Breaking the pesticide-suicide link

A53-years-old laboratory assistant at a reputed hospital in Kathmandu recently bought aluminium phosphide tablets and ingested three of them. He started vomiting immediately, and had to be rushed into emergency.

Because of his poor cardiopulmonary status and low mentation, he was intubated and transferred to the ICU. But that did not save the patient, who died a few hours later. The reason for self-poisoning was later found to be marital discord.

Aluminum phosphide is a pesticide that is widely available across the Subcontinent because farmers use it as a fumigant to protect stored grain from insects and rodents. But increasingly more people are using this lethal inorganic compound for suicide attempts. 

Aluminium phosphide releases the highly toxic phosphine gas in the presence of moisture. When ingested, therefore, it reacts with the contents of the stomach, releases phosphine and leads to serious multi-organ damage to the heart, brain, kidney and lungs. Since there is no specific antidote, the death rate is very high. 

A recent large study involving 4,148 patients conducted by the Centre for Pesticide Suicide Prevention at the University of Edinburgh in collaboration with Nepal Public Health Foundation revealed that aluminium phosphide accounted for 61% of all pesticide self-poisoning fatalities in hospitals. In the same study, of the 2,535 pesticide deaths, 300 were caused by aluminium phosphide.

There has been a sharp rise in suicide deaths since the Covid-19 pandemic with widespread societal impact of lockdowns and economic difficulties on mental health of individuals. According to the Nepal Police, there were 7,141 reported deaths due to suicides nationwide in the last 12 months -- up from 6,252 the year before. Many more make attempts to end their lives.

Mental health doctors in Nepal report an increase in patients suffering anxiety, depression, post-traumatic stress disorder, hypochondria, obsessive disorders and psychotic symptoms in the population in the past two years. Subsequent studies have drawn a direct correlation between the pandemic and a spike in mental health problems due to job loss as well as increased domestic and sexual abuse during the lockdowns.

Pesticide ingestion is the second most common method for suicide in Nepal as they are cheaper, do not need prescription, and are easily available in agro-vet shops. Most farming families also have pesticides readily available in their homes.

Deaths by suicide due to pesticide ingestion are preventable, and there are evidence-based cost-effective interventions such as bans on hazardous agro-chemicals or limiting access to them.

Sri Lanka and Bangladesh have clear data on how strict bans on just a few of the pesticides commonly used for self-harm can bring down the rate of suicides rapidly and without affecting agriculture output as the government replaces them with non-lethal agrochemicals.

Back in the 1990s, Sri Lanka had one of the highest suicide rates in the world with 57 deaths per 100,000 population. Twenty years after it banned the pesticides Monocrotophos and Methamidophos in 1995, suicide deaths fell by a remarkable 70% to 17 deaths per 100,000 people. That is 93,000 lives saved at $50 per person.

Similarly, after Bangladeshi banned 21 Highly Hazardous Pesticides (HHPs) suicide by pesticide ingestion fell dramatically from 6.3 per 100,000 population in 1996 to 2.2 in 2014.

This is proof that legislation and strict regulations work. The good news is that in August 2019, Nepal’s Pesticide Registration Board banned eight hazardous chemicals in Nepal including aluminium phosphide and dichlorvos.

This means that the production or import of the 3g tablet of aluminium phosphide which also goes by its trade name Celphos, Quickphos, Alphos, are restricted in Nepal. All remaining stockpiles after two years of phase-out period will be deposited in a government-built warehouse not to be sold anymore.

But given that a past government ban on ‘dirty dozen’ pesticides has been ignored by farmers, often unaware of just how harmful they are to human health and nature, they have continued to use them in vegetable patches in Kathmandu Valley. Bans alone are not the answer, they also have to be enforced with punitive action for infringement.

What we have seen from case studies elsewhere is also that after every ban on a hazardous pesticide, some new brand always comes up. The government must therefore replace HHPs with less toxic chemicals so that when people do ingest them they are not as lethal. Lack of accessibility to hazardous chemicals also means that people have to choose a more difficult method of suicide, which in turn discourages many and prevents more deaths.

Apart from regulation, farmers need to be educated on how to use pesticides responsibly and about their handling that includes using personal protective gear, gloves, masks and visors. Something as simple as marking the pesticide bottle or packet with red, yellow or green to indicate how lethal they are also saves lives.

Rakesh Ghimire is an assistant professor at the Tribhuvan University Teaching Hospital in Kathmandu, and was a national principal investigator of the study ‘Intentional Pesticide Poisoning and Pesticides.’

Do not shy away from seeking help. If you, or anyone you know, would like to speak to a trained mental health professional, contact:

TUTH Suicide Hotline: 9840021600

Transcultural Psychosocial Organisation-Nepal Crisis Hotline: 1660 0102005

Mental Health Helpline Nepal: 1660 0133666

Centre for Mental Health and Counselling Nepal Toll-free: 16600185080, Hotline: 1145

Koshish Toll-free helpline: 166001-22322 (Bagmati Province)

Patan Hospital Helpline: 9813476123

National Suicide Prevention helpline: 1166