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Chemical poisoning in three Telengana districts of Andhra Pradesh
Forensic Science International 122 (2001) 167±171
Chemical poisoning in three Telengana districts of Andhra Pradesh S. Gautamia, R.V. Sudershanb, Ramesh V. Bhatb,*, G. Suhasinia, M. Bharatia, K.P.C. Gandhia a
b
Andhra Pradesh State Forensic Science Laboratory, Red Hills, Hyderabad 500004, India Food and Drug Toxicology Research Centre, National Institute of Nutrition, Jamai Osmania, Hyderabad 500007, India Received 19 May 2000; received in revised form 16 August 2000; accepted 11 April 2001
Abstract Medical records of (i) toxico-medico-legal death cases from three districts of Telengana region in the state of Andhra Pradesh, viz. Hyderabad, Ranga Reddy and Medak, and (ii) clinical toxicology cases in suspected poisoning from hospitals in and around Hyderabad city were examined for a period of 5 calendar years. The age group at risk in both the types of cases is 15±24. The cause of suicides includes physical illness, family/spouse problems and ®nancial problems. Labourers form a dominant risk group in rural and semi-urban industrial area, whereas in urban area the employees were the dominant risk group. The agricultural pesticides and household insecticides were the predominant poisons used for suicide purposes. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Toxico-medico-legal deaths; Clinical toxicology; Pesticides; High risk age group
1. Introduction Accidents, injuries and poisoning contribute to 7% of mortality in the developing countries which is only 1% higher than the developed world [1]. In USA, the poisoning was reported as the third leading cause of injury and mortality and increased by 25% in the decade between 1985 and 1995 [2]. A part of the work load of non-fatal/ fatal poisoning data computation is shared by poison control centres in developed countries, where they work in conjunction with clinical/and hospital toxicology departments [3±5]. The existence of poison control centres are of recent origin in India and exist only at the capital city New Delhi and three other major cities in India [6]. Epidemiological/demographic data especially on chemical poisoning from India is not available. There is no published data on non-fatal poisoning. According to Cordner and Loff [7], the Coroner's inquest is a good source to identify and investigate the potentially preventable deaths such as suicides and accidental exposure to chemicals, etc. The major objectives of this study was to estimate the extent of mortality due to chemical poisoning either accidentally or *
Corresponding author. Fax: 91-40-7019074. E-mail address: [email protected] (R.V. Bhat).
suicidally in three Telengana districts of region in the state of Andhra Pradesh in India, viz. Hyderabad Ð urban and capital city of Andhra Pradesh, Ranga Reddy Ð semiurban and industrial and Medak Ð predominantly rural. The risk factors associated with the poisoning and their trends were also investigated. 2. Materials and methods The Andhra Pradesh State Forensic Laboratory (FSL) toxicology division receives samples of two kinds of cases for analysis: (A) toxico-medico-legal cases from different police groups, and (B) the clinical toxicology cases from different hospitals in and around Hyderabad. The toxicomedico-legal cases received for analysis from three districts: Hyderabad (urban), Ranga Reddy (semi-urban and industrial) and Medak (rural) for the ®ve calendar years from 1994 to 1998 were investigated. The inquest copy of police, detailed post-mortem report by forensic medical examiner and report of the analyst on the type of poison detected were taken into consideration. The parameters examined were total number of human cases received, age, sex, social background, i.e. occupation, marital status and the reason for suicide.
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S. Gautami et al. / Forensic Science International 122 (2001) 167±171
districts (Table 1). As indicated in Table 2, 68±70% of total fatalitics are due to poisoning/intoxication followed by injury. Agricultural pesticides and household insecticides form the dominant group of poisons accounting for 14±55% of total cases. In rural and semi-urban areas agricultural pesticides were the major poisons accounting for more than 50% deaths, where as in the city only 26% were due to agricultural pesticides followed by household insecticides (14.6%). Among the toxico-medico-legal cases registered in the districts of Ranga Reddy and Medak which are predominantly rural, more of agricultural labourers were involved while in the urban area, there were more employees (Table 3). Death due to suicides/chemical poisoning is higher in rural (40±60%) followed by family/spouse problems, dispute especially in semi-urban and rural. The suicide due to harassment for dowry (money), etc. is mostly in females, where as in case of males suicide was due to ®nancial problems (Table 4). The cases of snake bite/insect bite/scorpion bite constitute less than 1±2% of total human cases. In children, younger than 5- to 10-year-old, the ingestion of poison was either
In clinical toxicology case, the body ¯uids, blood and urine and gastric lavage were submitted for analysis to check whether it is a case of suspected accidental/suicidal poisoning/drug overdose. The data submitted by hospital, i.e. age and sex of the patient wherever mentioned was noted down along with analysis data of poison detected. 3. Results 3.1. Toxico-medico-legal cases A total of 5452 toxico-medico-legal death cases were referred to FSL from three districts of Andhra Pradesh (AP), viz. Hyderabad, Ranga Reddy and Medak during 1994±1998 calendar years. On average per year; 260 cases are received from Medak, 360 from Hyderabad and 463 from Ranga Reddy. There is a yearly gradual increase in the number of cases that are referred to FSL. The trend is similar in all three districts. The highest fatalitic occurred in the age group 16±25 followed by 26±35 then 36±45 and the trend is similar to all Table 1 Toxico-medico-legal cases age and sex distribution (1994±1998)a Age (years)
Sex
<15
M F
2.4 1.31 7.5 3.42
2.9 0.75 8.0 2.79
3.8 1.61 5.7 1.02
16±25
M F
24.2 4.25 46.3 5.80
29.2 2.45 50.5 2.32
28.9 4.07 51.4 3.90
26±35
M F
29.6 0.65 23.4 3.74
32.4 3.38 25.3 1.26
34.6 3.94 24.2 3.97
36±45
M F
23.7 3.92 12.4 2.30
19.1 1.98 9.0 3.18
17.7 3.90 9.5 2.40
46±55
M F
12.9 0.15 5.3 0.93
9.4 2.09 4.1 2.18
8.3 1.84 3.2 1.70
>55
M F
7.5 1.78 3.8 0.83
5.7 1.61 3.5 1.21
6.8 1.76 3.1 0.90
a
Hyderabad
Ranga Reddy
Medak
Values are expressed in percentage of total cases: mean S.D.
Table 2 Toxico-medico-legal cases types of poisons detected (1994±1998)a
Agric pesticides insecticides/rodenticides Household insecticides Alcohol Alcohol and other poisons Corrosives Sedatives and tranquillisers Others a
Hyderabad
Ranga Reddy
Medak
26.3 14.6 15.5 0.9 3.6 1,7 1.4
54.6 4.2 8.4 0.5 1.4 0.5 0.8
55.4 0.5 10.4 0.8 0.4 0.3 0.9
Values expressed in percentage of total cases: mean S.D.
4.50 3.04 3.50 0.83 1.14 0.88 0.75
8.30 0.94 3.39 0.06 0.52 0.43 0.26
2.00 0.17 2.10 0.72 0.36 0.26 1.15
S. Gautami et al. / Forensic Science International 122 (2001) 167±171
169
Table 3 Toxico-medico-legal cases occupation as per police inquest (1994±1998)a
Household Agriculture Agricultural labour/ labour Employees Unemployed and suspended from work Skilled labour Business Student Others Occupation not mentioned a
Hyderabad
Ranga Reddy
Medak
7.3 3.1 7.0 22.8 2.2 6.5 7.5 4.9 2.7 37.90
8.1 24.0 19.2 12.3 1.1 6.3 4.4 4.4 1.2 19.2
5.4 27.7 15.7 8.5 0.5 6.3 3.7 2.4 2.0 27.7
2.41 0.73 2.09 2.37 0.71 1.73 1.82 1.17 1.15 3.14
1.04 2.17 2.62 1.74 0.34 1.00 0.81 0.84 0.39 3.38
0.88 2.34 2.29 1.60 0.29 3.03 0.90 0.80 0.70 5.26
Values expressed in percentage of total cases: mean S.D.
accidental or given by parents/elders while committing suicide. The number of accidental chemical/pesticide poisonings were less than 1%. The number of hospital deaths were more in Hyderabad city (urban, 47%) than the Ranga Reddy (semi-urban and industrial, 37%) and in the Medak (rural area 21.5%). Interestingly, there were very few cases of attempt to commit suicide. The number of male cases are higher than the female cases with a ratio of 3:1. The married males and females constitute a larger proportion than the unmarried males and females. The ratio of married to unmarried is highest in the rural area (8:1 males; 33:1 females) followed by semi-urban, industrial (3:1 males; 18:1 females) and urban area (3:1 males; 8:1 females).
3.2. Clinical toxicology cases A total of 2181 cases received during 1994±1998 calendar year were studied. The number of cases referred by different hospitals show an increase and the number of cases referred by government hospitals such as Gandhi and Nizam's Institute of Medical Sciences are higher than any other private hospitals. The ratio of number of males and females was almost equal, unlike the toxico-medico-legal cases. The number of cases in the age group 16±25 was the highest followed by 26±35 age group. The household insecticides form a dominant group than agricultural pesticides and the cases of abuse/overdose of sedatives/tranquillisers are equal to agricultural pesticides (Fig. 1).
Table 4 Toxico-medico-logical cases Ð reasons for suicide as per police inquest (1994±1998)a Reason
Sex
Hyderabad
Ranga Reddy
Medak
Stomach ache and other physical illness
M F
23.1 2.46 16.7 1.04
21.1 4.15 16.6 2.06
31.5 12.83 17.6 4.77
Mentally ill or mentally unsound
M F
3.4 2.89 1.0 0.95
2.5 1.11 1.4 0.91
2.0 0.61 0.7 0.64
Spouse/marital family problems quarrels and disputes
M F
6.8 1.03 6.0 1.70
10.6 1.08 12.5 2.99
6.4 2.17 8.0 3.38
In-laws/husband/wife harassment for money, etc.
M F
0.2 0.44 7.8 2.82
Nil 9.4 1.24
0.6 0.51 12.5 2.38
General financial problems/unemployment/money misappropriation
M F
10.6 1.47 3.3 2.25
4.0 1.65 1.5 1.09
0.3 0.64 3.4 1.95
Debts/loans and business losses
M F
3.1 2.05 0.7 0.61
5.9 3.73 0.6 0.64
3.4 1.95 0.2 0.48
Agricultural losses
M F
Nil Nil
0.9 0.71 Nil
2.1 4.20 0.2 0.48
Other reasons
M F
10.5 4.39 6.3 1.35
6.6 2.21 6.5 2.84
7.8 3.41 4.1 2.88
a
Values expressed in percentage of total suicide cases: mean S.D.
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S. Gautami et al. / Forensic Science International 122 (2001) 167±171
Fig. 1. Clinical toxicology cases types of poisons detected.
4. Discussion There are no systematic studies of suicides/poisoning in India. The present data shows that the pesticides are the most common poisons available for suicidal purposes [8]. Similar observation were also made in other countries, i.e. Thailand, Indonesia, Malaysia, Srilanka [9,10] and Zimbabwe [11]. This is entirely different from the developed countries such as USA, where 77% of poisoning deaths are caused by drugs [2] and the acute pesticide poisonings are negligible [12]. This may be due to the fact that in USA only 2% of entire population constitutes the agricultural population/farm workers whereas 70% of population in developing countries are involved in agricultural pursuits. The reasons cited for suicides such as physical illness, family/spouse problems in the present study are same as reported earlier [13]. The female suicide due to harassment/ or for money (dowry deaths) is a problem typical to India that is still persisting. The suicide due to ®nancial reasons in males due to poverty and debts may not be the only problems of India as the study of Pollok et al. [14] of suicide in rural Britain suggested that ®nancial dif®culty as one of the reasons. The vital statistics from AP state [15] for year 1996 show that the high risk age group for injury and poisoning are 25±34 for males and 15±24 for females which differs from
the published data [4,16±22] from other countries. As per the vital statistics of AP state, the total number of cases due to suicide were 598, accidental poisoning were 140 and the ``poisoning and toxic effects'' (cases due to poisoning and affected by various toxins) were 249. This shows that overall cases of poisoning and suicide are only 987 in the Andhra Pradesh consisting of 23 districts. But the toxico-medicolegal human death cases received by FSL in 1996 from three districts of AP, i.e. Hyderabad, Ranga Reddy and Medak for toxicological analysis show that the number of poisoning cases are 754 and number of suicides as 227. Therefore, the AP health statistics data in fact a gross underestimate of poisonings and suicides. Even in developed countries like USA a similar underreporting in of®cial statistics has been observed [23]. The data presented here consistently con®rm that the high risk age group is 16±35 both in males and females. This was observed over the years in different districts. Injury and poisoning cases are very important in terms of public health and theoretically, they are preventable. The death certi®cate lacks the information on circumstances leading to injury or poisoning. The police inquest can form an important source of information in injury and poisoning cases. There is a need for the development of poison control centres either in conjunction with the laboratories or hospital to provide the emergency services.
S. Gautami et al. / Forensic Science International 122 (2001) 167±171
References [1] A.D. Lopez, Causes of death: an assessment of global and regional patterns of mortality around 1985, in: WHO 1990 Global Estimates for Health Situation Assessment and Projections, 1990, p. 39, WHO Stat. Quart. 43 (1990) 21, in preparation. [2] A. Lois, et al., Poisoning mortality 1985±1995, Publ. Health Rep. 113 (1998) 218±233. [3] Annual Poisoning Statistics, Blodgett Regional Poison Centre Grand Rapids, Michigan, 1993. [4] J.F. Krans, P.A. Corrinne, D. Vimalachandra, Injury control: the public health approach, in: R.B. Wallace (Ed.), Maxy Rosenan Ð Last Public Health and Preventive Medicine, 14th Edition, Prentice-Hall, Englewood Cliffs, NJ, 1998, pp. 1209±1222. [5] J.V. Jackson, in: A.C. Moffat, et al. (Eds.), Forensic Toxicology, 2nd Edition, The Pharmaceutical Press, London, 1986, pp. 35±54. [6] National Institute of Occupational Health (Indian Council of Medical Research) Ahmedabad, Report for the period 1st April 1992 to 31st March 1993, pp. 67±71. [7] S.M. Cordener, B. Loff, 800 years of coroners: have they future? The Lancet 344 (1994) 799±801. [8] C.A. Franklin (Ed.), Modi's Textbook of Medical Jurisprudence and Toxicology, 21st Edition, 6th Reprint, Pandy AS fol. NM Tripathi Pvt. Ltd., Bombay, 1994, Section II: Toxicology, Chapter XXV: Poisons and their Medico-legal Aspects, 1988, p. 10. [9] J. Jeyaratnam, R.S. De Alwis Seneviratne, J.F. Copplestone, Survey of pesticide poisoning in Srilanka, Bull. WHO 60 (1982) 615±619. [10] J. Jeyaratnam, Lunke, W.O. Phoon, Survey of acute pesticide poisoning among agricultural workers in four Asian countries, Bull. WHO 65 (1987) 521±527. [11] M.M.M. Hayes, N.G. Van Der Westhuizen, M. Gelfand, Organophosphate poisoning in Rhodesia, South Afr. Med. J. 54 (1978) 230±234.
171
[12] T.L. Litovitz, et al., Annual report of the American association of prison control centres: toxic exposure surveillance system, Am. J. Emerg. Med. (1996) 487. [13] L. Crooks, J. Stein, Psychology, Science, Behaviour and Life. Part 5. The Nature and Treatment of Psychological Disorders, Chapter 14: Psychological Disorders, pp. 460±503, Mood Disorders, pp. 477±489, Holt, Rinchart & Winston, New York, 1988. [14] L.R. Pollok, et al., Suicide in rural Britain, The Lancet 347 (1998) 403±404. [15] Of®ce of the Director of Health Ð Andhra Pradesh, Hyderabad, table 3.01 A. Medicinally Certi®ed Deaths by Age, Sex, According to National List of 9th Revision of ICD during 1996 (unpublished). [16] A. Moussa, Finlands aim to reduce suicide rate, The Lancet 348 (1996) 262. [17] B. Loff, S. Cordner, Suicide in Australia prompts action, The Lancet 352 (1998) 633. [18] D. Wasserman, A. Vamik, Increase in suicide among men in Baltic countries, The Lancet 343 (1994) 1504±1505. [19] D. Gunnel, H. Wehner, S. Frankel, Sex differences in suicide trends in England and Wales, The Lancet 353 (1999) 556±557. [20] K. Birchard, Suicide rates in Ireland continue to rise, The Lancet 353 (1999) 754. [21] M.L. Rosenberg, et al., The Emergence of youth suicide: an epidemiologic analysis and public health perspective in Bromet EJ, Psychiatric Disorders, Chapter 60, Section IV: Behavioural Factors Affecting Health. Fielding JE, etc., in: Wallace RB (Ed.), Maxy Rosenau Ð Last Public Health Preventive Medicine, 14th Edition, Prentice-Hall, Englewood Cliffs, 1998, Am. Rev. Publ. Health 8 (1987) 417±440. [22] WHO, The World Health Report, 1997, p. 64. [23] L.J.D. Wallace, et al., Injury mortality atlas of Indian health service areas 1979±1987, in: R.B. Wallace, et al. (Eds.), Maxy Rosenau Ð Last Public Health Preventive Medicine, 14th Edition, Prentice-Hall, Englewood Cliffs, NJ, 1998, pp. 9±18.
Chemical poisoning in three Telengana districts of Andhra Pradesh S. Gautamia, R.V. Sudershanb, Ramesh V. Bhatb,*, G. Suhasinia, M. Bharatia, K.P.C. Gandhia a
b
Andhra Pradesh State Forensic Science Laboratory, Red Hills, Hyderabad 500004, India Food and Drug Toxicology Research Centre, National Institute of Nutrition, Jamai Osmania, Hyderabad 500007, India Received 19 May 2000; received in revised form 16 August 2000; accepted 11 April 2001
Abstract Medical records of (i) toxico-medico-legal death cases from three districts of Telengana region in the state of Andhra Pradesh, viz. Hyderabad, Ranga Reddy and Medak, and (ii) clinical toxicology cases in suspected poisoning from hospitals in and around Hyderabad city were examined for a period of 5 calendar years. The age group at risk in both the types of cases is 15±24. The cause of suicides includes physical illness, family/spouse problems and ®nancial problems. Labourers form a dominant risk group in rural and semi-urban industrial area, whereas in urban area the employees were the dominant risk group. The agricultural pesticides and household insecticides were the predominant poisons used for suicide purposes. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Toxico-medico-legal deaths; Clinical toxicology; Pesticides; High risk age group
1. Introduction Accidents, injuries and poisoning contribute to 7% of mortality in the developing countries which is only 1% higher than the developed world [1]. In USA, the poisoning was reported as the third leading cause of injury and mortality and increased by 25% in the decade between 1985 and 1995 [2]. A part of the work load of non-fatal/ fatal poisoning data computation is shared by poison control centres in developed countries, where they work in conjunction with clinical/and hospital toxicology departments [3±5]. The existence of poison control centres are of recent origin in India and exist only at the capital city New Delhi and three other major cities in India [6]. Epidemiological/demographic data especially on chemical poisoning from India is not available. There is no published data on non-fatal poisoning. According to Cordner and Loff [7], the Coroner's inquest is a good source to identify and investigate the potentially preventable deaths such as suicides and accidental exposure to chemicals, etc. The major objectives of this study was to estimate the extent of mortality due to chemical poisoning either accidentally or *
Corresponding author. Fax: 91-40-7019074. E-mail address: [email protected] (R.V. Bhat).
suicidally in three Telengana districts of region in the state of Andhra Pradesh in India, viz. Hyderabad Ð urban and capital city of Andhra Pradesh, Ranga Reddy Ð semiurban and industrial and Medak Ð predominantly rural. The risk factors associated with the poisoning and their trends were also investigated. 2. Materials and methods The Andhra Pradesh State Forensic Laboratory (FSL) toxicology division receives samples of two kinds of cases for analysis: (A) toxico-medico-legal cases from different police groups, and (B) the clinical toxicology cases from different hospitals in and around Hyderabad. The toxicomedico-legal cases received for analysis from three districts: Hyderabad (urban), Ranga Reddy (semi-urban and industrial) and Medak (rural) for the ®ve calendar years from 1994 to 1998 were investigated. The inquest copy of police, detailed post-mortem report by forensic medical examiner and report of the analyst on the type of poison detected were taken into consideration. The parameters examined were total number of human cases received, age, sex, social background, i.e. occupation, marital status and the reason for suicide.
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S. Gautami et al. / Forensic Science International 122 (2001) 167±171
districts (Table 1). As indicated in Table 2, 68±70% of total fatalitics are due to poisoning/intoxication followed by injury. Agricultural pesticides and household insecticides form the dominant group of poisons accounting for 14±55% of total cases. In rural and semi-urban areas agricultural pesticides were the major poisons accounting for more than 50% deaths, where as in the city only 26% were due to agricultural pesticides followed by household insecticides (14.6%). Among the toxico-medico-legal cases registered in the districts of Ranga Reddy and Medak which are predominantly rural, more of agricultural labourers were involved while in the urban area, there were more employees (Table 3). Death due to suicides/chemical poisoning is higher in rural (40±60%) followed by family/spouse problems, dispute especially in semi-urban and rural. The suicide due to harassment for dowry (money), etc. is mostly in females, where as in case of males suicide was due to ®nancial problems (Table 4). The cases of snake bite/insect bite/scorpion bite constitute less than 1±2% of total human cases. In children, younger than 5- to 10-year-old, the ingestion of poison was either
In clinical toxicology case, the body ¯uids, blood and urine and gastric lavage were submitted for analysis to check whether it is a case of suspected accidental/suicidal poisoning/drug overdose. The data submitted by hospital, i.e. age and sex of the patient wherever mentioned was noted down along with analysis data of poison detected. 3. Results 3.1. Toxico-medico-legal cases A total of 5452 toxico-medico-legal death cases were referred to FSL from three districts of Andhra Pradesh (AP), viz. Hyderabad, Ranga Reddy and Medak during 1994±1998 calendar years. On average per year; 260 cases are received from Medak, 360 from Hyderabad and 463 from Ranga Reddy. There is a yearly gradual increase in the number of cases that are referred to FSL. The trend is similar in all three districts. The highest fatalitic occurred in the age group 16±25 followed by 26±35 then 36±45 and the trend is similar to all Table 1 Toxico-medico-legal cases age and sex distribution (1994±1998)a Age (years)
Sex
<15
M F
2.4 1.31 7.5 3.42
2.9 0.75 8.0 2.79
3.8 1.61 5.7 1.02
16±25
M F
24.2 4.25 46.3 5.80
29.2 2.45 50.5 2.32
28.9 4.07 51.4 3.90
26±35
M F
29.6 0.65 23.4 3.74
32.4 3.38 25.3 1.26
34.6 3.94 24.2 3.97
36±45
M F
23.7 3.92 12.4 2.30
19.1 1.98 9.0 3.18
17.7 3.90 9.5 2.40
46±55
M F
12.9 0.15 5.3 0.93
9.4 2.09 4.1 2.18
8.3 1.84 3.2 1.70
>55
M F
7.5 1.78 3.8 0.83
5.7 1.61 3.5 1.21
6.8 1.76 3.1 0.90
a
Hyderabad
Ranga Reddy
Medak
Values are expressed in percentage of total cases: mean S.D.
Table 2 Toxico-medico-legal cases types of poisons detected (1994±1998)a
Agric pesticides insecticides/rodenticides Household insecticides Alcohol Alcohol and other poisons Corrosives Sedatives and tranquillisers Others a
Hyderabad
Ranga Reddy
Medak
26.3 14.6 15.5 0.9 3.6 1,7 1.4
54.6 4.2 8.4 0.5 1.4 0.5 0.8
55.4 0.5 10.4 0.8 0.4 0.3 0.9
Values expressed in percentage of total cases: mean S.D.
4.50 3.04 3.50 0.83 1.14 0.88 0.75
8.30 0.94 3.39 0.06 0.52 0.43 0.26
2.00 0.17 2.10 0.72 0.36 0.26 1.15
S. Gautami et al. / Forensic Science International 122 (2001) 167±171
169
Table 3 Toxico-medico-legal cases occupation as per police inquest (1994±1998)a
Household Agriculture Agricultural labour/ labour Employees Unemployed and suspended from work Skilled labour Business Student Others Occupation not mentioned a
Hyderabad
Ranga Reddy
Medak
7.3 3.1 7.0 22.8 2.2 6.5 7.5 4.9 2.7 37.90
8.1 24.0 19.2 12.3 1.1 6.3 4.4 4.4 1.2 19.2
5.4 27.7 15.7 8.5 0.5 6.3 3.7 2.4 2.0 27.7
2.41 0.73 2.09 2.37 0.71 1.73 1.82 1.17 1.15 3.14
1.04 2.17 2.62 1.74 0.34 1.00 0.81 0.84 0.39 3.38
0.88 2.34 2.29 1.60 0.29 3.03 0.90 0.80 0.70 5.26
Values expressed in percentage of total cases: mean S.D.
accidental or given by parents/elders while committing suicide. The number of accidental chemical/pesticide poisonings were less than 1%. The number of hospital deaths were more in Hyderabad city (urban, 47%) than the Ranga Reddy (semi-urban and industrial, 37%) and in the Medak (rural area 21.5%). Interestingly, there were very few cases of attempt to commit suicide. The number of male cases are higher than the female cases with a ratio of 3:1. The married males and females constitute a larger proportion than the unmarried males and females. The ratio of married to unmarried is highest in the rural area (8:1 males; 33:1 females) followed by semi-urban, industrial (3:1 males; 18:1 females) and urban area (3:1 males; 8:1 females).
3.2. Clinical toxicology cases A total of 2181 cases received during 1994±1998 calendar year were studied. The number of cases referred by different hospitals show an increase and the number of cases referred by government hospitals such as Gandhi and Nizam's Institute of Medical Sciences are higher than any other private hospitals. The ratio of number of males and females was almost equal, unlike the toxico-medico-legal cases. The number of cases in the age group 16±25 was the highest followed by 26±35 age group. The household insecticides form a dominant group than agricultural pesticides and the cases of abuse/overdose of sedatives/tranquillisers are equal to agricultural pesticides (Fig. 1).
Table 4 Toxico-medico-logical cases Ð reasons for suicide as per police inquest (1994±1998)a Reason
Sex
Hyderabad
Ranga Reddy
Medak
Stomach ache and other physical illness
M F
23.1 2.46 16.7 1.04
21.1 4.15 16.6 2.06
31.5 12.83 17.6 4.77
Mentally ill or mentally unsound
M F
3.4 2.89 1.0 0.95
2.5 1.11 1.4 0.91
2.0 0.61 0.7 0.64
Spouse/marital family problems quarrels and disputes
M F
6.8 1.03 6.0 1.70
10.6 1.08 12.5 2.99
6.4 2.17 8.0 3.38
In-laws/husband/wife harassment for money, etc.
M F
0.2 0.44 7.8 2.82
Nil 9.4 1.24
0.6 0.51 12.5 2.38
General financial problems/unemployment/money misappropriation
M F
10.6 1.47 3.3 2.25
4.0 1.65 1.5 1.09
0.3 0.64 3.4 1.95
Debts/loans and business losses
M F
3.1 2.05 0.7 0.61
5.9 3.73 0.6 0.64
3.4 1.95 0.2 0.48
Agricultural losses
M F
Nil Nil
0.9 0.71 Nil
2.1 4.20 0.2 0.48
Other reasons
M F
10.5 4.39 6.3 1.35
6.6 2.21 6.5 2.84
7.8 3.41 4.1 2.88
a
Values expressed in percentage of total suicide cases: mean S.D.
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Fig. 1. Clinical toxicology cases types of poisons detected.
4. Discussion There are no systematic studies of suicides/poisoning in India. The present data shows that the pesticides are the most common poisons available for suicidal purposes [8]. Similar observation were also made in other countries, i.e. Thailand, Indonesia, Malaysia, Srilanka [9,10] and Zimbabwe [11]. This is entirely different from the developed countries such as USA, where 77% of poisoning deaths are caused by drugs [2] and the acute pesticide poisonings are negligible [12]. This may be due to the fact that in USA only 2% of entire population constitutes the agricultural population/farm workers whereas 70% of population in developing countries are involved in agricultural pursuits. The reasons cited for suicides such as physical illness, family/spouse problems in the present study are same as reported earlier [13]. The female suicide due to harassment/ or for money (dowry deaths) is a problem typical to India that is still persisting. The suicide due to ®nancial reasons in males due to poverty and debts may not be the only problems of India as the study of Pollok et al. [14] of suicide in rural Britain suggested that ®nancial dif®culty as one of the reasons. The vital statistics from AP state [15] for year 1996 show that the high risk age group for injury and poisoning are 25±34 for males and 15±24 for females which differs from
the published data [4,16±22] from other countries. As per the vital statistics of AP state, the total number of cases due to suicide were 598, accidental poisoning were 140 and the ``poisoning and toxic effects'' (cases due to poisoning and affected by various toxins) were 249. This shows that overall cases of poisoning and suicide are only 987 in the Andhra Pradesh consisting of 23 districts. But the toxico-medicolegal human death cases received by FSL in 1996 from three districts of AP, i.e. Hyderabad, Ranga Reddy and Medak for toxicological analysis show that the number of poisoning cases are 754 and number of suicides as 227. Therefore, the AP health statistics data in fact a gross underestimate of poisonings and suicides. Even in developed countries like USA a similar underreporting in of®cial statistics has been observed [23]. The data presented here consistently con®rm that the high risk age group is 16±35 both in males and females. This was observed over the years in different districts. Injury and poisoning cases are very important in terms of public health and theoretically, they are preventable. The death certi®cate lacks the information on circumstances leading to injury or poisoning. The police inquest can form an important source of information in injury and poisoning cases. There is a need for the development of poison control centres either in conjunction with the laboratories or hospital to provide the emergency services.
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