Brazil: the need for violence (including suicide) prevention

The political development of South American countries after the Second World War has been similar, with most of them having gone through phases of populism (1940s-1950s) and military dictatorship (1960s-1970s). During the 1980s, with re-democratization, several changes occurred in the context of social and political movements, including the introduction of national mental health programmes (1). The majority of these countries, however, devote less than 2% of their total health budget to mental health. This picture is aggravated by the fact that Latin America accounts for 29.2% of the world total burden of disease related to injuries consequent to acts of violence (2).

Brazil is the largest and most populous country in South America (2004 population estimate: 179 million). The low suicide rate in Brazil (around 4 per 100,000 inhabitants/ year) is similar to those of most South American countries. In spite of the low suicide rate, the total number of suicides was 7729 in 2001, which places Brazil amongst the ten countries with the highest numbers of suicide deaths. The proportional mortality due to suicide is higher among adolescents, corresponding to 3.8% of the deaths in this age group.

In Brazil, homicides greatly outnumber suicides. In 2002, deaths due to homicide were six times more frequent than those due to suicide. The homicide rate in Brazil more than doubled over the last two decades, reaching 28.4/100,000 in 2002 (110.5 among 15-24 year-old-people). Other countries in Latin America have experienced similar increases in homicide rates during this period. In Brazil, more than 90% of homicide victims are males and 52.2% are adolescents or young adults (3).

Violence has traditionally been related to broader social problems, such as increasing urbanization, expansion of illegal drug and firearms trafficking, a lengthy economic crisis, unemployment, and widening income inequality. On one hand, urban violence and high homicide rates have overshadowed the problem of suicidal behaviour in Brazil. On the other hand, the increasing discussion about violence which takes place in several sectors of the society has brought about the awareness related to suicide behaviour among adolescents and young adults, as well as the need for violence - including suicide - prevention policies.

Although Brazil lacks a national suicide prevention programme, some recent initiatives mentioned below illustrate the first steps towards a national suicide prevention strategy.

First, several violence prevention efforts have been developed in Brazil (e.g., a federal law that controls gun ownership). Non-governmental organisations have also played an important role in promoting awareness about the risks of carrying firearms and supporting projects for violence prevention. Nevertheless, a more severe legislation to inhibit illegal gun ownership is needed, since 70% of homicides are committed with clandestine firearms. There is also an urge for additional control of other means of suicide like pesticides and insecticides.

Second, governmental and non-governmental special training and educational programmes for low-income young people are a growing priority in Brazil. These are especially relevant to prevent violent acts, since both suicide and homicide victims around 18-24 years have a significant age/grade gap. In the suicide group, only 3.5% were enrolled in university and 49% had only primary schooling (4). This is a population highly vulnerable to unemployment, presently around 20% in large urban areas.

Third, Brazil is one of the countries participating in the World Health Organization (WHO)'s Suicide Prevention – Multisite Intervention Study on Suicide (SUPRE-MISS) (5). As part of this project we surveyed a random sample of 516 people living in Campinas, a city located in the most populous and industrialized region of the country. Life prevalence estimates in the general population were 17.1% for suicide ideation, 4.8% for suicidal plans and 2.8% for suicide attempts. This was the first national survey about suicide behaviour based on general population information. Hopefully, the data collected will guide preventive efforts.

Fourth, the City of São Paulo Health Secretariat has launched a programme, based on the SUPRE-MISS project, especially devoted to people who attempted suicide. It aims to collect a comprehensive data base of all suicide attempters seen at the emergency departments, as well as provide support by means of a follow-up protocol which comprises periodical visits and phone calls to these patients. The adoption of this policy has involved a partnership among the government, universities and a research sponsoring agency. The Health Secretariat and the Regional Board of Psychology have promoted a series of regular meetings with representatives of ten psychology faculties to discuss suicide prevention strategies. Results until now include the formation of groups specialized in the support for suicide attempters in these faculties' clinics and the improvement of their academic curricula concerning suicide.