China is the only country that reports more suicides by women than men. And, overall, it has one of the highest suicide rates in the world. Michael Phillips, an associate professor of social medicine at HMS and head of research at Beijing Hui Long Guan Hospital, is trying to understand and prevent this exceptional self-destruction. His investigation explores both suicide and fatal accidents, the latter a possible category for misreported suicides. Along the way, he is questioning some central assumptions about suicide and culture--American as well as Chinese.
| Michael Phillips directs a study to understand and prevent suicide in China, which has one of the highest rates in the world and the highest proportion of female victims. |
According to 1989 figures from the World Health Organization, the annual number of suicides in China is 17.1 per 100,000 residents. For the U.S., this rate is 12.2. Phillips, however, estimates that the Chinese rate is much higher--25 per 100,000. (The recent Global Burden of Disease study, directed by Christopher Murray of the Harvard School of Public Health, puts the rate higher still--30 per 100,000.)
The discrepancies come from the lack of a Chinese death registry system like that in the U.S. and other developed countries. In China, all suicide figures are extrapolated from sample data. The WHO numbers rely on information from the Chinese Ministry of Health, which Phillips says collects data from urban and better-off rural areas and does not adjust for uncounted deaths. The result is unrealistically low statistics.
A Rural Route
The suicide rate in the Chinese countryside is three times higher than that in the city. This predominance of rural suicide is another deviation from global norms, and it suggests that the underlying causes are independent of population density. "Young rural females have the highest incidence," Phillips says.
One explanation is that an effective means to commit suicide is easily available, since most farm families keep deadly pesticides and herbicides on hand. Medical care is often distant and unsophisticated. "The local country doctor may not be able to treat these cases," Phillips says. Consequently, such suicide attempts usually succeed.
This "success" rate may partially explain the preponderance of female victims. Though no national data on attempted suicide is collected in China or the U.S., research has found that twice as many American women as men report a history of trying to kill themselves, according to the National Institute of Mental Health (1995). By extension, lethal means in China may tip the scales toward suicide by women. Conversely, if American women were in the same trap as Chinese women--plenty of lethal bait and little means of rescue--the American gender ratio for suicide might approach the Chinese.
Perhaps the more fundamental question is what frame of mind would impel someone toward self-annihilation? In China, one answer is that rural society has traditionally placed greater value on boys than girls. A woman's life may seem expendable. Add to this the traditional belief that suicide is honorable and the apparent acceptance of suicide for those in a desperate situation who are powerless to escape, and the killing stage is set.
Whose Gender Imbalance?
Despite China's distinctive majority of female suicides, focusing on gender ratios--and not overall rates--tends to soften the glare of its suicide problem. The ratio of male to female suicides in China is 0.8/1; in the U.S., it is 4.1/1. Combining these with the ratios for several other countries begins to form a pattern: Japan--1.7/1; Singapore--1.3/1; United Kingdom--3.4/1; Canada--3.9/1. (The same WHO data, expressed in percentages, appear in the graph.) As Phillips notes, regardless of which sex has a higher suicide incidence, the figures show that the male and female rates in Eastern countries are closer together than the rates in Western countries.
Suicide Percentage by Gender
The percentages (rounded) of men and women who commit suicide in these countries suggest that gender ratios are more lopsided in the West than the East. Source: WHO, from World Mental Health, Oxford Univ. Press, 1995
"The imbalance is not in China, but the U.S.!" Phillips says. In fact, this disparity pervades the Americas--the 1990 male-female ratio for suicide in Puerto Rico, for example, is 9.2/1. Phillips says his research raises a central question about the West that is opposite the one raised about China--but just as provocative: Why are so many more men than women killing themselves?
It is axiomatic in the U.S. that virtually everyone who commits suicide has a mental illness, whether it be depression, schizophrenia, substance abuse, or a personality disorder. You have to be sick to kill yourself, right? Phillips argues that especially in China, the answer is no. The society offers suicide as a "normal" option.
"So far my study suggests that there is no demonstrable mental illness in one third of the cases," Phillips says. "These people impulsively commit suicide.
"There was a recent case in Macao, near Hong Kong," he continues. "Two children died in a fire, and the mother and father hanged themselves the next morning. Why? Suicide is a 'normal' response to certain kinds of stresses."
This conclusion extends the reach and complexity of any question about suicide prevention. "We don't have any real answers yet," Phillips says. But the project, being carried out at 26 sites in collaboration with the Chinese Academy of Preventive Medicine (similar to the U.S. Centers for Disease Control), is still in phase 1. This is a two-year period of identifying the causes of suicide. The next two phases will involve nearly a year working with communities to develop prevention programs and a two- to three-year period of applying and testing these interventions.
Phillips does say that the research suggests some preliminary ideas for reducing the suicide rate: "Support groups for rural women, controls on pesticides and herbicides, and expanded services for mental health."
--Robert Neal