Following a £6.5 million donation to support the Centre for Pesticide Suicide Prevention, Director & Founder Professor Michael Eddleston looks back on almost 30 years of work to prevent suicides from pesticide self-poisoning.
*Warning: contains content about self-harm and suicide that some people may find upsetting. Use this link to find an international helpline – www.findahelpline.com*
It is now 26 years since I published my first paper on pesticide self-poisoning, describing it as an ‘overlooked tragedy’.
I had stumbled across this major global health problem – practically unheard of in global policy circles – almost by accident.
It all began in 1995, on the wards of a Sri Lankan hospital. At the time, I was a medical student, who had been invited to take part in a clinical trial for snake bites. However, it was a quiet summer for snakes and, instead, I found myself watching patient after patient being brought into hospital with pesticide or plant poisoning.
The sheer number of patients being admitted was a surprise, but what I found particularly startling was that most patients had intentionally poisoned themselves. Pesticides, it appeared, were a leading method of self-harm and suicide.
It quickly became clear to me that very few people actually wanted to die. Instead, self-poisoning was a method of dealing with situational distress or crisis. There was a 16-year-old girl who poisoned herself after being told she couldn’t watch television. Another, a 14-year-old boy, because his pet bird had died.
Despite this low intent to die, there was often little we could do to save them if they had used an acutely toxic pesticide. Time and time again, we saw patients die in hospital from fatal sudden respiratory failure or from uncontrollable seizures.
Unfortunately, in Sri Lanka’s rural farming communities, these deadly pesticides were widely available and stored around homes and gardens. It was this easy access to a lethal means of self-harm that was leading to so many unnecessary deaths.
The search for better treatments
At the time, and as a clinician, I thought there must be better ways to treat poisoned patients and stop so many people dying. This led to me becoming involved in a mix of projects and clinical trials in Sri Lanka.
Alongside my mentors, David Warrell, Nick Buckley and Ed Juszczak, I set up a cohort of self-poisoning patients to trial new treatments. This included clinical trials for activated charcoal and pralidoxime.
We also aimed to standardize initial patient care. We encouraged a move away from gastric lavage, often done before any medical assessment, which we knew could harm patients. Our study was able to show that gastric lavage was not needed when careful resuscitation, observation and supportive care was provided.
However, this work was not without its challenges, especially when our approaches differed from those of some local doctors. In 2003, due to personal conflicts in one of the hospitals we were working in, I was accused of killing a patient. The story was given to the national press and the trial shut down. Fortunately, five months later, we were permitted to restart the study because the patients and clinicians in the two other hospitals were keen for it to continue.
Ultimately though, our clinical work showed only modest success treating patients in hospitals. It soon made me realise that other public health approaches were necessary to stop people dying.
Pesticide bans: a more effective approach
When I first arrived in Sri Lanka in the mid-1990s, it had one of the highest suicides rates in the world. This was largely driven by deaths from pesticide self-poisoning.
In 2002, I met Gamini Manuweera – Sri Lanka’s pesticide regulator. He was also concerned about deaths from pesticides, but had a different approach to tackling the problem. He had been carefully implementing a series of bans on acutely toxic pesticides.
Soon, I began working with Gamini, supporting him in his work. I was the person on the ground, visiting pesticide shops, finding out which formulations were being sold, and feeding back to him.
What was clear from the data was that this approach was having a major impact on Sri Lanka’s suicide rate, which was falling rapidly. Overall, there was a staggering 70% fall in the overall suicide rate between 1995 and 2015.
Years later, Gamini’s work was recognised at the 2021 Future Policy Awards (referred to as the ‘Oscar on best policies’), where Sri Lanka’s pesticide regulations were awarded a special accolade.
This remarkable fall in deaths showed me two things. First, that government action to reduce the availability of lethal pesticides was highly effective in preventing deaths from pesticide self-poisoning. And second, that people weren’t substituting pesticide self-poisoning with other lethal methods of suicide, as it was the overall suicide rate (not just pesticide suicides) that was falling.
People were still self-harming with pesticides, but they were no longer dying. Instead, they were able to access support from mental health services and from within their community. Few people reattempted.
I became convinced that this ‘means restriction’ approach was by far the most effective way to prevent deaths from pesticide poisoning.
Lockable storage does not make pesticides ‘safe’
As a trained researcher, I was interested in exploring other ways to restrict access to pesticides, to see if they had a similar effect.
An approach that is often advocated by pesticide manufacturers (who would rather not have their products banned) is ‘safe’ storage of pesticides.
To put this to the test, with a close colleague Prof Flemming Konradsen, I set up a community-based trial in a rural area of Sri Lanka, working with an international research team. The trial ran between 2010 – 2016, with over 20,000 pesticide storage containers distributed across 90 rural villages (compared to 90 control villages).
Ultimately, the study found no evidence that household pesticide storage reduces or prevents deaths from pesticide self-poisoning in any way.
One explanation may be that storage is a very active form of prevention. It requires ongoing effort by the farmer to store pesticides away after purchase and use, keep keys hidden, replace locks when damaged or key lost, and to replace damaged containers.
These findings cemented my belief that pesticide regulation was the only truly effective way to stop people dying.
Launching the Centre for Pesticide Suicide Prevention
By mid-2010s, I had been working on the issue of pesticide self-poisoning for nearly 20 years.
Although most of my work had been in Sri Lanka, I had realised that it was a much wider issue, affecting vulnerable communities across South Asia, Africa, and South America. This made pesticide poisoning one of the most common causes of global suicide, responsible for 14 million deaths since the Green Revolution in the 1960s.
My research, and Sri Lanka’s achievements, had left me in no doubt that pesticide bans were the solution to the problem. There were similar stories of success in China, Bangladesh, and South Korea. Not only did the bans prevent deaths but, when implemented correctly, there was no evidence of any adverse impact on agriculture and food production.
What we needed now was impact – to move beyond research and put our findings into practice. I wanted to see Sri Lanka’s success replicated elsewhere. However, globally, there was no-one working on this.
Then, in 2017, the University of Edinburgh (my academic institution) received a £1.3 million philanthropic donation to set up the Centre for Pesticide Suicide Prevention (CPSP). The aim was to create an initiative specifically focused on identifying problematic pesticides and encouraging effective pesticide regulation worldwide. This was followed by a further significant donation in 2021.
CPSP works in low and middle-income countries, where pesticide self-poisoning is a recognised health problem. Importantly, we work in collaboration with national policy-makers, supporting identification of pesticides responsible for deaths and regulatory action to save lives.
Expansion and impact
CPSP now has a team of 30, including University staff and local consultants, based across five continents. We are working directly in ten countries, with further regional and international work.
We work with experts in health, agriculture, and the environment, bringing these different areas together to tackle the problem. Close partnerships have been formed with United Nations organizations, particularly the World Health Organization (WHO) and Food and Agriculture Organization (FAO).
There have been some key successes, particularly in South Asia. In 2019, Nepal banned five highly hazardous pesticides, specifically with the intention to reduce suicides. This decision was the direct result of CPSP research and engagement in the country. Further pesticide bans have also been introduced in India, Bangladesh and China, as a result of our engagement.
While our work in Asia remains a key focus, new partnerships have also allowed us to expand into other regions, including Africa and the Caribbean.
Renewed funding, ongoing challenges, and new opportunities
We are fortunate to have just been granted a further £6.5 million donation from Open Philanthropy, to fund CPSP’s core work over the next two years.
I am enormously grateful to Open Philanthropy for their continued support for CPSP. They have estimated that our work has led to between 15,000 and 30,000 lives being saved over the last three years. This is heartening and fills me with optimism; however, I am in no doubt that there is still much more to be done.
Achieving effective pesticide regulation takes time and effort. We need strong evidence to demonstrate the scale of issue and engage policy makers, which can be challenging in countries with poor surveillance systems. We also need to find a way to counter the false narrative that deadly pesticides are needed for food security and economic prosperity.
Where pesticides have been banned, ongoing research is needed to monitor the impact on both health and agriculture. Research so far has clearly shown that careful bans of toxic pesticides do not result in any drop in agricultural output.
We also need to see more international action, led by United Nations organizations.
Over the next two years, CPSP hopes to continue its work in regions and countries where we are already having impact. India is a particular focus for us, with more deaths from pesticide self-poisoning than anywhere else in the world, and we recently appointed a team of India-based policy officers to drive forward our work there. However, we would also like to expand, with more people on the ground in other priority countries.
With our existing expertise, there are opportunities to broaden our approach beyond suicides, looking at other health impacts of pesticides. This includes the effects of toxicity on child development. We realise that the withdrawal of highly hazardous pesticides from agriculture for the purpose of suicide prevention also produces other benefits – less pollution of the environment, less harm to sprayers, less likelihood of children being poisoned, and healthier children.
We also know that regulatory action on pesticides is influenced by agriculture and economic interests, as much (or perhaps more) than it is by health concerns. Further work in this area, exploring the benefits – both for the environment and the economy – of more sustainable farming methods, could therefore help to prevent the harmful health effects of pesticides.
However, this extra work would require even more funding and resource, an ongoing challenge for everyone working on global development in this current economic climate.
Optimism for the future
It has been a long journey from the medical wards in Sri Lanka to the thriving university centre. At times it has been difficult, and it is hard to forget those who have lost their lives, but I also feel incredibility optimistic.
While there is much more to be done, through the work of CPSP and progressive policy-makers, we have never been in a stronger position to tackle this global health problem and save a hundred thousand lives every year.
Professor Michael Eddleston
Director, Centre for Pesticide Suicide Prevention
Michael Eddleston is Professor of Clinical Toxicology at the University of Edinburgh. His research has covered the natural history of pesticide poisoning (ie. what happens after people ingest various pesticides), the medical treatment of poisoned patients, and strategies for prevention of deaths from pesticide suicides.
Further reading
BLOG: How pesticide poisoning became a global health problem