IT claims more young lives than tuberculosis or road accidents. But it has been happening so quietly that almost no one has noticed. In China, and other parts of Asia, people are killing themselves in disturbingly large numbers. Since 1990, some 2 million Chinese people are believed to have committed suicide-equivalent to the populations of Washington DC and Manhattan combined.
No one knows for sure what underlies China鈥檚 staggering suicide rate, or even whether it has always been this bad. But one thing is clear: the pattern of suicide in this massive country is unlike anything seen in the West. Nor can the Chinese pattern of suicide be dismissed as an inconvenient exception to the norm. In 1990, the latest year for which reliable global data are available, China, with 22 per cent of the world鈥檚 people, accounted for more than 40 per cent of all suicides worldwide.
The differences are stark. Male suicides in the industrialised West outnumber female suicides by three or four to one; in China, female suicides outnumber male suicides, the only country in the world where this is the case. Among Chinese women aged 15 to 44 years old, as many as one in four deaths are suicides, compared with about one in ten in this age group in the rich West.
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Killing fields
Then there is the strange observation that, in contrast to Western countries, where suicide has come to be associated with city dwelling, suicide rates in China are about three times as high in the countryside as in the cities. And, finally, in the West most people who kill themselves are thought to be suffering from severe depression or other mental illness. But whether mental illness is also responsible for most suicides in China is hotly debated.
These differences are providing some much-needed clues about the causes of suicide in the East-and will force psychiatrists everywhere to rethink some of their favourite notions about which people are most likely to kill themselves, why and where. 鈥淏ecause the characteristics of suicide are different in China, they seem to throw into doubt some of the [Western] theories about suicide,鈥� says Michael Phillips, a Canadian psychiatrist and epidemiologist based at the Beijing Hui Long Guan hospital, on the city鈥檚 outskirts.
The new estimates for suicide rates in China are one of the fruits of a ground-breaking study of global health trends by epidemiologists and health economists at Harvard University and the WHO. When it was published last autumn (This Week, 14 September 1996, p 4), the figures came as a shock. 鈥淣obody knows about this, it鈥檚 just incredible,鈥� says Phillips.
Dragon鈥檚 share
China may have the dragon鈥檚 share of the Asian suicide problem, but it is certainly not alone. All along a ragged band from Sri Lanka to China via Hong Kong and Taiwan, people are killing themselves at high rates. The region is gaining an unenviable label-the Suicide Belt. The worst hit is Sri Lanka, with around 36 suicides per 100 000 people per year, though the absolute number of dead remains far smaller in a country of just under 18 million than in the massive China. There the suicide rate is estimated to be 30 per 100 000 people per year. That compares with between eight and 12 suicides per 100 000 people per year in Britain, the US and Australia.
With the shocking new figures has come some much-needed action. Suicide in China and other Asian countries will be high on the agenda this week at the congress of the International Association for Suicide Prevention in Adelaide, Australia. And Befrienders International, the umbrella organisation for the Samaritans, is helping to set up suicide prevention groups across China.
China is also tackling the issue head-on. A major five-year study into the causes of suicide and accidental deaths in 24 communities around the country is just beginning, headed jointly by Phillips and Yang Gonghuan, an epidemiologist at the Chinese Academy of Preventive Medicine in Beijing. The task will not be simple. West or East, suicide is notoriously difficult to analyse. 鈥淭he problem,鈥� says Rachel Jenkins, a psychiatrist and epidemiologist at the Institute of Psychiatry in London, 鈥渋s that there鈥檚 official and unofficial suicide.鈥�
For example, in some countries, the official figures are skewed because suicide is illegal, or-particularly in Catholic countries-heavily stigmatised, forcing relatives to lie about the cause of death. And many developing countries do not even attempt to record causes of death for large proportions of their populations. So although the industrialised countries have gradually improved the accuracy of their estimates, the raw numbers give a global picture of suicide that is as distorted as the one you see in a fairground mirror.
To get round those problems, Chris Murray and his colleagues at Harvard University and the WHO used the patterns of death from a Chinese system of data collection that provides reliable data for a representative sample of the population. To the number of recorded suicides, they added a percentage of the accidental deaths whose cause was unknown. The percentage was based on the proportion of accidental deaths of known cause that are suicide. The next stage was to extrapolate from these figures to the rest of the Chinese population. The final results were up to a third higher than the original figures published by the Chinese authorities. Jenkins, who until December was the principal medical officer for mental health at Britain鈥檚 Department of Health, says she is 鈥渧ery impressed by the painstaking nature of the work . . . [It] has convinced me.鈥�
As for theories about suicide, the new findings challenge decades of research. Since the 1950s, studies from the US, Britain and other European countries have found that as many as 90 per cent of people who kill themselves are suffering from serious psychological illness, mainly severe clinical depression and bipolar affective disorder-the condition that used to be known as manic depression. In Britain, about one in six people with severe mental illness eventually kill themselves. 鈥淩ational suicide is so rare as to be almost nonexistent,鈥� says Jenkins. The main exception to that generally accepted rule is that drug abuse and personality disorders also contribute significantly to suicides among teenagers and young adults in the West.
Of course, Western theory about what triggers suicide has to include other predisposing factors besides depression, not least because depression rates are relatively similar the world over while suicide rates vary dramatically from one industrialised country to another. And there is tantalising evidence that some social changes go hand in hand with increased suicide rates: for example, higher rates of unemployment and the increasing fragility of marriage and other family relationships have coincided with an increase in rates of suicide in younger European men over the past twenty years or so.
Some experts on suicide argue that urbanisation is also bad for your mental health. As long ago as 1897, the French sociologist Emile Durkheim argued that people are more likely to commit suicide if they live in loosely integrated, urban settings where individuals are 鈥渁lienated鈥� from society. Gradually, the view that cities are hotbeds of alienation, isolation, and consequently suicide, has become a given among health workers and social scientists with relatively little data to back it up.
But suicide in China seems to break all the rules. First, the link between mental illness and suicide is far more controversial inChina. Phillips believes that as few as 50 per cent of Chinese people who commit suicide may turn out to be suffering from diagnosable depression or other mental disorders at the time.
Unhappy families
Phillips speculates that social stresses may play a far larger role in suicide in China than they do in the West. Young women make up a disproportionately large number of the suicide victims in China. Phillips argues that social pressures that barely exist in Europe and the US, such as being confined to unhappy marriages, keeping the lid on sexual indiscretions, living with a constantly critical mother-in-law, or money problems-sometimes caused by gambling, an extremely popular pastime in the countryside-simply become intolerable to them. Others speculate that China鈥檚 one-child policy and all its social ramifications adds to these pressures-but for now, the absence of data is crippling.
Unhappy families certainly seem to weigh heavy on the minds of the suicidal in Shanghai. Of the 8000 callers who phoned the city鈥檚 Hotline for Mental Health over a two-year period, most wanted to discuss problems with lovers and partners, according to one analysis. Among unmarried callers half requested help with problems related to a love affair. Among married callers, more than half were having 鈥渕arital disputes and family problems鈥�. Still, Phillips鈥檚 views do not entirely square with those of others. Andrew Cheng, a psychiatrist at the Academica Sinica in Taipei, Taiwan, who has studied suicide on the island, says that it is nonsense to suggest that depression is rarer in Asia than in the West, or that the fundamental causes of suicide are different. And he has some data to back up his view.
In the early 1990s, Cheng studied suicide in three different ethnic groups-two aboriginal Taiwanese populations and the Han Chinese-in east Taiwan. At least 97 per cent of those who committed suicide during the study period had a history of mental illness, with depression and alcoholism being the most common. He reported his findings in the Archives of General Psychiatry in 1995. 鈥淭he psychiatric antecedents of suicide are the same in the West and the East,鈥� he argued. Deciding whether he or Phillips is right will depend on getting better estimates of the prevalence of depression in China, as well as the outcome of the Beijing study.
Another mismatch between West and East is the relative scale of suicide in the countryside. With rural rates of suicide that are fully threefold those of the cities, in China at least, the rural idyll appears an ugly myth. In another Taiwan-based study, Cheng has found that urban women were less likely to be depressed than rural women, and argued that the century-old notion that cities are bad for mental health is 鈥渕isleading鈥�.
But there are other possible explanations for the different patterns of suicide in China besides social stresses and rural living. The nation鈥檚 high rates might reflect a greater acceptance of suicide by Chinese society. The country certainly has a history of honourable suicides in the military at least, and in some interpretations of Confucianism, an honourable death is better than a life without honour. Still, Buddhism is generally intolerant of suicide, and some aspects of Confucian thought are too. Alternatively, it may simply be too easy to commit suicide in China. Where rates are highest in the countryside, the most common method of suicide is swallowing insecticide, which is found in the majority of homes. In the West, suicide rates have fallen every time a tried and tested method of suicide has ceased to be readily available-for example, when North Sea gas replaced the more toxic coal gas in Britain. All eyes are now on Australia to see if the suicide rate will drop after strict gun controls were introduced last year.
Another practical difference between West and East is the speed and ease of access to medical treatment. In most countries, attempted suicides vastly outnumber 鈥渟uccessful鈥� suicides. In England, for example, the 5500 successful suicides committed each year are dwarfed by the 100 000 unsuccessful attempts. Although there are no data on 鈥渁ttempted鈥� suicides in China, Yang and Phillips suspect that they may be relatively less common.
One explanation for that discrepancy, and one that Phillips and Yang intend to investigate in their study, is that a significant proportion of those who die in China do not intend to kill themselves. Medical professionals in the industrialised West are skilled at providing emergency treatment for drug overdoses, and consider botched suicide attempts as warning signs that a person is depressed and may become serious about killing themselves.
In contrast, although in some cases in China people who swallow the poisonous insecticides receive the correct medical treatment, many of the small rural health clinics lack the means or expertise to save the lives of attempted suicides. In addition, says Yang, 鈥渋n China, many doctors, especially in rural areas, do not understand the symptoms of depression鈥�.
Transformation
Yang and Phillips intend to settle the debates, and find out once and for all why so many Chinese people are killing themselves-and, with luck, how the loss of life can be reduced. The findings of the study, which is being partly funded by Befrienders International, may have implications for other countries in the Suicide Belt, such as Sri Lanka where suicide by swallowing insecticide is also common.
Their five-year study relies on a new way of collecting data that is already transforming the reliability of China鈥檚 health statistics-the so-called National Disease Surveillance Points system which Yang runs from a centre at the academy. It was this system of collecting data, which was first set up in 1978, that the Harvard-WHO team used to estimate the suicide rate in the first place. With a population of 1.2 billion to cover, and with resources scarce, Chinese health researchers are not able to compile data on every citizen. Rather than wait around for health workers to report death and disease to officials, the National Disease Surveillance Points system relies on trained workers actively recording births, age and cause of deaths, and outbreaks of certain infectious diseases among 10 million people in 145 communities that have been specially picked to provide a representative sample of the Chinese population.
Until now, the system has made no attempt to find out in detail why or how suicide deaths happen. By using a carefully chosen subgroup of the 145 communities, five years from now, Yang and Phillips should have a much clearer picture.
And they will need all the information they can get. As the number of Chinese people in the most at-risk age groups increases, the absolute number of suicides is expected to rise still further. Meanwhile, one thing is already clear: after China, our understanding of who commits suicide, why and where will never be the same again.
