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|Year : 2020
: 62 | Issue : 1 | Page
|Global goals and suicide prevention in the Circumpolar North
Nathaniel J Pollock1, Charlene Apok2, Tessa Concepcion3, Roberto A Delgado Jr4, Stacy Rasmus5, Susan Chatwood1, Pamela Y Collins6
1 School of Public Health, University of Alberta, Edmonton, Canada
2 Indigenous Studies, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska, USA
3 Department of Global Health, University of Washington, Seattle, Washington, USA
4 Office of Polar Programs, National Science Foundation, Alexandria, Virginia, USA
5 Center for Alaska Native Research, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska, USA
6 Department of Global Health; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
Click here for correspondence address and
|Date of Submission||23-Nov-2019|
|Date of Acceptance||18-Dec-2019|
|Date of Web Publication||3-Jan-2020|
| Abstract|| |
The purpose of this selective narrative review is to provide an overview of suicide and suicide prevention in the Circumpolar North and the relevance of global strategies and policies to these themes. We conducted a selective review of the English language literature on Arctic Indigenous mental health, suicide, and suicide prevention. We briefly present the social context, epidemiology, and risk and protective factors for suicide in the Arctic, with a focus on Indigenous peoples. We highlight a recent collaborative, intergovernmental response to elevated suicide rates in this region, the Reducing the Incidence of Suicide in Indigenous Groups – Strengths United through Networks Initiative, which used a consensus methodology to identify key outcomes for evaluating suicide prevention interventions in the circumpolar context. In relation to the Sustainable Development Goals, we examine recent policy developments in Indigenous-led suicide prevention and identify opportunities for strengthening policy, community interventions, and research. Globally, suicide prevention is a public health priority, and reducing the number of suicide deaths is a key target for sustainable development. Although overall and country-specific suicide rates have decreased since 1990, there remains wide variation at the regional and local level. This is particularly evident in the Arctic region known as the Circumpolar North, where Indigenous peoples experience marked disparities in suicide risk and suicide deaths compared to non-Indigenous populations. The factors that influence these variations are complex and often rooted in the social and economic consequences of colonization. The integration of science, community-based and Indigenous knowledge, and policies that address upstream risks for suicide will play an important role in suicide prevention alongside the growing number of Indigenous suicide prevention strategies tailored for specific populations.
Keywords: Arctic, circumpolar health, global health, Indigenous, suicide prevention
|How to cite this article:|
Pollock NJ, Apok C, Concepcion T, Delgado Jr RA, Rasmus S, Chatwood S, Collins PY. Global goals and suicide prevention in the Circumpolar North. Indian J Psychiatry 2020;62:7-14
|How to cite this URL:|
Pollock NJ, Apok C, Concepcion T, Delgado Jr RA, Rasmus S, Chatwood S, Collins PY. Global goals and suicide prevention in the Circumpolar North. Indian J Psychiatry [serial online] 2020 [cited 2021 Apr 19];62:7-14. Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/1/7/274834
| Introduction|| |
Globally, suicide prevention is a public health priority. For the first time, the reduction of deaths by suicide is a key target for global development. The 2030 Agenda for Sustainable Development articulates an extraordinary vision of a world freed from poverty, and strengthened by peace, resilience, and sustainability. The signatories to the 2030 Agenda acknowledge that a global plan for development must be holistic in its reach and collaborative in its implementation. This kind of international cooperation will be necessary to achieve the targets associated with the 17 Sustainable Development Goals (SDGs), including a 33% decrease in the incidence of suicide by 2030 (SDG 3.4)., Reaching this target demands a comprehensive and multisectoral approach to suicide prevention. The SDGs present a unique opportunity to address a range of social determinants that contribute to risk and resilience and can aid in the reduction of upstream risk factors for suicide.
Since 1990, suicide mortality has decreased by 32% globally; however, substantial rate differences between regions and subpopulations remain. The factors that influence these variations are complex and often rooted in social and economic inequities that disproportionately affect some communities and not others. For Indigenous peoples around the world, such inequities are traceable to the enduring legacies of colonization. The consequences of dramatic and deleterious social changes is particularly evident in the Circumpolar North where Indigenous peoples in several Arctic states experience marked disparities in suicide risk and suicide deaths compared to non-Indigenous populations.,,, Despite the persistence and recognition of these disparities, until recently, there has not been a coordinated or comprehensive approach to reducing the incidence of suicide across states in the Circumpolar North.
The purpose of this paper is to provide an overview of suicide and suicide prevention in the Circumpolar North and the global and local policy agendas aimed to reduce suicide deaths. We briefly review the social context, epidemiology, and risk and protective factors for suicide in the Arctic, with a focus on Indigenous peoples. We then describe a recent collaborative, intergovernmental response to elevated suicide rates in this region, the Reducing the Incidence of Suicide in Indigenous Groups – Strengths United through Networks (RISING SUN) Initiative. In relation to the SDGs, we examine recent policy developments in Indigenous-specific suicide prevention.
| Social Context|| |
The Circumpolar North refers to the global region comprising eight Arctic countries: The United States (US), Canada, Iceland, Denmark including Greenland and the Faroe Islands, Sweden, Norway, Finland, and Russia. The geopolitical boundaries of Arctic states are often drawn along 60°N. For the US, Canada, and Russia, circumpolar specifically refers to the northern-most administrative regions including Alaska, three territories (Nunavut, Northwest Territories, Yukon), and autonomous okrugs (i.e., districts), republics, and oblasts (i.e., Russian administrative regions). In Canada, circumpolar also refers to the subartic areas of several provinces which include the traditional territories of Inuit andFirst Nations peoples.
The eight Arctic states are some of the most industrialized and high-income nations in the world. Together, they comprise roughly 17 million square kilometers or 10% of the global land mass. The peoples that inhabit the Circumpolar North are culturally, linguistically, and socially diverse. As a global region, circumpolar countries have an estimated population of ~1.13 million Indigenous peoples including Inuit, Sami, Aleut, Athabaskan, Gwich'in, and Yakuts, Komi, and Komi-Permyak and other Indigenous peoples in Russia, many of whom cross international boundaries. The Inuit homelands, for example, span four nations (Greenland, Canada, Alaska, and Chukotka/Russia) and include two major linguistic groups. Indigenous peoples comprise a substantial minority in Alaska (20%), Yukon (25%), and Finnmark (30%) and constitute larger proportion of the population in the Northwest Territories (51%), Nunavut (85%), and Greenland (85%). In the several autonomous okrugs in northern Russia, Indigenous peoples account for between 2% and 41% of the population.
All Arctic States, with the exception of Russia, have adopted the United Nations Declaration on the Rights of Indigenous People, but legislative implementation varies widely. Across the Arctic, Indigenous peoples have varying levels of jurisdictional autonomy and diverse approaches to governance. The right to self-determination is enshrined in human rights, although control over lands, economic resources, and services differs substantially between Indigenous governments and communities. In the international context, all circumpolar nations are members of the Arctic Council, an intergovernmental forum aimed at promoting cooperation and collaboration related to sustainable development and environmental protection. Circumpolar Indigenous Peoples have been granted Permanent Participant status in the Arctic Council through six representative organizations.
Globally, Indigenous populations experience some of the largest social and economic inequities. In the Arctic in particular, elevated rates of respiratory illness, injuries, and chronic diseases are major drivers of the health gap between Indigenous and non-Indigenous peoples. The distribution of these disparities is uneven and influenced by localized factors such as community infrastructure, poverty, and access to care. In large part, the poor health outcomes experienced by Circumpolar Indigenous peoples are the consequences of traumatic and persistent histories of colonization.,,
| Epidemiology of Suicide|| |
In 2016, the global suicide rate was 10.5/100,000 population. Rates vary considerably across regions, and between and within countries. In general, men die by suicide at nearly twice the rate of women, although in some Asian and African countries (e.g., Bangladesh, China, Myanmar, Morocco, and Lesotho), more women die by suicide than men. Globally, a slight majority (52%) of suicides occur among people younger than 45 years of age, and suicide is the second leading cause of death among older adolescents and young adults aged 15–29 years olds. From 2010 to 2016, suicide rates decreased by 9.8%, with the exception of the Americas region, which saw a 6% rise in age-standardized suicides.
The vast majority (79%) of the world's suicides occur in low- and-middle income settings, with countries such as India accounting for nearly 36% of all suicide deaths. By contrast, high income countries account for smaller proportion of the global burden, but the highest rate by income group (11.5/100,000). Gender-specific suicide rates are highest among men from high income countries, whereas the highest suicide rates among women occur in lower-middle-income countries, especially those in South Asia. Although global and regional rates are valuable for tracking broad trends, they can also obscure significant differences between countries and among specific subpopulations. Rate differences and disparities between and within countries are particularly evident in the global Circumpolar North.,
In the US, the age standardized suicide rate was 13.7/100,000 in 2016; rates among men were approximately 3.5 times higher than among women (21.2 vs. 6.4/100,000). By contrast, the suicide rate in the State of Alaska, the country's Arctic region, was 29.2/100,000. The rate among men aged 20–24 years old was particularly elevated at approximately 86 suicide deaths/100,000. In the context of public health approaches to suicide prevention, these disparities are striking and important to recognize. The more than two-fold difference between national- and state-level rates suggests a more nuanced story.
Within Alaska, tremendous variation in suicide rates occurs across geographies and among subpopulations. Suicide rates are higher than the state average for some Alaska Native communities., Similar elevated rates can also be observed among Indigenous communities in the Arctic [Table 1], notably in Russia, Greenland, Canada,, and certain Nordic regions,,, although relative differences compared to non-Indigenous and general populations vary across the Circumpolar North.
|Table 1: Suicide mortality rates among Indigenous peoples in Arctic countries|
Click here to view
| The Complexity of Risk and Protective Factors for Suicide|| |
The risk and protective factors for suicide and suicidal behavior are complex, interactive, and involve factors at the individual, community, and population level. Conceptually, population-level factors such as social cohesion can influence distal individual-level factors, such as genetics, early life adversity, mental disorders, and substance use, and proximal factors such as personal crises and suicidal ideation. Factors from the social and environmental context such health care, access to lethal means, and media also influence individual-level risk for suicide. Similarly, external influences such as natural disaster, war and civil conflict, and economic recession can increase the risk for suicide because of the negative impacts on social well-being, health, housing, employment, and financial security.
In the general population, the single most important risk factor for suicide is a prior suicide attempt. Limited access to health care, stigma associated with suicidality and seeking help, mental disorders, and substance use can increase the risk of suicide for entire communities. On an individual level, discrimination, isolation, abuse, and interpersonal violence can contribute to risk, whereas parental confidence, strong social and familial support, participation in religion, and cultural norms confer protection.,,
| Indigenous Peoples in the Arctic Experience Particular Constellations of Risk|| |
The social, economic, and political histories of Arctic Indigenous communities shape their distribution of risk for suicide. Indigenous Peoples in the Arctic have experienced injustice, oppression, and continued social, political and environmental challenges. Societal and cultural differences can distinctly change the presentation and course of self-harm and suicidal ideation., Close family networks, for example, can play a larger role in this context as a protective or risk factor. Similarly, cultural continuity and identity on a community and individual level respectively can act as a hedge or protective factor against suicide;, but lack of connection and cultural identity has been shown to significantly increase risk for suicidality and alcohol misuse.,,
| Global Targets for Suicide Prevention|| |
Globally, efforts to promote mental health and reduce the burden of mental illness and suicide have lagged behind other major causes of morbidity and mortality. Yet, mental disorders as a group are the leading causes of disability worldwide and major contributors to the global burden of disease. In recognition of the widespread impact of mental illnesses and suicide on communities and health systems, the World Health Organization developed the Mental Health Action Plan 2013–2020. The foundational goal of the Action Plan is to “promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights, and reduce the mortality, morbidity, and disability for persons with mental disorders.”
The objectives of the Action Plan are to improve leadership and governance in mental health care, provide coordinated and comprehensive coverage of mental health services, support the development of national initiatives focused on promotion and prevention, and enhance the existing evidence base for intervention through research and health information. A key indicator for the success is for all member states to work towards reducing suicide rates by 10% by 2020. More recently, the Action Plan was extended to 2030, aligning it with the timeline for achievement of the SDG target of a 33% reduction in suicide mortality.
| Suicide Prevention as a Policy Imperative|| |
To support countries to work towards the ambitious but achievable targets for suicide prevention, the World Health Organization recommends that all member states develop a comprehensive and multi-faceted national suicide prevention strategy. The purpose is to recognize and sustain interest in suicide prevention as a coherent policy, prioritize investments in interventions and research, and enhance the coordination of activities across regions and organizations. In the landmark report, Preventing Suicide: A Global Imperative, WHO offers countries a framework for implementing evidence-based approaches to address the complex causality and risk of suicide.
As of 2018, 38 nations have established national suicide prevention strategies, including several Arctic nations. Canada does not have a national strategy, but did pass federal legislation in 2012 to establish a federal framework for suicide prevention. The U.S. Centers for Disease Control published a technical package for suicide prevention in 2017. In Russia, suicide prevention has been integrated into a national mental health action plan. Sweden, Norway, Denmark, and Finland have all developed and implemented strategies specific to suicide. A key challenge for national strategies is finding mechanisms for addressing health inequities with contextualized evidence as part of a broader approach to reducing national suicide rates.
| Community-Based Approaches to Suicide Prevention in the Circumpolar North|| |
Suicide prevention, and more broadly, promoting mental wellness and resilience, are priorities for many communities, health authorities, and governments across the Circumpolar North. Over the last 30 years, there has been widespread program development in communities that aim to improve mental health, connect people with their culture, and reduce the incidence of suicide. Until recently, this has largely occurred in isolation and on an ad hoc basis. Despite this, many communities have developed creative approaches to suicide prevention that integrate Indigenous knowledge and practices with clinical and public health interventions.,,,,
Local innovations, in many cases, address overlapping and related priorities including food security, intergenerational relationships, and mental health. Despite community knowledge about program success, the scientific evidence base for many programs is limited. A scoping review found that such suicide-related interventions in the Arctic often do not undergo rigorous evaluations; even for interventions that demonstrate beneficial outcomes, many commonly lack long term funding. These shortcomings severely hamper opportunities for continuity and scale up, which means that many circumpolar Indigenous communities struggle to sustain advances made in suicide prevention.
| The Arctic Council and the Reducing the Incidence of Suicide in Indigenous Groups – Strengths United Through Networks Initiative (Rising Sun)|| |
In recognition of the impact of suicide in northern communities and the challenges related to advancing the evidence base, the Arctic Council made suicide prevention a key priority and focus of collective action across three consecutive chairmanships. From 2015 to 2017, the US led an initiative aimed at identifying prioritized outcomes and measures for evaluating suicide prevention efforts across the Circumpolar North through the Arctic Council chairmanship., The RISING SUN initiative used a collaborative, consensus-building process similar to that used to identify priorities in global mental health. This section provides an overview of process and outputs from the initiative.
RISING SUN employed a mixed-methods approach including an adaptation of the consensus-building technique known as the Delphi. Following selection of a Scientific Advisory Group, RISING SUN recruited and selected multinational members for a Delphi panel from the eight Arctic States and five of the six Permanent Participants of the Arctic Council. This included representatives from the diverse Indigenous, policy, clinical, research, and advocacy groups in the Circumpolar North. Further, viewpoints of key local partners were incorporated through face-to-face meetings across circumpolar regions.
To achieve a shared and inclusive vision, the RISING SUN initiative convened a series of regional meetings in September 2015 (Anchorage, USA), May 2016 (Tromsø, Norway), and March 2017 (Iqaluit, Canada). Collectively, participants at these meetings reviewed the complexities of suicide prevention in Arctic communities. Participants also exchanged and assessed various local activities over the previous 5 years pertaining to evidence gathering and intervention strategies. During the final meeting, project coleads reported on the findings from RISING SUN, including the outcomes from the Delphi process, a discussion of methodological approaches, the form and function of a proposed RISING SUN Toolkit, the knowledge gaps that remained, and future opportunities for dissemination, implementation, and research.
The goal of the Delphi process was to identify the most important outcomes for suicide prevention interventions (in addition to reduced deaths by suicide) for Arctic Indigenous communities. The Delphi process revealed that participants prioritized outcomes from family-and community-level interventions. Following the Delphi, RISING SUN organized regional focus groups and interviews with Indigenous leaders, elders, and youth in Alaska and Canada. The purpose was to understand and highlight existing local assets that already led to healthy community outcomes, and to refine the outcomes identified through the Delphi process. In a qualitative analysis of the focus groups and interviews, the emergent theme arose of acknowledging the importance of relationships and interconnections – interpersonal as well as ecological – that are held sacred and kept in balance for the health and well-being of Indigenous communities.
A key output of RISING SUN included a collaboration with the Mental Health Innovation Network to host and disseminate a web-based Toolkit (www.mhinnovation.net/collaborations/rising-sun) identifying primary outcomes and measures to assess the impact and effectiveness of suicide prevention interventions in the Arctic. The Toolkit offers a range of information on factors related to suicide, as well as best practices in suicide prevention in circumpolar Indigenous communities based on our current knowledge. In addition to the key outcomes and recommendations for ways to use the Toolkit, the Mental Health Innovation Network provides background on the development of the initiative, the partners involved, and an overview of a blog detailing successful community practices in the circumpolar North.
| Indigenous-Led Suicide Prevention Strategies in the Arctic|| |
One of the conclusions of the RISING SUN initiative was that interventions needed to occur at multiple levels, including the level of policy. Although Canada does not have a national suicide prevention strategy, several Indigenous groups have developed their own strategies. In 2017, the national Inuit organization in Canada, Inuit Tapiriit Kanatami, created the National Inuit Suicide Prevention Strategy. This strategy was focused on Inuit across Nunangat, the Inuit homeland, which includes Nunavut, and northern regions in Labrador, Quebec, and the Northwest Territories. The strategy is innovative in several respects. It takes a life course approach to prevention and recognizes risks that are typically more acute and on the individual level while also taking into account factors that are historically and socially entrenched and arise in a community context. The strategy is also heavily influenced by a social determinants of health framework. Recommended interventions in the strategy address important risk factors related to social equity such as housing, food security and poverty.
In 2017, the Saami Council, which represents Indigenous Peoples in Norway, Sweden, and Finland, created a suicide prevention strategy focused on Sami. Although federal prevention initiatives exist in Nordic countries, this was the first and most comprehensive effort to address the specific needs of Sami communities and people. Major pillars of the strategy include reducing exposure to violence and discrimination, promoting healing from historical trauma, strengthening Sami self-determination and cultural identity, and ensuring culturally-appropriate and relevant mental health care.
In 2001, the Alaska Legislature established the state-wide Suicide Prevention Council, a body responsible for advising state leaders on ways to improve Alaskan's health wellbeing by reducing suicide, creating a statewide suicide prevention plan and putting it in action, and building and strengthening partnerships to prevent suicide. Casting the Net Upstream: Promoting Wellness to Prevent Suicide was a 5-year action plan for 2012–2017 and Recasting the Net:
Promoting Wellness to Prevent Suicide in Alaska, extends and broadens the first initiative for 2018–2022. The plan presents multilevel strategies and solutions emphasizing the interplay of individual risk factors such as a impacts of trauma and substance abuse with geographic and community level factors specific to an Alaskan context that create additional barriers and challenges to providing immediate access to treatment, prevention and recovery resources. The plan also details strategies for addressing data gaps and provides recommendations for the ways that research and evaluation can increase the uptake and expansion of promising and best practices.
In 2013, Greenland created a national suicide prevention strategy that focused on reducing suicide deaths and attempts among Inuit, the Indigenous peoples that comprise the majority (~88%) of the population. The strategy aimed to enhance and better coordinate services across health, social, and education systems, and build community-level capacity for prevention. Interventions included training and education for front line service providers, improved early intervention and follow-up care, providing support for families impacted by suicide loss, and strengthening research and surveillance.
| Progress Towards the Sustainable Development Goals in the Circumpolar North|| |
This was stated earlier in the manuscript. Nationally, rates in Canada have remained stable since 2008, though in the US, and Alaska in particular, deaths by suicide have increased. A recent ecological study assessed the impact of national suicide prevention strategies on suicide rates in four countries, three of which were in the Circumpolar North (Norway, Sweden, Finland, and Australia). Compared to a similar group of countries that do not have national strategies, the study found that suicide rates decreased significantly in countries with strategies, especially among adult males aged 25–64 years and among females aged 45 years and older and that rates did not have significant decreases in countries without strategies.
Disparities in suicide mortality persist for many Indigenous communities across the Circumpolar North, and incidence rates remain high. In Canada, Inuit Tapiriit Kanatami recommended that addressing the SDGs in Inuit Nunagaat, the Inuit homeland, will require substantial new investments in infrastructure such as housing, telecommunications, transportation, renewable energy, and education, and the prioritization of SDGs in the federal Arctic policy framework. ITK has also set a more ambitious and equity-focused goal of reducing the suicide rate among Inuit by 50% to create a “low suicide reality” for Inuit communities across Canada.
There is also recognition that Indigenous Peoples from many countries did not have a role in shaping the SDGs. In Canada, for example, neither the nationalFirst Nations assembly nor individual communities were participants in the SDG development process. At a global scale, the implication of such exclusion means that the global goals may not sufficiently reflect the diverse needs and priorities of peoples that experience some of the most acute socioeconomic inequities.
There is an urgent need to increase Indigenous engagement in suicide prevention planning with the goals to more fully and fairly integrate Indigenous knowledge into interventions aimed at addressing social equity and multilevel determinants. Indigenous knowledge driven strategies and solutions will not address suicide in isolation but will instead focus on regaining balance within socioecological systems. Current research on resilience and wellbeing in Indigenous communities in the Arctic is starting to make significant gains in changing the narrative from suicide to community level and cultural strengths,, but more focused research is needed.
There is an ongoing need to disaggregate data to monitor progress at subnational, regional and community level, and for Indigenous Peoples., Yet, in the context of suicide surveillance and indeed for many health indicators, this is not routinely done in many jurisdictions in some countries., While the US does have suicide data across racial and ethnic groups, neither Canada nor any of the Nordic countries include Indigenous identifiers in federal administrative data. This makes it difficult to assess potential mortality rate differences between ethnic and racialized groups within these populations.
To improve evidence, Indigenous suicide prevention requires significant and sustained investments. This goal also requires research collaborations that better support communities to mobilize what is already known about the procedures and components of effective interventions for improving social equity and integrating suicide prevention into policy, service delivery, and programming. In a recent op ed, Dr. James Allen, an experienced researcher working with Arctic Indigenous groups in Alaska to develop and evaluate community-based suicide prevention strategies, noted: “Suicide prevention – we know what to do but will we do it?” He argued that to achieve our suicide reduction goals we will need to shift our paradigm to more fully consider community interventions and solutions that allow for underrepresented ethnocultural perspectives to be counted on their own as valid, particularly within a relational Indigenous knowledge-based intervention science.
| Conclusion|| |
The SDGs acknowledge the multifactorial nature of suicide risk and prevention and provide a framework for addressing a range of social determinants of health and mental health that contribute to risk and resilience. Together with the WHO's Mental Health Action Plan, the SDGs present a powerful opportunity for countries to act to reduce the incidence of suicide worldwide. Together with locally relevant suicide prevention strategies developed in Arctic Indigenous communities, these plans and strategies can provide clear targets and guidance for communities deeply affected by suicide. The task remains to develop and apply effective suicide prevention interventions for these communities.
One of the challenges for suicide prevention in the Circumpolar North is the limited scientific evidence base for interventions that have been developed, adapted, scaled, or sustained, as these grassroots programs often lack resources or capacity for formal evaluation and broader dissemination. The RISING-SUN initiative identified key correlates and prioritized outcomes for prevention interventions across Arctic states – an effort that could assist in harmonizing evaluation efforts across communities. Such efforts need continued support and investment of sustained resources for the design, evaluation, and implementation of evidence-based practices through coproduction and/or strengths-based approaches.
This article was presented at the SNEHA Suicide Update on April 13, 2019 in Chennai, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Pamela Y Collins
Department of Global Health, University of Washington, Harris Hydraulics Building, 1510 NE San Juan Road, Seattle, Washington 98195
Source of Support: None, Conflict of Interest: None