How Nepal turned the tide on ‘pesticide poisoning’
Warning: This article discusses suicide and self-harm. If you have questions on self-harm or feel suicidal, use this link to find an international helpline – www.findahelpline.com
The 18-year-old’s death still haunts Dr Rakesh Ghimire. In 2011, when he was a junior doctor at a rural hospital in Nepal’s sweeping Terai lowlands, the young woman walked into the emergency department with an irritated throat. Two days later, she was dead.
It was the first time Dr Ghimire had treated someone who had intentionally ingested a dangerous yet totally ubiquitous toxin and nerve agent: pesticide.
“That young, 18-year-old girl – she was married, had a minor conflict with her husband, took a pesticide, and was no more in two days. I don’t think she intended to die,” says Dr Ghimire. “So, from that day, a thought came to mind: what if the pesticide had not been on the market?”
He will never know, but the case altered the trajectory of Dr Ghimire’s medical career. In the years since, he has been part of a small but vocal group of doctors and regulators who have pushed Nepal to ban the most hazardous pesticides for the sake of public health.
According to police data the widely available “plant medicines”, as locals call them, were implicated in roughly a third of suicide fatalities in 2018. Then, in 2019, regulators banned the sale and import of eight chemicals, followed by two more in July this year.
Early data suggests the move is having an impact; by the 2022/23 financial year, reported deaths had fallen by as much as 30 per cent.
Dr Ghimire, now a doctor in the department of clinical pharmacology at Kathmandu’s Tribhuvan University Teaching Hospital, is rightly proud of his teams work in restricting access to pesticides.
“This is the best thing I have done,” he says.
The issue is not unique to Nepal. Across the globe, consuming a pesticide remains one of the most common means of suicide, according to the World Health Organization.
Roughly 140,000 people die annually of self-induced pesticide poisoning, with the bulk of fatalities in low and middle income countries like Nepal, where the toxins can still be bought in small bottles for just a few pence in local shops selling everything from beer to biscuits.
Pesticides ‘nearly as dangerous as chemical nerve agents’
For pesticide manufacturers – most of which reside in the West, including the UK – making their products so easy to buy makes good commercial sense. However, most suicides are impulsive, rather than planned, hence the reason such products are so tightly controlled in West, and normally only available from specialist stores under strict licencing conditions.
“The worst of these pesticides are nearly as dangerous as chemical nerve agents”, Prof Michael Eddleston, head of the Centre for Pesticide Suicide Prevention (CPSP) at the University of Edinburgh told The Telegraph in 2019. “In many countries it remains the case that you can buy them in a local store and keep them on a shelf at home. Imagine being asked to keep a bottle of sarin stored safely under the stairs and that’s what you are dealing with.”
Today, a mounting body of research shows that curtailing access to the most dangerous pesticides in developing countries dramatically reduces suicide deaths without impacting agricultural output.
In Sri Lanka, which had one of the world’s highest suicide rates in the 1990s, deaths fell by more than 70 per cent over 20 years after specific, hazardous pesticides were phased out in 1995. Meanwhile Bangladesh saw fatalities fall by 65 per cent between 1996 and 2014 after 21 dangerous products were banned, and South Korea halved pesticide-related suicides after new restrictions in 2011. Nowhere recorded a hit to farming yields.
For most people, attempting suicide is “a spontaneous decision” made in a transient moment of crisis, says Prof Eddleston. It why we only sell paracetamol and other potentially dangerous over the counter drugs in the UK in small packet sizes and why guns – ubiquitous in the US – are the leading cause of suicide there.
Most suicide attempts are made in a sudden, impulsive manner, with the decision made just hours or minutes ahead of the act. “Many people are in their teens and early 20s, dealing with a stressful situation. They use what’s available at that time,” said Prof Eddleston.
And often, in developing countries where smallholdings proliferate, what’s available is pesticides.
The Green Revolution or Third Agricultural Revolution, which ran from the early part of the last century right through to the 1980s, drove what the Food and Agriculture Organization describes as a “quantum leap forward in food production” and saved many millions from starvation.
But the mass-adoption of chemicals in agriculture, including some pesticides, has come with a plethora of unintended health consequences.
It is estimated that, since the 1960s, there have been 14 million premature deaths due to pesticide self-poisoning alone, with over 95 per cent of these fatalities in low and middle income countries.
Developed nations, the WHO notes, have already banned or restricted use of potentially lethal pesticides.
‘We didn’t think about pesticide as a major cause for suicide’
“Unlike other modes of suicide, pesticide poisoning deaths can be controlled by regulating the most highly hazardous pesticides,” says Dr Ghimire. “Research has shown that there’s less chance of people who take pesticides as poison re-attempting again. So if it’s not easy to access on that first occasion, we can save lives.”
In Nepal, where around 66 per cent of people work in farming and a third of the country’s GDP comes from agriculture, the impact of targeted pesticide bans are only just emerging.
The country announced an initial ban affecting eight pesticides in 2019, after a 2018 study led by the CPSP tracked which of the “plant medicines” (as locals call them) were most often used in poisoning deaths. That research proved to be a major turning point.
“We had tried to manage the pesticide in the past, but we were focused on the harm to the environment and harm of the people and farmers directly using them in agriculture,” says Dr Dilli Ram Sharma, a former director general of the Department of Agriculture and member of Nepal’s pesticide regulatory board. “We didn’t think about pesticide as a major cause for suicide. The CPSP study opened our eyes.”
Prof Eddleston says this is fairly common worldwide. Ministries of health and agriculture often work in silos, with information about suicide deaths not always making it to regulators.
But in Nepal, change happened quickly after the paper identified the most dangerous products, with little opposition from industry or farmers.
“I felt a responsibility to society,” says Dr Sharma, who instituted the new regulations as one of his final acts before retirement, though he has since remained a key figure in the pesticide crackdown.
“[We weren’t] banning these pesticides without alternatives for farmers. If there were no alternatives, that would have been a problem… as pesticide remains of importance in agriculture everywhere in the world,” he adds.
As Nepal does not manufacture pesticides, the 2019 ban triggered an immediate restriction on imports, but the government allowed a two year grace period on sales. The same is true for the further bans agreed in July and due to be officially announced this month.
But early data suggests that, like Sri Lanka, Bangladesh and South Korea, the restrictions are proving effective. While suicide is not and has never been criminalised in Nepal – a misconception that has hampered some efforts to tackle the issue – data remains limited, with the police currently the only organisation to record deaths.
According to their data, which does not track suicide attempts, poisoning fatalities (which experts estimate are linked to pesticides in 95 per cent of cases) spiked in the 2020/21 financial year. But they have steadily decreased since then, with overall deaths dropping by 29 per cent, from 1,320 in 2018/19 to 932 in 2022/23.
Yet challenges remain: Dr Sharma says monitoring is not always enforced, especially in the most remote areas, while a porous border with India means some farmers can continue to bring hazardous pesticides into Nepal.
Dr Ghimire says that bans alone will not solve the problem. At the same time as pushing for pesticide restrictions, he and Prof Eddleston developed the country’s first treatment guidelines, frustrated that doctors were seeing pesticide self harm “again and again and again” with few recommendations on how to respond.
Now, that endeavour has evolved into Nepal’s first Poison Information Center, tucked away in a small office down a dark corridor in Tribhuvan Hospital. The initiative, funded by Brown University in the US, provides a 24/7 hotline for health workers across the country to call for advice dealing with a range of poisoning cases, from snakebites and carbon monoxide to pesticides.
But the country also needs to provide more mental health services to those struggling, says Dr Ghimire. While poisoning accounted for 13 per cent of suicide deaths last year, down from 23 per cent in 2018/19, the number of people dying after hanging has risen since the Covid pandemic.
“There are many factors contributing to mental health, and a lot of stigma in talking about it,” says Dr Ghimire. “These are not always easy issues to tackle.”
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