- Email: [email protected]
Inuit take action towards suicide prevention
Comment
Inuit take action towards suicide prevention Sept 10, 2016, is World Suicide Prevention Day (WSPD), an opportunity to reflect on suicide in a global context, and also on what regions can learn from each other. The unique challenges of addressing suicide within Indigenous communities calls us to learn from efforts by and with Indigenous peoples, which may have global relevance. Inuit Tapiriit Kanatami (ITK), a political organisation representing Inuit in Canada, launched its National Inuit Suicide Prevention Strategy (NISPS) on July 27, 2016,1 in Kuujjuaq, Nunavik. This isolated community in northern Quebec has been reeling from the suicides of five young people, and 85 other suicide attempts by youth, in the past 8 months. Inuit are an Indigenous circumpolar people who primarily inhabit four Arctic regions of Canada: Inuvialuit, Nunatsiavut, Nunavik, and Nunavut. Rates of suicide among Inuit, particularly youth, are elevated across all four regions, with 745 Inuit deaths by suicide between 1999 and 2013.1 Rate of suicide in Nunavik and Nunavut was ten times Canada’s national average of 11 per 100 000 population, in that
Inuit Tapiriit Kanatami
For more on see World Suicide Prevention Day see https:// www.iasp.info/wspd/
1036
period. In Nunatsiavut, northern Labrador, the rate was 275 deaths per 100 000 between 2009 and 2013, or 25 times the national suicide rate. Among Inuit males aged 15–29 years, that rate increases to 40 times the national average in some regions. High rates of suicide among Indigenous youth are not a uniquely Canadian problem. Suicide is the second leading cause of death globally for 15–29 year olds,2 and among those with the highest rates are Indigenous communities in Australia, New Zealand, Greenland, and the USA.3 The Lancet’s 2016 analysis of Indigenous peoples’ health did not include indicators of mental health or suicide.4 ITK President Natan Obed explicitly linked the new strategy with a public health approach when he remarked that it is “premised on the belief that suicide among Inuit is a preventable public health crisis that demands a systematic response from all who wish to work with Inuit”. Obed described the strategy as evidence informed, but also Inuit led and Inuit specific, inviting partnership with government while foregrounding it in Inuit self-determination, knowledge, and resilience. ITK’s dual commitment to global evidence in suicide prevention and Inuit knowledge aims to develop approaches that are culturally specific and meaningful to Inuit, but is not without its challenges. Little scientific guidance exists on how such a balance is best achieved and can be effective. Moderate evidence suggests that national suicide prevention strategies (NSPS) can reduce the prevalence of suicide,5 and common risk factors for suicide of depression, impulsivity, substance use, access to lethal means, and exposure to suicide among peers and in the media are documented.2,6 Yet much remains unknown about suicide in Indigenous contexts. No research has been undertaken about how the limited number of other national Indigenous strategies were created,7,8 what implementation factors are important, nor outcomes research of the effectiveness of such strategies. Even the nature of suicide and risks for suicide among these Indigenous groups has not been fully conceptualised, often leading to application of biomedical models of suicide risk that might not capture the full spectrum of risk and protective factors for suicide.9,10 www.thelancet.com Vol 388 September 10, 2016
Comment
A notable exception comes from a recent psychological autopsy study11 in Nunavut that identified risk factors among those in the suicide group, including depression, personality disorders, substance use, particularly cannabis, higher rates of impulsivity and aggression, and a history of childhood maltreatment, including childhood sexual abuse. Historical and social factors that affect entire communities are also known to be involved, because even the control group in this study had a high burden of risk. As Canada’s Minister of Health, Jane Philpott, said during the NISPS launch “hopefully today will help Canadians acknowledge the consequences of decisions made in the 1950s…some of the many seeds of the suicide crisis Inuit are experiencing today”. Still, how best to intervene as part of suicide prevention efforts remains unknown. Despite the research gap, the NISPS considers the full breadth of risk and protective factors for suicide, from historical, social, developmental, and mental health factors, affecting the individual, family, and community. NISPS promotes a multi-level strategic approach to suicide prevention, with six key strategic priority areas aiming to: create social equity, through addressing social determinants of health; create cultural continuity, through approaches that connect Inuit with their land, culture, and language to foster healing; nurture healthy Inuit children; ensure access to a continuum of mental wellness services; heal unresolved trauma and grief; and mobilise Inuit knowledge for resilience and suicide prevention. Implementation of these approaches will be a challenge. ITK is constrained by not directly overseeing health and educational services at the regional level. Instead they are focusing on fostering communication, knowledge sharing, and research between Inuit regions; reducing stigma; advocating at regional and national levels of government; providing training, adaptation, and coordination of Inuit interventions; and creating a network of Inuit helplines, available in Inuktut across regions. ITK will be the main body that implements and evaluates the NISPS, with ongoing regional representation. At the same time, the NISPS will hold Canada’s federal and provincial governments accountable for action and resources to prevent suicide. Although the federal government committed CAN$9 million www.thelancet.com Vol 388 September 10, 2016
in funding over the next 3 years to support the new strategy, much more will be required to address social determinants of health, including early childhood development. The Inuit leadership, self-determination, process of engagement, focus, and scope of the NISPS are beginning to do the work of making suicide prevention specific for Inuit. ITK is also committed to evaluating the NISPS, which will bolster its own as well as international efforts in suicide prevention by guiding others, particularly other Indigenous groups, in bridging available evidence and community-specific and culturally specific needs. This approach is compatible with other recent suggested approaches to address global health disparities for Indigenous peoples.12 The research and knowledge gaps are considerable— and they present a dilemma for health-care and public health professionals who engage in developing policy and interventions with Indigenous people. At our most discerning, policy makers and mental health practitioners can continue to generate and use available evidence. However, best practices will only emerge through working in partnerships, particularly those guided by Indigenous leadership who create suicide prevention approaches by and for Indigenous peoples. We need to connect with and across Indigenous communities to advance local and collective efforts. Allison Crawford Centre for Addiction and Mental Health, University of Toronto, Toronto, ON M5T 1R8, Canada [email protected] AC worked for ITK as a consultant in the development of the NISPS. 1
2 3
4
5
6 7
Inuit Tapiriit Kanatami. National Inuit suicide prevention strategy. 2016. https://www.itk.ca/national-inuit-suicide-prevention-strategy/ (accessed July 30, 2016). Saxena S, Krug EG, Chestnov O. Preventing suicide: a global imperative. Geneva: World Health Organization, 2014: 89. Leenaars AA, EchoHawk M, Lester D, Leenaars L. Suicide among Indigenous peoples: what does the international literature tell us? Can J Native Stud 2007; 27: 479–501. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study. Lancet 2016; 388: 131–57. Matsubayashi T, Ueda M. The effect of national suicide prevention programs on suicide rates in 21 OECD nations. Soc Sci Med 2011; 73: 1395–400. Hawton K, Saunders KEA, O’Connor RC. Self-harm and suicide in adolescents. Lancet 2012; 379: 2373–82. Australian Government. National aboriginal and torres strait islander suicide prevention strategy. 2013. http://www.health.gov.au/internet/ main/publishing.nsf/Content/305B8A5E056763D6CA257BF0001A8DD3/ $File/Indigenous%20Strategy.pdf (accessed July 30, 2016).
1037
Comment
8
9
10
New Zealand Ministry of Health. New Zealand Suicide Prevention Strategy 2006–2016. 2006. https://www.health.govt.nz/system/files/documents/ publications/suicide-prevention-strategy-2006–2016.pdf (accessed July 30, 2016). Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health 2014; 14: 201. Wexler LM, Gone JP. Culturally responsive suicide prevention in indigenous communities: unexamined assumptions and new possibilities. Am J Public Health 2012; 102: 800–06.
11
12
Chachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, Mccormick R, Turecki G. Suicide among Inuit: results from a large, epidemiologically representative follow-back study in Nunavut. Can J Psychiatry 2015; 60: 268–75. Kirmayer LJ, Brass G. Addressing global health disparities among Indigenous peoples. Lancet 2016; 388: 105–06.
Against the odds, Sri Lanka eliminates malaria
Ministry of Health, Nutrition and Indigenous Medicine , Government of Sri Lanka
Published Online September 5, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31572-0
1038
Sri Lanka’s achievement in eliminating malaria, certified by WHO on Sept 5, 2016, is an inspiring public health success story.1 With its population of about 22 million, this Indian Ocean island is the largest lower-middleincome country in the malaria-endemic tropics to achieve elimination.2,3 Income per person in Sri Lanka is still below the level at which countries typically succeed in eliminating malaria.2 More than 80% of Sri Lanka’s population live in rural areas, providing ideal ecosystems for Anopheles culicifacies, one of the main vectors for malaria in the region. And, remarkably, the groundwork for elimination was laid during a period of internal armed conflict.4 The elimination of malaria brings to an end one of Sri Lanka’s most devastating health burdens. Of the country’s 25 districts, only six had low to no risk for malaria.4,5 Epidemics and endemic transmission intensified in the 19th and 20th centuries as plantation, irrigation, and agricultural projects— undertaken by the British colonial administration and
then by the independent government—opened up forested areas.5 Major epidemics occurred every few years. The 1934–35 epidemic killed over 1·5% of the population.5 In 1945, Sri Lanka was a regional pioneer in introducing indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT).4,5 The dramatic results led to IRS being used across the country, and in 1958 Sri Lanka joined WHO’s Global Malaria Eradication Programme. By 1963, there were just 17 cases of malaria reported in Sri Lanka, of which 11 were imported.5,6 Elimination seemed certain. But the subsequent scaling back of IRS led to the resurgence of malaria, with about 1·5 million cases in Sri Lanka during 1967–69.2–6 For the next 30 years, Sri Lanka did its best to control malaria but with little success. Then in the late 1980s technical leadership by Sri Lanka’s Anti-Malaria Campaign (AMC) Directorate led to the jettisoning of single vector-control methods, such as IRS, in favour of integrated vector management. This integrated approach relied on several carefully selected interventions, including vector control in major irrigation and agriculture projects, rigorous entomological surveillance leading to targeted spraying in high-risk areas, new classes of insecticides for IRS, insecticide-treated nets and larval control, and strengthened parasitological surveillance for active case detection combined with rapid response.5 Despite these efforts, major epidemics occurred during the 1980s and 1990s. In the country’s 1986–87 epidemic there were more than 600 000 cases of malaria, while in 1999 the number of confirmed cases of malaria was 264 549.4,5 Fortunately, mortality was limited by wide access to quality treatment and because most infections were Plasmodium vivax malaria rather than www.thelancet.com Vol 388 September 10, 2016
Inuit take action towards suicide prevention Sept 10, 2016, is World Suicide Prevention Day (WSPD), an opportunity to reflect on suicide in a global context, and also on what regions can learn from each other. The unique challenges of addressing suicide within Indigenous communities calls us to learn from efforts by and with Indigenous peoples, which may have global relevance. Inuit Tapiriit Kanatami (ITK), a political organisation representing Inuit in Canada, launched its National Inuit Suicide Prevention Strategy (NISPS) on July 27, 2016,1 in Kuujjuaq, Nunavik. This isolated community in northern Quebec has been reeling from the suicides of five young people, and 85 other suicide attempts by youth, in the past 8 months. Inuit are an Indigenous circumpolar people who primarily inhabit four Arctic regions of Canada: Inuvialuit, Nunatsiavut, Nunavik, and Nunavut. Rates of suicide among Inuit, particularly youth, are elevated across all four regions, with 745 Inuit deaths by suicide between 1999 and 2013.1 Rate of suicide in Nunavik and Nunavut was ten times Canada’s national average of 11 per 100 000 population, in that
Inuit Tapiriit Kanatami
For more on see World Suicide Prevention Day see https:// www.iasp.info/wspd/
1036
period. In Nunatsiavut, northern Labrador, the rate was 275 deaths per 100 000 between 2009 and 2013, or 25 times the national suicide rate. Among Inuit males aged 15–29 years, that rate increases to 40 times the national average in some regions. High rates of suicide among Indigenous youth are not a uniquely Canadian problem. Suicide is the second leading cause of death globally for 15–29 year olds,2 and among those with the highest rates are Indigenous communities in Australia, New Zealand, Greenland, and the USA.3 The Lancet’s 2016 analysis of Indigenous peoples’ health did not include indicators of mental health or suicide.4 ITK President Natan Obed explicitly linked the new strategy with a public health approach when he remarked that it is “premised on the belief that suicide among Inuit is a preventable public health crisis that demands a systematic response from all who wish to work with Inuit”. Obed described the strategy as evidence informed, but also Inuit led and Inuit specific, inviting partnership with government while foregrounding it in Inuit self-determination, knowledge, and resilience. ITK’s dual commitment to global evidence in suicide prevention and Inuit knowledge aims to develop approaches that are culturally specific and meaningful to Inuit, but is not without its challenges. Little scientific guidance exists on how such a balance is best achieved and can be effective. Moderate evidence suggests that national suicide prevention strategies (NSPS) can reduce the prevalence of suicide,5 and common risk factors for suicide of depression, impulsivity, substance use, access to lethal means, and exposure to suicide among peers and in the media are documented.2,6 Yet much remains unknown about suicide in Indigenous contexts. No research has been undertaken about how the limited number of other national Indigenous strategies were created,7,8 what implementation factors are important, nor outcomes research of the effectiveness of such strategies. Even the nature of suicide and risks for suicide among these Indigenous groups has not been fully conceptualised, often leading to application of biomedical models of suicide risk that might not capture the full spectrum of risk and protective factors for suicide.9,10 www.thelancet.com Vol 388 September 10, 2016
Comment
A notable exception comes from a recent psychological autopsy study11 in Nunavut that identified risk factors among those in the suicide group, including depression, personality disorders, substance use, particularly cannabis, higher rates of impulsivity and aggression, and a history of childhood maltreatment, including childhood sexual abuse. Historical and social factors that affect entire communities are also known to be involved, because even the control group in this study had a high burden of risk. As Canada’s Minister of Health, Jane Philpott, said during the NISPS launch “hopefully today will help Canadians acknowledge the consequences of decisions made in the 1950s…some of the many seeds of the suicide crisis Inuit are experiencing today”. Still, how best to intervene as part of suicide prevention efforts remains unknown. Despite the research gap, the NISPS considers the full breadth of risk and protective factors for suicide, from historical, social, developmental, and mental health factors, affecting the individual, family, and community. NISPS promotes a multi-level strategic approach to suicide prevention, with six key strategic priority areas aiming to: create social equity, through addressing social determinants of health; create cultural continuity, through approaches that connect Inuit with their land, culture, and language to foster healing; nurture healthy Inuit children; ensure access to a continuum of mental wellness services; heal unresolved trauma and grief; and mobilise Inuit knowledge for resilience and suicide prevention. Implementation of these approaches will be a challenge. ITK is constrained by not directly overseeing health and educational services at the regional level. Instead they are focusing on fostering communication, knowledge sharing, and research between Inuit regions; reducing stigma; advocating at regional and national levels of government; providing training, adaptation, and coordination of Inuit interventions; and creating a network of Inuit helplines, available in Inuktut across regions. ITK will be the main body that implements and evaluates the NISPS, with ongoing regional representation. At the same time, the NISPS will hold Canada’s federal and provincial governments accountable for action and resources to prevent suicide. Although the federal government committed CAN$9 million www.thelancet.com Vol 388 September 10, 2016
in funding over the next 3 years to support the new strategy, much more will be required to address social determinants of health, including early childhood development. The Inuit leadership, self-determination, process of engagement, focus, and scope of the NISPS are beginning to do the work of making suicide prevention specific for Inuit. ITK is also committed to evaluating the NISPS, which will bolster its own as well as international efforts in suicide prevention by guiding others, particularly other Indigenous groups, in bridging available evidence and community-specific and culturally specific needs. This approach is compatible with other recent suggested approaches to address global health disparities for Indigenous peoples.12 The research and knowledge gaps are considerable— and they present a dilemma for health-care and public health professionals who engage in developing policy and interventions with Indigenous people. At our most discerning, policy makers and mental health practitioners can continue to generate and use available evidence. However, best practices will only emerge through working in partnerships, particularly those guided by Indigenous leadership who create suicide prevention approaches by and for Indigenous peoples. We need to connect with and across Indigenous communities to advance local and collective efforts. Allison Crawford Centre for Addiction and Mental Health, University of Toronto, Toronto, ON M5T 1R8, Canada [email protected] AC worked for ITK as a consultant in the development of the NISPS. 1
2 3
4
5
6 7
Inuit Tapiriit Kanatami. National Inuit suicide prevention strategy. 2016. https://www.itk.ca/national-inuit-suicide-prevention-strategy/ (accessed July 30, 2016). Saxena S, Krug EG, Chestnov O. Preventing suicide: a global imperative. Geneva: World Health Organization, 2014: 89. Leenaars AA, EchoHawk M, Lester D, Leenaars L. Suicide among Indigenous peoples: what does the international literature tell us? Can J Native Stud 2007; 27: 479–501. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study. Lancet 2016; 388: 131–57. Matsubayashi T, Ueda M. The effect of national suicide prevention programs on suicide rates in 21 OECD nations. Soc Sci Med 2011; 73: 1395–400. Hawton K, Saunders KEA, O’Connor RC. Self-harm and suicide in adolescents. Lancet 2012; 379: 2373–82. Australian Government. National aboriginal and torres strait islander suicide prevention strategy. 2013. http://www.health.gov.au/internet/ main/publishing.nsf/Content/305B8A5E056763D6CA257BF0001A8DD3/ $File/Indigenous%20Strategy.pdf (accessed July 30, 2016).
1037
Comment
8
9
10
New Zealand Ministry of Health. New Zealand Suicide Prevention Strategy 2006–2016. 2006. https://www.health.govt.nz/system/files/documents/ publications/suicide-prevention-strategy-2006–2016.pdf (accessed July 30, 2016). Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health 2014; 14: 201. Wexler LM, Gone JP. Culturally responsive suicide prevention in indigenous communities: unexamined assumptions and new possibilities. Am J Public Health 2012; 102: 800–06.
11
12
Chachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, Mccormick R, Turecki G. Suicide among Inuit: results from a large, epidemiologically representative follow-back study in Nunavut. Can J Psychiatry 2015; 60: 268–75. Kirmayer LJ, Brass G. Addressing global health disparities among Indigenous peoples. Lancet 2016; 388: 105–06.
Against the odds, Sri Lanka eliminates malaria
Ministry of Health, Nutrition and Indigenous Medicine , Government of Sri Lanka
Published Online September 5, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31572-0
1038
Sri Lanka’s achievement in eliminating malaria, certified by WHO on Sept 5, 2016, is an inspiring public health success story.1 With its population of about 22 million, this Indian Ocean island is the largest lower-middleincome country in the malaria-endemic tropics to achieve elimination.2,3 Income per person in Sri Lanka is still below the level at which countries typically succeed in eliminating malaria.2 More than 80% of Sri Lanka’s population live in rural areas, providing ideal ecosystems for Anopheles culicifacies, one of the main vectors for malaria in the region. And, remarkably, the groundwork for elimination was laid during a period of internal armed conflict.4 The elimination of malaria brings to an end one of Sri Lanka’s most devastating health burdens. Of the country’s 25 districts, only six had low to no risk for malaria.4,5 Epidemics and endemic transmission intensified in the 19th and 20th centuries as plantation, irrigation, and agricultural projects— undertaken by the British colonial administration and
then by the independent government—opened up forested areas.5 Major epidemics occurred every few years. The 1934–35 epidemic killed over 1·5% of the population.5 In 1945, Sri Lanka was a regional pioneer in introducing indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT).4,5 The dramatic results led to IRS being used across the country, and in 1958 Sri Lanka joined WHO’s Global Malaria Eradication Programme. By 1963, there were just 17 cases of malaria reported in Sri Lanka, of which 11 were imported.5,6 Elimination seemed certain. But the subsequent scaling back of IRS led to the resurgence of malaria, with about 1·5 million cases in Sri Lanka during 1967–69.2–6 For the next 30 years, Sri Lanka did its best to control malaria but with little success. Then in the late 1980s technical leadership by Sri Lanka’s Anti-Malaria Campaign (AMC) Directorate led to the jettisoning of single vector-control methods, such as IRS, in favour of integrated vector management. This integrated approach relied on several carefully selected interventions, including vector control in major irrigation and agriculture projects, rigorous entomological surveillance leading to targeted spraying in high-risk areas, new classes of insecticides for IRS, insecticide-treated nets and larval control, and strengthened parasitological surveillance for active case detection combined with rapid response.5 Despite these efforts, major epidemics occurred during the 1980s and 1990s. In the country’s 1986–87 epidemic there were more than 600 000 cases of malaria, while in 1999 the number of confirmed cases of malaria was 264 549.4,5 Fortunately, mortality was limited by wide access to quality treatment and because most infections were Plasmodium vivax malaria rather than www.thelancet.com Vol 388 September 10, 2016