Cultural dimensions of suicidal behaviour in the Sundarban region, India, and Basel, Switzerland
Von Sohini Banerjee & Claudia Sauerborn / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Cultural barriers to health care and treatment are often exclusively discussed as prevalent in non-western settings or among minority groups in the Euro-American context. The research and prevention efforts of suicidal behaviour in Switzerland and India described in this paper show that even though patient identified the same socio-cultural problems leading to their suicide attempt, treatment and prevention efforts are structurally and culturally different. While in Switzerland prevention efforts are exclusively based on the assessment of psychiatric illnesses, efforts in the Sundarban region, where mental health services are absent, can only address the socio-cultural context through community participation. Successful prevention efforts of suicidal behaviour in the Euro-American and Asian countries have to combine clinical and community approaches taking into account local cultural and structural differences.
While the importance of cultural context is increasingly getting acknowledged in international health, it is still often reduced to an either protective or vulnerable variable assuming that culture has an inherent objective definition applicable universally (1). It seems often in international health that the concept of culture exclusively appears in research and intervention projects targeting "the other", the one which is different to ours; other cultures, other diseases, other behaviour. The difference of approaches in research and intervention projects to health and disease between low and high income countries is evident (2). Research on suicidal behaviour, for example, shows a striking contrast between explanations of suicidal behaviour: while western research and prevention efforts emphasize psychiatric risk factors, the role of socio-cultural values and situational stressors among communities are accentuated in Asian societies. The question arises: Are differences in Euro-American and Asian studies of suicide in fact cross-cultural differences in the nature of suicide in respective populations, or alternatively, do these differences more accurately reflect cultural orientations of health systems?
In 2000, approximately one million people committed suicide and it is estimated that 10 to 20 times more people try to take their lives and survive. In Switzerland, 1400 people took their lives in 2000. Suicide is among the top ten causes of death in India and among the top three causes of death among those between 16 and 35 years.
Suicidal behaviour encompasses a deliberate act of harming oneself which might lead to death without a medical intervention. As the name says, it is the behaviour and not an illness or disease, even though the prevalent western explanation of suicidal behaviour is that over 90% of all suicides are due to a psychiatric disorder. Therefore, most prevention efforts target exclusively high risk groups such as individuals with severe depression.
Two studies of suicidal behaviour, one in India and the other in Switzerland (still in progress), were conducted in order to explore the question of cultural differences in regard to suicidal behaviour. An emphasis was placed on studying people's own perspective on their suicide attempts. In semi-structured interviews conducted by the two authors of this paper, underlying problems, triggers and causes leading to the suicide attempt were explored, as well as prior help seeking and possible support mechanisms. Some of the results are presented in this paper.
Basel: “Private stress. Trivial things.
Everything together… Boom!”
The Swiss health care system can be described as one of the best in the world. Switzerland has a high concentration of psychiatrists and psychotherapists (Switzerland: 2.3/10'000; Germany: 1.6/10'000). For a population of 7’489’370 there are 8152 beds in psychiatric clinics. Besides these clinical possibilities for treatment, community based prevention and intervention programmes are scattered, short lived, especially because of lack of funding. Even though the public awareness of suicidal behaviour as a major public health problem is high, politically, programmes for its prevention are rarely supported. Switzerland is among the 20 WHO/EURO countries that lack a national action programme for suicide prevention.
Patient's explanation of their suicide attempt: In the interviews made in Basel, most people reported as underlying problems leading to the suicide attempt, a severe crisis where "everything just came together" underlying the multicausality of suicidal behaviour. "Everything" most often meant interpersonal problems with the partner or other family members, financial problems, and work problems.
There are a lot of troubles. Small troubles. Mood changes. Christmas time. Christmas frustrations. The death day of my father. Private stress. Trivial things. Everything together….Boom!
Treatment approach in Basel: Patients almost never explained their suicide attempt as a mental health problem. Nevertheless, treatment of patients after their suicide attempt was exclusively based on the psychiatric diagnoses they received immediately after admission to the clinic. Most often when the diagnosis was known to them, they rejected it as the sole explanation for their suicide attempt.
Interviewer: You said that you were diagnosed with depression. What do you think about that?- Patient: No, not at all. ….The depression is a result of being cornered because of these dates of payment. But in the end, it boils down to these external appointments, which pushed me, and which made me think that suicide would be the only way out.
The experience and explanations of patients of their suicidal behaviour differed often to the one of the treating clinician. The patients who openly expressed their disagreement were often described by clinicians as "difficult", "noncompliant", or their behaviour was explained by their underlying psychiatric illness. This clash of accounts of individual experience with objectified aetiology has been discussed by medial anthropologist extensively (3). The implications of this discrepancy on treatment and prevention of suicidal behaviour are important for clinical practice and prevention efforts. Not only that those patients hardly attend follow-up meetings after a suicide attempt, but for example, compliance to administered treatment regimes is low.
Sundarban, India: “Until now, I have borne
everything silently but, I cannot take it anymore”
The Sundarban region of India is the largest delta in the world, spread over both Bangladesh and India. In this region there are no designated specialised health facilities and mental health services are completely absent. The infrastructure is underdeveloped and most people live on subsistence agriculture.
Community mental health research in the Sundarban region of India previously identified widespread concerns about suicidal behaviour, mainly because of pesticide ingestion and the lack of effective treatment for pesticide poisoning. Acknowledging the problem and responding to the requests from the community, a programme for preventing suicidal behaviour that combined research, clinical services, and community intervention was developed.
Patient's explanation of their suicide attempt: Similarly to the patient's explanation in Switzerland, the majority of the patients identified interpersonal problems such as fights within the family, domestic violence, extramarital relation of spouse etc., as causes or triggers of their attempt.
We had a quarrel when I suspected that my husband was having an affair with my daughter-in-law. My husband and son beat me ruthlessly. Until now, I have borne everything silently but, I cannot take it anymore. It is too much. So, I consumed poison.
People also acknowledged underlying social factors, such as poverty, as a cause of their unbearable situation.
Yes, that (poverty) is a big factor. You see, they (in-laws) are poor and I told you, they themselves cannot eat properly. Then, was it right to marry me? Now, they have to provide for my meals. Where will it come from? So, sometimes I go to my sister’s house, but my husband does not like it. He thinks I will expose the financial problems of his family.
Treatment approach in the Sundarbans: While in Switzerland, treatment of patients after a suicide attempt focused exclusively on psychiatric assessment, patients in the Sundarban region were treated mainly because of pesticide poisoning. This is understandable, given the lack of mental health expertise in this setting. The problem which arises is, that suicidal behaviour which did not come to clinical attention due to pesticide poisoning, was not treated. Given the scarcity of health services in general, mortality due to pesticide poisoning was therefore high.
Traditional Indian marriage is typically arranged and patri-local whereby the new bride moves in with her husband’s family. She is expected to take on numerous responsibilities and is as an outsider often blamed for conflicts within the household. As a result, quarrels between in-laws were commonly reported by female patients. These stressors are not commonly identified as risk factors for a clinical condition, and it is questionable that even if they would be treated as such, it would not be useful to do so in a setting which has no mental health services available.
The interrelationship of poverty and gender violence, especially in India, has been documented extensively. The high rate of suicidal behaviour among women in the Sundarban region emphasizes the urgent need to address this problem more vigorously. A community participation intervention was added to the research component, organizing women's organisations to address this problem in the community. Additionally, IEC (Information, Education and Communication) materials were created and distributed in the community depicting the most common cultural contexts of suicidal behaviour.
The underlying problems are neglected
Suicide research and prevention has primarily been concerned with sociological, medical, and psychiatric risk factors of suicidal behaviour. These efforts have neglected underlying patient-identified problems and the influence of the accessibility and acceptability of the existing mental health system.
In Switzerland, the culture of a purely clinical approach to suicidal behaviour caused barriers to prevent future suicidal attempts, mainly because the patient-identified problems were not addressed by this medical system. Even though other studies have shown a great effectiveness of a "proactive" patient-oriented treatment (whereby people are visited at home several times after a suicide attempt), the deep medical orientation focusing exclusively on the clinical setting is a great cultural barrier for adequate aftercare and prevention of suicidal behaviour.
In a rural underdeveloped setting like the Sundarban region suicidal behaviour also only gets treated as a consequence of the method of the attempt such as poisoning, but its underlying infrastructural and cultural problems make community prevention efforts essential.
In order to make prevention programs more effective, both approaches, medical treatment and community education, need to be considered in order to prevent suicidal behavior and its impact on families and communities.
As we have shown, cultural barriers to adequate illness prevention and disease treatment do not exist exclusively in "other" low income countries. Health research needs to include cultural dynamics not only as a static measurable concept, but as an inherent component of a health system in a given cultural context.
*Claudia Sauerborn is a medical anthropologist conducting her PhD at the Swiss Tropical Institute in cultural epidemiology. Sohini Banerjee completed her PhD in cultural epidemiology at the Swiss Tropical Institute and is now working with the Psychiatric Institute, Kolkata, India. Contact: Claudia.Sauerborn@unibas.ch
Notes / References:
- Hunt, Linda M. (2005). Health research: what's culture got to do with it? Lancet, Vol 366.
- KFPE (2001). Enhancing research capacity in developing and transition countries. Swiss Commission for Research Partnerships with Developing Countries (KFPE). Berne: Geographica Bernensia.
- Kleinman, Arthur (1997). Writing at the margin: discourse between anthropology and medicine. University of California Press.