1. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN Suicide with pesticides - a global public health problem Flemming Konradsen University of Copenhagen Pesticider i udviklingslandene sundhed og miljø, etiske problemstillinger og løsningsmodeller Århus Universitet

2. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 2 Scale of the Problem Approximately 300 000 death per year at global level from pesticide self-harm/suicides primarily in developing countries (Gunnell & Eddleston 2003) WHO now estimate that pesticides are the most commonly used means of suicide globally (Bertolote et al, 2006) Pesticides the most commonly used means of suicide in rural areas of Asia (e.g. 60% China - Phillips et al, 2002; 90% Malaysia - Maniam et al, 1988; 42% India - Aaron et al 2004); 71% Sri Lanka -Somasundaram & Rajadurai, 1995) but we fear for the future scenario in Africa!

3. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 3

4. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 4 Scale of the Problem Suicides will have major socio-economic and long psychological impacts on the families A burden on the intensive care units and hospital services The very high case-fatality from pesticide self- harm makes it difficult for the society and health authorities to target vulnerable individuals (people who repeat)

5. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 5 A case A 15 year old girl drank 20% paraquat after an argument and fight with her 11 year old brother… She told doctors she had not known it was paraquat and in her distress had simply grabbed the nearest bottle in the house and drunk it. She died from cardio- respiratory arrest 2 days after admission (Eddleston and Phillips 2004)

6. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 6 Why is pesticide suicide so common? Extremely toxic compounds have become easily accessible as agricultural systems change and pesticides are made available to even the smallest of farming households Easy access in the homes has great impact as most suicides are very impulsive, often linked with alcohol consumption or follows sudden emotional distress Alternatives to pesticides are far less lethal, less available or require more planning

7. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 7 Why is pesticide suicide so common? The capacity to manage poisoning case limited in most developing country settings The hundreds of chemicals sold makes the management very difficult Intake of alcohol and pesticides in combination makes case management even more difficult

8. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 8 Human toxicity of Organophosphate (OP) insecticides Eddleston et al unpublished

9. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 9 Pesticides as an underlaying cause of Suicide? Insufficient documentation to argue that pesticides increase suicidal behavior Pesticide availability will have some but minor impact on incidence of attempted suicides but will increase the overall mortality from attempted suicides

10. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 10 How to reduce the mortality from pesticide self-poisoning Short term (immediately!) Phase out all WHO class I pesticides Medium term Restrict the availability of the most hazardous/ difficult to mange WHO class II products Develop formulation of current pesticides that are less acute toxic Increase capacity to undertake case management Improve domestic and community level storage Restrict sale of pesticides via private vendors Support the establishment of community crises ”centers” Provide significant support to IPM and other farming systems that reduce the need for pesticides including new plant varieties Long-term Support community level activities to reduce alcohol misuse, school oppression, domestic violence etc. Support counseling and mental health services

11. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 11 Safe storage

12. DEPARTMENT OF INTERNATIONAL HEALTH UNIVERSITY OF COPENHAGEN 12 The End