Print edition : April 15, 2000

Kerala is something of a role model in welfare-oriented development, and yet the State has been reporting one of the highest suicide rates in the country.

R. KRISHNAKUMAR in Thiruvananthapuram

GOD's own country, the blurbs hail Kerala. The setting is picturesque, the mood apparently upbeat. Despite low levels of income, Kerala society has successfully engineered a fall in fertility, a rise in life expectancy at birth, and a decline in birth, d eath and infant mortality rates. In development terms Kerala is something of a model. Indeed, its achievements on the health front are considered to be comparable to those of developed countries. Yet, for some time now, Kerala has been reporting one of t he highest suicide rates in the country.

The expressions of worry are often countered by arguments that the seemingly higher figures are but a reflection of a high level of reporting, a better health care system and awareness among the people and that there is no objective evidence of morbidity rates being higher in Kerala than in other parts of the country. However, the constraints facing the health care system in the government segment and the increasing commercialisation in the health sector are worrisome. It is in this context that the Sta te now faces the phenomenon of rising suicide rates and trends that point towards problems in the state of the mental health of the population.

Even though local bodies and voluntary agencies have been coming forward in the past few years to try and evolve suicide prevention strategies, Kerala has been showing an alarming trend of even members of entire families opting or being forced to end the ir lives together.

Outside a house in Thiruvananthapuram, where a family of four committed suicide on March 12.-C.RATHEESHKUMAR

Consider the following illustrative incidents in the State in the past three years:

* March 2000, Mattancherry: A 26-year-old man ends his life by consuming poison, after his parents refuse to buy him a car. The next day, the parents, aged 60 and 52, kill themselves in similar fashion, unable to bear the grief.

* July 1997, Thiruvananthapuram: A 36-year-old man creates terror in a housing colony, pacing the streets with a blood-stained chopper with which he hacked his wife and children (aged five and two) to death. He has consumed poison and has repeatedly stab bed himself. The Police find that he has no history of psychiatric disorder, violence or criminal acts. The man later tells the police that he has decided to end his life and that of his family as "they have no one to turn to and the future is all uncert ain."

* February 1998, Thiruvanantha-puram: A couple, aged 45 and 37, kill four of their children (the oldest being only 15) by electrocuting them while they are asleep and then commit suicide in the same manner. The man, formerly an electrician in the Gulf, s ays in his suicide note that he is "depressed as he is unable to return to his overseas employment."

* April 1998, Kadakkal: A 42-year-old woman and her three daughters end their lives by consuming poison, "as we have no one to turn to" after her husband became mentally ill.

It was Chief Minister E. K. Nayanar who directed the attention of the State to the problem when he told the State Assembly that between April 1992 and March 1997, there were 41,397 cases of suicide in the State. He said that in the 22 months preceding Ap ril 1998, when he made the statement, about 15,200 people had ended their lives. This included 10,320 men and 4,888 women, and members of 38 families who opted or were forced to die together. The Chief Minister was, of course, referring only to the off icially reported cases.

Kerala is one State where the police were forced to start a telephonic suicide-prevention counselling centre in a small village (Nooranad in Alappuzha district) because 30 to 50 suicides used to occur there each year. Another tiny village, Panangad in Ko zhikode district, has started attracting similar attention with 227 suicide reports in five years.

Police sources say that at least 24 people end their lives every day in Kerala, and a hundred others make unsuccessful suicide attempts. One in every four attempts is successful. According to the National Crime Record Bureau's report on 'Accidental Death s and Suicides in India - 1997', the rate of suicides in Kerala per lakh of population was 28.5 - the highest among States (excluding Union Territories) - while the all-India figure was only 10.

THE trend of an increasing rate of suicides in Kerala was first noticed in the early 1980s, according to P.K.B. Nair, former Chairman and Dean of the Faculty of Social Sciences, University of Kerala. "From around the mid-1970s, it was a period of rapid c hanges in Kerala society, possibly the cumulative outcome of the revolutionary land reform measures initiated in the late-1950s, and later, the boom in employment in and remittances from the countries of the Gulf. The people of the State had always disp layed a strong spirit of independence and an emotional sensitivity which were responsible for the isolating and divisive tendencies that marked Kerala society in general."

According to P.K.B. Nair, the most important change that occurred in Kerala in this context was the proliferation of nuclear families, of which the State today had the highest percentage in the country. He said Kerala was almost like one large village of individual families and the resultant sociological impact had been tremendous.

Krishna Prasad Sreedhar, Professor of Psychology, University of Kerala, who is also a clinical psychologist, said: "Kerala is predominantly an 'intellectual State', not an 'emotional State', as is evident in the sober response of the people to many event s. People, for instance, do not douse themselves in kerosene when a leader like EMS (Namboodiripad) dies, as would possibly happen in some other States. But the flip side is that this society does not provide a release mechanism for the tensions that cou ld build up within an individual as a result of the rapidly changing social climate around him or her."

Sreedhar added: "The psychology of the suicide-prone is well-known. People attempting suicide have been found to be suffering from unbearable emotional pain caused by pent-up emotions. The majority of them are those who, at a particular time, feel isolat ed, desperately unhappy and alone because of pressures which they believe they cannot cope with, but in fact can."

"Those who attempt to commit suicide are often acutely distressed, though the presence of multiple risk factors, including depression, need not necessarily mean that a person will become suicidal," Dr. Suraraj Mani, a psychiatrist and the secretary of th e State Mental Health Authority (SMHA), a statutory body formed as per the Central Mental Health Act, 1987, said. "But most of the time people who try to kill themselves suffer from depression or one of the other types of depressive illnesses, which, the y and those close to them fail to realise are treatable."

Says P.K.B. Nair: "Kerala has become very materialistic. Increasingly, alien values replaced traditional ones and nuclear families took the place of a once-predominant joint family system. It is today a very individualistic society, caught in a state of imperfect modernisation. Imperfect education and easy Gulf money had led to the creation of a society which has great expectations but not enough resources and other means to bring them to reality. Rapid changes have taken place in the material culture, but there has been no change at all in the State's non-material culture. Kerala society is caught in a cultural lag."

THE most frequently cited reasons for suicides in Kerala, as reported by the Crime Records Bureau (in 1998), are family problems, illness, bankruptcy and sudden change in economic status, poverty, unemployment, fall in social reputation and failure in lo ve affairs and in examinations. Significantly, in the vast majority of cases reported in the media, especially in cases involving whole-family suicides, a major cause has been a sudden fall in the financial status and a consequent lowering of living stan dards and prestige.

James Vadakkumcherry, Crimino-logist, State Police Training College, Thiruvananthapuram, said a number of suicides in Kerala were impelled by strains and tensions within the family. Increasingly, people are committing suicide within their own homes. Many such cases of suicide are, however, not being reported as such according to him. According to the Crime Records Bureau, even among the cases reported, the largest number involved married men and women between the ages of 18 and 50. Quarrel with spouse w as a major reason. The majority of them had studied only up to the secondary school level, with the largest number having only primary- or middle-school-level education.

The occupational profile of the victims shows that the largest number of victims were unemployed persons and housewives, followed by self-employed people in agriculture and other activities. Interestingly, though the majority of the victims were men, a l arger number of women than men attempted unsuccessfully to end their lives. Also, twice as many men than women committed suicide following quarrels with their parents-in-law. Far more number of men than women called it quits following quarrels with their spouse. In 1998, 70 dowry-related suicides were reported, four of them by men. However, fall in incomes, and poverty combined with other social factors, were the main causes for a large number of family death pacts.

Said James: "Alcohol is the villain in many homes with suicide victims. Women are now more independent in Kerala society and this has bought consequent problems, along with the positive aspects. The old are neglected and so are their values. A vulgar cul ture, glorifying the ills of society, pervades the living rooms through the media. This together with the fragmentation of families has formed in a potent combination, disturbing peace within families. Of the total number of suicides in the State, 15 to 20 per cent are group or family suicides."

Says Dr. Mani: "Earlier, a joint family system could cushion situations of sudden personal misfortunes. Within today's nuclear families, certainly not built on selfless love as is widely believed, relationships have become weak. A sudden change in econom ic status, for example, becomes a traumatic experience for the small families which exist in urban settings, isolated from traditional support systems."

Significantly, the so-called 'family suicides' are in fact partly group murders, according to James. In most cases, the decision was taken by the dominant personality, often the father, and was imposed on the other members, he said.

LEELA GULATHI, Associate Fellow, Centre for Development Studies, Thiruvananthapuram, however believes that the so-called proliferating "nuclear" families in Kerala are not "nuclear" at all in the strict sense of the term as used in Western countries. "He re it is really a loose form of nuclearisation. There is nuclearisation as far as sharing economic resources and staying together are concerned. The kitchen is nuclear. There might not be inter-dining, perhaps. But members of the larger family still have very strong links, they come and go and there is still a lot of socialisation," she said. So in Kerala today, a different kind of joint-family system is in place, where people do not stay together, cook and eat together, but still depend on others of th eir family for emotional and social support. She believes, therefore, that it would be premature to conclude that 'nuclearisation' is a major reason for the increasing rate of suicides.

The suicide prevention clinic at the Government General Hospital in Thiruvananthapuram.-C.RATHEESHKUMAR

According to Sreedhar, in Kerala the rich have become richer and the poor, poorer. But in all strata of society, owing to the high level of literacy and exposure to media and the temporary Gulf boom, expectations rose. Once the flow of Gulf money began t o ebb, there were very few opportunities within the State for social advancement and for the nouveau-riche to maintain the standard of living that they had suddenly gotten used to. "It is the middle class that has been affected the most. It is not surprising that suicide rates are higher among people who are downwardly mobile," he said.

An interesting observation by Sreedhar was that in the earlier days, Kerala society allowed certain popular release mechanisms - such as faith healing, hysterical dances in temples or exorcism - which, however negative or undesirable they may have been, he said, provided emotional outlets. With the rise in the level of education and the general advancement of society, such means naturally became the butt of social ridicule. But a positive alternative did not evolve. "Instead, it has become fashionable t o get depressed," he said.

There has also been condemnation of the role of some sections of the media in the increasing rate of suicides. A high level of literacy has also meant a large readership for newspapers and magazines, but the frustrations of the educated unemployed have p robably resulted in a huge audience also for the so-called pulp-fiction magazines and television serials. Also, there are indications that the vivid depictions in the media of the frequent instances of suicides and the methods used by the victims have en couraged a large number of persons to end their lives in a similar manner.

THE rising suicide rate cannot, however, be seen in isolation. If at all, it seems part of a deep social malady that has affected Kerala society in general. For example, the alcohol consumption rate in the State has increased manifold and it is today one of the highest in the country. The per capita consumption of alcohol in the State stands at 8.3 litres, according to the Alcohol and Drug Information Centre (ADIC), India. Fifteen per cent of the population consumes alcohol. The average age of first con sumption of liquor came down - from 19 in 1986, to 17 in 1990 to 14 in 1994. (A 1999 ADIC-India study among college students in three southern districts shows the age to be 13.5.) Most drinkers are in the 21 to 40 age group, the same group where the maxi mum number of suicides also take place.

Says Dr. Mani: "Depression together with alcohol or drug use can be lethal. People might try to alleviate the symptoms of their depressive illness by drinking or by using drugs (which also is rising in the State). Alcohol and drugs only make the problem worse, increasing the risk of suicide."

Kerala has also registered an increase in crimes registered under the Narcotic Drugs and Psychotropic Substances Act. The divorce rate is going up. So are instances of examination-related mental illness. "For the past few years, in the days immediately p receding the SSLC examination, we have been flooded with calls from students wanting to commit suicide," Dr. Mani said.

In the absence of reliable data, Mani said, indications from the figures of pharmaceutical companies was that there was now a fast-expanding market in the State for psycho-therapeutic drugs. In 1994, from these data, 25 per cent of the market of psychole ptics in South India was in Kerala; the growth of psycholeptics market in the State was 47 per cent. South India as a whole accounted for only 17 per cent of the national market.

Dr. Elizabeth Vadakekara, psychiatrist at the Government General Hospital, Thiruvananthapuram, who is also a researcher in child psychiatry, said that though further studies were required on this, unknown to society at large, sexual abuse of children was also a reason for psychotic and depressive illnesses in adolescents and youth in Kerala who attempted to kill themselves or had suicidal tendencies.

"Most of the time, such patients have later revealed that they were victims of sexual abuse at a very young age, and in the majority of such cases the culprits were from within the family circle. They would usually never reveal it to anyone, especially i f the abuse happened at a very young age, say below seven, but instead would internalise their agony, a feeling of guilt and a sense of having been used. This often develops into paranoia or depressive illness," she said.

The SMHA has also identified child abuse as an area of concern, according to Dr. Mani. Often parents and teachers are unaware of this problem and fail to recognise tell-tale signs of sexual abuse in children.

Another group at risk identified by the SMHA consists of those addicted to drugs. In one of the successful attempts by the SMHA, a rehabilitation centre for drug addicts at Vallakkadavu in Thiruvananthapuram is being run with the participation of the loc al community. Surprisingly, all the 27 young men who attended the encouraging first phase of the de-addiction programme told counsellors that they had attempted to commit suicide at least once, at one stage or the other of drug use.

ACCORDING to James, the attitude of Kerala society towards suicides has also been changing. Most strikingly, some religious groups, especially Christian ones, have come to accept the phenomena of suicides and in recent years have even issued special dire ctions offering burial rights for suicide victims. Marriage relationships with the families of suicide victims are also becoming less of a taboo.

This, he said, however did not mean that suicide was no longer a taboo topic. Kerala has not accepted depressive illness or its end result as it has accepted, for example, a malaise such as alcoholism. The taboo prevents people from getting help, and pre vents society from learning more about suicide and depression. Instead, myths are perpetuated.

Says Dr. Mani: "Depression is being trivialised as a psychological problem, and only 5 per cent of the patients in Kerala get treatment. A person complaining of chest pain gets immediate medical attention and stands only a 20 per cent risk of dying of it . But a person complaining of depression is ignored, though he stands a 15 per cent chance of committing suicide."

Another serious, related problem is that faced by the family members and even friends and close associates of suicide victims. Those who choose to end their lives leave behind not merely grief but often, guilt, resentment, anger, confusion and distress a mong their family members and friends. Says Sreedhar: "The stigma attached to suicides makes it extremely difficult for survivors to deal with their grief and often results in unjust isolation and consequent psychological problems."

Experts believe that the social stigma attached to mental health problems is a major obstacle to suicide prevention efforts. Counselling centres are few and are often not very effective. There is also the lack of reliable studies to assess the mental hea lth status of Kerala society.

For the first time, an epidemiological field study to provide an official estimate of severe mental morbidity was conducted in 13 of the 14 districts of the State by the SMHA in 1998, and its results have just been submitted to the State Government. Alth ough the study covered only the chronically mentally ill, its findings are significant insofar as they point to the dearth of data and facilities for the increasing number of others who require help.

Among the major findings of the study are: there is a two per thousand prevalence of schizophrenia in Kerala; the distribution of chronic schizophrenia is equal among both sexes and in the urban and rural areas; the prevalence of the disease is high amon g divorcees (and more in men divorcees than women divorcees), and more among the less-educated and unemployed; about 90 per cent of the patients seek help under one system of medicine or the other (51.1 per cent in the private sector); 0.6 per cent each still seek faith healing and manthravadam or such black magic remedies; and 9.7 per cent do not seek any help at all.

PERHAPS for the first time in the country, a people's initiative for suicide prevention was launched at the panchayat level in January at Ponnani in north Kerala. The aim is to make four gram panchayats (which witnessed a spurt in suicides in recent year s) a 'no-suicide zone'. The Ponnani block panchayat also set up a Centre for Community Mental Health Studies in order to create awareness about depressive illnesses, psychosis, alcohol and drug abuse and about ways to identify risk groups and prevent sui cides.

The Centre has identified rapid socio-cultural changes, a rising gap between the aspirations and capabilities of individuals, a false impression that a high consumption capability is the symbol of a higher social position, disappearing moral values and d isintegration of traditional support systems, among others, as possible special circumstances in Kerala that may be responsible for the high incidence of suicide.

The Centre organised a two-day State-level camp with the support of the Planning Board at Tavanur on January 15 and 16, which called for immediate intervention by the Kerala Government and the local bodies to curb the number of suicides. The 'Ponnani Doc ument' adopted by the camp includes guidelines for the State Government, the local bodies and non-governmental organisations (NGOs) to evolve immediate long-term preventive strategies.

The document suggests that the government and the local bodies establish at least one suicide prevention centre in each district, continuing education facilities for doctors to identify and treat depression-related mental illnesses, life-skills education for children (incorporating approaches to seek, offer and appreciate crisis support, problem solving and evolve mature views on matters of love and sex), counselling centres in colleges, reorientation of priorities by NGOs to make suicide prevention a m ajor area of their activity, and training for priests, social workers, public men, the police, teachers and others to deal with people in distress. It also calls on the media to be restrained in reporting incidents of suicide, especially in glorifying th em and presenting them as a problem-solving method.

The Planning Board-supported Ponnani Initiative is perhaps the first official recognition of the seriousness of the problem of increasing suicides and lack of facilities to prevent them. It has sought to address a felt need to evolve a community support system for people at risk who have been challenged by changes in a rapidly modernising society, which has so far only sought to neglect them. It is only a beginning.

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