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Print version ISSN 0042-9686
Bull World Health Organ vol.87 n.12 Genebra Dec. 2009
Suicide in China accounts for about a quarter of all suicides worldwide. In contrast to western populations, in China more women than men kill themselves. It is a gloomy picture, but there are signs that the situation may be improving. Cui Weiyuan reports.
In the days leading up to her suicide attempt, Zhang Xihuan was becoming more and more depressed. An attractive woman in her mid-40s, Zhang scrapes a living by farming a tiny plot of land in the village of South Sanguanmiao, in Shandong province, supplementing her income by picking up coal that falls off trucks from the nearby mines. Having hepatitis B, she had found herself isolated in her small community. A recent boundary dispute with neighbours, after she built a house for her 25-year-old son, was adding to her anxieties. "We had to borrow because we ran short of money," says Zhang. "Before that we spent about as much money to treat my liver problems and the debt added up."
Financial worries. Health worries. Social stress. Things came to a head on 11 May 2009. Zhang ate dinner at around 4 pm, went out for a walk and returned home just after 7 pm. What she did next, she did without any kind of plan or thought for the consequences. She was acting purely on impulse.
Suicide in China accounts for 26% of all suicides worldwide: It is the fifth leading cause of death in the country overall along with injuries, poisoning and falls, and it is the leading cause of death for young women in China. People are two to five times more likely to kill themselves in rural areas than in cities. In contrast to western populations, the suicide rate in China is higher among women than men and this was highlighted in a World Health Organization (WHO) report Women and health: today's evidence, tomorrow's agenda released last month. It is a gloomy picture, but impulse suicides - that is to say, spur-of-the-moment decisions in which mood meets means - among women in the area may be on the decline, according to a 2008 study carried out in Shandong province by Dr Su Zhonghua, vice-president of the Daizhuang Hospital, Jining Medical School in the province.
"My statistics are collected from emergency rooms of five county-level hospitals. This does not count as an epidemiological study, so it is hard to say precisely whether the number of suicide cases has increased or decreased," Su says. "But in our interviews with medical staff of these hospitals, all almost unanimously believe the number has decreased over the previous three years."
Not all suicides are impulse-driven. In China, as elsewhere, people with mental illness are more likely to attempt suicide than the rest of the population. The stigma attached to schizophrenia - a severe mental disorder characterized by profound disruptions in perception and thinking, including delusions and hearing voices - can lead to isolation, as in the case of Dong Baoxin, a 30-year-old woman, whose mother (who also had schizophrenia) committed suicide the day after Dong got divorced. "She thought she had lost face," Dong says. "The next day, on 7 July, she hanged herself. When we saw her body in the morning, it was too late." Dong's husband divorced her because he was tired of paying her medical bills. After the divorce, he gained custody of their daughter and Dong went into hospital. "I miss my daughter. She is only five years old. Every day I wonder how she is." Dong's husband says it would be shameful if people knew about the child's "abnormal" mother.
In a study that included follow-up interviews, Su and his colleagues looked at 240 cases of attempted suicide in counties including Wenshang, Yanzhou and Jiaxiang in Shandong province. Su attributes the decline in part to improving social and economic conditions for women thanks to China's economic boom. "More and more [women] become migrant workers or make money on their own," says Su, noting that even women in economically dependent homemaking roles are becoming less confined as a result of changing social structures. He cites the departure of migrant workers from the area as an example. "The traditional tension within a rural family is alleviated as people of different generations no longer live together as long as they used to," he explains, adding that values too are changing. For example, according to Su, divorce has become a more acceptable way of dealing with family problems, including domestic violence.
Women may be less trapped than they used to be, but many difficult situations persist. Women like Chen Liping (name changed), a 40-year-old mother of one who is receiving treatment for manic depression at Daizhuang Hospital, carry not only the burden of maintaining a household and raising a family, often under the critical gaze of their neighbours, but must also work full-time to survive. Chen worked in a local wool textile factory before becoming a waitress in a restaurant, then took over the running of a Hot-Spicy-Hot food stand. She was hospitalized in June after her sister found her beating herself in the face with her shoes. Like Zhang, she has also attempted suicide.
Ironically, this crushing double burden of work results in shorter hospitalizations in mental health units for women than for men. In 2008, Su's hospital received 5224 female inpatients, who were hospitalized for an average of just over 28 days, whereas their 4992 male counterparts were admitted for more than 38 days. "Many female patients are [asked to be] discharged as soon as they show signs of recovering," says Su, often because they are needed at home: "Traditionally women play a more essential role in maintaining a family's daily life," says Su. "They cook, do laundry, take care of the children, etc., without which a family cannot function properly. Therefore their family often needs or demands them to be discharged sooner."
Of course it is precisely the kind of pressures that come with so much responsibility that lead to mental illness in the first place, and once an already vulnerable woman is sucked back into the grind of running a household, the desire for release returns. All that is required is the impulse and the means to satisfy it. Su recalls a traditional Chinese saying that there are three solutions to women's problems: "one - to cry; two - to scream; and three - to hang herself".
Zhang found the means for her release behind a staircase. It was in a bottle marked Yang Hua Le Guo - the name of a liquid pesticide, which she and her husband had bought seven years earlier to kill the pests damaging the cotton crop they were growing. At the time of her suicide attempt the couple no longer grew cotton but kept the pesticide anyway.
Yang Hua Le Guo is an organophosphate pesticide of a kind widely used in China. Organophosphates are of particular concern not only because they are often used in suicide attempts, but because exposure to them may actually increase the likelihood of a person developing a mental disorder. According to a recent study examining the link between organophosphate pesticide and suicidal ideation published in the October issue of the Bulletin of the World Health Organization this year suicide rates are higher in areas where organophosphates are used, while exposure is also a possible risk factor for Parkinson, and Alzheimer diseases. The report states that exposure to the chemical could also be implicated in the development of depressive and anxiety disorders, and in deaths ascribed to mental disorders. In 2006, WHO published a report on community interventions for safer access to pesticides and, in 2008, a document entitled Clinical Management of Acute Pesticide Intoxication to disseminate this information as widely as possible, particularly among policy-makers.
Pesticide ingestion was implicated in 62% of suicides in China between 1996 and 2000 (around 175 000 cases per year). When she grabbed the bottle behind the staircase, Zhang was doing what many women had done before her. "I don't know how I went to fetch the pesticide bottle," she says. "I must have lost my mind. I went there and swallowed a mouthful. Then I lost consciousness."
Fortunately for Zhang, after the attempt, people in her village were supportive . "After I was discharged, many villagers came to my home to visit me, bringing chicken eggs," she says. Since it happened, she has found ways to be positive about her life, including a renewed interest in her children's marriage prospects. As for the likelihood of future suicide attempts, she dismisses it out of hand: "It is too expensive," she says. "The hospitalization and urgent care cost us 13 900 yuan last time." She pulls out a bundle of receipts, shaking her head. "The rural cooperative insurance does not compensate you a penny if you attempt suicide."▪