IJE vol.32 no.6 © International Epidemiological Association 2003; all rights reserved.
International Journal of Epidemiology 2003;32:902–909
EDITORIAL
Suicide by intentional ingestion of pesticides:
a continuing tragedy in developing countries
David Gunnell1 and Michael Eddleston2,3
Deliberate self-poisoning has become an increasingly common
response to emotional distress in young adults,1 and it is now
one of the most frequent reasons for emergency hospital admis-
sion.2 In industrialized countries, the drugs that people commonly
take in overdose—analgesics, tranquillisers, antidepressants3—
are relatively non-toxic. The estimated case fatality for overdose
in England, for example, is around 0.5%.4 Most individuals who
self-harm do not intend to die. Studies carried out in industrial-
ized countries have found that only 2% go on to commit suicide
in the subsequent 12 months.5
In developing countries the situation is quite different.6 The
substances most commonly used for self-poisoning are agricultural
pesticides.6–11 Overall case fatality ranges from 10% to 20%.12
For this reason, deaths from pesticide poisoning make a major
contribution to patterns of suicide in developing nations, par-
ticularly in rural areas.6 In rural China, for example, pesticides
account for over 60% of suicides.8 Similarly high proportions of
suicides are due to pesticides in rural areas of Sri Lanka (71%),13
Trinidad (68%),14 and Malaysia (
90%).10 There is, however,
no evidence that levels of suicidal intent associated with pesticide
ingestion in these countries are any higher than those asso-
ciated with drug overdose in industrialized countries, where the
drugs taken in overdose are less toxic.
Patterns of suicide in countries where
pesticide poisoning is commonplace
In countries where the use of pesticides for self-harm is
commonplace conventional epidemiological features of suicide
appear to be distorted. In industrialized nations, suicide rates are
two to three times higher in men than women, and its incidence
tends to increase with age, although in some countries recent
rises in young male suicides have distorted this pattern.15 The
incidence of non-fatal self-harm in industrialized countries is
20+ times higher than that of suicide; in contrast to suicide, self-
harm rates peak in 15–24 year olds and are generally highest in
women (Figure 1a).16
1 Department of Social Medicine, University of Bristol, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR, UK.
2 Ox-Col Collaboration, Department of Clinical Medicine, University of
Colombo, Colombo, Sri Lanka.
3 Centre for Tropical Medicine, Nuffield Department of Clinical Medicine,
University of Oxford, Oxford, UK.
Correspondence: David Gunnell, Department of Social Medicine, Canynge Hall,
Whiteladies Road, Bristol BS8 2PR, UK. E-mail: D.J.Gunnell@bristol.ac.uk
902
DOI: 10.1093/ije/dyg307
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A possible explanation for these differences in the age- and
sex-patterning of fatal and non-fatal self-harm is that young
people, particularly females, are more likely to engage in impulsive
acts of self-harm—as indicated by the comparatively lower levels
of suicidal intent in young people.17 Because these acts are
unplanned, the methods used are those that are readily available
at the time of acute distress—prescribed and non-prescribed
medicines—and these are relatively non-toxic. If more lethal
methods of self-harm, such as pesticides, were favoured and
readily accessible in industrialized nations the epidemiology of
suicide in these countries might be quite different. Thus the wide-
spread availability of pesticides may contribute to the difference
in the age- and sex-patterning of suicide in China,18 Sri Lanka,19
India,20 and several other developing countries compared with
that commonly seen in industrialized nations (Figure 2). In
these developing countries some of the highest rates are seen in
young adults and the ratio of male:female suicide approaches or
exceeds unity at this age.
In China, whilst suicide rates do tend to increase with age,
there is a notable peak in rates amongst males and females aged
20–24 (Figure 2); recent data show that this peak is more
prominent in rural localities.18 In rural India rates of suicide in
15–24 year old females are higher than rates in males of the
same age and most other female age groups.20 Similar patterns
are seen in Sri Lanka (Figure 2). In both China and Sri Lanka
pesticides are the most frequently used method of suicide, like-
wise in India self-poisoning is the commonest method 20 and
pesticides are the most frequently used agents.9,21 It is of note
that the age- and sex-patterns of self-poisoning in Sri Lanka in
the younger age groups are similar to those in industrialized
countries, (Figure 1b) although in contrast, the case fatality in
Sri Lanka is much higher.38
Part of the distinct age- and gender-patterns of suicide deaths
in the developing world may therefore reflect a mixture of deaths
with high suicidal intent (predominantly in the elderly) and an
excess of deaths with low suicidal intent amongst the young where
the method chosen for impulsive acts of self-harm (pesticide inges-
tion) is highly lethal. A possibility strikingly born out in Western
Samoa in the 1980s, where two-thirds of all suicides were a
result of pesticide ingestion and the age- and sex-patterning of
suicide and non-fatal self-harm were almost identical.22
Method availability and suicide
The common use of pesticides for self-harm in part reflects their
ease of availability. Whilst their use in agriculture is widespread
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Figure 1 Hospital admissions for self-poisoning. a. England (Source: Hospital Episode Statistics
April 1999–March 2000), b. Sri Lanka (Source: Eddleston and colleagues unpublished data: data
are for the two secondary referral hospitals in North Central Province: April 2002–March 2003;
NB data for Sri Lanka are given as numbers rather than rates as there are no appropriate
population denominator data)

in industrialized countries, large-scale farming is practised by
a small number of landowners, thus reducing the number of
people with direct access to pesticides. In contrast, most people
living in rural regions of developing countries are involved in
agriculture and farm small areas of land. Subsistence farmers
keep their own supply of pesticides, commonly within, or close
to, the household.23 A recent study in China found that 65% of
pesticide suicides used chemicals stored in the home.8
There is general consensus that the ease of availability of
particularly lethal means of self-harm may influence patterns of
suicide. Suicidal impulses are often short lived and if time can
be ‘bought’ allowing such impulses to pass—by making the means
of suicide less readily available—a proportion of suicides will be
prevented.24 The best documented evidence of this was the
effect of the detoxification of the domestic gas supply in Britain
in the 1960s25—this was thought to have contributed to the
prevention of an estimated 6700 suicides.26 Similarly, temporal
and geographical variations in the availability of other commonly
used methods have influenced patterns of suicide in Australia
(barbiturates),27 USA (firearms),28,29 and Britain (catalytic con-
verters for car exhaust fumes).30
This evidence has prompted the inclusion of policies aimed at
reducing access to, or the lethality of, commonly used methods
within national and international suicide prevention strategies.31–33
In Britain attention has focused on restricting the availability of
paracetamol (acetaminophen)34,35 and in the USA there are
similar concerns about the ease of availability of firearms.28,29
The number of deaths caused by pesticides36 make Western
concerns about these two methods of suicide appear somewhat
trivial. For example, in Britain where paracetamol suicide is
comparatively common,34 there are only around 200 paracetamol
suicides per year (4% of all suicides).35 If a similar proportion
of suicides were due to paracetamol worldwide (an overestimate34)
then using the WHO’s current estimate of 849 000 suicides
worldwide each year37 a maximum of 34 000 of these might be
attributable to paracetamol.
In contrast, the WHO estimated in 1990 that there are around
3 million hospital admissions for pesticide poisoning each year,
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Figure 2 Age and sex patterns of suicide. a. In China (Source: WHO), b. Sri Lanka (Source: WHO), and
c. Kaniyambadi region, S. India (Source: Joseph et al.20)

2 million of which are as a result of deliberate ingestion, and
these result in around 220 000 deaths.36 The size of the problem
is probably larger now—there have, for example, been well-
recognized increases in pesticide poisonings in South Asia.21
The best evidence for estimating the global burden of suicide
deaths from pesticide ingestion comes from China and South
East Asia. In 2001 there were an estimated 517 000 suicides in
developing countries in these regions37and research evidence
(see above) suggests pesticide ingestion accounts for over 60%
of these suicides. We therefore estimate there are around 300 000
pesticide suicides each year in these regions alone. As pesticide
suicides from other developing nations in Africa and South America
are not included in this figure the global toll is likely to be higher.
Economics of pesticide poisoning
Deaths from pesticide ingestion are a major contributor to the
global burden of suicide and premature mortality. This burden
is increased by the economic and indirect health care effects of
self-harm following ingestion of pesticides. Such effects have
been less well documented in the research literature.
The hospital management of pesticide poisoning often
requires intensive care, in particular ventilation. In 1995–1996,
in one general hospital in Sri Lanka, 41% of bed occupancy on
medical intensive care beds was for the treatment of pesticide
poisoning.38 This not only drains limited healthcare budgets but
also prevents the treatment of other patients requiring intensive
care. Furthermore, the loss through premature death, of young,
economically active, community members and the impact of
their death on others (spouses, children, friends, and family) may
influence productivity in communities that are on the margins
of subsistence.
The costs of self-harm should be balanced against the
agricultural benefits of pesticides. These have not been formally
quantified and work over the last 20 years with integrated pest
management has shown that reduced use of pesticides can be
compatible with at least stable levels of crop production.39,40
Pesticides are also used to control disease vectors (e.g. mosquito
vectors of dengue and malaria) but supplies of pesticides used
for this purpose are kept in official store rooms and are there-
fore less likely to be available for acts of self-harm.
Any analysis of the competing adverse and beneficial effects
of pesticides should incorporate the possibility of replacing
pesticides which are toxic to humans with less toxic, but equally
effective alternatives.6 Likewise the short-term effects on crop
yields should be balanced against wider effects on the environ-
ment, development of parasite resistance, and possible longer-
term effects of pesticide exposure on human health.6
How can the death toll from pesticide
poisoning be reduced?
Possible approaches to reducing deaths from pesticide ingestion
are outlined in the Table. The importance of broad-based com-
mitment from industry as well as Non-Governmental Organiza-
tions (NGO), and national and international health and regulatory
organizations is highlighted.
The first broad approach is to restrict the availability of pesti-
cides either directly, for example through restricting the import
and use of pesticides, or indirectly through ensuring supplies are
SUICIDE BY INTENTIONAL INGESTION OF PESTICIDES 905
kept in a secure facility in each geographical locality. Restricting
availability could be achieved by either direct control of particular
pesticides (banning, requiring licences for use or prescriptions)
or through the promotion of practices that minimize their use.
Such health protection approaches appear to have led to a
reduction in serious paracetamol poisonings in England35 and
a decline in barbiturate suicides in Australia.27 The WHO has
encouraged countries to restrict the availability of more lethal
pesticides32 and countries such as Sri Lanka have followed this
approach.41 In Jordan, a steady rise in fatal pesticide poisonings
was reversed by increased awareness of the problem, decreased
imports of some toxic pesticides, and bans on the imports of
others.42 Similar effects have been observed in Western Samoa
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after reduced use of paraquat and a campaign to raise awareness
of suicide; however, here fluctuations in imports were driven by
the nation’s financial problems rather than a concern with suicide.22
The second approach is to improve public education regard-
ing the dangers of pesticide poisoning and the safekeeping
of pesticides—through media campaigns and clear labelling of
product containers. The effects are difficult to predict and there
is a suggestion that enhanced knowledge concerning the
toxicity of pesticides resulted in an increase in their use for self-
harm in some settings.12 Furthermore, it is widely recognized
that media portrayal of acts of self-harm can lead to increases in
‘copy-cat’ suicides.43
The third general approach is to encourage manufacturers to
improve the safety of their products. This may be achieved by
diluting the concentrations of liquid pesticides, incorporating
emetics or agents to make them unpleasant to taste or, more
fundamentally, to produce pesticides which are non-toxic to
humans.44 Company responsibility for the safe use of pesticides
should extend for the entire life cycle of their use.
Lastly, if the occurrence and lethality of pesticide ingestions
cannot be prevented then improved medical management is
crucial.12 The lethality of pesticide poisoning is for the most part
due to the difficulty of treatment and their greater toxicity
compared with substances taken in overdose in industrialized
countries. Antidotes to pesticides are not completely effective.
In rural areas, where the majority of cases occur, health care is
often distant and of poor ‘quality’. In the UK, where paracetamol
is the most common poison used for self-harm, a similar situation
could be envisaged if all the antidotes became unavailable—
the medical wards might once again become filled with
paracetamol-poisoned patients with either anticipated or florid
liver failure.
Why has there been a failure to act?
The problem of death from pesticide self-poisoning is neither
new12,45–48 nor unique to a few countries, so reasons for the lack
of a global response need to be understood if this continuing
tragedy is to be reversed.
Five main factors appear to contribute. First, the pattern of
agriculture practised in developing countries—where most
people living in rural areas cultivate small areas of land—is
quite different from that in industrialized nations where a small
number of farmers cultivate large tracts of land. In industrialized
countries access to pesticides is therefore largely restricted to
the few individuals engaged in farming. In developing nations
pesticides are available within most peoples’ place of residence.
906 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Table 1 Possible approaches to reducing deaths from intentional pesticide ingestion

Who should be responsible

Possible strategy Advantages Disadvantages for action?
Reduce availability of highly toxic pesticides
Introduce a ‘minimum pesticides list’6 Reduced case fatality Industry pressure against WHO/FAO
restricting pesticide use to a few, less restriction from companies National regulatory authorities/
dangerous pesticides whose products are regulated National Government
Prohibit sales of the pesticides most lethal to Reduced case fatality Replacement pesticides may National Government
humans after ingestion be less effective agriculturally
Subsidize or reduce the costs of pesticides Reduced case fatality Reduced industry profits. Industry.
which are less toxic to humans Costs to national Governments. National Government
May increase pesticide use
Ensure all pesticides are kept in a locked Limited availability in Inconvenience. National Government (legislation).

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cabinet with the key held by the licensed times of acute emotional Costs, difficulty policing Purchaser of pesticide
user crisis legislation
Appoint a village elder, schoolteacher, police Limited availability at Inconvenience. National Government (legislation).
officer or councillor to hold the locality’s times of emotional crisis Administration costs. Local Government/community
stocks of pesticides centrally Diminished access for farmers
Reduce the use of pesticides in agricultural Less pesticides around at Reduced industry profit. United Nations.
practice (e.g. Integrated Pest Management times of emotional crisis Possibly reduced agricultural National Government
[IPM])39 yield—further studies are
required
Ensure all remaining pesticides are returned Limited availability in Administration costs. Local Government/community
to vendor after application times of emotional crisis Costs to farmers

Reduce use of pesticides in acts of self harm

Public education campaigns regarding the
dangers of pesticide ingestion22,44
Better labelling of products with advice
regarding dangers, need for safe-keeping,
need for early treatment
May lead to reduced
quantities of pesticides
being taken in self harm
May lead to more rapid
help seeking from those
who have ingested
pesticides, as well as their
friends and relatives
Limited availability.
Reduced case fatality
because of early help-
seeking and treatment
May, by highlighting lethal National and Local Government
dose and potential for using
this method, lead to increases
in suicides.
There is already widespread
a wareness regarding the
dangers/toxicity of pesticides.
No clear evidence of effect in
Western Samoa22
Industry.
National and Local Government

Reduce the toxicity of pesticides taken in overdose

Addition of emetic agent/antidote to all Possibly reduced case Costs to industry. Industry.
pesticide products fatality Possibly reduced agricultural National regulatory bodies
effectiveness of the pesticide.
No consistent evidence of
effectiveness44
Change formulation of pesticides: reduced Reduced case fatality Costs to industry Industry
concentration or addition of agents that make
them unpleasant to taste/smell
Industry research to produce agents which Reduced case fatality Costs to industry Industry
are non-toxic to humans

Improved management of pesticide poisoning

Ensure all villages have first aid kits for the Possibly reduced poison Costs of ensuring supplies National and Local Government
immediate management of pesticide poisoning absorption and therefore regularly updated
—charcoal; possibly emetics case fatality No evidence of effectiveness
Improve speed of transfer to hospital Ensure patient is in a Costs to cash restricted health National and Local Government
hospital when services
deterioration occurs
Ensure all hospitals have adequate supplies Reduce requirements for Costs to cash restricted health National and Local Government
of antidotes transfer, reduce case services
fatality
Perform research to establish best management Establishment of agreed Research costs Major research funding bodies
guidelines and determine effectiveness of best practice
antidotes
Promulgate management guidelines Reduced case fatality Costs of synthesizing evidence Major research funding bodies
to produce such guidelines

Interventions to limit access in such settings are complex and
need to involve most rural adults, rather than a select few.
Second, the sale of pesticides is a multi-billion dollar business.
In all, 1.5 million tons of pesticides are sold annually and sales are
worth an estimated US$30 billion.6 Tensions commonly exist
between commercial interests and population health, furthermore
industry has not always acknowledged the impact of the easy
availability of lethal suicide methods on patterns of suicide.49 In
describing Western Samoa’s preventive considerations following the
epidemic rise in pesticide suicides in that country Bowles noted:
There was at that time a contentious debate about actually
banning paraquat [(the pesticide)] entirely. We knew however
that there were powerful and influential people who had a
vested interest in continuing the importation and we did not
want to be aligned with a lobby group likely to fail.22
Third, the issue of pesticide self-poisoning has never been taken
up as a campaign issue by any of the international organizations.
The WHO is the pre-eminent public health organization and
its Department of Mental Health and Substance Dependence
(MNH) is responsible for suicide prevention.50 It has managed
to successfully draw mental health up the worldwide political
agenda over the last 10 years.32 It has also emphasized the global
health importance of suicide, organizing workshops across the
world to discuss strategies for reducing self-harm, but it has not
taken up pesticides as a central issue. Recent WHO publications
with major input from the MNH32,51 have put greater emphasis
on psychiatric and social models of self-harm aetiology. While
pesticide self-poisoning was mentioned in both reports, it received
much less attention than its importance warrants.
The International Programme on Chemical Safety (IPCS) is
the major WHO programme dealing with pesticides.52 It was set
up in 1980 by the United Nations Environment Programme, the
International Labour Organization, and the WHO, to establish
the scientific basis for safe use of chemicals and to strengthen
national capabilities for chemical safety. Current IPCS activities
aim to increase knowledge of the epidemiology of pesticide poison-
ing and to encourage the setting up of poisoning information
centres.52,53 The IPCS has not, however, actively taken up the
issue of intentional pesticide self-poisoning, concentrating instead
on occupational and environmental poisoning.54 This is unfortu-
nate since its own studies have indicated the great importance
of self-poisoning in the Asia Pacific region.53 The interests of its
parent organizations may be the reason for this lack of advocacy
for the problem of intentional poisoning.
Fourth, the self-inflicted nature of suicide, together with the fact
there are fewer suicide deaths than deaths from other global health
problems such as human immunodeficiency virus (HIV)/AIDS,
tuberculosis, and malaria, may have lead to policy makers giving
it lower priority than the number of premature deaths warrant.
Fifth, pesticide self-poisoning is ideologically and politically
inconvenient. Pesticide use has adverse effects on the environ-
ment and human health.55–57 This has become a major global
political issue. Many of the adverse effects of pesticides are con-
sidered to result from their overuse and poor treatment of workers
and communities due to globalization58—in which pesticide
corporations are major participants. The issue has been taken
up by numerous national and international non-governmental
organizations (NGO), in continual ‘battle’ with the pesticide
SUICIDE BY INTENTIONAL INGESTION OF PESTICIDES 907
companies. In this battle, the fact that the vast majority of
severe and fatal pesticide cases are self-inflicted may be incon-
venient to the environmentalists. If the pesticide industry can
argue that they should not be held responsible for people who
drink pesticides, then this may be seen as undermining the
environmentalists’ case. People therefore want to avoid the issue
of self-poisoning and deal with issues where the pesticide industry,
and globalization in general, can be held responsible.
This need not be true. An overall assessment of public health,
environmental and agricultural factors should determine
regulatory actions, not simply their political appropriateness.
Pesticide self-harm is just as important as occupational poison-
ing for regulatory issues and, in some countries, regulatory
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authorities have been very effective in banning the pesticides
that have been problems only for self-harm.41
Conclusion
Pesticide self-poisoning is a major contributor to population
patterns of morbidity and mortality in developing nations. The
use of pesticides for self-poisoning may distort conventional
epidemiological features of suicide in these countries and con-
tribute to their excess premature mortality. We estimate there
are around 300 000 self-inflicted pesticide deaths worldwide
each year. Research dating back over 30 years has documented
the size of this problem and yet contemporary research bears
witness to its continuing impact.
Research to identify the most acceptable means of restricting
the availability of pesticides within rural communities is urgently
required together with randomized controlled trials to determine
the best means of treatment and cost-effectiveness of possible
interventions. Some of this research is now underway (M Eddleston,
unpublished). Preventive measures must take account of the
local needs and context and should be rigorously evaluated.
Thus far there has been no global leadership to respond to the
problem. Engagement of national governments and leadership
of the WHO, in particular the MNH and IPCS sections, on the
issue is essential. Commitment from industry and the need for
them to acknowledge their responsibility for some of these deaths
is vital (Table), as is the need to ensure they understand the
scale, importance, and preventability of the problem. Reducing
the number of pesticide deaths by 50% could rapidly reduce the
number of suicides worldwide by 150 000. This is quite possible.
Acknowledgements
We thank Shah Ebrahim, John Haines, Flemming Konradsen,
and Mark van Ommeren for helpful comments and suggestions
and Nicos Middleton, Davidson Ho, and Sanjay Kinra for obtain-
ing some of the suicide statistics. Hospital Episodes Statistics
(HES) data were made available by the Department of Health to
the authors courtesy of the HES National Service Framework
project (Prof. Shah Ebrahim and colleagues), funded by a South
and West Regional project R & D grant. The Medical Research
Council (MRC) Health Systems Resource Centre are data custodians
and also fund some of the support costs. The Department of
Social Medicine is the lead Centre of the MRC Health Services
Research Collaboration. ME is a Wellcome Trust Career
Development Fellow in Tropical Clinical Pharmacology, funded
by grant GR063560MA.
908 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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