Developing a national registry to prevent suicides in Nigeria

BY NNAMDI OBASI AND NZUBECHUKWU OGAMBA

Suicide refers to the act of intentionally taking one’s life. The risk factors include physical disorders such as chronic fatigue syndrome, mental disorders including depression, bipolar disorder, autism spectrum disorders, schizophrenia, personality disorders, anxiety disorders, nihilistic beliefs and substance use disorders including alcohol use disorder and the use of and withdrawal from benzodiazepines.

This serious public health challenge leads to the death of 703,000 people annually. Each of these deaths is followed by many other non-successful attempts. It was the fourth leading cause of death among 15-19-year-olds in 2019. Suicides occur in every country of the world. However, they are more common among developing countries which account for 77% of suicide deaths globally.

In 2016, 17,710 cases of suicide were recorded in Nigeria. This placed the country at sixth position on the list of countries with high suicide rates and highest in Africa.

Out of these cases, 9,300 were males while 8,410 were females giving the percentage ratio of men to women to 47:53. These numbers put Nigeria as the leading country in the African continent; followed by Ethiopia and South Africa with 7,323 and 6,476 cases respectively.

Suicide is a complex issue with varying perspectives spanning across religious, philosophical, social, legal and health fields.

In ancient Athens, if someone died through suicide without the approval of the state, he was denied normal burial rites. The person would be buried on the outskirts of the city or alone without a headstone or marker. In Ancient Rome, it was initially permitted but was later outlawed due to its perceived economic costs.

The Renaissance period brought along with many other things, a slow shift in the attitude towards suicide. David Hume, in his 1777 Essays on Suicide and the Immortality of the Soul argued that suicide was not a crime as it affected no one and was perhaps an advantage to the individual.

No country in Europe currently considers suicide a crime. However, in up to 20 countries, suicide is still a criminal offence and, as can be expected, these countries are all developing countries. In Nigeria, children as young as seven can be arrested, tried and prosecuted for attempting suicide. In fact, according to section 327 of the Nigerian Criminal Code act, attempted suicide is punishable by one year in prison.

Prevention strategies in Nigeria

If criminalising suicide is a prevention strategy by the Nigerian government, one is left to wonder what other prevention strategies are adopted by the country.

A simple search shows that there is none. The country is yet to develop and implement a multi-sectoral plan to fight suicides as recommended by the WHO. According to the WHO, having a national suicide prevention strategy is necessary to elevate suicide prevention to the political goals of every country.

Why are we not taking suicide seriously?

Aside from the general neglect of Nigeria’s health sector, a plausible reason for the observed apathy towards suicide prevention is the lack of accurate data on the suicide burden in Nigeria. The WHO publishes data from time to time. However, experts believe that suicides are greatly underreported in the country. You can only fight what you are aware of and so this attitude from the government is not surprising.

The solution is not just in quantifying the burden of suicides but also in the specification of the methods, age and sex of the victims. Recording this information is critical to the development of targeted suicide prevention strategies. In addition to these benefits, a robust registration system will provide information on trends of suicide over time. With this knowledge, policymakers can modify their strategies to achieve the best fit.

Information contained in a suicide register is not useful for policymakers alone; researchers could use such information to make more meaning of the atmosphere in the country.

Clinicians too are not left out. A good knowledge of suicide epidemiology will help them make better decisions in their day-to-day care of patients.

How do we go about it?

In many developed nations, recording suicide mortality spans across the country. However, this may not be feasible in developing nations like Nigeria where there is a lack of financial resources or trained staff. The remoteness of certain geographical locations might also make data capture difficult.

To get around this, we can record suicide mortality from a smaller sample of our entire population as defined by a region, state or even a city; although ensuring that the sample is representative of the country in terms of age, sex, socio-economic characteristics etc.

According to the WHO, a suicide registry should aim at capturing the following information:

• Sex;
• Age;
• Method of suicide;
• Date of suicide;
• Time of suicide;
• Location of where the person was found or carried out the suicide;
• Place of residence;
• Presence of suicide note;
• A statement indicating an intention to die.

It is also useful to collect information that can help reconstruct the circumstances surrounding death. These include:

• Consumption of alcohol or drugs immediately prior to death;
• History of suicide attempts;
• Mental disorder;
• Chronic pain and/or physical illness;
• Emotional distress and/or adverse life experiences;
• Relationship status (e.g. single, married, widowed etc.);
• Ethnicity
• Sexual orientation (e.g. homosexual, heterosexual);
• Employment status at the time of death, and;
• Occupation at the time of death.

These records can be gotten from the following people and institutions:

• Physicians;
• Coroners and other medico-legal authorities;
• Police;
• Mental health and health workers;
• Mortuary or funeral staff
• Health information systems staff and statistics officers;
• Researchers in health-related disciplines (e.g. epidemiologists and bio-statisticians, suicide researchers, psychologists, and sociologists); and
• Those employed at relevant non-governmental or community organisations.
• Automated data collection systems can also be designed by data scientists to obtain information from verifiable reported suicides on online and social media platforms.

Suicide is a public health challenge that demands our utmost attention and commitment. As a matter of urgency, a national prevention plan should be designed and this process begins with accurate record-keeping of suicide cases in the country.

Ogamba and Obasi are both medical doctors at the University of Nigeria Teaching Hospital and co-founders of the Youth Health Action Network (YOHAN Africa)