) stand next. Obviously many of
the cases visit government clinics at a very late stage of the illness.
Ignorance, illiteracy, distance, lack of suitable alternative system and
poverty helps to flourish different categories of traditional healers including
quacks in the region who enjoy a good grip over the community in health and
distress. It is also evident that people never seek help to government clinic
without consulting them first.
Recommendations and Conclusion
The entire
sundarban area needs comprehensive psycho-social intervention coverage. A
community psychiatric approach addressing the community participatory technique
and field study should be launched to explore the different aspects of health
seeking behavior of the people, their illness condition, the stress generating
area and their modes of operation to tackle mental illness. A strong drive for
a preventive programme against self-poisoning and deliberate self harm, gender
exposition and alcoholism is an urgent agenda for this region. This research recommends the development of an
intersectoral programme linking the interests of the agriculture department,
local administrative bodies, the health sector and the community at large. This
conjoint approach - by promoting awareness about safe pesticide practice,
developing alternative methods of pesticide use, sensitizing and encouraging
community supports to those vulnerable to DSH and suicide and improving medial
management of pesticide poisoning - would help to reduce morbidity and
mortality due to pesticide-related DSH and suicide in not only Namkhana but
also in similar settings in India and the world.
References:
Bandopadhyaya,
S. 1996 Sagar Island: Some environmental problems and man.
Visva Veeksha 5: 24-37.
FAO 1986 International
code of conduct on the distribution and use of
Pesticides. Rome,
FAO
Jeyaratnam, J. 1985 Health problems of pesticide usage in the third world.
British Journal of Industrial Medicine,
42:505-506.
Nandi, D.N,
S.P.Mukherjee,
G.Banerjee et al. 1979 Is pesticide
preventable by restricting the availability of lethal agents? A Rural Survey of
West Bengal. Indian Journal of
Psychiatry, 21:251-255.
1
Assistant Professor, RKMVU, Ranchi Campus
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