Sadness and Madness: the unsung global killers

I was blown away by these stats on global mortality buried in the Lancet’s Global Burden of Disease Study:

* In 1990, “self-inflicted injuries” were the #12 cause of death worldwide (suicide jumped to #10 by the next study)

*there were 50% more suicides than deaths from non-war homicide.

*Among women aged 15-44, suicide was the 3rd highest cause of death (right after “maternal disorders” and TB, and right over war and road traffic accidents)

*In China, 1 in 4 deaths of women in this age group were suicides.

Suicide.org also adds the following (gathered mostly from WHO data):

*Over one million people die by suicide worldwide each year.

*On average, one person dies by suicide every 40 seconds somewhere in the world.

*Global suicide rates have increased 60% in the past 45 years.

(And we should remember these are only deaths that are classified as suicides, so we’re not counting “accidents” that may have actually been self-inflicted, much less risky behavior intentionally taken by suicidal individuals)

So my question is: WHERE’S THE PUBLIC HEALTH OUTCRY?!?!? Depression (or, if we want to be less western medicine-y about our terminology, hopeless misery, unbearable emotional or physical pain,) kills more people every year than cirrhosis, stomach and liver cancer! More than war!! More than HIV and breast cancer combined!! But there’s no Global Campaign to End Insufferable Sadness, no celebrity ambassador for suicide.

I’m no expert, but I have had some pretty substantial experience (with both friends/loved ones who have psych issues, as well as shrinks and other mental health systems) in diverse locations and cultures from the Upper East Side of Manhattan to the mountains of Guatemala, from the majority-Dominican Southside of Providence, RI to Zhejiang University in Hangzhou, China. And I have a couple of theories about this, why hundreds of thousands of humans would rather die than continue to live, why suicide rates are increasing, and why more isn’t being done to stop it. I hope that folks will comment and lend their opinions. As students at a particularly suicide-prone school, I think perhaps we may have a unique insight.

A. Crazies = more than just biochemistry. Even psychiatrists admit that their field constitutes one of the fuzziest sciences. Although very few doctors (or Western lay-people, for that matter) will stray from a strictly biomedical conception of physical health, almost all doctors acknowledge the role that environment, psychological make up, life experience, and factors that, frankly, no one quite understands yet, contribute to mental illness.

Personally, I subscribe to a three-pronged theory of madness; some of it is genetic/biochemical (not enough serotonin neuroprenephrin, etc.), some of it is due to psychological pathology (the kind of stuff Freud wrote about and that you’d talk about with a talk therapist), and some of it has less to do with the individual, and a lot more to do with this crazy, messed up world we live in. We live in a society that represses dissent and creativity, distracts from what’s really important, robs individuals of agency and control over their lives, and in which there is a whole lot of suffering. Is it really all that crazy to be depressed when thousands of children die every day from preventable illnesses? Who is sane, the man who sits at his desk and commands an army to slaughter thousands in Iraq, or the soldier who comes home traumatized because he can’t rationalize the write off the deaths he witnessed as acceptable casualties of war? Those that present as crazy may be more sensitive and more resistant to the world’s insanity. (For more on this third prong, I encourage folks to check out The Icarus Project, a rad group and full of great resources for crazy people and their allies)

B. One man’s schizophrenic is another man’s shaman. Perceptions of mental illness and sanity are incredibly culturally contingent, more so than any other aspect of health. The diverse ways in which various cultures conceptualize and make meaning out of all types of sickness are important for global health officials to understand, but while we can be pretty sure that a pill that cures an American teenager’s Chlamydia will cure the same strain in her Bangladeshi counterpart, bringing each girl out of a deep depression would almost certainly require non-identical methods. Approaches to dealing with emotions, trauma, hallucinations or visions, grief, and deviance vary drastically not just across countries, but also between subcultures, microcommmunities. A public health policy-maker can’t possibly be expected to comprehend so many divergent worldviews and priorities.

C. Public health folks suspect this and are scared to deal with it. And I don’t blame them. The crazies are complicated, and go beyond the expertise of professionals educated in principles of Western medicine. Although public health interventions often target problems outside the scope of that which is strictly “medical” (i.e. clean water initiatives, latrine construction, etc.), addressing that last component of mental health would require an interdisciplinary approach that would not only extend past the official purview of “global public health”, but challenge the very political-economic structures which fund and shape them.

D. Many think of psych issues as Rich People health problems. I think this belief comes in two forms. In one, people who perhaps romanticize foreign cultures whom they see as “simpler” or “less materialistic”, mistakenly believe that those who live in poverty are somehow happier, less prone to existential crises and inner turmoil than the wealthy (ignoring the fact that unequal resources and power differentials may just make rich people’s unhappiness a lot louder and more visible). In the second, the existence of mental health problems among the poor is acknowledged, but considered “less important” than matters of physical health and thus less of an urgent priority for global health agendas. The result this, whether by denial or devaluation, is that psych problems become another Neglected Tropical Disease.

E. Globalization drives us bonkers. For two reasons: first, the “developed” world’s cultural hegemony over the Global South is facilitated by both improved communication technology and economic dominance. We don’t just export Big Macs and clothing styles; we impose notions of how the mind and body work. Theories of disease, especially psychopathology, shape not only our conception of illness, but also how these problems are manifested. (In a recent New York Times article, Eric Watters called this “The Americanization of Mental Illness”).  Moreover, the influence exerted on the developing world by psychopharmaceutical companies has increased as free trade agreements give it greater access to global markets. Although I don’t believe that mental health practitioners are merely dancing marionettes controlled by Big Pharm, the role the industry has played in globalizing biomedical conceptions of mental health is well documented and undeniable. This hypothesis is entirely speculative, but perhaps suicide rates have increased because expressions of “psychiatric” illnesses have changed, not because of an increase in some universal, objective insanity.

Second, neoliberal political/economic systems destroy communities’ traditional support structures. I don’t have space for a comprehensive explanation here, (I recommend Noam Chomsky’s Profits Over People if you need more background) but the expansion of global capitalism mandates the restructuring of entire societies to suit the greed of economic elites rather than the needs of communities. Privitization, free market principles, commodification, though they may impart benefits in certain areas, often deprive communities of supports without providing an alternative. For example, if a Mexican subsistence farmer who tends a communal ejido has to stay home for a few days to grieve for the loss of a relative, his compañeros can continue to work the fields without him and his family will still be fed, but if this same man migrates to a city and works in a factory, his friends cannot work multiple shifts simultaneously to make up for his lost wages. The emotional hardships people suffer due to the inequality, environmental destruction, poverty, and exploitation brought about by neoliberal economics are compounded by this loss of safety nets and security; without support, psychological strife feels more unbearable and hopeless.

E. Other? What am I missing? And more importantly, how can we, as potential global health activists/providers/policy-makers, go about reducing suicide (and more importantly, the suffering that causes it) given the messy complexity of the mind, human emotions, and the world we live in? I look forward to your comments and to discussing this further.

Love and Outrage,

Claire ;D

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