Identifying and influencing the social determinants of elevated rates of suicide by Inuit youth

1
Identifying and influencing the social
determinants of elevated rates of suicide by
Inuit youth
Jack Hicks jack_at_jackhicks.com External
Ph.D. student, Ilisimatusarfik (The
University of Greenland) Qaujivallianiq
inuusirijauvalauqtunik (Learning from lives that
have been lived) suicide follow-back study
/ McGill Group for Suicide Studies, Douglas
Hospital Research Centre, McGill
University 15th Inuit Studies Conference Paris,
France October 26-28, 2006
2
If the populations of 'mainland' Canada, Denmark
and the United States had suicide
rates comparable to those of their Inuit
populations, national emergencies would be
declared.
Upaluk Poppel, representative of the Inuit
Circumpolar Youth Council, presentation to the
United Nations Permanent Forum on Indigenous
Issues, May 18, 2005
3
This has not always been the case. In Greenland,
Berthelsen (1935) calculated an annual rate of
death by suicide of 0.3 per 100,000 population
for the period 1900 to 1930. He concluded that
the few suicides occurring in Greenland at that
time were all the result of serious mental
illness. In Alaska, Krauss and Buffler (1979)
calculated that in the 1950s American
Indians/Alaska Natives had a rate of death by
suicide that was considerably lower than that of
the non-native residents of the state. And as
recently as 1971 the rate of death by suicide by
Inuit in Canada was close to that of the
non-aboriginal population of the country (Long,
1995).
4
Data from Nunavut
5
The rate of death by suicide by Nunavut Inuit
more than tripled during the 20 years beginning
in 1983, and is currently just over 120 per
100,000.
note 3-year averages
6
85 of suicides in Nunavut are by Inuit men, with
60 being by Inuit men between 15 and 24 years of
age.
7
The rate of death by suicide by Nunavut Inuit
aged 15 to 24 has increased more than six fold
since the early 80s.
8
The rate of death by suicide by Inuit men in the
Qikiqtani region is significantly higher than
those of other groups.
9
Most suicides by men are by hanging, with a
minority using firearms (which are very common in
Nunavut communities). Most suicides by women are
also by hanging, with a minority using firearms
or overdoses. Anecdotally we believe that women
in Nunavut attempt suicide at twice the rate that
men do, but many female attempts are more cries
for help than actual attempts to end life and
use less lethal means.
10
Data from Nunavik
11
The rate of death by suicide by Nunavik Inuit has
increased more than six fold since the mid-1980s,
and was 160 per 100,000 during the period
1999-2003.
note 3-year averages
12
80 of suicides in Nunavik are by Inuit men, with
63 being by Inuit men between 15 and 24 years of
age.
13
The rate of death by suicide by Nunavik Inuit
aged 15 to 24 has increased dramatically since
the early 80s.
14
The rate of death by suicide by Inuit living in
communities on the Hudson coast has risen much
faster than that of Inuit living in communities
on the Ungava coast.
15
Data from Alaska
16
The rate of death by suicide by Alaska Natives
increased from 15 per 100,000 in the 1950s to
more than 50 per 100,000 in the mid-1980s, and
has since decreased.
note 3-year averages
17
The increase and decrease in the rate of death by
suicide among Alaska Natives has largely been the
result of changes in the rates among Alaska
Native men.
18
Since the mid 1980s Alaska has experienced a
decrease in the rate of death by suicide in the
young male Native population.
19
The rate of death by suicide by Alaska Natives
living in the rural parts of the state are more
then 3.5 times higher than by Alaska Natives
living in the urban parts of the state.
note Urban is defined as Anchorage, Kenai
Peninsula Borough, Mat-Su Borough, Fairbanks
Borough and Juneau.
20
Data from Greenland
21
The rate of death by suicide by persons born in
Greenland rose sharply during the late 1970s and
early 1980s, and has since leveled off at 100
per 100,000.
note 3-year averages
22
Men between the ages of 15 and 30 are the
Greenlanders at the highest risk of suicide
23
The number of deaths by suicide by Greenlandic
men in their 20s has declined since the
mid-1980s, while that of other male cohorts have
stayed more or less constant and the number of
women committing suicide has gradually increased
24
This has resulted in the rate of death by suicide
by men born in Greenland to have declined
somewhat since the mid-1980s, while the rate for
women has remained the same.
25
Peter Bjerregaard has calculated the rate of
death by suicide of persons born in Greenland, by
sex and by year of birth
note 3-year averages
source Bjerregaard and Lynge (2006)
26
There has been a significant and sustained
decrease in the rate of death by suicide by young
men in Nuuk since the early 1980s.
27
There has been a significant and sustained
decrease in the rate of death by suicide by young
men in Nuuk since the early 1980s.
28
A note on the limitations of these data
29

• These slides present the very limited data
  available on Inuit who have died by suicide in
  recent decades. They are really nothing more than
  body counts.
• Ideally we would also like to know the rates and
  patterns of mental disorders, substance abuse,
  medical history, family history and early
  childhood experiences, education history, work
  history, relationship history, access to health
  care services, and other factors that may have
  played a role in the suicidal behaviour of these
  individuals and the presence or absence of a
  number of protective factors.

30
There as an accepted methodology for obtaining
these much richer data the suicide follow-back
study (or psychological autopsy). Such a study
is currently underway in Nunavut the
Qaujivallianiq inuusirijauvalauqtunik (Learning
from lives that have been lived) suicide
follow-back study. This study is attempting to
develop detailed life histories and psychological
profiles of 100 suicides that have occurred since
January 1, 2003. For each suicide completer,
similar data are collected for a suicide
attempter and a randomly selected case control,
matched to the suicide completer by community,
ethnicity, sex and age cohort. The results of
this study, when completed in 2008, should
greatly increase our understanding of suicide by
Inuit in Nunavut.
31
The Inuit suicide transition seen in a
circumpolar perspective
32
The transition from the historical Inuit suicide
pattern to the present day Inuit suicide
pattern was first documented in Alaska by
psychiatrist Robert Krauss. In a paper presented
at a conference in 1971, he noted In the
traditional pattern, middle-aged or older men
were involved motivation for suicide involved
sickness, old age, or bereavement the suicide
was undertaken after sober reflection and, at
times, consultation with family members who might
condone or participate in the act and suicide
was positively sanctioned in the culture. In the
emergent pattern, the individuals involved are
young the motivation is obscure and often
related to intense and unbearable affective
states the behaviour appears in an abrupt,
fit-like, unexpected manner without much warning,
often in association with alcohol intoxication
and unlike the traditional pattern, the emergent
pattern is negatively sanctioned in the culture.
33
The Inuit suicide transition occurred first in
Alaska beginning in the late 1960s
34
then occurred in Greenland,beginning in the
late 1970s
35
The transition from the historical Inuit suicide
pattern to the present day Inuit suicide
pattern occurred still later in Canadas Eastern
Arctic, and reached an even higher rate there.
note Eastern Arctic is defined here as the
Qikiqtani region of Nunavut plus all of Nunavik
36
Attempts at explanation
37
We have seen that the Inuit suicide transition
happened first in Alaska, later in Greenland, and
still later in Canadas Eastern Arctic (Nunavik
and the Qikiqtani region of Nunavut). Each
transition resulted in higher overall rates of
death by suicide. In each case it was the rates
of death by suicide by young (lt30 years of age)
men which increased most dramatically. Over time
the youth suicide rate tends to fall with the
suicide rate among both women and middle aged
(and older) men tends to increase.
38

• And in each case there were sub-regions with
  particularly and persistently high suicide rates
  the Bering Strait and Northwest Arctic regions
  in Alaska, East Greenland, the Hudson Bay coast
  of Nunavik, and the Qikiqtani region of Nunavut.
  (The rate of death by suicide by young men has
  declined in urban areas in Alaska and Greenland.)
• Any serious attempt to explain suicidal
  behaviour by Inuit in recent decades would
  therefore need to be able to explain
• the differing rates between men and women
• the differing rates between age cohorts
• the differing rates between regions and
  sub-regions and,
• the changes in all of these rates over time.

39
The temporal sequence in which the regional
suicide transitions occurred is
noteworthy. Beginning in the 1950s, governments
across the Arctic subjected Inuit to intense
disruptions of the lifeways they were accustomed
to a process we describe as active colonialism
at the community level. The details varied
considerably across the Arctic (see Csonka, 2005
on diverging Inuit historicities), but the
fundamental economic, political and social
processes were similar. The widespread
introduction of southern medical practices
resulted in sharp declines in the incidence of
tuberculosis first in Alaska, then in
Greenland, and finally in Canadas Eastern
Arctic. We can therefore use the decline in TB
incidence as a historical marker of the early
years of active colonialism at the community
level.
40
The historical sequence in which Inuit rates of
death by suicide rose across the Arctic (first
Alaska, then Greenland, then Canadas Eastern
Arctic) was the same order in which Inuit
infectious disease rates fell.
source Bjerregaard and Young (1998)
41
My working hypotheses are that

• The high rates of suicide by Inuit are not a
  stand alone problem, but a part of the
  widespread social suffering prevailing in Inuit
  societies today.
• A significant social determinant of elevated
  rates of suicide by Inuit youth is the
  intergenerational transmission of historical
  trauma, much of which is rooted in processes and
  events which occurred (or were particularly
  intense) during the initial period of active
  colonialism at the community level. The temporal
  sequence in which these internal colonial
  processes impacted Inuit across the Arctic was
  replicated some years later by rapid and
  significant increases in suicidal behaviour,
  primarily by young men.

42

• The higher rates of suicides in some sub-regions
  of the Inuit world can be attributed to higher
  levels of unresolved historical trauma existing
  in those sub-regions as a result of actions by
  the state such as (but by no means limited to)
  coerced sedentarization.
• One important mode of transmission is family
  dysfunction impacting on the social and emotional
  well-being of children in many, but by no means
  all, families. Child development is a critical
  determinant of physical, mental and emotional
  health across the life course. Parenting
  problems, neglect, child sexual abuse and other
  adverse childhood experiences may result in youth
  being less able to cope with stressors such as
  poverty, widespread substance abuse, and
  relationship difficulties that arise later in
  life.

43
In addition to the overall modernization process
having been significantly injurious to Inuit
mental health, the circumpolar data summarized in
this presentation suggests that the later a
region (or sub-region) underwent the transition
from the historic Inuit suicide profile to the
present day Inuit suicide profile the higher the
resulting rate of death by suicide would result.
This suggests that a time compression factor
exists. It should also be noted that it is the
sub-regions which have experienced the most
development in recent decades that have
generally experienced the lowest rates of death
by suicide. It may be that a new life script has
come into existence in urban areas across the
Inuit world, and that the young Inuit men at
greatest risk are those situated somewhere
between the historical Inuit life script and
the emerging urban Inuit life script.
44
My hope is that these hypotheses will allow the
important research contributions of Drs. Robert
Krauss in Alaska, Inge Lynge and others in
Greenland, and Laurence Kirmayer and his
collaborators in Nunavik to be understood in a
new historical and circumpolar framework.
45
Observations Reflections
46

• Language matters.
• Many suicide researchers avoid the terms
  suicide epidemic and epidemic levels of
  suicide because they suggest that suicidal
  behaviour is something viral, something one can
  catch.
• Similarly, I avoid the term Inuit suicide
  because it suggests that there is something
  uniquely Inuit about what is happening. Suicide
  by Inuit puts the emphasis where I believe it
  belongs on a universal problem (suicidal
  behaviour) as it occurs in one specific (in this
  case Inuit) context.

47

• We need to challenge the stereotypes that have
  developed around suicide by Inuit.
• Not all historic suicide by Inuit was of the
  type a sick and/or older person ends his/her
  life so as not to be a burden to the group. One
  of the earliest records of a suicide by an Inuk
  is a Greenlandic narrative which can be dated to
  between 1787 and 1789. It tells the story of
  Savannguaq, a young wife and mother who drowned
  herself after enduring psychological abuse from
  an old woman who lived in the same house as her
  and her husband, who was away hunting. The
  husband and his father later learned the
  circumstances which had led to Savannguaqs
  suicide, and took revenge on the vile old
  crone.

48
Similarly, not all present day suicides by
Inuit in Nunavut are by young men who have
recently suffered a relationship break-up. There
are also suicides by young Inuit women, suicides
by men and women in their 30s, 40s, 50s and 60s
(and in Greenland, in their 70s and 80s), and
suicides by people with mental illnesses. Suicide
by Inuit is every bit as complex a phenomenon as
suicide by non-Inuit, and should be treated as
such.
49

• We should resist explanations of elevated rates
  of suicide by Inuit which externalize causality
  and responsibility.
• One such type of explanation is that of suicide
  being the result of demonic possession.
• A second such type of explanation are polemics
  which simply blame the state. While historical
  colonialism and on-going internal colonialism
  are undoubtedly (in my opinion) important
  contributing factors to suicide by Inuit, we must
  not reduce suicide by Inuit to a problem brought
  about entirely by outsiders. To do so is
  fundamentally disempowering how does such an
  approach help communities, families and
  individuals figure out how best to heal
  themselves?

50

• We must learn from the hard-earned lessons of
  research conducted elsewhere in the world
• suicidal behaviour cannot be understood in
  isolation from its social context
• suicide is a complex, multicausal phenomenon
• a wide range of possible risk factors (e.g.
  depression, drug use, etc.)
• Comorbidity depression drug use (1 1 gt 2)
• high degree of impulsivity
• trigger event
• it is possible to identify risk and protective
  factors that are significant for a specific
  population/sub-population

51

• both adverse childhood experiences and living
  conditions later in life play a role in suicidal
  behaviour
• a sense of hopelessness is present in almost
  all suicides, regardless of the other factors
  that may or may not be present
• a public health approach can be effective in
  structuring suicide prevention efforts
• general initiatives for the general public
• targeted initiatives for groups at elevated risk
• specific initiatives for individuals at elevated
  risk

52

• While recognizing that the role of historical
  trauma is crucial, Kirmayer et al (2003)
  cautioned
• The location of the origins of trauma in past
  events may divert attention from the realities of
  a constricted present and murky future which are
  the oppressive realities for many aboriginal
  young people living in chaotic and demoralized
  communities.
• The Inuit experience suggests that we must be
  cautious about assuming that self-government
  arrangements are, in and of themselves, the
  answer to the problem of high rates of suicide.
  It took Greenlands Home Rule Government more
  than two decades to begin to seriously tackle its
  suicide problem, and after seven years the
  Nunavut government has yet to develop a coherent
  and comprehensive suicide prevention strategy.
  Why this has been the case is a thesis topic in
  and of itself.

53

• There is a precedent in Canada for recognizing
  and addressing the intergenerational transmission
  of historical trauma in indigenous communities
  the legacy of the residential schools.
• As a result of research conducted by and
  recommendations made by the Royal Commission on
  Aboriginal Peoples (RCAP), the federal government
  created and funded the Aboriginal Healing
  Foundation (AHF) to address the historical trauma
  resulting from residential schools. Healing
  programs funded by the AHF have made a tremendous
  difference to indigenous people living in
  communities from coast to coast to coast.

54

• Suicide by Inuit has not been understood to exist
  in a political context to the degree that suicide
  by some other indigenous groups has been.
• See for example, the following cartoons from
  Australia

55
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56
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57

• There is reason for optimism.
• There is no reason why Nunavummiut and other
  Inuit should suffer decades of elevated rates of
  suicide among their young men it IS possible to
  break the cycle of transmission of historical
  trauma.
• The fledgling Nunavut government, with its
  limited resources, is not capable of solving the
  problem on its own. There is an urgent need for
  the Canadian state to acknowledge the nature and
  scope of the problems, and to commit the
  resources required to address them. In a rich
  country like Canada the state is quite capable of
  influencing the social determinants of mental
  health if it chooses to do so.

58
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