'People just take their lives lightly'

China is the only place in the world where more females than males commit suicide. For many women living downtrodden rural lives with little hope of change, they see death as their only way out.

It has become an accepted fact in the West that more men than women commit suicide, and that suicide rates are higher in cities than in rural areas. Now recent research on China has thrown up some alarming statistics that not only challenge this view, but also reveal that Chinese women are killing themselves in horribly large numbers.

China has 21 per cent of the world's women but, according to the "World Burden of Disease" study - a major report conducted by the World Bank, the World Health Organisation and Harvard University - it has almost 56 per cent of the world's female suicides. And, in contrast with preconceptions, the suicide rate in the Chinese countryside is running at three times the rate in cities. For China's downtrodden rural women, a lethal bottle of pesticide all too often appears to offer the only way out.

Dr Michael Phillips, a Canadian psychiatrist working in China, says that China is the only place in the world where more females, on a national level, commit suicide than males. As always with such a sensitive subject, there are varying sets of statistics for the absolute number of suicides, but they all show the same pattern. "Whoever's data you look at for China, there are higher rates for females than males, and much higher rates for rural areas," says Dr Phillips, the director of the Research Centre of Clinical Epidemiology at Peking's Hui Long Guan psychiatric hospital.

Xie Lihua is the editor of Rural Women Knowing All, a magazine that aims to educate rural women about how to make the most of their limited horizons. Last September she started running a regular column "Why does she choose the road of suicide?", analysing suicide cases provided by readers' letters and trying to show rural women that there are alternatives. In one area of Hubei province, the magazine asked for records from the local health clinics. "The doctors said suicide looked like a contagious disease there; people just took their lives very lightly," says Ms Xie. Suicide in many villages was mentioned in a very matter-of-fact manner. "People talked about this family's daughter or that family's daughter-in-law drinking pesticide very naturally, as if it was not a serious matter."

The individual stories unearthed by Ms Xie's magazine are desperately sad. In Yanshan county, Hebei province, one 38-year-old peasant woman killed herself by drinking pesticide in 1994. Her husband was having an affair, while leaving her to manage the heavy farm labour and run the eight-person household with no support. After the mother killed herself, the burden of all this work fell on her 16-year-old daughter, with nothing but scolding and criticisms from her father and no help from other family members. After a year of this, the daughter began to talk of "joining her mother". After making seven pairs of cloth shoes for her younger brothers as a parting gift, she too drank pesticide and died.

The dismal status of women in China's countryside is the backdrop to much despair, says Ms Xie. "Suicide is not a new problem, it has existed for a long time. In traditional Chinese culture, rural women do not value themselves and are not valued by others. They take their lives very lightly. If they meet some unsolvable problems, they solve them by taking their own lives."

Official statistics on suicide only go back a decade, so it is impossible to say whether the situation is getting worse or better. But at least now, with social reform in China, the subject is being aired. "The Chinese government realises that it is a big problem and it is willing to do something about it. This is a really positive sign," says Dr Phillips. He is hoping that his research, which is being done in collaboration with the Chinese Academy of Preventive Medicine (CAPM), will provide a clearer understanding of why Chinese women are committing suicide in such large numbers and thus lead to effective interventions.

The figures for China in the "World Burden of Disease" study, published last September, were based on raw data from the 145 Disease Surveillance Points operated by CAPM. The study estimated that there were 343,000 suicides in China in 1990, and that the annual rate of suicide in Chinese females was 33.5 per 100,000, compared to 7.1 per 100,000 on average for females in the rest of the world combined. China's men were also disproportionately suicidal with a rate of 27.2 per 100,000, compared with 14.4 per cent for the rest of the world.

To arrive at these figures, however, the authors made various adjustments. In particular, they assumed that a certain proportion of accidental deaths where the cause was unknown were probably suicides. This seems a reasonable adjustment, but Dr Phillips has taken a closer look at the Chinese raw data for 1990 and found that there was an atypically high number of accidental deaths of unknown cause that year, possibly inflating the study's final figures by as much as one-third. Even if this is so, however, it would still leave China's female suicide rate at about four times that of the rest of the world combined.

The question of how to prevent such a large number of unnecessary deaths is urgent. The anecdotal evidence from the cases collected so far is that social stresses may be as much to blame in China as serious psychiatric disorders or alcohol abuse. In a country where the birth of a baby girl in backward agricultural regions still produces condolences rather than congratulations, Chinese rural women often have a miserable life. Many young girls are virtually sold into marriage, and wives generally have little status in their husband's household.

Huang Chunfang's husband died in 1993 leaving her with four children to look after. Reluctant to marry her idle brother-in-law, according to local custom, she left the village the next year and remarried. That went wrong because she could not have any more children, and many other attempts to find another man to support her also failed. Despondent, she returned to her mother-in-law's home, and the next evening was found dead in bed with an empty pesticide bottle on the floor.

Dr Phillips and the CAPM project have completed a pilot study in three sites, covering 55 suicides, most of which were women. The main causes identified so far were family conflicts including unfaithful husbands, and arguments about household finances. Dr Phillips believes that between one-third and one-half of the suicides "are impulsive acts that do not have an underlying major depression". A suicide may be a "cry for help" that ends in death because of limited medical care, or the lethal methods that are readily available - some pesticides are so strong that two tablespoons can kill a woman in two hours.

Dr Phillips also suspects that the worst hit areas may not be the poorest. "This is a guess, but I think the problem may be worse in the rural areas that have seen some improvement in the standard of living with the economic reforms." In these villages, women watch television and see how much better off the urban Chinese women are, they see women with equal status to men, and women able to assert themselves. "Before, yes they were downtrodden, but they were not quite as aware of it as they are now," says Dr Phillips.

Dr Phillips believes the results of his work could prompt a rethink in accepted theories of suicide, which have tended to focus on patterns in developed Western countries. "I would contend that developing countries have a lot to say about suicide, and if they develop their own theories based on their own data, they may come up with quite different conclusions," says Dr Phillips. "The question is not only why so many women are killing themselves in Asia, but also why a disproportionate number of men are killing themselves in Western countries"n