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The social determinants of elevated rates of suicide by Inuit youth

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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.)

49
  • 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?

50
  • 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.

55
  • 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.

56
  • 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.

57
  • 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

58
  • 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

59
  • 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

60
  • 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...

63
  • 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.

64
  • 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.

65
  • 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)

66
  • 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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