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CPSP: Bi-Annual Report

Working together to prevent suicide

I. Intro

September 2019 marks two years since the Centre for Pesticide Suicide Prevention (CPSP) was launched. The Centre is funded by an Incubator Grant from the Open Philanthropy Project Fund, an advised fund of the Silicon Valley Community Foundation, on the recommendation of GiveWell, USA. It was formed under the auspices of the University of Edinburgh and grew out of its founder’s work on suicide prevention in Asia.

Rural Sri Lankan health care, showing a doctor working in a small peripheral hospital in the 1960s. The painting also shows a pesticide sprayer in the right background, since DDT spraying had almost eliminated malaria in the early part of that decade.

Rural Sri Lankan health care, showing a doctor working in a small peripheral hospital in the 1960s. The painting also shows a pesticide sprayer in the right background, since DDT spraying had almost eliminated malaria in the early part of that decade.

II. Who we are/ What we do

CPSP aims to substantially reduce the number of pesticide suicides globally. It works in low and middle-income countries (LMICs) with local staff and national stakeholders to identify the most highly hazardous pesticides (HHPs) in use in these countries. CPSP reviews the situation with these pesticides, and funds and trains local researchers to identify the suicide, accidental poisoning, and environmental consequences of HHP use. It then works with government authorities, World Health Organization (WHO) and Food and Agriculture Organization (FAO) to support pesticide regulation, with the aim to ban or phase out HHPs that cause most harm to human health.

The problem

Pesticide poisoning is a major public health problem in agricultural communities in LMICs. People become severely ill and sometimes die from acute pesticide poisoning due to occupational exposure, unintentional exposure, and intentional self-poisoning. The latter form of poisoning is a major contributor to global suicide and the primary focus of CPSP’s work.
Pesticide poisoned patient in a hospital

75.5% of all global suicides occur in LMICs. In 2012, the South-East Asian and Western Pacific WHO regions accounted for 25.9% of the global population, but 39.1% of global suicides, respectively (WHO 2014). In these regions, pesticide suicides are particularly important. Overall, of the 800 000 individuals who die from suicide each year - one death every 40 seconds – around 19% (150,000) (WHO 2018) die from pesticide self-poisoning.

Most pesticide suicides follow ingestion of HHPs such as organophosphorus (OP) insecticides including methyl parathion, monocrotophos, or dimethoate. People die because they stop breathing, frequently before they arrive at hospitals where they could receive life-saving treatment. Others die from very difficult-to-treat poisonings from herbicides such as paraquat or fumigants such as aluminium phosphide.

Pesticide suicides may be underreported due to the stigma of suicide and the perceived negative consequences of reporting cases in countries where attempted suicide remains illegal. In addition, in many countries, data collection on suicide is difficult due to immature surveillance systems, making high quality estimates of suicide incidence difficult.

Toxic pesticides that harm peoples’ health and the environment are in widespread use in developing countries where the conditions of use significantly increase risks of exposure. The fact that many of these same pesticides are used as a means of suicide is tragic for the victims as well as their families and wider communities. We have to take these highly hazardous pesticides out of use to save lives, improve health and make farming safer and more sustainable. Mark Davis, Director for Agriculture and Regulatory Outreach

A clear barrier to pesticide suicide reduction in LMICs is a lack of human capacity for collection of data (for example, on the HHPs most commonly used for suicide) and effective pesticide regulation. Since countries may register a variety of pesticides, in formulations and under brand names that differ from other countries, each country needs to conduct its own assessment of which HHPs lead to most harm, although there are often lessons to be learnt from regional successes.

Reducing access to the means of suicide is an effective way to prevent pesticide suicides.

Means reduction, particularly reducing access to highly lethal means, is an effective strategy for suicide prevention. The WHO believes that many pesticide suicides can be prevented through restricting access to HHPs in rural small-holder LMIC farming communities (WHO 2016, Gunnel et al 2017). Improved government regulations to reduce the availability of HHPs has provided a highly cost-effective means to dramatically reduce pesticide suicides in South Korea, Bangladesh, and particularly Sri Lanka.

III. Accomplishments

In 2018, CPSP initiated work in Nepal, India, and Taiwan. All have substantial problems with pesticide suicides. In each case, the Centre developed project methodology and data collection forms and tools in collaboration with local partners. We have made contacts with stakeholders on the ground and are proud to work with dedicated and committed partners and community members.

In 2019, CPSP continued studies in Nepal and Taiwan. Our plan to work in India has now undergone significant changes.

“Sri Lanka’s pesticide regulations appear to have contributed to one of the greatest decreases in suicide rate ever seen.”

Michael Eddleston, The lancet Global Health

In 2014, WHO estimated that Nepal had the 7th highest suicide rate in the world (24.9 per 100,000), the 3rd highest for women (20 per 100,000), and 17th highest for men (30.1 per 100,000). The main aim of the project in Nepal is to markedly reduce the number of pesticide suicide deaths. The short-term goal is to identify the key HHPs used in Nepal as means of suicide.

The project is conducted in partnership with the Nepal Public Health Foundation. CPSP received the necessary institutional and ethics permissions in 2018. It started data collection on the cases and pesticides involved in poisoned patients presenting to seven hospitals in Kathmandu, Lalitpur, Banke, Chitwan, and Rupandehi districts of Nepal (Tribhuvan University Teaching Hospital, Bir, Patan and Bharatpur hospitals, Lumbini and Bheri Zonal Hospitals, and Pokhara Academy of Health Sciences). It started collecting information on the pesticides offered for sale in local shops and data from the police and national forensic toxicology labs on the pesticides involved in poisoned people who die before hospital presentation. These data have been analysed and presented to the Nepalese Registrar of Pesticides so that decisions about pesticide regulation can be informed. Nepal National Forensic Science Laboratory

After one year of data collection, following the advice from the Advisory Committee, the methodology was expanded to include a scoping review of the issue of pesticide poisoning in Nepal, legislation analysis and stakeholder interviews. CPSP’s staff have analysed pesticide legislative and policy framework in Nepal and published several newspaper articles (links: 1, 2, 3). Ongoing work includes a study on the legal status of attempted suicide in Nepal as well as pesticide management legislation and policy related to the incidence of suicide and pesticide suicide.

Hospital study

A retrospective quantitative study was done in the seven study hospitals for one year from March 2018 to April 2019. All patients with acute pesticide poisoning presenting to emergency department were included in the study.

The study identified 1145 pesticide poisoning cases. Females accounted for more cases (60%) than males while 52% resulted from self-poisoning. Fifty patients died (giving a case fatality [CFR] of 4%). The pesticide types responsible for most deaths were fumigants (34%) followed by insecticides (20%). The most important individual pesticide was the fumigant aluminum phosphide (30%), followed by the insecticides methyl parathion (8%) and a chlorpyrifos and cypermethrin combination product (8%).

The study showed the need for improved recording of poisoning cases, particularly related to the type and specific name of the pesticide and to the outcome.

Teaching hospital Nepal

Forensic toxicology study

Researchers also collaborated with the Nepalese national toxicology laboratories to access forensic toxicology data for one year (National Forensic Science Laboratory: Apr 2017 to Apr 2018; Central Police Forensic Science Laboratory: Jul 2017 to July 2018).

Data from the Nepal Forensic Science Laboratory showed 28% positive results for pesticide related suicide out of 336 samples received, with dichlorvos and aluminium phosphide being the most common pesticides used. Data from the Central Police Forensic Science Laboratory showed organophosphorus insecticides (19%) to be the most common pesticide class used for suicide followed by organochlorine (6%) out of 2387 autopsy samples.

Pesticide bans in Nepal:

Nepal has extensive experience of pesticide regulation to address health and environmental effects of pesticides. Most organochlorine insecticides were banned in 2001 removing many persistent organic pollutant (POP) pesticides from the country. In response to major suicide problems with methyl parathion and monocrotophos, these OP HHPs were banned in 2006. A difficulty with these acts of regulation is that both pesticides are legal in India and are smuggled across the border into Nepal.

Pesticide shop in Nepal

In 2019, the Pesticide Regulation Board took the decision to ban five WHO Class I pesticides still being used in Nepal: the OP insecticides dichlorvos and triazophos and the carbamate insecticides carbofuran, carbaryl, and benomyl. The decision is in the process of being published in the government gazette, at which point they should be withdrawn from agriculture.

Because our toxicology laboratory data indicate that dichlorvos is problematic for suicides, we are hopeful that this ban will have substantial effects on suicide numbers. As people switch away from HHPs to less toxic pesticides for self-harm, due to availability, the number of people surviving the event will increase, allowing them to get the support they need from family, community and health services.

Work Nepal

Aluminium phosphide has long been a problem for pesticide suicides in India and Nepal due to its formulation as a 3 g tablet of 56% purity. The fumigant is highly toxic, and this small amount is sufficient to kill. Unfortunately, the 3 g tablets are widely available and often (and easily) ingested in acts of fatal self-harm. In the late 1990s, India changed the formulation from the tablet to a loose powder which is less easy to ingest and less toxic after dilution in water. As a result, the proportion of patients dying in India appears to have fallen markedly, from over 50% to about 20% in one study.

The toxicology laboratory data indicate the importance of aluminium phosphide poisoning for suicide in Nepal. Following a presentation of these data to the Pesticide Registration Board by the project’s local principal investigator Dr. Rakesh Ghimire, and due to the work of a collaborator Dr Dilli Sharma, a decision was made in August 2019 to withdraw the 3 g tablet from use in Nepal. We again expect to see an effect of this ban on pesticide suicide deaths.

Aluminum Phosphide deregistration committee meeting

In India, our plan to collaborate with two hospital networks – Emmanuel Hospital Association (EHA) and Christian Medical College, Vellore (CMC) - on a hospital study has been revised with such a study no longer planned. Over the last year, CPSP has aimed to learn about the issue of pesticide suicide by speaking with key local experts (pesticide shop keepers, village authorities and government hospital staff).

At the invitation of the Government of Maharashtra, CPSP is developing a Technical Support Unit for acute pesticide poisoning, including pesticide suicides. This aims to work with government hospitals to increase the training of medical staff to treat pesticide poisoned patients. As part of this work, CPSP staff participated in post-graduate medical training in Yavatmal, Maharashtra, and Adilabad, Telangana, in Feb 2019. Pesticide poisoned patient

In 2018, CPSP was invited to provide an expert opinion on pesticide suicides to a Supreme Court public interest litigation case submitted in May 2018. The case concerned a request to adjudicate on the government’s delay in banning several HHPs as per the Malhotra Committee. The Centre’s submission was covered in the Indian press (links: 1, 2).

In August 2018, subsequent to the work of the Malhotra committee, 12 pesticides including several HHPs were banned with immediate effect by the central government. These pesticides include the key HHP methyl parathion as well as several other highly toxic compounds. Most importantly, six pesticides are scheduled to be phased out in 2020. This includes four really important HHPs, responsible for many hundreds of thousands of pesticide suicides in India and across Asia: dichlorvos, phorate, phosphamidon, and triazophos.

Sri Lanka

Sri Lanka’s pesticide suicide and overall suicide rates have fallen markedly over the last two decades due to the implementation of effective bans of highly hazardous pesticides. However, within rural regions where pesticides are widely used, pesticide suicides are still more common than all other forms.

Dr Manjula Weerasinghe has continued to work on pesticide suicides in the North Central Province. He has written up a study showing that the carbamate insecticide carbosulfan is now responsible for more than 50% of pesticide suicides, with profenofos in a distant second place.

We have provided these data to the Ministry of Agriculture and to a national commission looking at effective ways of addressing suicide in Sri Lanka. We hope that regulation of these two pesticides, plus perhaps the organophosphorus insecticide quinalphos, will make a further impact in reducing deaths from pesticide suicides in Sri Lanka.

A large study testing the value of providing lockable pesticide containers to households was finally finished and published in 2017. This trial definitively demonstrated that improving the household storage of pesticides did not result in a reduction in either cases of pesticide ingestion or of deaths from pesticide poisoning.

It has been cited by the WHO as the main publication that drove them to look at the cost effectiveness of pesticide regulation for suicide regulation, a piece of work that was posted for external consultation on 01 SEP 2019

This figure shows the complete lack of effect of improving household pesticide storage on the number of cases of pesticide poisoning presenting to hospital (comparing intervention areas which received the lockable container with control areas that did not).

Dr Weerasinghe welcomed journalists from the Telegraph (UK) and the BBC interested in Sri Lanka’s success in reducing suicides through pesticide regulation. An article was published in the Telegraph in early September. The BBC are working on radio and TV programs.

Dr Weerasinghe is now working on a large study testing whether helping pesticide shop keepers to identify people at risk of drinking pesticides - so that they do not sell pesticides to them - will reduce the number of people who buy pesticides for the act of self-harm (link). This study was funded by the American Foundation for Suicide Prevention.

Designed by / Freepik

In Taiwan, using CPSP funding, our partner Dr. Shu-Sen Chang at the National Taiwan University has studied pesticide poisoning and suicides by reviewing the medical notes of over 1,000 patients hospitalised with such poisoning. Analysis so far shows that paraquat is the leading pesticide used among both fatal and non‐fatal pesticide self‐poisonings in Taiwan. It accounted for 32% of hospital presentations and 79% of deaths, with a very high case fatality of 60% (60 out of 100 die), compared to 8% (8 out of 100) for poisoning with any other (non-paraquat) pesticide.

The Taiwanese government banned the import and production of paraquat from 01 Feb 2018 with a plan to completely ban its sale and use after two years (01 Feb 2020). This project will provide the baseline data to allow the effect of this regulation to be monitored and to inform suicide prevention strategies in Taiwan.

Bottles with pesticides, Taiwan.
Designed by lifeforstock / Freepik

South Africa

We are actively engaging with African countries to obtain data on the extent of acute pesticide poisoning and suicide on the continent.

CPSP’s project in South Africa is run in partnership with Professor Andrea Rother of the School of Public Health and Family Medicine of the University of Cape Town (UCT). In Nov 2018, Ms. Maxine Brassell started working with CPSP to coordinate the project research component. The project is focusing on investigating the prevalence of suicide and self-poisoning using pesticide in South Africa.

Laboratory of the Tropical Pesticide Research Institute, Tanzania The project started by initiating contact with the INDEPTH network Health and Demographic Surveillance System (HDSS) sites in South Africa to determine if their databases and verbal autopsy reports might hold pertinent data. These INDEPTH HDSS sites are all part of the Medical Research Council’s (MRC’s) South African Population Research Infrastructure Network (SAPRIN); Maxine has made contact with SAPRIN and is now working on how to collaboratively interpret the data held within its databases.
Report of our work in the Tanzanian newspaper

East African Countries

Dr Ayanthi Karunarathne is currently working to establish collaborations with organisations and individuals with access to verbal autopsy data from HDSS sites in Ethiopia, Tanzania, Uganda, Kenya, Malawi and Burundi.
Ayanthi has been able to establish collaborations with all 7 HDSS sites in Ethiopia, one site out of three in Uganda and the Malawi site. Some of these countries are not members of the INDEPTH network, but have verbal autopsy data from other surveys – such as SAVVY in Tanzania and in Burundi.

One of the difficulties encountered is that the current verbal autopsy format does not capture specific data on pesticide suicides. It only includes information on whether poisoning was involved in the death. The type of poison is not defined. There is a separate entry for suicides. Researchers therefore plan to look into the combination of both “poisoning” and “suicide” in the data base and then perform literature reviews to assess how many poisoning suicides are likely to be due to pesticides.

As a result of this project, CPSP plans to request the WHO subcommittee working on the Verbal Autopsy Form format 2020 to incorporate a separate entry ID on pesticide poisoning. Type of poison will be included under the section poisoning. If accepted, this change would make it easier to analyse pesticide suicide deaths in all the countries where verbal autopsies are carried out. Participants of the Pesticide politics in Africa conference in Arusha, Tanzania, TPRI

CPSP's other priorities

Finding out the situation with pesticide poisoning:

Forensic Laboratory in Nepal CPSP is working with interested experts, decision-makers, and other stakeholders on obtaining existing information on acute pesticide poisonings in their respective countries. CPSP is planning to engage with regional pesticide and agricultural authorities to explore ongoing regional approaches to addressing the problem.

Improving Pesticide Poisoning Treatment:

Pesticide poisoning is difficult to manage in resource poor hospitals that see most patients. Many patients die after presentation to hospital. CPSP is helping to develop treatment guidelines (protocols), taking into account local conditions and contexts. It participated in several trainings for medical personnel on pesticide poisoning management, including in Yavatmal (Maharashtra, India), Adilabad (Telangana, India), and Kathmandu (Nepal). CPSP is now developing a proposal to take to the WHO to develop global management guidelines for all cases of pesticide poisoning.

Human Rights mainstreaming:

Acute pesticide poisoning that affects mostly low-income people living in rural areas in LMIC is not only a health and environment problem, it is also a human rights violation. CPSP is engaged with human rights experts and institutions to raise awareness of the human rights issues associated with acute pesticide poisoning.

Acute pesticide poisoning more heavily affects low-income farming families and other rural communities. In its work CPSP approaches the issue comprehensively, taking into account inequality, vulnerability, stigma, and other social and gender factors that may exacerbate the problem. We talk about human rights such as the right to life, the right to health, safe environment and work conditions, gender equality, as well as the underlying social determinants of these rights in the context of HHP use. Leah Utyasheva, Policy Director

Awareness raising and community work

CPSP works with individual and institutional stakeholders such as government officials, parliamentarians, academics, and civil society actors to raise awareness of the neglected problem of pesticide suicides among the general public and the expert community. Our efforts to do that include working with local media and activities for the World Suicide Prevention Day.

The 2018 “World Suicide Prevention Day” on the 10 September was observed by our partners in India and Nepal. In India, it developed into a week-long campaign under the theme - ‘Working Together to Prevent Suicide’ - by Emmanuel Hospital Association under its eight hospitals across the seven northern states of India. The event was supported by CPSP.

Apart from these research implementing sites, other EHA units also organised events to mark the day. The main objective of this event was to collectively address the challenges presented by suicidal behaviour in society through awareness raising among the general community in rural India.

Event Activities were developed by unit hospitals themselves and included
  • Wall painting in the local community
  • An awareness raising programme with the skit play and rally at the village level
  • Observation and open dialogue with the important key stakeholders at unit hospital
  • A poster campaign at the block and district levels
  • Printing and essay competition for school children and young people

Other highlights included 60-person community consultation in Hebertpur hospital area and distributing Suicide Prevention Awareness Ribbon.

Media highlights and conference talks

Read - Criminalisation of Attempted Suicide in India.
Hinders Effective Suicide Prevention Response
During the last 2 years, CPSP’s staff have participated in conferences, given talks, and published newspaper and blog articles, as well as academic papers. CPSP’s director Michael Eddleston published 23 peer-reviewed articles addressing pesticide suicide and gave more than 30 talks on the issue.

CPSP and its collaborators published several newspaper articles in India and Nepal.

CPSP staff presented in conferences and workshops in London, New Delhi, Kathmandu, Geneva, Arusha. This autumn, CPSP’s staff will give conference presentations in Kathmandu (Nepal), Londonderry (Ireland), Miami (USA), and Kula Lumpur (Malaysia).

Michael Eddleston for the journal "Science", read more
CPSP's participation in conferences and workshops

IV. What we learned and plans for the future

We are expanding!

2019 has become a year of expansion for the Centre for Pesticide Suicide Prevention. We are happy to announce that starting from July, Mark Davis, a FAO expert with many years of experience in pesticide management came onboard as a Director for Agriculture and Regulatory Outreach. Starting from September, Ms Aastha Sethi will work as a Program Coordinator of the CPSP-Maharashtra Government Technical Support Project on acute pesticide poisoning.

During last two years CPSP has grown and learned a lot. We learned that underreporting depends not only on the fear of perceived negative consequences, but also on the strengths of local surveillance systems, including suicide recording and reporting.

CPSP realises that despite some highly hazardous pesticides being banned in both India and Nepal in 2018-2019, awareness of pesticide suicides and finding alternatives to the banned HHPs remain on high priority for these countries.

In the future, CPSP will continue working in its project countries and look for partners in other affected countries. Understanding the burden of pesticide suicide deaths in interested countries will be the initial step of our work. We believe that the next few years will bring us closer to achieving our mission and vision of reducing the numbers of suicide deaths globally, and decreasing the burden of acute pesticide poisonings in general.

Organisational chart