Suicide, suicide attempts and pesticides: a major hidden public health problem.

In addition to its specific focus on self-directed violence, the paper by Eddleston et al. in this issue of the Bulletin highlights how intersectoral collaboration can be crucial to furthering the cause of public health. (1) With nearly 900 000 deaths from suicide every year, worldwide, (2) suicide takes more lives than homicides and wars combined; it is commonly acknowledged that this figure is an underestimation and that the real magnitude can barely be guessed. Added to these deaths are the many non-fatal suicide attempts, some of which are addressed by Eddleston et al. In the absence of national registries or reliable hospital-based systems for recording suicide attempts, a large-scale study was conducted by the WHO Regional Office for Europe to estimate the number of suicide attempts in several European cities of various sizes. (3) The findings were compared with corresponding national rates for completed suicides, and showed suicide attempt rates to be 10-40 times higher than rates for completed suicides. Projecting these figures to the global total of completed suicides would give the mind-boggling worldwide estimate of between 9-36 million suicide attempts every year. Whatever the real numbers, self-directed violence clearly constitutes a major public health challenge that health planners, policy-makers and practitioners simply cannot afford to ignore. Imprecision in recording efforts does not only affect the figures for suicide. For every real case of suicide that is misrecorded as something else (e.g. accident, stroke or cardiac arrest), another mortality category will be unduly inflated, thus distorting the entire system of mortality records. Individual studies on the reliability of suicide mortality recording have indicated that numbers of deaths may be underestimated by 30-200%. (W4) Reliable information on suicide mortality and suicide attempts is therefore not only useful for better planning and delivery of suicide prevention programmes, but will also help to provide a clearer picture of the mortality attributable to other causes, particularly those indicated above. Perhaps even less well understood is the specific link between suicide and pesticides, which is significant in rural areas generally and in Asian countries in particular. It is estimated that in the last 10 years between 60-90% of suicides in China, Malaysia, Sri Lanka, and Trinidad and Tobago were by pesticide ingestion. (W5) This led Gunnell & Eddleston to estimate that there are as many as 300 000 deaths each year from intentional pesticide poisoning in those parts of the world. (W6) More recently, WHO has received reports of a growing number of suicides due to pesticide ingestion in many other Asian countries and in Central and South American countries (e.g. Brazil, El Salvador, Guatemala, Guyana, Nicaragua and Paraguay). This may well mean that the global number of suicide deaths is considerably higher than currently estimated, and clearly makes pesticide ingestion the most common method of suicide on a worldwide basis. This new information provides clear indications of directions for action. …