In April, both candidates in the race for President of the United States talked about the “woman card.” Donald said the Democrats were playing it. Hillary replied passionately, “Deal me in.” The ensuing discussion ranged on important topics from equal pay to health care, but we must now add one more.
The tragic CNN headline appeared the same week of the events above: “Suicide rates up,
especially among women.” The story was repeated frequently after a new report from the Centers for Disease Control and Prevention (CDC) reported that the age-adjusted rate in the United States was 24% higher in 2014 than in 1999, with the increase among non-Hispanic white females up by a confounding 60%.
We see every other disease going the other way, with significant declines in mortality for HIV/AIDS, heart disease and breast cancer over the last decades. This only makes the heartbreak more difficult that our efforts have not generated the same kinds of outcomes with suicide. Leaders in the field publically questioned to what degree more accurate reporting is a factor, as we struggle to comprehend.
Major Suicide Reductions in China
It’s a little uncanny, but we are living the exact opposite story from five years ago in China. It was 2011, and I was headed to Beijing for the World Congress of the International Association for Suicide Prevention (IASP). And, I was questioning whether their data could be real.
The headline at the time: “China’s Suicide Rate Has Declined Drastically.” In the early 1990s, 30 out of 100,000 individuals died of suicide in China annually, compared to 15 in 2009. Instead of 25% increased as in the US, China was reporting suicide was down 50%! And, again, central to the story and the primary driver in the reduction: a significant change related to women.
The 2010 Daily Beast blog “China’s Female Suicide Mystery,” explained the hardship on women in rural farmlands, and their strength and pride in withstanding suffering, sadness and stress, to “eat bitterness,” as they call it. “But every woman has her breaking point,” the author concluded in describing the only country in the world where the female rate of suicide was higher than their male counterparts (25% higher in the late 1990s).
I’ve written on the myth of suicide as a choice. People die of suicide when their supports, strength, resources, and hope utterly and completely fail. However, this idea has little meaning divorced from the concept of “acquired capability.” It’s been a little over a decade since Thomas Joiner’s Interpersonal Model of Suicide cracked and broke the foundation of what we used to believe about the causes of suicide. Essentially, “acquired capability” suggests that extraordinary intrapsychic emotional pain is insufficient. Dying of suicide requires that the person also has help.
The most powerful allies in suicide prevention are our own bodies and minds. Put simply, it’s extraordinarily difficult to harm one’s self because it requires breaching the human innate self-preservation security system. It protects us from threats, both external and internal. Our brain’s amygdala sends us frightening messages to warn us away from sources of pain and death. Our blood clots to stop leaks. Our body will even shut down and reboot, with unconsciousness as a way to restore breathing if required.
The difference in the US and China was the method and the means to short-circuit these natural defenses.
In the United States, a typical presentation during the late 1990s for a young woman in desperate emotional pain was an overdose and self-poisoning, with the most common substances being benzodiazepines, antidepressants, or paracetamol. After the attempt, the brain’s survival mechanism regains control and the person experiences ambivalence. Outreaching emergency medical services results in 98% of individuals being saved.
However, in the rural countryside of China during the late 1990s, a young woman experiencing a similar emotional hell had access to something much more deadly: a jar of organophosphate pesticide with product banned in many other parts of the world. Within a couple of hours of ingesting half a cup of toxic pesticide the individual dies, and there is no opportunity for reversing the course.
New and Unusual Partnerships
There was no getting around the obvious: a suicide prevention plan that did not incorporate a critical strategy for pesticides was not going to be effective. It was involved in 60% of Chinese suicide deaths according to the World Health Organization.
So, leading researchers in suicide prevention approached large companies that manufacture pesticides, like Syngenta. The ask was that they play an active role in reducing access, as opposed to blame and claiming they were directly responsible given the misuse of their product. The goal was partnership and material change.
The recent World Health Organization report “Preventing Suicide: A Global Imperative” was in part sponsored by Syngenta, who has also funded projects to increase the safe-storage of pesticides so that they would be unavailable to those in distress, and assess the toxicity of new formulations of paraquat, a widely used herbicide.
Three significant shifts have reduced the level of access to these deadly means. There have been governmental actions to prohibit certain types of pesticides that are the most deadly in several Asian nations, including China and Sri Lanka. And, a migration away from rural farm life to the large metropolitan areas has also meant that many women in emotional distress no longer have access. But, part of the success must be attributed to the pesticide companies who are funding and partnering on creating new solutions.
I traveled to China skeptical of the data around a drastic reduction in suicide death, and I returned from this nation of 1.4 billion people convinced that they had answers the United States should replicate. Hundreds of thousands of lives are being saved annually because individuals in enormous distress do not have access to a jar of deadly pesticide.
The Analogue for the United States
Half of suicide deaths in the United States are the result of firearms. Guns are clearly our pesticide. But, I’ve not been aware of any tangible efforts to replicate China’s success partnering with the manufacturers of the means. We’ve cast stones at times, but true efforts at partnership to date have centered on small gun shops or local firing ranges, and nothing has been taken to scale. Yet.
It’s just beginning.
In February, I spoke at a Zero Suicide in Healthcare summit in Washington State and had the privilege to spend a few minutes with the indomitable Jennifer Stuber. She is an associate professor of public policy at the University of Washington and co-founder ofForefront: Innovations in Suicide Prevention.
In her April Washington Post opinion piece, she described her initial awkward call to the National Rifle Association after her husband died of suicide. To her surprise, “they were not just willing to talk but also willing to listen.” These are individuals who have also been touched by suicide, and they had been like others in our society, including healthcare- they assumed suicide was inevitable for someone who “chooses” to die.
Jennifer describes an active year-long conversation with the NRA and the Second Amendment Foundation about saving lives in Washington State. And, they did what Syngenta and the World Health Organization did in 2007 to address pesticide and suicide. They convened a working group led by Rep. Tina Orwall (D) comprised of gun rights advocates and suicide prevention leaders.
The first result of this new partnership is a law signed by Governor Jay Inslee last month designed to reduce suicide deaths by firearm and overdose. Rather than mandating changes, the law focused on encouraging industry participation through incentives and will focus on gun dealers, shooting ranges, gun shows, pharmacies and drug stores. “There was strong backing by legislators on both sides of the political aisle,” Jennifer wrote.
Challenging the Status Quo
In China, reductions in the access to deadly pesticides meant that women were much less likely to die of suicide. In the United States, we are seeing a significant increase in suicide deaths, and firearms are increasingly involved with women. But, the new partnership in Washington State is extremely encouraging that our society is taking serious actions to reverse the disturbing trend.
The status quo is well known. “In the US, we cannot have a meaningful dialogue about guns and suicide.” We’ve said it again and again, but Jennifer Stuber and the NRA have proved us wrong in Washington State. “There’s too much self-interest for large manufacturers.” Today, Syngenta is cited as a key partner in the World Health Organization’s seminal report on suicide prevention, and they are creating better solutions that will save lives and have enormous potential to do so at a societal level.
Means matter, and we too in the United States can reverse our upward trend of suicide as we take bold steps and engage in new partnerships. Jennifer writes that the Washington state law “marks the beginning of a different way of talking about gun violence in America.” Staking out our common ground is hard work, but leaders in Washington State are simply getting started and moving forward.