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BRIEF COMMUNICATIONS Table of Contents   
Year : 2007  |  Volume : 49  |  Issue : 2  |  Page : 117-120
Pesticide poisoning in nonfatal, deliberate self-harm: A public health issue


Institute of Psychiatry, 7 D. L. Khan Road, Kolkata - 700 025, India

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   Abstract 

Background: Nonfatal, deliberate self-harm (DSH), particularly with pesticides, is a major public health problem in many developing countries of the world. Agriculture is the primary occupation of most people living in the Sundarban region in West Bengal, India. Pesticides are extensively used in agriculture and these agents are most frequently used in DSH.
Aim: This study sought to identify the nature of methods and agents used in nonfatal DSH attempts in the Sundarban area under South 24 Parganas district of West Bengal.
Materials and Methods: Detailed demographic and clinical data on DSH cases of 13 Block Primary Health Centres (BPHCs') admission registers were analysed. Focus Group Discussions (FGDs) were conducted with the Panchayat Samithy of each block to elicit their perception about the problem of pesticide-related DSH or suicide in the region.
Results: Five thousand, one hundred and seventy-eight (1,887 male and 3,291 female) subjects were admitted in the BPHCs during the study period from 1999 to 2001. Organophosphorous pesticide poisoning was found to be the most common method (85.1%) in DSH. This emphasizes the importance of developing an urgent poisoning prevention program with a special focus on improving clinical services as well as initiating farmers' education programs focusing on safe pesticide practices at the primary care level.

Keywords: Community psychiatry, deliberate self-harm, pesticide poisoning, primary care, Sundarban

How to cite this article:
Chowdhary A N, Banerjee S, Brahma A, Biswas M K. Pesticide poisoning in nonfatal, deliberate self-harm: A public health issue. Indian J Psychiatry 2007;49:117-20

How to cite this URL:
Chowdhary A N, Banerjee S, Brahma A, Biswas M K. Pesticide poisoning in nonfatal, deliberate self-harm: A public health issue. Indian J Psychiatry [serial online] 2007 [cited 2019 Dec 13];49:117-20. Available from: http://www.indianjpsychiatry.org/text.asp?2007/49/2/117/33259


Deliberate self-harm (DSH), particularly with pesticides, is a major public health problem in the developing countries. [1],[2],[3] Some studies from India have reported similar findings, [4],[5],[6],[7] although documentation on this issue is often not available from very remote areas such as the Sundarban region in West Bengal, India. Sundarban is the largest delta in the world and famous for its mangrove vegetation and Royal Bengal tigers. Indian Sundarban is the southern most part of the state of West Bengal at the confluence of the river Hooghly and the Bay of Bengal.

The Sundarban region in the South 24 Parganas district has 13 community development blocks (CDBs). Each CDB has an average population of 1-1.5 lakhs (1 lakh = 10 5 ) and a nodal health service facility known as the Block Primary Health Centre (BPHC). Sundarban is a backward region by all yardsticks of socio-economic development. The literacy rate and per capita income is much lower than the state average and about 88.5% inhabitants are dependent on agriculture. Life in the entire region is subject to various ecological hazards. Coastal erosion, tidal ingression, sand encroachment and salinity of soil are the few factors that adversely affect agriculture. [8]

In the course of a previous mental health research study in the Sundarban region, the local community expressed concerns about DSH and suicide particularly with pesticides. To study the extent of DSH in the region, research was carried out in all the BPHCs of the 13 CDBs, viz , Basanti, Canning I and Canning II, Gosaba, Joynagar I, Joynagar II, Kakdwip, Kultali, Mathurapur I, Mathurapur II, Namkhana, Patharpratima and Sagar.


   Materials and Methods Top


DSH data: The research team made 3-4 visits to each of the 13 BPHCs between January and April 2002. Information on DSH was collected for the period from 01.01.99-31.12.01 from admission and emergency registers. Data on suicides and accidental poisoning was also collected which have been reported elsewhere. This article discusses the different types of agents used in DSH.

Participatory Research observation: Thirteen Focus Group Discussions (FGDs) were conducted with the Panchayat Samithy of each block. Their opinions about socio-cultural dynamics of DSH and pesticide use were collected. The Panchayat Samithy is the locally elected democratic body, which acts as the local administrative organ in the three-tier Panchayat system, responsible for implementation of all developmental work for the blocks including health services.


   Results Top


There were 1691 cases (male 579, female 1112) of DSH in 1999, 1775 cases (male 668, female 1107) of DSH in 2000 and 1712 cases (male 640, female 1072) of DSH in 2001. [Table - 1] shows the sex-wise distribution of all the combined cases (5178 cases: 1887 male, 3291 female) according to the BPHCs. The maximum number of cases was admitted in Joynagar I (1286) followed by Canning I (898) BPHC. Females (63.6%) inflicting DSH have a clear predominance over males (36.4%) in all the three years.

[Table - 2] shows the nature of different methods / agents used in DSH attempts. Poisoning, especially by organophosphorous pesticides, was the most common (85.1%) with a slight male preponderance (86.5%) over females (84.3%). The miscellaneous category termed 'Others' (Unknown Poisoning and Medicines like Sedatives, Homeopathic medicines etc.) comes next (6.5%) followed by household chemicals (3.0%) like kerosene, rat killer, lice killer etc. and indigenous poisons (2.7%) like oleander seeds, Datura seeds etc. Traditional methods like self-immolation (1.8%), hanging (0.8%) and drowning (0.2%) were attempted by very few subjects.

[Table - 3] shows the summary findings from the FGDs from 13 Panchayat Samities, which mostly highlight the issue of DSH with pesticide poisoning as an emerging public health problem in the region. They also endorsed the opinion that varied types of psychosocial stressors, especially among young married females are positively linked with suicidal behavior. All Panchayat Samities felt the need for greater empowerment of the Panchayat to supervise the local trade of pesticides along with imposition of stricter regulations on pesticide sale by the administration.


   Discussion Top


In many Asian countries, hanging, self-immolation and jumping from heights are common methods of self-harm acts. [9] However, in the present study, deliberate pesticide poisoning was found to be the most frequent method. Similar findings were reported earlier from Sagar island of the Sundarban region. [10] This study and the concurrent participatory observations in this region revealed some interesting findings that need attention. These are listed as follows:

Availability of pesticides: Agriculture is the main livelihood of people in the Sundarban region. However, Sundarban is well-known for its saline soil and varieties of pests and insects. An inverse relation was observed between the increase in population and a decrease in per-capita cultivable land in successive years. To compensate for the low yield of crops, aggressive use of fertilizers, pesticides and insecticides has been the general rule for the farmers in the region. This invites easy availability of different varieties of organophosphorous pesticides through an unregulated, open local market. Most of the farmers lack proper education about storage and use of these lethal chemicals. They keep pesticides carelessly in their home within easy access of other family members including children. There is also no control on the sale or purchase of pesticides. Numerous unregistered pesticide shops are available in the entire region. Pesticides are sold even from grocery shops in the villages. To cite an example, the small island of Sagar has 114 registered and over 210 unregistered pesticide shops. [10]

The present study found that 'unknown poisoning' was responsible for a good number of DSH cases. Unregistered shops sell various kinds of pesticides that are recognized only by local brand names, not by the chemical compositions. This causes a practical difficulty for the physicians at the BPHC to identify the poison and treat those poisoning cases. Thus, some restrictions and instructions for safe use and custody are imperative to reduce the burden of pesticide-related morbidity and mortality in the region. Restriction on the availability of lethal pesticides is now considered as one of the cornerstone approaches in suicide prevention. [11],[12],[13]

Psychosocial stressors and gender specificity: Reduction of psycho-social stressors constitutes an important strategy in suicide prevention in developing countries. [14] The number of female suicide attempters exceeded that of the male attempters. The FGDs with the Panchayat Samities revealed that different gender-specific causes are responsible for DSH attempts by females such as dowry demands, torture, mental and physical humiliation by the in-laws, derogatory behavior by alcoholic husbands or emotional or economic distress resulting from extra-marital relations of the husbands.

On the other hand, failure in examinations or love affairs and economic hardship were more common causes in males inflicting DSH. It is also stated that in most of the female attempters, there were no intentions to die; rather they used pesticides in a manipulative way to enforce threats on their family members to overcome distressing situations that they could not negotiate in a normal way. Examinations and interviews of many DSH cases in the field are consistent with this revelation. In this sense, DSH in some cases acted as a cultural mode of communication that followed the mechanism of hysterical symptom formation. The standard of living is very poor in the region and most of the families have some form of economic distress.

The dowry system is widely prevalent and dowry demand was one of the most important causes of familial conflict. An interesting comment came from an FGD with a Panchayat member of Namkhana block who admitted that self-poisoning by pesticide has become a fashion in the entire Sundarban region and this popularity of pesticides is fast replacing the traditional methods (like hanging or immolation) of self-harm in recent years. According to him, whenever people are subjected to some stressful life situations, they tend to ingest pesticide either to die or for a change (in the familial relationship dynamics) that is profitable to them. Meetings with pesticide shop owners revealed that quite often females or children went to the shops to buy pesticides as instructed by their parents. This type of practice also makes ready accessibility to lethal poisons even when it is not available in the home.

Lack of education on safe use of pesticides: Information regarding potential health hazards of pesticides is nonexistent in the entire area. Most of the farmers never use masks, gloves and eye-protectors while spraying pesticides in the field. Nonfunctioning and complete inattention of the local agricultural office in this regard is a serious drawback. It is felt that the easy availability of these compounds acts as a catalyst to facilitate self-harm among vulnerable subjects. Easy access to pesticide poisons was also found to be linked with DSH motives and high impulsivity. [5]

Agriculture is the most common occupation in our country and agrochemical pesticides were associated with high morbidity and mortality in the DSH cases, particularly from rural areas. [9] Therefore, an urgent intervention program is needed to reduce this preventable morbidity and mortality.

An intersectoral program involving local agricultural offices (for farmers' education on safe use and custody and health hazards of pesticides) and BPHCs (community awareness and psychosocial intervention) is the ideal goal for a community mental health program in this rural region. Restricted use and sale of pesticides, [15],[16] improved awareness regarding safe custody of pesticides, using less harmful compounds in agriculture, rules for banning unlicensed shops that sell pesticides illegally may all be effective and should be encouraged. Public health advocacy to prevent poisoning by indigenous substances like yellow oleander seeds is also warranted.

At the same time, improved hospital infrastructure for proper medical care of poisoning cases [17] and timely psychosocial intervention at the community level will be beneficial. The study has some limitations: 1) Canning II, Basanti and Gosaba show very poor documentation of data mainly because of improper hospital infrastructure in those remote rural areas, 2) Not all cases of DSH attended hospitals for various reasons. Therefore, the actual number is well in excess of what is recorded in this study.


   Acknowledgments Top


The authors thankfully acknowledge the fund provided by the State Health System Development Project, Government of West Bengal for this study and the academic input by Prof. M.G. Weiss, Swiss Tropical Institute, Switzerland.

 
   References Top

1.Phillips M. Suicide prevention in developing countries: Where should we start? World Psychiatry 2004;3:156-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Van der Hoek W, Konradsen F, Athukorala K, Wanigadewa T. Pesticide poisoning: A major health problem in Sri Lanka. Soc Sci Med 1998;46:495-504.  Back to cited text no. 2  [PUBMED]  
3.Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: A continuing tragedy in developing countries. Int J Epidemiol 2003;32:902-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Mohanty MK, Kumar V, Bastia BK, Arun M. An analysis of poisoning deaths in Manipal, India. Vet Hum Toxicol 2004;46:208-9.  Back to cited text no. 4  [PUBMED]  
5.Joseph A, Abraham S, Muliyil JP, George K, Prasad J, Minz S, et al. Evaluation of suicide rates using verbal autopsies, 1994-9. BMJ 2003;326:1121-2.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, et al. Suicides in young people in rural southern India. Lancet 2004;363:1117-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Srinivas RC, Venkateswarlu V, Surender T, Eddleston M, Buckley NA. Pesticide poisoning in South India: Opportunities for prevention and improved medical management. Trop Med Int Health 2005;10:581-8.  Back to cited text no. 7    
8.Chowdhury AN, Chowdhury S, Chakraborty A. Eco-stress, quality of life and mental health in Sundarban delta of India. Int Med J 1999;6:59-63.  Back to cited text no. 8    
9.Eddleston M. Patterns and problems of deliberate self-poisoning in developing world. Q J Med 2000;93:715-31.  Back to cited text no. 9    
10.Chowdhury AN, Sanyal D, Dutta SK, Weiss MG. Deliberate self-harm by ingestion of poisons on Sagar Island in Sundarban delta, India. Int Med J 2003;10:85-91.  Back to cited text no. 10    
11.Lin JJ, Lu TH. Association between the accessibility to lethal methods and method-specific suicide rates: An ecological study in Taiwan. J Clin Psychiatry 2006;67:1074-9.  Back to cited text no. 11  [PUBMED]  
12.Ohberg A, Lonnqvist J, Sama S, Vuori E, Penttila A. Trends and availability of suicide methods in Finland: Proposals for restrictive measures. Br J Psychiatry 1995;166:35-43.  Back to cited text no. 12    
13.Bowles J. Suicide in Western Samoa: An example of a suicide prevention programme in a developing country. In : Preventive strategies on suicide. Diekstra R, Gulbinat R, Leo D, Brill K. Leiden: The Netherlands.  Back to cited text no. 13    
14.Konradsen F, Hoek W, Peiris P. Reaching for the bottle of pesticide: A cry for help. Self-inflicting poisoning in Sri Lanka. Soc Sci Med 2006;62:1710-9.  Back to cited text no. 14    
15.Mann J, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: A systematic review. JAMA 2005;294:2064-74.  Back to cited text no. 15    
16.Nandi DN, Mukherjee SP, Banerjee G, Boral GC, Chowdhury AN. Is suicide preventable by restricting the availability of lethal agents? A survey of West Bengal. Indian J Psychiatry 1979;21:251-5.  Back to cited text no. 16    
17.Rihmer Z. Strategies of suicide prevention: Focus on health care. J Affect Disord 1996;39:83-91.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]

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Correspondence Address:
A N Chowdhary
HA 244, Sector III, Salt Lake City, Kolkata - 700 097
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.33259

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    Tables

  [Table - 1], [Table - 2], [Table - 3]

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