I had a shock the first time I visited
a nursery for newborn babies. Dozens of babies were arranged
side by side, all of them wrapped in swaddling. Regularly, at
a precise time, a nurse wearing a mask was conscientiously picking
up one of the little parcels: it was feeding time. I could not
help thinking of the future of all these human beings. As soon
as they were born they were learning to be hopeless. They were
obviously in danger. They were already losing that impulse which
makes us struggle, struggle for life.
The context of a second visit to China
I went back to China 25 years later. This was in 2002. The pessimistic
anticipations inspired by my first visit were undoubtedly grounded.
The cyclists were replaced by car-drivers coping with traffic
jams. In general, commuters who were still on a bike and those
on the sidewalks looked serious, thoughtful, preoccupied, even
worried. I could not look at them without thinking of the statistics
I was carrying in my bag. Today China accounts for 44% of all
suicides and for 56% of all female suicides in the world (1,
2, 3, 4). This rate translates to over a quarter of a million
suicide deaths per year in China (according to the most optimistic
evaluations). The important point is that the toll is particularly
high among teenagers and young adults: suicide is the leading
cause of deaths in individuals 15-34 years of age, accounting
for 19% of all deaths.
At the very time when the Lancet was publishing its authoritative
statistical study about suicide deaths in China (4), a more
specialized medical journal was providing important information
about depression and suicide ideation in Chinese adolescents
(5). A survey using self-completion questionnaires was carried
out in six middle schools (predominant age range 13-17 years)
in an urban and a rural setting in Zhejiang Province in eastern
China. The results are frightening. One-third of the students
had suffered symptoms of severe depression, with 16% admitting
to suicide ideation and 9% to actually having attempted suicide.
Suicide and Primal Health Research
The suicide of adolescents is highly topical. We focused on
China as a country where the rates are still higher than elsewhere,
and also because some of the particularities of this huge country
can help us interpret an increasing phenomenon of modern age.
If we refer to the work of anthropologists and historians (6,7)
it appears that young suicide was almost unknown in other cultures.
This is confirmed by reviews of the western literature. There
are many references to suicide in texts written by such authors
as Montesquieu, Shakespeare (8) and Rousseau (9), for example.
It seems that the suicide of students started to arouse public
concern at the beginning of the twentieth century. As early
as 1910, the psychoanalysis association of Vienna held a meeting,
under the chairmanship of Alfred Adler and in the presence of
Sigmund Freud, to exchange views on constantly rising suicide
rates among students.
Today the issue of suicide of young people is familiar to Primal
Health Research. We might even suggest that Primal Health Research
is holding the keys for interpreting this global phenomenon.
Explore our data bank and type the key word “suicide”.
You’ll be directed towards entries 0009, 0010, 0017, 0253
and 0338. An overview of these studies suggests that there are
risk factors during the primal period in general and the perinatal
period in particular. The study by Lee Salk (0019) is specifically
about the suicide of adolescents in relation to what the birth
was like. The studies by Bertil Jacobson (0009, 0253) look at
the methods used to commit suicide in relation to the sort of
birth complications they might have experienced. An overview
of our data bank is still more fruitful if it includes all sorts
of highly topical self-destructive behaviors, such as drug addiction
(entries 0005, 0006, 0007, 0008, 0032, 0295) and anorexia nervosa
(entry 0260).
Although the high incidence of self-destructive behaviors among
young people is a characteristic of our societies, the number
of relevant entries in the Primal Health Research Data Bank
is comparatively small. Furthermore the medical articles I mentioned
are rarely referenced afterwards in the medical literature.
It seems that looking at any sort of “impaired capacity
to love oneself” in relation to obstetrical practices
is not politically correct. The authors of this sort of research
must overcome terrible bureaucratic problems. I took such studies
as examples when publishing my definition of “cul-de-sac
epidemiology” (10), which is the opposite of “circular
epidemiologiy”: epidemiologists usually have a regrettable
tendency to constantly repeat the same studies, even when the
results are known in advance.
Learning from international comparisons
For many reasons the case of China is appropriate to start
international comparisons. First because more than a billion
people are involved. Also because the suicide rates are exceptionally
high. Furthermore – for those who keep in mind data provided
by Primal Health Research – it is noticeable that this
is a part of the world where childbirth became abruptly and
recently highly medicalised: today the rates of C-sections are
in the region of 40% in most Chinese hospitals. Another important
point is that almost all the inhabitants of China live less
than 45 degrees north from the equator. Yet latitude is the
best-documented factor influencing the rate of suicides in a
given population. Life below the 45th parallel is usually associated
with low rates. Life above the 60th parallel (in the Northern
Hemisphere) is associated with increased risks. This is the
case of Finland, Norway, Northern Russia and Alaska. These are
countries where there is no sunlight during the winter weeks
and where seasonal depression is an important preoccupation.
The issue of latitude can therefore be eliminated when trying
to interpret the rates of suicides in China.
In the discussion that followed the publication of the Lancet
article (11,12,13), it appeared that the current family planning
policies do not provide direct explanations for such high rates
of suicides, particularly among young women. To address this
question, the authors included items about pregnancy, sterilisation,
fines for exceeding the birth quota and birth of a female child
in the life-event scale they have developed as part of their
continuing national psychological autopsy study of accidental
deaths. They could conclude that the social and psychological
effects of the Chinese family planning policy are not an important
determinant.
This aspect of the discussion was to a great extent induced
by the fact that in China the rates of suicides in women are
25% higher than in men, while in Western countries the male-to-female
ratio of completed suicide if often in the region of 3:1. Such
data can easily be interpreted from a primal health research
perspective. In a society where the birth of a girl is often
seen as a catastrophe, the primal period of a human being is
highly dependent on his or her sex. So far as the rates of suicides
are still higher in the rural areas than in the cities, this
leads to underline first that the medicalisation of childbirth
spread out quickly to the whole China. It also leads to underline
that, if there are risks factors in the period surrounding birth,
it is not a reason to underestimate the importance of other
possible risk factors. Furthermore, from the discussion that
followed the Lancet article, it appeared that substantial proportions
of victims of attempted and successful suicide had no known
characterized mental illness.
In fact, what we must remember is that none of those who participated
in this discussion ever suggested a possible link with how babies
are born…an opportunity to refer again to the reality
of “cul-de-sac epidemiology”.
What about the rest of the world? Everywhere the main preoccupation
is the suicide of adolescents and young adults. An analysis
of European statistics strongly supports data provided by the
Primal Health Research perspective. The World Health Organization
has published an evaluation of the number of suicides in the
age group 15 to 24 in the main European countries (14). The
rates are expressed as the number of suicides per 100 000 inhabitants.
It is therefore possible to look at the number of young suicides
in populations that have comparable standards of living and
that live between the 45th and the 60th parallels. This leads
to exclude Finland and Norway on the one hand, and Greece, Portugal,
Italy and Spain on the other hand.
Among this group of well-defined European countries, the lowest
rate of young suicides is found in…Holland (6.4 per 100
000). It is 7.3 in the UK, 7.8 in Denmark, 8.0 in Germany, 8.3
in Sweden, 9.1 in France, 9.6 in Poland, 10.3 in the Czech Republic,
11.8 in Ireland, 12.3 in Hungary, 13.8 in Austria and 14.9 in
Switzerland. Everybody knows that Holland is unique where childbirth
is concerned. In Holland 82% of the midwives are independent.
When a Dutch woman discovers that she is pregnant, her reflex
is usually to visit a midwife. The midwife will decide –
during the pregnancy and during labour – if the advice
of a doctor is needed. The effect of the Dutch system is that
about 30% of the births occur at home, while many hospital-births
are attended by a midwife who is not answerable to any doctor.
The rates of C-sections are around 10% and the rates of epidural
anesthesia remain below 10%. Let us add that, among this group
of European countries, Holland also has the lowest overall (i.e.
all ages) rates of suicides (Hungary has the highest one).
These European statistics might inspire many other comments.
Let us underline, for example, that the rate of young suicides
is higher in France (although a part of the population lives
below the 45th parallel) than in Sweden (although a part of
the population lives above the 60th parallel). The degree of
medicalisation and the rates of obstetrical intervention are
much higher in France than in Sweden. We might also underline
that the rates of young suicides are higher in Ireland –
the realm of “active management of labour”- than
in the UK…
The WHO statistics make comparisons possible with Japan, which
is an Asian country, like China. The rates of young suicides
(6.2) are pretty similar to the Dutch rates…so are the
rates of C-sections (around 10%) and the rates of epidural anesthesia
(below 10%). Obstetrics in Japan is characterised by the small
average size of maternity units and by the great number of midwives.
Let us mention that the rates of young suicides are 12.9 in
the USA. American statistics are difficult to interpret, as
they mix data from states as far apart as Alaska and Florida.
The future
We should not conclude too quickly that the future of China
is gloomy. In such a country the concept of “cultural
revolution” does not belong to the imaginary island of
Utopia. The only fact that “Midwifery Today” conferences
could be held last June in Guangzhou and Shanghai is a reason
for optimism. At these conferences most participants were obstetricians,
for the simple reason that midwives have disappeared. But many
of them were young women who feel – still vaguely - that
there is something wrong in their current practices. We must
realize that these doctors are at the ascending phase of their
fascination for high technology. This was illustrated, for example,
by the fact that none of the Chinese speakers could imagine
a presentation without a power-point, while most Western speakers
were using more rudimentary means of communication. I look forward
to participate in the next Midwifery Today conference in China
in 2004…will it be the beginning of the ‘descending
phase’?
China is now influenced more than ever by Western countries.
We cannot dissociate this huge country from the rest of the
world. The rising rates of self-destructive behaviour among
young people is a global phenomenon. It should prevail upon
any other preoccupation. Studying the future of suicidal behaviour
is trying to anticipate the future of Humanity. The conclusions
of two trips to China, combined with the Primal Health Research
perspective and with international comparisons leads us to ask
a simple question: can humanity survive obstetrics…?
Michel Odent
References:
1 – WHO. The World Health Report 1999. Geneva: WHO, 1999.
2 – Yin DK. Current status of mental health work in China:
problems and recommendations. Chin Ment Health J 2000; 14: 4-5.
3 – Yip PS. An epidemiological profile of suicides in
Beijing, China. Suicide Life Threat Behav 2001; 31(1): 62-70.
4 – Phillips MR, Li X, Zhang Y. Suicide rates in China,
1995-99. Lancet 2002; 359: 835-40.
5 – Hesketh T, Ding QJ, Jenkins, R. Suicide ideation in
Chinese adolescents. Soc Psychiatry Epidemiol 2002; 37(5): 230-5.
6 – Garrison, Gaston. Le suicide dans l’antiquité
et dans les temps modernes. Paris 1885.
7 – Crocker, Lester. The discussion of suicide in the
Eighteen century. Journal of History of ideas 1952; 13: 47-72.
8 – Faber, Mel D. Shakespeare’s suicides. Some historic,
dramatic and psychological reflections. In Essays in self-destruction.
Edwin S ed. Shneidman ed. NY 1967.
9- Bédé, Joseph Albert. Madame de Stael, Rousseau
et le suicide. Revue d’histoire litteraire de la France.
1966: 52-70.
10 – Odent M. Between circular and cul-de-sac epidemiology.
Lancet 2000; 355: 1371.
11 – Reardon DC. Suicides rates in China. Lancet 2002;
359: 2274.
12 – Bertolote JM, Fleischmann A. Suicides rates in China.
Lancet 2002; 359: 2274.
13 – Phillips MR, Li X, Zhang Y, Eddleston M. Suicides
rates in China. Lancet 2002; 359: 2274-75.
14 – www2lysator.liu.se/nordic/scn/suicides.html
15 – Odent M. Primal Health. Century-Hutchinson. London
1986
16 – Seymour-Reichlin. Neuroendocrine-immune interaction.
N Engl J Med 1993 ; 329 : 1246-53
GLOSSARY
We propose a vocabulary adapted to the scientific context (15).
Primal - first in time and first in importance.
Primal period - the time which included fetal
life, perinatal period and early infancy. It is during the primal
period that the adaptive systems involved in what we commonly
call health reach maturity. It is the time of close dependence
on the mother. One can anticipate that any kind of event happening
during this period can have irreversible effects.
Primal adaptive system - the subcortical nervous
system, the endocrine system and the immune system should no
longer be separated and should be understood as a whole (e.g.
the brain is a gland, insulin is a neuromediator, lymphocytes
can release endorphins, etc.). We call this network the ‘primal
adaptive system’. Phrases used in the medical literature,
such as ‘psychoneuroimmuno endocrinological system’,
‘psychoneuro immunology’, immuno endocrinology’,
etc., should be expressed in simpler terms. A recent review-article
in the New England Journal of Medicine gave a perfect updated
description of what we call the ‘primal adaptive system’.
(16)
Health - is how well the primal adaptive system
works (it is not the absence of disease).
Primal health - at the end the primal period
we are in a basic state of health called primal health. The
objective of primal health research is to explore correlations
between the Primal period and what will happen later on.
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