Building capacity to address emerging problems in developing countries: intentional self-poisoning and pesticides.

If you mention the phenomenon of pesticide poisoning in developing countries to well-informed health advocates, it is likely that the 1984 industrial disaster in Bhopal, India, will come to mind. In Bhopal, a Union Carbide pesticide plant leaked 40 tonnes of methyl isocyanate gas into the environment, leading to at least 15 000 deaths over the next 20 years.1 What is not so well known is that intentional self-poisoning by pesticide ingestion has become an enduring epidemic that is estimated to result in 250 000 to 370 000 deaths annually, predominantly in Asia.2 This means that in some areas of the developing world, pesticide poisoning, including self-poisoning, is responsible for more deaths than infectious diseases.3 The World Health Organization (WHO) recently identified pesticide ingestion as the most common method of suicide in the world and stated that its prevention is a priority.4 However, this is one of the most convoluted issues for public health systems in developing countries and it remains poorly understood and largely overlooked. These problems are exacerbated by the difficulty in raising the profile of mental health in the global public health community. The importance of the factors that contribute to pesticide self-poisoning — the availability of the toxic agent and the impulsivity that leads someone to commit the act — is not fully understood across cultures, but pesticide ingestion may not be substantially different from self-poisoning behaviours in industrialized countries. One significant difference, however, is that pesticides are much more toxic than the medicinal and illicit drugs used most often for self-harm in industrialized countries,5 and survival in rural areas is further impeded because of limited access to effective treatment. Michael Eddleston, a leading investigator of the phenomenon, describes the situation in Sri Lanka like so: “In a moment of extreme stress — when the crops fail, when constraints and losses imposed by the war seem insurmountable, there are enough reasons at times — people just grab the nearest thing and drink it.”6 The nearest thing in such circumstances is often not prescription drugs but rather highly toxic pesticides, which cause muscle paralysis, respiratory arrest requiring ventilation, and injuries that result in long-lasting social, functional and economic problems for individuals and communities. The phenomenon has been investigated to a considerable extent in Sri Lanka. On the surface, a self-poisoning incident appears to be triggered by an acute interpersonal crisis, such as by a romantic partner or a dispute with a family member. However, the triggering crisis can also be the breaking point in an accumulation of frustrations linked to social factors, including poverty, lack of economic opportunities, and a sense of social injustice.7 To add to this complexity, community-based studies in Sri Lanka have found that self-poisoning is not always associated with a clear desire to end one’s life but, rather, with a variety of motivations, including shame, rage and a desire to frighten others.8, 9 It is thus conceivable that the combination of widespread availability of toxic pesticides, an environment lacking in opportunity, and the apparent normalization of self-harm as a response to stress may begin to explain the pervasiveness of self-poisoning in agricultural communities.