Why doctors hail TN ban on rat poison, but feel more needs to be done to curb suicides

The Tamil Nadu government’s recent decision to ban the sale of rat poison has been welcomed by the medical fraternity. However, the state health minister and the government are being trolled on the grounds that an isolated ban will not bring down the suicide rates.

It is in this backdrop, a study conducted by Dr CE Eapen, senior gastroenterologist, hepatology department, Christian Medical College (CMC), Vellore, on rodenticide related suicides in Tamil Nadu in 2019, seems key to understanding the rationale behind the government’s move.

Conducted by the Tamil Nadu chapter of Indian Society of Gastroenterology (TN-ISG), the study titled ‘Rodenticide Ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, Southern India’, was published in the 2020 issue of Indian Journal of Gastroenterology. The aim of the study is to assess exposure to rodenticide as a risk factor for acute hepatotoxicity.

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The study conducted in 15 hospitals in six districts namely Chennai, Coimbatore, Madurai, Tirunelveli, Thanjavur and Vellore between January 2019 and June 2019 revealed that out of 702 patients, 685 patients had allegedly consumed rodenticide, while the rest consumed other drugs or took an overdose of paracetamol. It should be noted that it was the first of its kind study carried out across the state to gauge the problem.

“Of the 685 patients who ingested rodenticide, 492 patients (72 per cent) used paste form, 83 (12.1 per cent) and 42 patients (6.1 per cent) used them in powder and cake forms respectively. One patient ingested both the powder and the cake forms. No information was available on the rodenticide form used by the remaining patients,” the paper revealed.

It further said: “The intent for consuming the toxin/drug overdose was available in 700 patients. It was suicidal in 678 patients (97 per cent), accidental in 14 (2 per cent) and homicidal in 8 patients (1.1 per cent). The youngest patients who consumed poison / drug overdose with suicidal intent were 13 years old (two boys, one girl), while the oldest patient was an 86-year-old male.”

While data on reasons for attempted suicide was not available in 507 patients, the study added that 143 patients (22.1 per cent) were experiencing marital discord, 28 children (4.1 per cent) had exam related stress, with 21 of these children reporting this in the preparatory period before annual exams in March and April.

And, overall, 23 patients (11.8 per cent) had a history of prior suicide attempt and all had an underlying psychiatric illness.

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Data poses grim situation

Though the National Crime Records Bureau comes up with data on the number of suicides in each state every year, it does not have a list of what type of suicides have happened. But in a worrying trend, in March this year, the Union government said that Tamil Nadu tops in the list of suicides by women with more than 5,000 cases.

While the state also also fails to maintain any data on the nature of suicides, the available data reported in a large section of the media from some districts such as Tiruppur (more than 100 cases died of consuming rat paste in 2014), central Tamil Nadu districts like Tiruchy, Pudukkottai, Karur, Perambalur and Ariyalur (138 cases in 2018 and 165 in 2019 died of rat paste) are the worst.

Interestingly, in March 2020, when D Ravikumar, Villupuram MP raised a question in Lok Sabha on rat poison related suicides, the Union government had said that “no information is available with National Crime Records Bureau on the suicide and accidental death of children due to yellow phosphorus used in rat poison paste”. Incidentally, the CMC study revealed that about 60 per cent of patients have consumed rat paste containing yellow phosphorus.

‘Regulate, instead of banning’

Subsequently, the AIADMK government in August 2019 had announced that it will ban the sale of rat paste. Almost three years later, the DMK government banned the sale of rat paste. However, Dr Eapen, while appreciating the government for realising the seriousness of this issue, also cautioned that rat paste must be regulated not completely banned.

“A large number of suicide cases in the study was from Thanjavur. While the fertilisers and pesticides are regulated and the shops which sell these items maintain proper records like the farmer’s name, the quantity of the product, etc., the same shops selling rat pastes (medicine) do not maintain any records. They are being sold over the counter. Regulating the sale will restrict the easy accessibility and prevent suicides,” he emphasised.

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When asked if the ban on rat medicines will help to lower suicides (since the person can find other means to end their lives), Dr Eapen said many suicide attempts are ‘parasuicides’. This means that largely people display self-injurious behaviour without any actual intent of killing themselves.

“These kinds of suicides are mostly attempted by the youngsters and rat paste is the one which is easily accessible to them. Particularly among students, these kinds of suicides occur after the exam results. So, the government should take precautionary actions like counselling the students well in advance before the exams,” he pointed out.

Treating rat paste cases – TN’s novel way

Further, Dr Eapen said banning rat medicine is the state government’s second step to reduce suicide rates caused by rodenticide. Earlier, the government had implemented a novel method of rodenticide poisoning management. It was based on the guidelines brought out by the TN-ISG immediately after the study. The guidelines were published in the January 2022 issue of GHEP (Gastroenterology, Hepatology and Endoscopy Practice) Journal and the state has now implemented it, he said.

Patients with rodenticide hepatotoxicity can be treated by urgent liver transplantation and there are non-transplant options as well. At present, the majority (>99 per cent) of rodenticide hepatotoxicity patients in Tamil Nadu cannot access urgent liver transplantation. So, the focus of these guidelines is to improve survival in patients with acute hepatotoxicity without urgent liver transplantation, said Eapen.

According to Eapen, a person who consumes rat medicine will not die immediately. It will take at least three or four days for him or her to develop hepatotoxicity. “So, if one comes to know that a person has consumed rat paste, he or she should be taken to the primary level hospital immediately. They will be given medicines to first clear the rodenticide ingestion and make the patient stable. Then the patient has to be taken to a taluk level hospital and monitored for five days. After which, the patient must be sent to a medical college hospital in the district, where he or she will be given plasma exchange,” explained Eapen.

He added that generally, while treating the poison patients consume, the doctors will prescribe sedative drugs to keep them calm, so that both patients and their relatives will not be subjected to psychological pressures.

“However, in our guidelines, the doctors are advised to avoid or use sedative drugs judiciously, so that the patient will not develop drowsiness or respiratory problems, because the sedative drugs will stay in the patient’s liver for a longer time than in a normal condition,” observed Eapen.

He also added that about 700 government doctors across Tamil Nadu have been trained about these guidelines by the CMC.