The social determinants of elevated rates of suicide by Inuit youth presentation

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Title: The social determinants of elevated rates of suicide by Inuit youth

1
The social determinants of elevated rates of
suicide by Inuit youth
Jack Hicks jack_at_jackhicks.com International
Network for Circumpolar Health Research, and
National Network for Aboriginal Mental Health
Research Qaujivallianiq inuusirijauvalauqtunik
(Learning from lives that have been lived)
suicide follow-back study / McGill Group for
Suicide Studies, Douglas Hospital Research
Centre, McGill University External Ph.D. student,
Ilisimatusarfik (The University of
Greenland) Public Policy Forum seminar
Economic Transformation North of 60 December
13, 2006
2
Introduction to research initiatives
3
International Network for Circumpolar Health
Research (INCHR) www.inchr.org A network of
researchers, research trainees, and supporters of
research based in academic research centres,
indigenous peoples organizations, regional
health authorities, scientific/professional
associations, and government agencies, who share
the goal of improving the health of the residents
of the circumpolar regions through international
cooperation in scientific research. Funded by the
Canadian Institutes for Health Research (CIHR)
through its Global Health Research Initiative.
4
National Network on Aboriginal Mental Health
Research (NNAMHR) www.mcgill.ca/namhr A
partnership between aboriginal communities and
academic researchers, the goal of which is to
develop research and training to address the
mental health needs of aboriginal people in
Canada in both urban and rural settings. The
Network trains new researchers to develop
capacity in the area of aboriginal mental health
research. It will provides research consultation
services for and in collaboration with aboriginal
communities. Funded by the Canadian Institutes
for Health Research (CIHR).
5
Qaujivallianiq inuusirijauvalauqtunik ('Learning
from lives that have been lived') suicide
follow-back study www.douglasrecherche.qc.ca/group
s/suicide/project-nunavut.asp?le This study is a
process of detailed interviews that allow the
researchers to develop a detailed understanding
of someones entire life story. Collecting 300
life stories (100 suicide completers, 100 suicide
attempters and 100 controls) will give the study
team a much better understanding of the factors
contributing to one of Nunavuts most urgent
social problems. Funded by the Canadian
Institutes for Health Research (CIHR) through a
New Emerging Team grant.
6
Introduction to suicide by Inuit
7
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
8
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
illnesses. In Alaska, Krauss and Buffler (1979)
found 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).
9
Suicide data for Nunavut
10
As of December 1, 2006, there have been 220
suicides by residents of Nunavut since the
territory came into being on April 1, 1999. All
but three have been by Inuit. Of the 217 suicides
by Nunavut Inuit, 171 (83) have been by men and
36 (17) have been by women.
11
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 population.
note Nunavut data are 3-year averages, not
age-standardized
12
64 of suicides in Nunavut are by men less than
25 years of age, compared to 7 Canada-wide.
13
The rate of death by suicide by Nunavut Inuit
aged 15 to 24 has increased more than six fold
since the early 80s.
14
The rate of death by suicide by Inuit men in the
Qikiqtani region is significantly higher than
those of other groups.
15
78 of suicides by men are by hanging, with 20
being by firearms (which are very common in
Nunavut communities). 86 of suicides by women
are by hanging, with a few being by firearms or
overdoses. The Government of Nunavut Dept of
Health Social Services does not collect data on
suicide attempts. Anecdotally we believe that
women in Nunavut attempt suicide at twice the
rate of men. Many female suicide attempters use
less lethal means.
16
Nunavut in Canadian context
17
The Inuit of Nunavik and Nunatsiavut have even
higher suicide rates than Nunavut Inuit.
18
Men residing in Nunavut have a rate of death by
suicide that is nine times the rate for all men
residing in Canada.
source CANSIM series 102-0551
19
Men aged 15 to 24 residing in Nunavut have a rate
of death by suicide that is 40 times the rate for
all young men residing in Canada.
source CANSIM series 102-0551
20
Data from the circumpolar Arctic
21
Data from Alaska
22
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
23
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.
24
Since the mid-1980s Alaska has experienced a
decrease in the rate of death by suicide in the
young male Native population.
25
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.
26
Data from Greenland
27
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
28
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)
29
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)
30
This graph shows the sharply elevated rate of
death by suicide by young men living on
Greenlands east coast
31
but it also shows that there has been a
significant and sustained decrease in the rate of
death by suicide by young men in the capital Nuuk
since the early 1980s.
32
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.
33
A note on the limitations of these data
34

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 like to know the rates and
patterns of family history and early childhood
experiences mental disorders medical history
education history work history relationship
history substance use/abuse engagement with the
justice system availability of, access to and
use of health care services and, other factors
that may have played a role in the suicidal
behaviour of these persons.
We would also like to know about the presence or
absence of a number of protective factors.

35
There is 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 Learning
from lives that have been lived suicide
follow-back study. This study will 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 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.
36
The suicide transition by Inuit seen in a
circumpolar perspective
37
The transition from the historical pattern of
suicide by Inuit to the present-day pattern of
suicide by Inuit 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.
38
This suicide transition by Inuit occurred first
in Alaska beginning in the late 1960s
39
then occurred in Greenland,beginning in the
late 1970s
40
The transition from the historical pattern of
suicide by Inuit to the present-day pattern of
suicide by Inuit 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
41
Attempts at explanation
42
We have seen that a suicide transition by Inuit
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.
43

In each case there were sub-regions with
particularly and persistently high suicide rates
the Bering Strait and Northwest Arctic regions
in Alaska, the Qikiqtani region of Nunavut, the
Hudson Bay coast of Nunavik, and East Greenland.
But in recent years, 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.

44
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 I 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.
45
The historical sequence in which Inuit infectious
disease rates fell was the same order in which
Inuit rates of death by suicide later rose across
the Arctic.
source Bjerregaard and Young (1998)
46
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 suicide
transition 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.
47
Working hypotheses
48
My working hypotheses are that

Suicide by Inuit is every bit as complex a
phenomenon as suicide by non-Inuit, and should be
treated as such.
(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.)

We should resist explanations of elevated rates
of suicide by Inuit which are simplistic and/or
which externalize causality and responsibility.
Examples of the first type of explanation are
boredom, demonic possession, the impact of moon
cycles, etc.
An example of the second type of explanation are
polemics which simply blame the state. While
historical colonialism and on-going internal
colonialism are (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?

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 woman.

51
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 teenaged girls, men and
women in their 30s, 40s, 50s and 60s (and in
Greenland, in their 70s and 80s), and suicides by
people with diagnosable mental illnesses. The
follow-back study currently underway in Nunavut
may reveal that these different groups within the
population have quite different patterns of risk
and protective factors.
52

Social determinants are the only logical
explanation for the pattern of the suicide
transition that occurred across the Inuit world
beginning in Alaska in the 1960s.
A significant social determinant of elevated
rates of suicide by Inuit 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,
particularly by young men.

53
The higher rates of suicides in some sub-regions
of the Inuit world can be attributed at least in
part 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, the
imposition of colonial education systems, etc.
54

That being said, we must keep in mind the caution
expressed by Kirmayer et al (2003)
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.
Living conditions in Nunavut communities today
are also important social determinants that
contribute to elevated rates of suicide.

The high rates of suicide by Inuit in Nunavut
are not a stand alone problem, but a part of
the widespread social suffering prevailing in
Inuit communities today.
Nunavuts high suicide rate should not be viewed
in isolation, but as a symptom of a society
experiencing rapid and difficult social, cultural
and economic change under specific historic and
political conditions and suffering
high levels of violence and abuse
high rates of unemployment
high levels of unresolved traumas of various
types
high rates of substance abuse
a 75 school drop-out rate and,
widespread poverty.

One important mode of intergenerational
transmission of historical trauma 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, negative experiences in school, and
other adverse childhood experiences may result in
youth being less able to cope with stressors
such as poverty, substance abuse, and
relationship difficulties that arise later in
life.

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
there are a wide range of possible risk factors
(e.g. biological factors, depression, drug use,
etc.)
comorbidity (multiple risk factors operating
simultaneously) significantly increases risk
an elevated degree of impulsivity
a trigger event
it is possible to identify risk and protective
factors that are significant for a specific
population/sub-population

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

Among the recent research findings that may be
of relevance to Nunavut
Research from the United States which found that
Youth with poor reading ability were more likely
to experience suicidal ideation or attempts and
more likely to drop out of school than youth with
typical reading, even after controlling for
sociodemographic and psychiatric variables.
Suicidality and school dropout were strongly
associated with each other. Prevention efforts
should focus on better understanding the
relationship between these outcomes, as well as
on the developmental paths leading up to these
behaviors among youth with reading difficulties.
Daniel et al, Suicidality, school dropout,
and reading problems among adolescents, Journal
of Learning Disabilities, 2006

Research from Australia which found that
Socio-economic status (SES) remained
significantly associated with suicide after
controlling for the prevalence of mental
disorders and other psychiatric symptomatology.
Mental conditions and previous suicidal behaviour
may play an intermediary role between SES and
suicide, but this study suggests that an
independent relationship between suicide and SES
also exists.
Taylor et al, Mental health and
socio-economic variations in Australian suicide,
Social Science Medicine, 2005
Other research from Australia which found that
Since the late 1990s there has been a sharp
downward trend in Australian young male suicide.
It is possible that a major government youth
suicide prevention initiative, the National Youth
Suicide Prevention Strategy (NYSPS), implemented
during 1995-1999 may have influenced the
decline.
Morrell et al, The decline in Australian
young male suicide, Social Science Medicine,
forthcoming

61
Conclusions
62

Unless appropriate and concerted efforts are
made, it is entirely possible that suicide rates
in Nunavut will remain at or near their current
rates for the foreseeable future.
It should be noted that, after peaking in 1986,
Greenlands overall suicide rate has remained
very high for the last TWENTY years.
There is so much accumulated loss, pain and
trauma in Nunavut communities already it is
hard to imagine what they would be like after
twenty more years of tragically high rates of
suicides...

Experience from elsewhere in the world tells us
that effective suicide intervention and
prevention measures ARE possible. The World
Health Organization believes that developing a
comprehensive suicide prevention strategy is an
essential first step, and has formulated a set of
guidelines for the preparation of such
strategies.
Canada, however, lags behind the United States
and other countries in not having a national
suicide prevention strategy in place.
It took decades for the governments of Alaska
and Greenland to develop and implement suicide
prevention strategies.
Despite its high suicide rate, the Nunavut
government has yet to develop a suicide
prevention strategy.

Canada is, however, a world leader in
acknowledging 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.
Nunavut needs programs to heal the historical
trauma resulting from sedentarization and
community formation.

Immediate action needs to be taken to reduce
poverty and improve living conditions in Nunavut
communities.
No society whose school system fails 75 of the
students who enter it can expect to have a low
rate of suicide by its marginalized young people.
As Nunavut takes flight you are dealing with
immense challenges. Whether it is educating your
fast growing population, alleviating poverty and
social breakdown or building the capacity within
your own government to address these challenges,
you have your work cut out for you. Work that
will require patience, creativity and tremendous
energy to resolve.
Prime Minister Jean Chrétien, addressing the
open session of the Legislative Assembly of
Nunavut (emphasis added)

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 Government of Canada 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 significantly influencing the
social determinants of mental health if it
chooses to do so.

67
Again 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.
note Eastern Arctic is defined here as the
Qikiqtani region of Nunavut plus all of Nunavik

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