The medical journal, TheLancet has published a study today which should bring attention to a little known human tragedy which is being played out across our country. The research is based on the first national survey of the causes of death, conducted in 2001-03, by the Registrar General of India. Many people die at home in India, especially in rural areas, and without medical attention. As a result, their deaths, like many in the developing world, have no certifiable cause and are invisible to the public health system and society at large. This landmark effort of the Registrar General to systematically document the causes of death has transformed our understanding of why Indians die.
Higher in the South
The study has reported some startling findings with regards to suicide in India. Suicide rates in India are among the highest reported from any country. Suicide rates are much higher in rural areas, and in the southern states of the country. The fatality rates may be higher in India than in many western countries because the favoured method of suicide is the use of pesticides (in comparison to, say, taking an overdose of sleeping pills). Less surprisingly, the National Crime Records Bureau (NCRB) data, the only routinely collated national data on suicide, under-report between a quarter and a third of all suicides in men and women respectively. But perhaps the most important finding of all is that the burden of suicide falls disproportionately on India’s youth. Nearly 60 per cent of all suicide deaths in Indian women occur between the ages of 15 and 29 years, the corresponding figure for men being 40 per cent. Suicide is the second leading cause of death in young people of both genders and, with the falling trends of maternal mortality, is likely to become the leading cause of death in young women in the near future.
Unless, of course, the country takes action to stem this tragic tide.
The immediate course of action must be to recognise with urgency that suicide is a leading public health concern in India, in particular for young people. Policy actions need to address the causes of suicidal behaviour. The fact is that the high risk of suicidal behaviour in young people is a finding reported from many other countries and is likely to be related to the risk-taking and impulsivity which characterises this phase of life. In a nutshell, one is more likely to react to upsets in life in a risky and impulsive way during one’s youth. But this fact alone is not a sufficient explanation, for there still needs to be something which causes the person to become upset in the first place. While there are no nationally representative studies of the causes of suicide in India, a number of smaller studies, mainly from southern and western India, all point to similar findings of the risk factors which lead an individual to attempt suicide. In essence, social and inter-personal factors such as violence and disappointments in relationships, coexist with mental health factors, notably depression and substance abuse, as the leading determinants of suicidal behaviour.
Surveys
These individual level determinants, however, do not fully explain the dramatic regional variations in suicide in India. The new study findings show that suicide death rates were generally greater in the more developed southern states which have nearly a ten-fold higher suicide rate than some of the less developed northern states. This South-North gradient has also been observed by the NCRB, but has often been discounted as it was believed to be due to a reporting bias, viz., that the cause of death statistics were more reliable in south India. The new study has confirmed that these variations are, in fact, real. Further support for this concentration of the burden of youth suicide in southern India comes from the World Mental Health surveys whose site in Puducherry reported one of the highest rates of self-reported suicidal behaviours in the world. One is forced, then, to ask potentially sensitive questions about what contextual factors may be contributing to this dramatic regional variation. One possibility is that the higher rates of suicide in the more developed and educated communities of India may be attributed to the greater likelihood of disappointments when aspirations that define success and happiness are distorted or unmet by the reality faced by young people in a rapidly changing society where jobs may be higher paying but less secure and where social networking more accessible but loneliness more common. This might be pure conjecture, of course, but I cannot think of any more plausible explanation why a young person in a more developed society of India where health care, education and economic growth are relatively more advanced should be more likely to attempt suicide than a peer in a much less developed society of the country.
Irrespective of these questions, the fact remains that suicide is a leading cause of death of young people in India, killing twice as many people as HIV/AIDS and nearly as many women as maternal causes. However, unlike these two other conditions, suicide attracts little public health attention. Beyond the toll of deaths, we need to acknowledge that completed suicide rates may reflect only the tip of the iceberg; the majority of suicide attempts are not fatal and simply go uncounted. The vast majority of people in this country have no access to any of the evidence based strategies which are well-established to address the risk of suicide, from limiting access to lethal methods such as pesticides, addressing violence experienced by young people, building life skills and promoting mental health in schools and colleges, and improving access to treatment for depression and counselling for those who survive a suicide attempt. But, we must also be honest that the story of suicide in India is likely to be a complex one which needs further inquiry to address the bigger questions about the role of society and, in particular, social change, as a driver of this marker of hopelessness. If, indeed, social change is a driver of youth suicide, then we need to reflect on our model of development for the speed of change is only increasing, and spreading, across the country. In the end, suicide is perhaps the quintessential example of a health outcome in which society plays as crucial an explanatory role as medicine — and it will need a partnership between medicine and society to understand and address its toll.
(Vikram Patel is with the London School of Hygiene and Tropical Medicine, and Sangath, Goa.)
