In Pakistan, a predominantly Muslim country, suicide is considered a sin and a crime. There is no official data on suicide, which is underreported due to social, cultural and religious stigma. The most reliable information, found in police evidence, shows an increase in suicide as well as deliberate self-harm, which affects more women than men and is putting a heavy financial burden on Pakistan’s health care system. Poverty, unemployment, corruption, human rights violations, discrimination, violence and reduced cohesion in society are considered contributing factors to the increase.
With support from Fogarty, Dr. Muhammad Shahid of Aga Khan University embarked on a study of suicide and self-harm with guidance from his mentor, Dr. Adnan Hyder of Johns Hopkins University. A long-term collaboration between the researchers’ institutions has been partially funded through a Fogarty trauma and injury research and training grant.
In the absence of government statistics, the team relied on studies of suicide and deliberate self-harm that are descriptive and almost exclusively based on reviews of hospital records, newspaper reports and police data.
Photo by Curt Carnemark/World Bank
Fogarty-supported researchers are studying the causes of
suicide, a major public health problem in Pakistan, a Muslim
country where that act is considered a sin and a crime.
“Only by measuring, studying and researching issues like suicide do we uncover some of the important public health problems affecting a country like Pakistan,” says Hyder.
Their systematic review yielded a consolidation of risk factors and causes. Interpersonal conflict is the most commonly reported reason for both deliberate self-harm and suicide. Pakistanis at greatest risk of self-harm are poor married housewives under 35. Risk factors for suicide differed only in gender; it is more prevalent for males.
The gender imbalance for self-harm may be attributed in part to the concept of izzat or honor, a major influence over some Pakistani women who are taught to be submissive and even accepting of harsh behavior from their husbands. Acts of self-harm may be one way to cope with hopelessness and helplessness.
Deliberate self-harm most often involves overdosing on medication, which is inexpensive and readily available in Pakistan. Sedatives are sold over-the-counter. Firearms, hanging and pesticide poisoning are the most frequent suicide methods. More males choose violent methods.
In a recent article, Hyder and Shahid say that although prosecution is rare, laws should be changed. “The criminalization of attempted suicide leads to stigma, avoidance of seeking help, lack of involvement of health professionals and limitations in developing innovative programs of suicide prevention.”
To raise awareness of this growing public health problem, Shahid organized the country’s first national seminar on suicide prevention, sponsored by the Aga Khan-Johns Hopkins collaboration. A subsequent workshop covered the epidemiology of suicide; suicidal behavior in children, adolescents and women; and identification and management of suicide risk.
After studying emergency room dynamics, the researchers found that effective medical and psychological management of these patients could have a positive impact in reducing future related acts.
Shahid and Hyder would like to see additional funding support the development of training and educational programs for emergency room personnel, and increased attention to suicide and deliberate self-harm in general, with sound prospective and interventional studies and research into prevention and care. They suggest that community institutions and intervention centers that work well in similar cultures, such as India and Sri Lanka, might be implemented in Pakistan.
Deliberate Self-Harm and Suicide: a Review from Pakistan. Muhammad Shahid and Adnan A. Hyder. International Journal of Injury Control & Safety Promotion, Vol. 15, No. 4, December 2008, 233–241.