Cultural, social, and medical equity could provide lasting solutions to Sri Lanka’s suicide epidemic

Following a decade of decline, Sri Lanka’s suicide rate – once amongst the highest in the world – is reported to be on the rise once again. It’s too early to tell whether this is a temporary blip or the beginnings of something more serious. But what is known is that the fall in the suicide rate was the result of ‘means restriction’ – chiefly sales restrictions placed on the most toxic pesticides – and not the result of falling levels of suicide attempts per se. In fact, the evidence suggests that the number of suicide attempts has actually increased in the same period, with suicidal behaviour remaining a leading cause of serious injury and death in youth and older persons in Sri Lanka.

The relationship between suicide and culture is one that suicidologists are beginning to take increasingly seriously. As suicide rates rise across the Asia-Pacific region, many experts are questioning the validity of prevention programmes developed for Euro-American contexts. While the methods by which people harm themselves or commit suicide might be universal, the reasons they give for doing so and the meanings they attach to them are always culturally specific. The thinking goes that if suicide is culturally variant, intervention strategies need to be culturally tailored: what works in one context might not work in another. This is also true in South Asia, where suicidal behaviours are very different to those in the West.

In the Euro-American context, many people understand suicide to be the result of deep-seated psychological illnesses like depression. When people feel suicidal or are suspected of being suicidal, they are referred to mental health specialists who might encourage them to follow a programme of therapy and, or, pharmaceutical treatment. Suicidal ideas and plans develop over a period of days, weeks, or even months. Family, friends, and health professionals have many opportunities to recognise the danger signs and intervene. People contemplating suicide might start hording medicines or talking about life after they’re gone; they might complain about being ‘trapped’ by circumstances beyond their control and of not knowing how to escape. Thoughts like these can be enough to encourage suicidal people to seek professional help or for others to encourage them to do so.

But in Sri Lanka suicidal behaviours tend to arise ‘impulsively,’ with little or no warning. Researchers working on suicide in the country, including psychiatrists, psychologists, and sociologists, agree that only a minority of suicide cases are linked with depression – somewhere between 10% and 40%, depending on who you ask. Instead, a family quarrel or sudden disappointment might cause feelings of overwhelming suffering, frustration, and anger, leading to the swallowing of poison as a public statement. Suicidal ideas and plans develop in a matter of hours or even minutes – leaving very little time for family or friends to see the danger signs and intervene. Because the idea of suicide arises very suddenly, people don’t have time to reflect on their thoughts and try to speak to someone before committing self-harm.

This difference poses real challenges for suicide prevention in Sri Lanka. It’s not clear when between the precipitating event and resulting act of self-harm interventions can be made. It’s also not clear what, beyond means restriction, might even be appropriate. Frontline mental health providers increasingly favour the prescription of anti-depressants, even though many self-harmers might not actually be depressed. Beyond this, there are currently several prevention programmes active in Sri Lanka, some run by government agencies and others by local and international NGOs. Many share the view that suicide is ultimately a mental health problem that can be tackled through counselling, or that ‘resilience’ to suicidal ideas can be imparted through life-skills training. Although these programmes are designed and run by excellent and committed professionals, the jury’s still out as to whether they can bring about lasting change.

A crucial problem is cost. Given the sheer size of the suicide and self-harm epidemics, the government would struggle to provide services at the scale and depth required. A blanket prescription of pharmaceuticals would be expensive and anyway likely to be ineffective. Local suicide prevention and mental health charities fail to attract funds from within Sri Lanka, and now the country has obtained ‘middle-income’ status international donors are looking to put their funds elsewhere. In the competition for resources, suicide – a difficult problem to solve in better circumstances – loses out to more ‘tangible’ health problems like cancer or diabetes.
But sustainability might be achieved if interventions are designed so they are culturally, socially, and medically equitable.

First, prevention programmes need to be designed with local meanings of suicide in mind – they need to be culturally equitable. Simply applying global solutions to a local problem is inefficient. Greater fit between how suicidal people understand the causes of their behaviour and how professionals respond to those understandings can reduce the risk of wasted resources and lead to better patient outcomes. In many cases this will require rethinking how self-harm is professionally defined in Sri Lanka, from its current designation as a mental health problem to one that takes into consideration its cultural roots. A rethink of this kind is not easy, and much work needs to be done. It calls for inter-disciplinary cooperation between health and social researchers and the maintenance of a dialog over time.

Secondly, prevention programmes need to avoid reproducing the inequalities leading to suicide in the first place – they need to be socially equitable. In Sri Lanka, suicidal behaviours are widely performed to bring attention to relational conflicts, often some kind of maltreatment or abuse. Typical examples include violence against children and women, attempts to control women’s bodies either sexually or in terms of women’s migration overseas. A large number of men’s suicides are performed in response to challenged masculinities. In these contexts self-harm offers an important – if risky – opportunity for communication when others aren’t available. Limiting that opportunity can mean limiting a person’s ability to bring about change in their lives. Health workers must honour their pledge to save lives but also to ‘do no harm.’ First aid treatment and the offer of psychosocial counselling shouldn’t end with returning patients to an abusive domestic environment. This will require greater cooperation between agencies, for example mental health and social services, so care between hospital and the community is streamlined.

Greater cultural and social equity can lead to enhanced medical equity. Faced with suicidal behaviours that don’t fit the textbook definition of depression, too many frontline medical staff try to deter future attempts by making first aid treatments unnecessarily painful. This practice isn’t limited to Sri Lanka, but represents a common misunderstanding that non-fatal acts of self-harm are ‘just cries for help’ by ‘attention seekers.’ But if instead recognised for what they are – as culturally meaningful practices transforming social relations between oneself and others – health and social service professionals will be better placed to respond with empathy and ultimately help suicidal individuals to a place where such drastic measures needn’t be taken.

Sri Lanka’s continuing suicide epidemic represents a major challenge. After more than five decades of world-high suicide rates, the time has come for a significant rethink in how self-harm is understood. If Sri Lanka rises to meet the challenge a sustainable and equitable solution to its protracted suicide epidemic might be found.

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