Dhaka, Bangladesh
Why are more Pakistanis taking their own lives?

Why are more Pakistanis taking their own lives?

Tanzeel Hassan

Draped in a red plaid scarf worn loosely around her head, 21-year-old Aasia* has just been shifted to the ward after five days in intensive care. Her skin looks pale and her legs are flexed. Even at 21, Aasia seems to have carried the weight of the world on her tender shoulders. And perhaps, this burden was all too much for her to bear: Aasia is in hospital after ingesting rat poison in an attempt to end her life. Standing beside her is an elderly man, her father, while her mother is sitting on a vacant bed next to her. "Aasia doesn't have any mental health issues," her father avows. The family has been lodged at the National Poison Control Centre (NPCC) at the Jinnah Postgraduate Medical and Dental Centre (JPMC) in Karachi ever since Aasia was brought in. The father simply doesn't understand how matters came to such a head. Being the only daughter remaining in the house after the marriage of her six elder sisters, he claims she is loved unconditionally. "She tried to end her life because her mother had taken her to task for cooking the food too spicy," he narrates. "She was making mistakes for the past few days while preparing meals for the family and was being criticised over that." Little did the parents know the toll such taunts were taking on Aasia. Fed up with the bickering, Aasia consumed poison. It took the family three hours to take Aasia to the NPCC, but luckily, they reached in time. The increasing number of suicide cases reported indicates is that there is a mental health emergency that remains unaddressed. On the extreme right to Aasia lies another young woman named Khizra* who attempted suicide by consuming insecticide. The 20-year-old was admitted to the hospital a few hours ago and is now stable after receiving the treatment. A small quarrel with her younger brother over ironing of clothes had made her feel worthless and convinced her to take her own life. Khizra ran and consumed insecticide soon after the quarrel was over, giving no time to the family to comprehend the situation. Her mother laments that children don't think about their parents when they resort to such extreme decisions. Aasia and Khizra are only two of the patients admitted at Ward 5 of JPMC. There are many other patients of both genders who have either intentionally ingested poison or are victims of venomous insect bites or stings. Dr Muhammad Junaid Mahboob, resident doctor at the NPCC, tells Eos that approximately 15-20 patients are admitted daily at the NPCC, many of whom consume poison deliberately in order to kill themselves. The number of patients brought in is surprisingly higher on weekends. While 98 percent of the patients of intentional poisoning survive, Dr Mahboob states that the survival chances depend on the type of poison, the amount taken, and the time it takes to reach the hospital. While poisoning is one of the three leading modes of suicide in Pakistan besides hanging and firearms, Dr Mahboob specifies insecticide and rat poison as the most-opted poisonous substances by people who attempt suicide. The other less-reported poisonous substances are phenyl and acids. Explaining the reasons of poisoning, he says, the most common problems reported by patients are loneliness, family quarrels, domestic violence, and interpersonal relationship issues. The NPCC, established in 1989 with the help of the World Health Organisation (WHO), treats patients of intentional and accidental poisoning. As routine practice, doctors at the centre recommend all suicide survivors to see a psychiatrist at Ward 20, Department of Psychiatry and Behavioural Science, when they are being discharged. Despite doctors' recommendation and the psychiatry ward being only a few metres away from the NPCC, Dr Mahboob believes that not many patients see a psychiatrist because they never accept they need professional help. "[Underlying] causes when left untreated increases the vulnerability to suicide risk after attempted suicide," he says. "Within the first six to 12 months following a suicide attempt, people are at increased risk of another attempt," corroborates Dr Murad Moosa Khan, president of the International Association for Suicide Prevention (IASP) and professor at the Department of Psychiatry, Aga Khan University. "Since these people have already experienced death closely, they are not afraid of dying anymore," he elaborates. "This persuades them to attempt suicide more aggressively." Trust and betrayal Most loved ones respond to suicide as something out of the blue. In reality, those thinking about suicide have been doing so for long. And in many cases, it's a pressure cooker inside those people's minds - in terms of helplessness and feeling overwhelmed - that has exploded and manifested as suicide or suicide ideation. That said, there is no single cause for suicide, states the American Foundation for Suicide Prevention. It occurs when stressors and health issues converge to create an experience of hopelessness and despair. Millions of women in Pakistan, for example, are constantly being told, by their spouses, by in-laws, and even by parents, that they are good-for-nothing; they are neither beautiful nor intelligent so much so that it kills their self-esteem and they gradually start doubting themselves. "This is called conditioning," explains Adeel Hijazi Chaudhry, CEO of psychiatric helpline Talk2Me. "We receive numerous calls from women plagued by self-doubt asking us whether they are really not good enough." Such situations tend to hurt a person's ego. If loved ones are questioning their existence, who does one find love and validation from? Such existential questions can, and often do, lead to an abyss, out of which there is no return. "More than the chemical changes in the brain, suicide is linked with the thoughts running in the brain. When a person is unable to find solutions to the problems and has lost the ability to control their thoughts, they resort to suicide," says Dr Khan. More than 90 percent of people who die by suicide have some form of mental illness at the time of their death. Dr Iqbal Afridi, dean of JPMC's Psychiatry and Behavioural Sciences department, argues that depression is one of the leading risk factors of suicide but other medical conditions, such as bipolar disorder and schizophrenia, can also contribute to it. Dr Khan implies that any change in behaviour or the presence of a new behaviour is a warning sign that should never be ignored. For instance, if a person stops receiving calls, starts avoiding people or going to gatherings, he should be reached out to understand what triggered this change. Warning signs indicate a person is in crises and needs immediate attention, whereas risk factors suggest someone is at increased risk of suicide, but not necessarily in crisis. Risk factors classified by the American Foundation for Suicide Prevention into health, environmental and historical factors, are conditions that increase the chances of a person attempting suicide. Establishing and identifying risk factors can improve the prevention and treatment of suicidal thoughts and behaviours. "According to a conservative estimate, nearly 15-20 percent adults and 10 percent children in Pakistan have some form of mental disorders. Some studies quote an even alarming number of 34 percent," says Dr Khan. The most common mental illnesses are depression and anxiety, but they either remain undiagnosed or untreated, and therefore, increase the risk for suicide. The uncertainty of numbers The WHO estimates that nearly 800,000 people die by suicide every year, making it a global phenomenon. Suicide, an act of killing oneself voluntarily and intentionally, is quite prevalent in low- and middle-income countries and is the second leading cause of death among young people (15-29 years of age). Although Pakistan is said to have lower suicide rates than other countries, the absence of official statistics makes these rates hard to determine. Suicide rates are described as the number of self-initiated, intentional deaths. Accurate collection of data on suicide is affected by a number of reasons, including whether a suicide is reported in the first place, how a person's intention of killing himself or herself is determined, who is responsible for completing the death certificate, whether a forensic investigation is carried out, and the confidentiality of the cause of death. Existing data [for official purposes] relies on reported cases. It follows, then, that existing data relies largely on reported cases, the number of unreported cases goes misrepresented and is not part of the official count. For each adult who dies by suicide, there may be 25 others attempting suicide, and 100 others struggling with suicidal ideation. "There are indications that for each adult who died by suicide there may have been 25 others attempting suicide and 100 others with suicide ideation," says Dr Afridi. If ever there was any doubt about the growing scale of this phenomenon in Pakistan, the numbers show it is slowly becoming an epidemic. "More than 13,000 people died by suicide in Pakistan since 2012, according to a WHO report on suicide prevention," states Dr Khan. "These are the latest statistics we know," he adds. Data generated by the Human Rights Commission of Pakistan (HRCP), an independent non-government organisation, also presents a grim picture. Based on the monitoring of leading newspapers and reports from volunteers, the HRCP estimates that more than 3,500 cases of suicide and attempted suicide were reported in 2017, over 2,300 cases were registered in 2016, while more than 1,900 cases were recorded in 2015. The WHO has also researched the extent of known suicide, suicide attempts and self-harm cases (reported to hospitals) and declared reported cases to be only the tip of the iceberg. The organisation claims that a majority of cases remain "hidden" under the surface and are never reported to healthcare services. The crude suicide rate in Pakistan, according to WHO Global Health Estimates 2016, was 2.9 per 100,000 population in 2015 and 2016. Although the WHO Global Health Estimates provides a comprehensive assessment of mortality for countries, these figures underestimate the actual magnitude of the issue, taking the legal, sociocultural and religious stigma, and poor reporting of cases in consideration. An associated matter in the Pakistani context is the issue of death certificates. Since a death certificate is mandatory to make funeral arrangements in urban areas, suicide cases are often reported to police and hospitals, but many family members don't opt for autopsy or forensic investigation due to religious and legal issues, hence the manner of death remains unknown, says Dr Khan. While in rural areas, where a death certificate is not a requirement for burial, he suspects that many suicide cases are hushed up. (To be continued)

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