No more taboos: Pakistanis must destigmatise suicides
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A few years ago, I heard about a young student in Pakistan on scholarship to a prestigious university, commit suicide. Being away from Pakistan, I could not learn anything beyond hearsay. He had apparently failed an exam, the consequence of which was losing his scholarship, and he didn't know how to tell his family.
Vexed by this terrible tragedy, I shared it with a fellow Pakistani, who responded, quite shockingly, not with sympathy but rather, with anger:
“Parents ka nahi socha. Dost nahi hongay aur koi solution nahi dhoondna aya.”
[He should've spared a thought for his parents. Probably didn't have many friends and wasn't able to find a real solution.]
The sheer ignorance in the above statement was jarring and shook me up. That is probably the day the topic of suicide became an area of interest for me and spurred me on a fact-finding mission.
Also read: Suicide and depression: Can we snap out of snap judgements?
The World Health Organisation estimates that around one million people die from suicides every year, the global rate being 16 per 100,000 population. On average, one person dies by suicide every 40 seconds somewhere in the world, accounting for 1.8 per cent of worldwide deaths. These rates have increased by about 60 per cent in the past 45 years.
Pakistan does not report its suicide data to WHO. The numbers here are vastly underreported anyway, due to the stigma attached with suicide.
The need to have more conversations about this public health concern is urgent. There has to be a sustainable solution for destigmatising suicide victims.
Thanks to Dr Murad Moosa Khan, Professor of Psychiatry at the Aga Khan University, there has been research and conversation on this important topic, and the information on suicide in Pakistan that follows, has been amalgamated from his published work and excerpts of talks at forums, such as T2F.
The facts
Unofficial, independent estimates put the annual number of those committing suicide in Pakistan at 6,000 to 8,000. To every completed suicide, there are 10-20 attempts.
Most of the suicide cases were reported from Sindh, followed by Punjab, with very few from Khyber-Pakhtunkhwa and Balochistan. That, however, may be a reflection of the poor reporting systems more than an actually low incidence of suicide in the latter two provinces.
A psychological autopsy (a well-established method of studying suicides) study showed that depression was the single most important primary factor in 100 suicides in Karachi. Secondary factors that were related to depression and suicides included domestic disputes, financial concerns and unemployment, amongst others.
The common methods of suicide in Pakistan are (in order of frequency) hanging, followed by poisons (including insecticides and pesticides), firearms, drowning, self-immolation.
The majority of those completing suicide were under the age of 30. Twice as many men commit suicide than women. The majority of those who completed suicide, both men and women, were married.
This is in contrast to data from the west, where marriage is a protective factor. In Pakistan, interaction with spouses, in-laws and fulfilling other social and cultural obligations, such as producing male heirs, appears to be a source of considerable stress.
Why is suicide such a big taboo?
It was difficult for me to understand why, even educated and well-to-do individuals who have had a plethora of experiences and exposure, respond to suicide with derision and judgement. The answer, perhaps, lies in the sociocultural, religious and legal constructs within the country.
Read on: Who is responsible for the two Pakistani teenage 'suicides'?
97 per cent of Pakistan’s population is Muslim and although we inherited the British penal system, much like India, there have been subsequent amendments rendering the current penal code a hybrid between Muslim and English law.
Per this penal code, suicide and parasuicide are criminal offenses (PPC 309 of the Criminal Procedure Act) punishable with a jail term and/or a fine of up to Rs10,000. By law, all cases of parasuicide should be reported to the police of the area where the person is a resident. Interestingly, India has the same penal code and is actively working on removing section 309.
In Pakistan, in an effort to avoid run ins with the police and face possible harassment these cases are kept quiet and help is sought at hospitals that do not report these as forensic cases.
Social constructs that focus on a woman’s marriage prospects conceal all evidence of mental illness, including suicide attempts and deliberate self-harm. Families in which someone has attempted or completed suicide, become social pariahs.
This stigma, unfortunately, keeps people from seeking help for themselves or their loved ones.
What needs to change?
The facts presented above are staggering and paint a dismal picture.
Policies and attitudes need to be changed on a macro level. The government needs to focus on decriminalising and reducing access to means such as firearms and poisons.
With the dearth of psychiatrists, primary care providers need to learn how to assess and treat mental illnesses and refer complex cases to psychiatry. Realistically, all of that will require time and concentrated dedication.
How can you help?
People resort to self-harm and suicide as a last measure – a cry for help, an act of desperation, perhaps an inability to see the light at the end of the tunnel of life, darkened by mental illness.
It’s important to remember that while social problems – the oft-cited reason for suicide – are widely prevalent in Pakistan, it is only a very small minority of those who are underprivileged and unemployed, who indulge in self-harm or suicide. The majority do not. Safe to assume, then, that the minority who do, may have developed mental health issues and may have poor coping and problem-solving skills.
The most important fact to remember, however, is that suicides are preventable.
There is help to be had, even in Pakistan. All major cities have mental health professionals and almost all medical colleges have psychiatry departments with trained professionals. There are also charitable mental health services with free or nominal charges.
So, if you know someone who is struggling, don't judge them or make fun of them. Instead, give them your empathy and support; they are quite capable of judging themselves negatively, they don't need your help for that.
Feeling this way is not a failure of faith. Encourage them to talk, encourage them to seek help and if you happen to feel suicidal, don’t be ashamed, don’t despair. There is help.
Special acknowledgements to Dr Murad Moosa Khan for lending the author an ear and providing guidance and insight for this blog.
Related:
Filza Hussain is a psychiatrist at the Mayo Clinic Health System in Wisconsin.
Her interests lie in suicide, psychosomatic medicine, personality disorders and cultural psychiatry.
