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J. M. Bertolote, A. Fleischmann, M. Eddleston and D. GunnellDeaths from pesticide poisoning: a global response

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SummarySummary Self-poisoningwithSelf-poisoningwith

pesticides accounts for about a third of allpesticides accounts for about a third of all

suicidesworldwide.Totacklethisproblem,suicidesworldwide.Totacklethisproblem,

theWorld Health OrganizationtheWorld Health Organization

announced a globalpublic health initiativeannounced a globalpublic health initiative

inthe secondhalf of 2005.Plannedinthe secondhalf of 2005.Planned

approacheswere to range fromapproacheswere to range from

governmentregulatory actionto thegovernmentregulatory actionto the

developmentof new treatments fordevelopmentof new treatments for

pesticide poisoning.With broad-basedpesticide poisoning.Withbroad-based

support, this strategy shouldhave amajorsupport, this strategy shouldhave amajor

impactonthe global burden of suicide.impactonthe globalburden of suicide.

Declaration of interestDeclaration of interest D.G. andD.G. and

M.E. are onthe Scientific Advisory GroupM.E. are onthe Scientific Advisory Group

of a Syngenta-funded study to assess theof a Syngenta-funded study to assess the

toxicityof a new formulation of paraquat;toxicityof a new formulation of paraquat;

theyhavereceived travel expenses totheyhave received travel expenses to

attendresearch groupmeetings.attendresearch groupmeetings.

Suicide is an important cause of prematureSuicide is an important cause of premature

mortality, accounting for an estimatedmortality, accounting for an estimated

877 000 deaths every year (World Health877 000 deaths every year (World Health

Organization, 2003).Organization, 2003). In many agriculturalIn many agricultural

communities of low-communities of low- and middle-incomeand middle-income

countries, pesticide self-poisoning accountscountries, pesticide self-poisoning accounts

for a large proportion of these deathsfor a large proportion of these deaths

(Gunnell & Eddleston, 2003). In 1985,(Gunnell & Eddleston, 2003). In 1985,

using data from Sri Lanka, Jeyaratnamusing data from Sri Lanka, Jeyaratnam

estimated that there were approximatelyestimated that there were approximately

2.9 million cases of acute pesticide poison-2.9 million cases of acute pesticide poison-

ing, resulting in about 220 000 deaths eaching, resulting in about 220 000 deaths each

year in the developing world (Jeyaratnam,year in the developing world (Jeyaratnam,

19851985aa). More recently, according to the). More recently, according to the

finding that pesticide ingestion accountedfinding that pesticide ingestion accounted

for over 60% of suicides in many rural areasfor over 60% of suicides in many rural areas

of China and South East Asia, Gunnell &of China and South East Asia, Gunnell &

Eddleston (2003) estimated that there mayEddleston (2003) estimated that there may

be as many as 300 000 deathsbe as many as 300 000 deaths each yeareach year

from intentional poisoning (i.e. suicide byfrom intentional poisoning (i.e. suicide by

ingestion of pesticides) in these regionsingestion of pesticides) in these regions

alone. This makes it likely that pesticidealone. This makes it likely that pesticide

poisoning is the most frequently usedpoisoning is the most frequently used

method of suicide worldwide.method of suicide worldwide.

The research and policy attention thatThe research and policy attention that

pesticide poisoning has received has beenpesticide poisoning has received has been

relatively small in comparison with therelatively small in comparison with the

magnitude of the problem (Gunnell &magnitude of the problem (Gunnell &

Eddleston, 2003; BuckleyEddleston, 2003; Buckley et alet al, 2004)., 2004).

Jeyaratnam (1985Jeyaratnam (1985aa) suggested that part) suggested that part

of the reason why pesticide poisoningof the reason why pesticide poisoning

had not received the global attention ithad not received the global attention it

deserved was the lack of scientific evidencedeserved was the lack of scientific evidence

concerning the extent of the problem. Evenconcerning the extent of the problem. Even

though a global estimate is still notthough a global estimate is still not

possible today, because of the lack ofpossible today, because of the lack of

large-scale, rigorous surveillance data,large-scale, rigorous surveillance data,

evidence is growing that the burden ofevidence is growing that the burden of

pesticide poisoning has by no means beenpesticide poisoning has by no means been

underestimated. Although data from low-underestimated. Although data from low-

income countries in South America are lessincome countries in South America are less

comprehensive than from China andcomprehensive than from China and

South-East Asia, evidence is emerging thatSouth-East Asia, evidence is emerging that

pesticide poisoning is equally important inpesticide poisoning is equally important in

such settings. In Brazil, for example, thesuch settings. In Brazil, for example, the

high suicide rates in tobacco growinghigh suicide rates in tobacco growing

regions may be owing to the wide use andregions may be owing to the wide use and

availability of pesticides (Csillag, 1996).availability of pesticides (Csillag, 1996).

Furthermore, pesticides accounted forFurthermore, pesticides accounted for

18% of male and 7% of female hospital18% of male and 7% of female hospital

admissions for self-harm in Campinas,admissions for self-harm in Campinas,

Brazil, in 2002–2004 (FleischmannBrazil, in 2002–2004 (Fleischmann et alet al,,

2005). In Southern Trinidad, over 80%2005). In Southern Trinidad, over 80%

of suicides in one rural area were by pesti-of suicides in one rural area were by pesti-

cide poisoning (Hutchinsoncide poisoning (Hutchinson et alet al, 1999). In, 1999). In

Suriname, a high proportion of both fatalSuriname, a high proportion of both fatal

(55%) and non-fatal (44%) episodes of(55%) and non-fatal (44%) episodes of

suicidal behaviour involved pesticidessuicidal behaviour involved pesticides

(Graafsma(Graafsma et alet al, 2006). In Africa, data, 2006). In Africa, data

from Zimbabwe show rising levels offrom Zimbabwe show rising levels of

admissions for organophosphate self-admissions for organophosphate self-

poisoning; self-poisoning accounted forpoisoning; self-poisoning accounted for

about three-quarters of the approxi-about three-quarters of the approxi-

mately 200 admissions in one studymately 200 admissions in one study

(Dong & Simon, 2001). More re-(Dong & Simon, 2001). More re-

cently, data from Malawi implicatedcently, data from Malawi implicated

pesticide self-poisoning in almostpesticide self-poisoning in almost

80% of suicides (Dzamalala80% of suicides (Dzamalala et alet al,,

2006).2006).

Despite the problems in estimating theDespite the problems in estimating the

global burden of pesticide poisoning, weglobal burden of pesticide poisoning, we

may safely assume that we are confrontedmay safely assume that we are confronted

with millions of cases of pesticidewith millions of cases of pesticide

poisoning, hundreds of thousands of whichpoisoning, hundreds of thousands of which

result in deaths each year in low- andresult in deaths each year in low- and

middle-income countries. There is anmiddle-income countries. There is an

urgent need for immediate action.urgent need for immediate action.

APPROACHES TOSUICIDEAPPROACHES TOSUICIDEPREVENTIONPREVENTION

Two of the major components of currentTwo of the major components of current

international suicide prevention strategiesinternational suicide prevention strategies

are the improved recognition and treatmentare the improved recognition and treatment

of mental illness and restricting access toof mental illness and restricting access to

commonly used methods of suicide (Worldcommonly used methods of suicide (World

Health Organization, 2004).Health Organization, 2004).

Mental disorders are found less fre-Mental disorders are found less fre-

quently in suicides in Asian than in Westernquently in suicides in Asian than in Western

countries, possibly because a greater pro-countries, possibly because a greater pro-

portion of deaths in Asia result from theportion of deaths in Asia result from the

use of highly lethal pesticides in impulsiveuse of highly lethal pesticides in impulsive

acts of self-harm. Nevertheless, mental ill-acts of self-harm. Nevertheless, mental ill-

ness is present in a significant proportionness is present in a significant proportion

of Asian suicides (Phillipsof Asian suicides (Phillips et alet al, 2002) and, 2002) and

is thought to play an important role inis thought to play an important role in

suicidal behaviours, underlining the rolesuicidal behaviours, underlining the role

of psychiatrists and other mental healthof psychiatrists and other mental health

workers in these settings.workers in these settings.

Epidemiological evidence demonstratesEpidemiological evidence demonstrates

that restricting access to commonly usedthat restricting access to commonly used

methods of suicide may lead to reductionsmethods of suicide may lead to reductions

in overall as well as method-specific sui-in overall as well as method-specific sui-

cidecide rates. The potential impact of changingrates. The potential impact of changing

the availability of pesticides on boththe availability of pesticides on both

pesticide poisoning and overall suicidepesticide poisoning and overall suicide

numbers has been demonstrated in Westernnumbers has been demonstrated in Western

Samoa (Bowles, 1995). Furthermore, theSamoa (Bowles, 1995). Furthermore, the

benefits of restricting pesticide use to thosebenefits of restricting pesticide use to those

compounds least harmful to humans incompounds least harmful to humans in

self-poisoning is demonstrated by theself-poisoning is demonstrated by the

widely differing case fatality rates asso-widely differing case fatality rates asso-

ciated with different pesticides – fromciated with different pesticides – from

4460% for paraquat (Hettiarachchi &60% for paraquat (Hettiarachchi &

Kodithuwakku, 1989) toKodithuwakku, 1989) to 5510% for several10% for several

other products (Eddleston, 2000; Eddlestonother products (Eddleston, 2000; Eddleston

et alet al, 2005). Likewise, just as the develop-, 2005). Likewise, just as the develop-

ment and widespread use ofment and widespread use of NN-acetyl-acetyl

cysteine had a dramatic effect on trendscysteine had a dramatic effect on trends

in paracetamol mortality in England andin paracetamol mortality in England and

Wales (Flanagan & Rooney, 2002), so tooWales (Flanagan & Rooney, 2002), so too

may the development of new antidotes tomay the development of new antidotes to

pesticide self-poisoning reduce suicides inpesticide self-poisoning reduce suicides in

low- and middle-income countries. Interna-low- and middle-income countries. Interna-

tional research in this area should be ational research in this area should be a

global priority (Buckleyglobal priority (Buckley et alet al, 2004). How-, 2004). How-

ever, to date, the global response to theever, to date, the global response to the

problem of self-poisoning with pesticidesproblem of self-poisoning with pesticides

has been poor.has been poor.

2 012 01

BR I T I SH JOURNAL OF P SYCHIATRYBR IT I SH JOURNAL OF P SYCHIATRY ( 2 0 0 6 ) , 1 8 9, 2 0 1 ^ 2 0 3 . d o i : 1 0 . 11 9 2 / b j p . b p .1 0 5 . 0 2 0 8 3 4( 2 0 0 6 ) , 1 8 9 , 2 0 1 ^ 2 0 3 . d o i : 1 0 . 11 9 2 / b j p . b p .1 0 5 . 0 2 0 8 3 4 E D I TOR I A LE D I TOR I A L

Deaths from pesticide poisoning: a global responseDeaths from pesticide poisoning: a global response

J. M. BERTOLOTE, A. FLEISCHMANN, M. EDDLESTON and D. GUNNELLJ. M. BERTOLOTE, A. FLEISCHMANN, M. EDDLESTON and D. GUNNELL

BERTOLOTE ET ALBERTOLOTE ET AL

ANINTERSECTORALGLOBALANINTERSECTORALGLOBALPUBLICHEALTHINITIATIVEPUBLICHEALTHINITIATIVE

In collaboration with other relevant UnitedIn collaboration with other relevant United

Nations agencies, governments, academicNations agencies, governments, academic

institutions, non-governmental organisa-institutions, non-governmental organisa-

tions and interested parties, the Worldtions and interested parties, the World

Health Organization has announced anHealth Organization has announced an

intersectoral global public health initiativeintersectoral global public health initiative

with the overall goal of reducingwith the overall goal of reducing

morbidity and mortality related to pesticidemorbidity and mortality related to pesticide

poisoning, adhering to a strategy of con-poisoning, adhering to a strategy of con-

certed action at various levels. The fivecerted action at various levels. The five

objectives of the programme are to:objectives of the programme are to:

(a)(a) review and recommend improved pesti-review and recommend improved pesti-

cide regulatory policies;cide regulatory policies;

(b)(b) implement sustainable epidemiologicalimplement sustainable epidemiological

surveillance and monitoring of pesticidesurveillance and monitoring of pesticide

poisoning in clinical settings andpoisoning in clinical settings and

communities;communities;

(c)(c) improve the medical management andimprove the medical management and

mental healthcare of people with pesti-mental healthcare of people with pesti-

cide poisoning in healthcare facilitiescide poisoning in healthcare facilities

at different levels;at different levels;

(d)(d) provide training in the safe handlingprovide training in the safe handling

of pesticides and identification andof pesticides and identification and

management of pesticide poisoning atmanagement of pesticide poisoning at

different sectors and levels;different sectors and levels;

(e)(e) develop or strengthen communitydevelop or strengthen community

programmes that minimise risks ofprogrammes that minimise risks of

intentional and unintentional pesticideintentional and unintentional pesticide

poisoning.poisoning.

There are three components to theThere are three components to the

World Health Organization strategy. First,World Health Organization strategy. First,

to establish sentinel projects in selectedto establish sentinel projects in selected

countries with a high burden of intentionalcountries with a high burden of intentional

and unintentional pesticide poisoning.and unintentional pesticide poisoning.

Second, to establish regional centres, asso-Second, to establish regional centres, asso-

ciated with the sentinel project sites, forciated with the sentinel project sites, for

the prevention and management ofthe prevention and management of

pesticide poisoning and for enhanced sur-pesticide poisoning and for enhanced sur-

veillance, training and community action.veillance, training and community action.

Third, to disseminate information toThird, to disseminate information to

governments, decision makers and thegovernments, decision makers and the

public at large about insights, experience,public at large about insights, experience,

and lessons learnt from research, formu-and lessons learnt from research, formu-

lated as recommendations to guide globallated as recommendations to guide global

policy and local action for the preventionpolicy and local action for the prevention

and management of pesticide poisoning.and management of pesticide poisoning.

When suicidal behaviour plays anWhen suicidal behaviour plays an

important role in non-fatal and fatal self-important role in non-fatal and fatal self-

poisoning by pesticides, it is key thatpoisoning by pesticides, it is key that

relevant preventive measures are anchoredrelevant preventive measures are anchored

in national suicide prevention programmes;in national suicide prevention programmes;

these, unfortunately, mostly do not exist asthese, unfortunately, mostly do not exist as

yet in low- and middle-income countries.yet in low- and middle-income countries.

To this end, the World Health Organiza-To this end, the World Health Organiza-

tion has started to work with governmentstion has started to work with governments

worldwide to raise awareness of the im-worldwide to raise awareness of the im-

portance and magnitude of suicidal behav-portance and magnitude of suicidal behav-

iours and to provide technical assistanceiours and to provide technical assistance

in the development and implementation ofin the development and implementation of

national strategies for suicide prevention.national strategies for suicide prevention.

It is crucial that governments ratifyIt is crucial that governments ratify

and implement the hazardous chemicalsand implement the hazardous chemicals

and wastes conventions (i.e. the Basel,and wastes conventions (i.e. the Basel,

Rotterdam, and Stockholm Conventions)Rotterdam, and Stockholm Conventions)

which cover key elements of the man-which cover key elements of the man-

agement of hazardous chemicals (seeagement of hazardous chemicals (see

http://www.basel.int; http://www.pic.int;http://www.basel.int; http://www.pic.int;

http://www.pops.int). Whereas this firsthttp://www.pops.int). Whereas this first

crucial step has been taken by many coun-crucial step has been taken by many coun-

tries, the implementation poses major chal-tries, the implementation poses major chal-

lenges, such as the shortage of funds, thelenges, such as the shortage of funds, the

lack of expertise, human resources andlack of expertise, human resources and

training, the need for advanced technolo-training, the need for advanced technolo-

gies and equipment, the limited databasegies and equipment, the limited database

systems available and the lack of publicsystems available and the lack of public

awareness. Konradsenawareness. Konradsen et alet al (2005) stressed(2005) stressed

the need for these conventions not only tothe need for these conventions not only to

propose actions such as phasing out thepropose actions such as phasing out the

most toxic chemicals, promoting alterna-most toxic chemicals, promoting alterna-

tive pest management strategies, or improv-tive pest management strategies, or improv-

ing safe storage, but also to explicitlying safe storage, but also to explicitly

include self-poisonings in risk assessmentsinclude self-poisonings in risk assessments

and to deal directly with the subject ofand to deal directly with the subject of

self-harm.self-harm.

CLOSINGREMARKSCLOSINGREMARKS

The available data suggest that acute pesti-The available data suggest that acute pesti-

cide poisoning has been a major problem incide poisoning has been a major problem in

low- and middle-income countries for manylow- and middle-income countries for many

years and that it should be a major publicyears and that it should be a major public

health concern today. Jeyaratnam (1985health concern today. Jeyaratnam (1985bb))

argued over 20 years ago that most researchargued over 20 years ago that most research

studies and publications on the impact ofstudies and publications on the impact of

pesticides on health concentrated on as-pesticides on health concentrated on as-

pects relevant to the industrialised world,pects relevant to the industrialised world,

and that the industrialised countries haveand that the industrialised countries have

in fact been able to successfully controlin fact been able to successfully control

pesticide poisoning.pesticide poisoning.

Although little has been done in low-Although little has been done in low-

and middle-income countries, there is en-and middle-income countries, there is en-

couraging work in progress. Pilot studiescouraging work in progress. Pilot studies

are under way in some areas of China andare under way in some areas of China and

Sri Lanka to assess the effects on suicideSri Lanka to assess the effects on suicide

and suicide attempts in rural areas of theand suicide attempts in rural areas of the

adoption by farmers of a double-lockedadoption by farmers of a double-locked

box where pesticides are stored. In Sribox where pesticides are stored. In Sri

Lanka, the non-governmental organisationLanka, the non-governmental organisation

Sumithrayo and other groups are active inSumithrayo and other groups are active in

evaluating interventions of this sort. Earlyevaluating interventions of this sort. Early

results from one group working on the fea-results from one group working on the fea-

sibility of double-locked boxes in Sri Lankasibility of double-locked boxes in Sri Lanka

suggest that this is a practical approach tosuggest that this is a practical approach to

pursue, if developed in collaboration withpursue, if developed in collaboration with

local communities, signalling the import-local communities, signalling the import-

ance of large-scale evaluations (F. Konrad-ance of large-scale evaluations (F. Konrad-

sen, personal communication, 2006). Withsen, personal communication, 2006). With

creativity, willingness and appropriatecreativity, willingness and appropriate

funds much can be done to prevent thisfunds much can be done to prevent this

unnecessary loss of life.unnecessary loss of life.

Considerable work is still required toConsiderable work is still required to

determine the appropriate balance betweendetermine the appropriate balance between

public health approaches to reduce pesti-public health approaches to reduce pesti-

cide poisoning and the need of the agricul-cide poisoning and the need of the agricul-

tural sector for crop protection products.tural sector for crop protection products.

Action has to be effective at leastAction has to be effective at least

in the areas of pesticide policy, pesticidein the areas of pesticide policy, pesticide

information, mental healthcare, clinicalinformation, mental healthcare, clinical

management of pesticide intoxication andmanagement of pesticide intoxication and

restricting hazardous exposure to pesti-restricting hazardous exposure to pesti-

cides. In view of the complexity and noveltycides. In view of the complexity and novelty

of many of these areas, a solid yet feasibleof many of these areas, a solid yet feasible

research programme has to back them.research programme has to back them.

This will only succeed if broad intersec-This will only succeed if broad intersec-

toraltoral and financial support is madeand financial support is made

available involving the governmental andavailable involving the governmental and

the private sector, including relevant non-the private sector, including relevant non-

governmental organisations and agenciesgovernmental organisations and agencies

of the United Nations.of the United Nations.

REFERENCESREFERENCES

Bowles, J. R. (1995)Bowles, J. R. (1995) Suicide inWestern Samoa: anSuicide inWestern Samoa: anexample of a suicide prevention program in a developingexample of a suicide prevention program in a developingcountry. Incountry. In Preventive Strategies on SuicidePreventive Strategies on Suicide (eds R. F.W.(eds R. F.W.Diekstra,Diekstra, et alet al), pp.173^206. Leiden: Brill.), pp.173^206. Leiden: Brill.

Buckley,N. A., Roberts, D., Eddleston, M. (2004)Buckley, N. A., Roberts, D., Eddleston, M. (2004)Overcoming global apathy in research onOvercoming global apathy in research onorganophosphate poisoning.organophosphate poisoning. BMJBMJ,, 329329, 1231^1233., 1231^1233.

Csillag,C. (1996)Csillag,C. (1996) Brazil’s soaring suicide rate revealed.Brazil’s soaring suicide rate revealed.LancetLancet,, 348348, 1651., 1651.

2 0 22 0 2

J.M.BERTOLOTE,MD, A. FLEISCHMANN, PhD,Department of Mental Health and Substance Abuse,WorldJ.M.BERTOLOTE,MD, A. FLEISCHMANN, PhD,Department of Mental Health and Substance Abuse,WorldHealth Organization,Geneva, Switzerland; M. EDDLESTON, Scottish Poisons Information Bureau,RoyalHealth Organization,Geneva, Switzerland; M. EDDLESTON, Scottish Poisons Information Bureau,RoyalInfirmary, Edinburgh; D.GUNNELL, PhD,Departemnt of Social Medicine,University of Bristol, Bristol,UKInfirmary, Edinburgh; D.GUNNELL, PhD,Departemnt of Social Medicine,University of Bristol,Bristol,UK

Correspondence: Jose M.Bertolote,Department of Mental Health and Substance Abuse,World HealthCorrespondence: Jose¤ M.Bertolote,Department of Mental Health and Substance Abuse,World HealthOrganization, 20 avenue Appia,CH-1211Geneva 27, Switzerland. Email: bertolotejOrganization, 20 avenue Appia,CH-1211Geneva 27, Switzerland. Email: bertolotej@@who.intwho.int

(First received 16 December 2005, final revision 3 April, 2006, accepted 2 May 2006)(First received 16 December 2005, final revision 3 April, 2006, accepted 2 May 2006)

DEATHS FROM PEST ICIDE POISONINGDEATHS FROM PEST ICIDE POISONING

Dong, X. & Simon, M. A. (2001)Dong, X. & Simon, M. A. (2001) The epidemiology ofThe epidemiology oforganophosphate poisoning in urban Zimbabwe fromorganophosphate poisoning in urban Zimbabwe from1995 to 2000.1995 to 2000. International Journal of Occupational andInternational Journal of Occupational andEnvironmental HealthEnvironmental Health,, 77, 333^338., 333^338.

Dzamalala,C. P., Milner, D. A. & Liomba,N. G.Dzamalala,C. P., Milner, D. A. & Liomba,N. G.(2006)(2006) Suicide in Blantyre,Malawi (2000^2003).Suicide in Blantyre,Malawi (2000^2003). JournalJournalof Clinical Forensic Medicineof Clinical Forensic Medicine,, 1313, 65^69., 65^69.

Eddleston, M. (2000)Eddleston, M. (2000) Patterns and problems ofPatterns and problems ofdeliberate self-poisoning in the developing world.deliberate self-poisoning in the developing world. QJM:QJM:Monthly Journal of the Association of PhysiciansMonthly Journal of the Association of Physicians,, 9393,,715^731.715^731.

Eddleston, M., Eyer, P.,Worek, F.,Eddleston, M., Eyer, P.,Worek, F., et alet al (2005)(2005)Differences between organophosphorus insecticides inDifferences between organophosphorus insecticides inhuman self-poisoning: a prospective cohort study.human self-poisoning: a prospective cohort study.LancetLancet,, 366366, 1452^1459., 1452^1459.

Flanagan, R. J. & Rooney,C. (2002)Flanagan, R. J. & Rooney,C. (2002) Reducing acuteReducing acutepoisoning deaths.poisoning deaths. Forensic Science InternationalForensic Science International,, 128128, 3^19., 3^19.

Fleischmann, A., Bertolote, J. M., de Leo, D.,Fleischmann, A., Bertolote, J. M., de Leo, D., et alet al(2005)(2005) Characteristics of attempted suicides seen inCharacteristics of attempted suicides seen inemergency-care settings of general hospitals in eightemergency-care settings of general hospitals in eight

low- and middle-income countries.low- and middle-income countries. PsychologicalPsychologicalMedicineMedicine,, 3535, 1467^1474., 1467^1474.

Graafsma,T., Kerkhof, A., Gibson, D.,Graafsma,T., Kerkhof, A., Gibson, D., et alet al (2006)(2006)High rates of suicide and attempted suicide usingHigh rates of suicide and attempted suicide usingpesticides in Nickerie, Suriname, South America.pesticides in Nickerie, Suriname, South America. CrisisCrisis,,2727, in press., in press.

Gunnell, D. & Eddleston, M. (2003)Gunnell, D. & Eddleston, M. (2003) Suicide bySuicide byintentional ingestion of pesticides: a continuing tragedyintentional ingestion of pesticides: a continuing tragedyin developing countries.in developing countries. International Journal ofInternational Journal ofEpidemiologyEpidemiology,, 3232, 902^909., 902^909.

Hettiarachchi, J. & Kodithuwakku,G. C. S. (1989)Hettiarachchi, J. & Kodithuwakku,G. C. S. (1989)Pattern of poisoning in rural Sri Lanka.Pattern of poisoning in rural Sri Lanka. InternationalInternationalJournal of EpidemiologyJournal of Epidemiology,, 1818, 418^422., 418^422.

Hutchinson, G., Daisley, H., Simeon, D.,Hutchinson, G., Daisley, H., Simeon, D., et alet al(1999)(1999) High rates of paraquat-induced suicide inHigh rates of paraquat-induced suicide insouthernTrinidad.southernTrinidad. Suicide and Life Threatening BehaviorSuicide and Life Threatening Behavior,,2929, 186^191., 186^191.

Jeyaratnam, J. (1985Jeyaratnam, J. (1985aa)) Health problems of pesticideHealth problems of pesticideusage in the third world.usage in the third world. British Journal of IndustrialBritish Journal of IndustrialMedicineMedicine,, 4242, 505^506., 505^506.

Jeyaratnam, J. (1985Jeyaratnam, J. (1985bb)) 1984 and occupational health in1984 and occupational health indeveloping countries.developing countries. Scandinavian Journal of Work andScandinavian Journal of Work andEnvironmental HealthEnvironmental Health,, 1111, 229^234., 229^234.

Konradsen, F., van der Hoek,W.,Gunnell, D.,Konradsen, F., van der Hoek,W.,Gunnell, D., et alet al(2005)(2005) Missing deaths from pesticide self-poisoning inMissing deaths from pesticide self-poisoning inthe IFCS Forum IV.the IFCS Forum IV. Bulletin of theWorld HealthBulletin of theWorld HealthOrganizationOrganization,, 8383, 157^158., 157^158.

Phillips, M. R.,Yang,G., Zhang,Y.,Phillips, M. R.,Yang,G., Zhang,Y., et alet al (2002)(2002)Risk factors for suicide in China: a national case^Risk factors for suicide in China: a national case^control psychological autopsy study.control psychological autopsy study. LancetLancet,, 360360,,1728^1736.1728^1736.

World Health Organization (2003)World Health Organization (2003) TheWorld HealthTheWorld HealthReport 2003; Shaping the FutureReport 2003; Shaping the Future.Geneva:WHO..Geneva:WHO.

World Health Organization (2004)World Health Organization (2004) The Prevention ofThe Prevention ofMental Disorders: Effective Interventions and PolicyMental Disorders: Effective Interventions and PolicyOptionsOptions.Geneva:WHO..Geneva:WHO.

2 0 32 0 3