Skip to main content Accessibility help
Hostname: page-component-5cfd469876-7frv5 Total loading time: 0.594 Render date: 2021-06-24T15:58:29.792Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true }

Deaths from pesticide poisoning: a global response

Published online by Cambridge University Press:  02 January 2018

J. M. Bertolote
Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
A. Fleischmann
Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
M. Eddleston
Scottish Poisons Information Bureau, Royal Infirmary, Edinburgh
D. Gunnell
Departemnt of Social Medicine, University of Bristol, Bristol, UK
E-mail address:
Rights & Permissions[Opens in a new window]


Self-poisoning with pesticides accounts for about a third of all suicides worldwide. To tackle this problem, the World Health Organization announced a global public health initiative in the second half of 2005. Planned approaches were to range from government regulatory action to the development of new treatments for pesticide poisoning. With broad-based support, this strategy should have a major impact on the global burden of suicide.

Copyright © Royal College of Psychiatrists, 2006 

Suicide is an important cause of premature mortality, accounting for an estimated 877 000 deaths every year (World Health Organization, 2003). In many agricultural communities of low- and middle-income countries, pesticide self-poisoning accounts for a large proportion of these deaths (Reference Gunnell and EddlestonGunnell & Eddleston, 2003). In 1985, using data from Sri Lanka, Jeyaratnam estimated that there were approximately 2.9 million cases of acute pesticide poisoning, resulting in about 220 000 deaths each year in the developing world (Reference JeyaratnamJeyaratnam, 1985a ). More recently, according to the finding that pesticide ingestion accounted for over 60% of suicides in many rural areas of China and South East Asia, Gunnell & Eddleston (Reference Gunnell and Eddleston2003) estimated that there may be as many as 300 000 deaths each year from intentional poisoning (i.e. suicide by ingestion of pesticides) in these regions alone. This makes it likely that pesticide poisoning is the most frequently used method of suicide worldwide.

The research and policy attention that pesticide poisoning has received has been relatively small in comparison with the magnitude of the problem (Reference Gunnell and EddlestonGunnell & Eddleston, 2003; Reference Buckley, Roberts and EddlestonBuckley et al, 2004). Jeyaratnam (Reference Jeyaratnam1985a ) suggested that part of the reason why pesticide poisoning had not received the global attention it deserved was the lack of scientific evidence concerning the extent of the problem. Even though a global estimate is still not possible today, because of the lack of large-scale, rigorous surveillance data, evidence is growing that the burden of pesticide poisoning has by no means been underestimated. Although data from low-income countries in South America are less comprehensive than from China and South-East Asia, evidence is emerging that pesticide poisoning is equally important in such settings. In Brazil, for example, the high suicide rates in tobacco growing regions may be owing to the wide use and availability of pesticides (Reference CsillagCsillag, 1996). Furthermore, pesticides accounted for 18% of male and 7% of female hospital admissions for self-harm in Campinas, Brazil, in 2002-2004 (Reference Fleischmann, Bertolote and de LeoFleischmann et al, 2005). In Southern Trinidad, over 80% of suicides in one rural area were by pesticide poisoning (Reference Hutchinson, Daisley and SimeonHutchinson et al, 1999). In Suriname, a high proportion of both fatal (55%) and non-fatal (44%) episodes of suicidal behaviour involved pesticides (Reference Graafsma, Kerkhof and GibsonGraafsma et al, 2006). In Africa, data from Zimbabwe show rising levels of admissions for organophosphate self-poisoning; self-poisoning accounted for about three-quarters of the approximately 200 admissions in one study (Reference Dong and SimonDong & Simon, 2001). More recently, data from Malawi implicated pesticide self-poisoning in almost 80% of suicides (Reference Dzamalala, Milner and LiombaDzamalala et al, 2006).

Despite the problems in estimating the global burden of pesticide poisoning, we may safely assume that we are confronted with millions of cases of pesticide poisoning, hundreds of thousands of which result in deaths each year in low- and middle-income countries. There is an urgent need for immediate action.


Two of the major components of current international suicide prevention strategies are the improved recognition and treatment of mental illness and restricting access to commonly used methods of suicide (World Health Organization, 2004).

Mental disorders are found less frequently in suicides in Asian than in Western countries, possibly because a greater proportion of deaths in Asia result from the use of highly lethal pesticides in impulsive acts of self-harm. Nevertheless, mental illness is present in a significant proportion of Asian suicides (Reference Phillips, Yang and ZhangPhillips et al, 2002) and is thought to play an important role in suicidal behaviours, underlining the role of psychiatrists and other mental health workers in these settings.

Epidemiological evidence demonstrates that restricting access to commonly used methods of suicide may lead to reductions in overall as well as method-specific suicide rates. The potential impact of changing the availability of pesticides on both pesticide poisoning and overall suicide numbers has been demonstrated in Western Samoa (Reference Bowles and DiekstraBowles, 1995). Furthermore, the benefits of restricting pesticide use to those compounds least harmful to humans in self-poisoning is demonstrated by the widely differing case fatality rates associated with different pesticides - from >60% for paraquat (Reference Hettiarachchi and KodithuwakkuHettiarachchi & Kodithuwakku, 1989) to <10% for several other products (Reference EddlestonEddleston, 2000; Reference Eddleston, Eyer and WorekEddleston et al, 2005). Likewise, just as the development and widespread use of N-acetyl cysteine had a dramatic effect on trends in paracetamol mortality in England and Wales (Reference Flanagan and RooneyFlanagan & Rooney, 2002), so too may the development of new antidotes to pesticide self-poisoning reduce suicides in low- and middle-income countries. International research in this area should be a global priority (Reference Buckley, Roberts and EddlestonBuckley et al, 2004). However, to date, the global response to the problem of self-poisoning with pesticides has been poor.


In collaboration with other relevant United Nations agencies, governments, academic institutions, non-governmental organisations and interested parties, the World Health Organization has announced an intersectoral global public health initiative with the overall goal of reducing morbidity and mortality related to pesticide poisoning, adhering to a strategy of concerted action at various levels. The five objectives of the programme are to:

  1. (a) review and recommend improved pesticide regulatory policies;

  2. (b) implement sustainable epidemiological surveillance and monitoring of pesticide poisoning in clinical settings and communities;

  3. (c) improve the medical management and mental healthcare of people with pesticide poisoning in healthcare facilities at different levels;

  4. (d) provide training in the safe handling of pesticides and identification and management of pesticide poisoning at different sectors and levels;

  5. (e) develop or strengthen community programmes that minimise risks of intentional and unintentional pesticide poisoning.

There are three components to the World Health Organization strategy. First, to establish sentinel projects in selected countries with a high burden of intentional and unintentional pesticide poisoning. Second, to establish regional centres, associated with the sentinel project sites, for the prevention and management of pesticide poisoning and for enhanced surveillance, training and community action. Third, to disseminate information to governments, decision makers and the public at large about insights, experience, and lessons learnt from research, formulated as recommendations to guide global policy and local action for the prevention and management of pesticide poisoning.

When suicidal behaviour plays an important role in non-fatal and fatal self-poisoning by pesticides, it is key that relevant preventive measures are anchored in national suicide prevention programmes; these, unfortunately, mostly do not exist as yet in low- and middle-income countries. To this end, the World Health Organization has started to work with governments worldwide to raise awareness of the importance and magnitude of suicidal behaviours and to provide technical assistance in the development and implementation of national strategies for suicide prevention.

It is crucial that governments ratify and implement the hazardous chemicals and wastes conventions (i.e. the Basel, Rotterdam, and Stockholm Conventions) which cover key elements of the management of hazardous chemicals (see;; Whereas this first crucial step has been taken by many countries, the implementation poses major challenges, such as the shortage of funds, the lack of expertise, human resources and training, the need for advanced technologies and equipment, the limited database systems available and the lack of public awareness. Konradsen et al (Reference Konradsen, van der Hoek and Gunnell2005) stressed the need for these conventions not only to propose actions such as phasing out the most toxic chemicals, promoting alternative pest management strategies, or improving safe storage, but also to explicitly include self-poisonings in risk assessments and to deal directly with the subject of self-harm.


The available data suggest that acute pesticide poisoning has been a major problem in low- and middle-income countries for many years and that it should be a major public health concern today. Jeyaratnam (Reference Jeyaratnam1985b ) argued over 20 years ago that most research studies and publications on the impact of pesticides on health concentrated on aspects relevant to the industrialised world, and that the industrialised countries have in fact been able to successfully control pesticide poisoning.

Although little has been done in low- and middle-income countries, there is encouraging work in progress. Pilot studies are under way in some areas of China and Sri Lanka to assess the effects on suicide and suicide attempts in rural areas of the adoption by farmers of a double-locked box where pesticides are stored. In Sri Lanka, the non-governmental organisation Sumithrayo and other groups are active in evaluating interventions of this sort. Early results from one group working on the feasibility of double-locked boxes in Sri Lanka suggest that this is a practical approach to pursue, if developed in collaboration with local communities, signalling the importance of large-scale evaluations (F. Konradsen, personal communication, 2006). With creativity, willingness and appropriate funds much can be done to prevent this unnecessary loss of life.

Considerable work is still required to determine the appropriate balance between public health approaches to reduce pesticide poisoning and the need of the agricultural sector for crop protection products.

Action has to be effective at least in the areas of pesticide policy, pesticide information, mental healthcare, clinical management of pesticide intoxication and restricting hazardous exposure to pesticides. In view of the complexity and novelty of many of these areas, a solid yet feasible research programme has to back them. This will only succeed if broad intersectoral and financial support is made available involving the governmental and the private sector, including relevant non-governmental organisations and agencies of the United Nations.


Declaration of interest

D.G. and M.E. are on the Scientific Advisory Group of a Syngenta-funded study to assess the toxicity of a new formulation of paraquat; they have received travel expenses to attend research group meetings.


Bowles, J. R. (1995) Suicide in Western Samoa: an example of a suicide prevention program in a developing country. In Preventive Strategies on Suicide (eds Diekstra, R. F.W., et al), pp. 173206. Leiden: Brill.Google Scholar
Buckley, N. A., Roberts, D., Eddleston, M. (2004) Overcoming global apathy in research on organophosphate poisoning. BMJ, 329, 12311233.CrossRefGoogle Scholar
Csillag, C. (1996) Brazil's soaring suicide rate revealed. Lancet, 348, 1651.CrossRefGoogle Scholar
Dong, X. & Simon, M. A. (2001) The epidemiology of organophosphate poisoning in urban Zimbabwe from 1995 to 2000. International Journal of Occupational and Environmental Health, 7, 333338.CrossRefGoogle ScholarPubMed
Dzamalala, C. P., Milner, D. A. & Liomba, N. G. (2006) Suicide in Blantyre, Malawi (2000–2003). Journal of Clinical Forensic Medicine, 13, 6569.CrossRefGoogle Scholar
Eddleston, M. (2000) Patterns and problems of deliberate self-poisoning in the developing world. QJM: Monthly Journal of the Association of Physicians, 93, 715731.CrossRefGoogle ScholarPubMed
Eddleston, M., Eyer, P., Worek, F., et al (2005) Differences between organophosphorus insecticides in human self-poisoning: a prospective cohort study. Lancet, 366, 14521459.CrossRefGoogle ScholarPubMed
Flanagan, R. J. & Rooney, C. (2002) Reducing acute poisoning deaths. Forensic Science International, 128, 319.CrossRefGoogle Scholar
Fleischmann, A., Bertolote, J. M., de Leo, D., et al (2005) Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychological Medicine, 35, 14671474.CrossRefGoogle ScholarPubMed
Graafsma, T., Kerkhof, A., Gibson, D., et al (2006) High rates of suicide and attempted suicide using pesticides in Nickerie, Suriname, South America. Crisis, 27, in press.CrossRefGoogle ScholarPubMed
Gunnell, D. & Eddleston, M. (2003) Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. International Journal of Epidemiology, 32, 902909.CrossRefGoogle ScholarPubMed
Hettiarachchi, J. & Kodithuwakku, G. C. S. (1989) Pattern of poisoning in rural Sri Lanka. International Journal of Epidemiology, 18, 418422.CrossRefGoogle ScholarPubMed
Hutchinson, G., Daisley, H., Simeon, D., et al (1999) High rates of paraquat-induced suicide in southern Trinidad. Suicide and Life Threatening Behavior, 29, 186191.Google ScholarPubMed
Jeyaratnam, J. (1985a) Health problems of pesticide usage in the third world. British Journal of Industrial Medicine, 42, 505506.Google Scholar
Jeyaratnam, J. (1985b) 1984 and occupational health in developing countries. Scandinavian Journal of Work and Environmental Health, 11, 229234.CrossRefGoogle Scholar
Konradsen, F., van der Hoek, W., Gunnell, D., et al (2005) Missing deaths from pesticide self-poisoning in the IFCS Forum IV. Bulletin of the World Health Organization, 83, 157158.Google ScholarPubMed
Phillips, M. R., Yang, G., Zhang, Y., et al (2002) Risk factors for suicide in China: a national case– control psychological autopsy study. Lancet, 360, 17281736.CrossRefGoogle ScholarPubMed
World Health Organization (2003) The World Health Report 2003; Shaping the Future. Geneva: WHO.Google Scholar
World Health Organization (2004) The Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: WHO.Google Scholar
Submit a response


No eLetters have been published for this article.
You have Access
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Deaths from pesticide poisoning: a global response
Available formats

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Deaths from pesticide poisoning: a global response
Available formats

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Deaths from pesticide poisoning: a global response
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *