Suicide for a Cause

What's behind the Middle East's new trend of self-immolation?

On Dec. 17, 2010, a 26-year-old unemployed college graduate named Mohamed Bouazizi stood in front of a government office in the Tunisian town of Sidi Bouzid, poured gasoline over his body, and lit himself on fire. In doing so, he seems to have sparked a much broader flame that has spread throughout the country and much of North Africa.

Bouazizi has been credited as the "martyr who toppled the Tunisian government" and the political inspiration for a series of similar self-immolation attempts throughout the region. In the month that followed his now famous act, at least eight other individuals in Algeria, Mauritania, and Egypt have set themselves on fire.

Historically, self-immolation has often been seen as a political act, and the famous images of Buddhist monks setting themselves on fire to protest persecution in Vietnam stand out as particularly harrowing. The tactic has been used by political activists in China, India, the United States, the former Soviet Union, and a range of other countries.

It is thus no surprise that many commentators have been quick to attribute political motives to Bouazizi and those who followed him. For instance, though acknowledging that frustration and despair may have played a role in the Egyptian cases, Associated Press correspondent Hamza Hendawi declared that the immolations "are deeply symbolic means of protest in a region that has little or no tolerance for dissent."

However, although these acts may be imbued with symbolism after the fact, it is not yet clear that any of these individuals were primarily motivated by politics. They may have simply been suicidal. Unable to find work despite his college degree, Bouazizi had become a fruit and vegetable vendor to survive. When police confiscated his cart and all the food with it, insisting that he somehow find the money for a vendor's license before it would be returned, it seems to have pushed the desperate young man over the edge. Similarly, the other self-immolators throughout North Africa were reportedly struggling with a range of personal problems such as unemployment, homelessness, and depression.

If these suicidal acts were personal, not political, they would not be the first collection of self-immolations to fit that psychological profile. From 2005 to 2006, there were approximately 150 reported cases of women committing suicide by setting themselves on fire in the Herat province of Afghanistan. Subsequent studies by the Afghanistan Independent Human Rights Commission revealed that such self-immolations are severely underreported, increasingly common, and usually sparked by personal problems, including forced marriage, physical abuse, and sexual assault. Given the power of traditional gender norms in the Islamic world, it seems likely that the shame, dishonor, and desperation experienced by those violated women in Afghanistan may be similar to what was felt by these jobless, homeless, frustrated, and powerless men in North Africa.

There is another major reason to think that Bouazizi and those who followed were not staging political protests. There has been no evidence that any of them left videos, letters, manifestos, or suicide notes of any substance in which they claimed that their acts were calculated political statements and then articulated their grievances. Purely rational actors who are planning to sacrifice their lives for a cause should be expected to care about how their deaths are interpreted. These individuals left it completely up to chance.

A useful comparison can be made to suicide terrorists. A significant percentage of bombers make martyrdom videos for this precise reason: They want to make sure that their audience -- their friends, family members, and the public -- are convinced that their acts were politically and ideologically motivated, rather than some form of suicidal escape. Suicide bombers who do not speak out before their deaths usually know that they will be spoken for afterward by the terrorist organizations they leave behind that attest to their motives. If Bouazizi and the self-immolators were politically motivated, they would similarly have cared about their audience and not wanted to leave their public in the dark. The fact that they apparently did not put this forethought into their actions suggests that they were motivated more by desperation and suicidal compulsion, rather than political premeditation.

By setting himself on fire near a government building during a period of political turmoil, Bouazizi must have anticipated that his act would be interpreted as a sign of political protest. And those who followed him were also no doubt aware of how their actions would be interpreted in this climate. However, it is relatively common for depressed and suicidal people to try to latch on to something bigger and more significant than themselves in their last moments on Earth -- regardless of their primary agenda.  

Again, the parallel to suicide terrorists informs this issue. Growing evidence indicates that many suicide bombers were in fact clinically suicidal, and that no matter what they may have claimed, no matter what doctrine they may have spouted, it was actually personal psychological problems that led them to blow themselves up. Terrorist organizations exploit this psychological vulnerability for their own strategic reasons, but their pawns appear far less invested in the political consequences of their attacks.

For instance, in interviews conducted by Israeli researchers with failed Palestinian suicide bombers, they usually claim that they wanted to kill themselves for the cause because of their hatred for Israel and its treatment of their people. However, if you dig a little deeper, their true psychological motives surface: Suicide bombers are often consumed by clinical risk factors for conventional suicide such as depression, hopelessness, guilt, shame, and rage. I have conducted a series of studies on the life histories and underlying motives of suicide terrorists, and there is a consistent pattern of these individuals attempting to mask their psychological angst as self-sacrificial martyrdom. Furthermore, their attacks are often triggered by the same types of personal crises that cause people to kill themselves in New York, Paris, or Tokyo, including financial problems, divorce, unwanted pregnancies, inability to get married, poor health, physical disabilities, or the death of a loved one. Both self-immolators and suicide terrorists may indeed channel the political frustrations of a much larger population, but the primary difference between the very few who choose to kill themselves "for the cause" and the much greater majority who do not is usually the presence of classic suicidal traits.

Despite this evidence, both types of suicide are often interpreted as primarily constituting political acts. Perhaps this says as much about us, the public, as it does about the deceased. We see an increase in suicide bombings or an increase in people setting themselves on fire, and we put it in a broader political context because it is this context -- and not the personal psychological problems of the individuals involved -- that has the biggest effect on our lives. However, studies suggest that the apparent increase in these behaviors may have nothing to do with politics at all, that conventional suicide can spread via social contagion, and that a "copycat effect" may increase suicidal thoughts and suicide attempts, regardless of political developments.

In addition, it is possible that the behavioral change we are seeing is primarily in the method of suicide, more than in the total number of suicides themselves. The self-immolators who followed Bouazizi may be copying his modus operandi, but they may very well have found another way to kill themselves had he never appeared. What seems like a sudden spike in suicides in North Africa may mostly be a function of the media paying more attention than usual, due to the political turmoil in the region. Nine people setting themselves on fire in a month may seem like a trend, but in the United States, approximately 94 people commit suicide every day, and similar per capita rates of suicide are seen among some African countries.

Furthermore, though suicide by fire may seem inherently dramatic and symbolic, the Afghan women who chose this method did so simply because they thought it was more reliable than overdosing on pills.

This is not to say that there aren't some legitimate links between politics and suicide. A government is at least partially responsible for the mental health of its people. When citizens lose faith in their leaders, the inherent justice and fairness of the system, and their ability to overcome adversity, they lose hope, and hopelessness is one of the most common psychological causes of suicide. The motives for Bouazizi's suicide may have been personal, but it was Tunisia's political leaders who failed him and millions like him. Ultimately, that is the symbolic legacy of his act and why those leaders have been held accountable.

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Smoke and Mirrors

It's time for Washington to stop giving cigarette makers an open door to developing markets.

If it seems fewer people are smoking in the United States, that's because it's true. Since 1965, the proportion of U.S. adults who smoke has plummeted from 42 percent to 19 percent as a result of higher excise taxes, civil and criminal litigation, and tobacco-control programs in U.S. cities and states.

But as tobacco use declines in the United States, it is on the rise in low- and middle-income countries, spurred by higher incomes, trade liberalization, and intensive industry marketing. There are 1.2 billion smokers in the world, roughly one-third of the world's adult population. Seven-hundred million children -- approximately 40 percent of the world's youth population -- are exposed to second hand tobacco smoke at home. According to the World Health Organization (WHO), tobacco use already kills more people annually than HIV/AIDS, malaria, and tuberculosis combined. Unless urgent action is taken, it is expected to kill hundreds of millions more in the coming decades, mostly in developing countries. The World Economic Forum's 2010 global risk report ranked non-communicable diseases, for which tobacco use is a leading risk factor, as a greater threat to global economic development than fiscal crises, natural disasters, transnational crime and corruption, and infectious disease.

This week marks 10 years since President Bill Clinton signed an executive order, which remains in effect, requiring U.S. agencies to take "strong action to address the potential global epidemic of diseases caused by tobacco use." While the intervening decade has seen significant efforts to reduce smoking domestically, Washington continues to do too little to address the expanding tobacco use in developing countries and its devastating consequences.

At home, the U.S. government is cracking down on tobacco. In 2009, President Barack Obama signed a law that gave the U.S. Food and Drug Administration (FDA) sweeping new powers to regulate tobacco products. Graphic images of diseased lungs and deceased smokers will soon adorn cigarette packs sold in the United States. The Congressional Budget Office estimates that these new regulations will reduce U.S. youth smoking by another 11 percent over the next decade.

Abroad, however, U.S. engagement on tobacco control is minimal. The United States has yet to join the 171 countries that have ratified the WHO Framework Convention on Tobacco Control, a binding, comprehensive treaty designed to reduce tobacco supply and demand worldwide. Less than $7 million of the more than $8 billion global health budget in 2009 was dedicated to international tobacco control. Nearly every trade and investment agreement that the United States has negotiated over the last decade reduces tobacco tariffs and improves the protection of tobacco-related investments overseas. The same new law that restricts cigarette marketing and labeling in the United States specifically excludes cigarettes destined for sale or distribution abroad.

Multinational tobacco companies' strategy toward tobacco control has been the mirror image of the U.S. government's. In the United States, the industry's response to the new domestic tobacco-control initiatives has been relatively muted. The Altria Group, which owns Philip Morris USA, supported the 2009 anti-smoking legislation and has not protested the FDA's proposed graphic warnings. Again, the story is different abroad. Tobacco com­panies have aggressively sought to expand markets for their products in low- and middle-income countries and have fiercely opposed marketing and labeling regulations more modest than those currently proposed in the United States.

Multinational tobacco companies employ advertising tactics in lower-income countries --billboards, cartoon characters, and music sponsorships -- now prohibited in the United States. Young women, who have historically smoked less than men in most parts of the developing world, are a major target of these campaigns. And marketing gimmicks -- such as purse-packs containing super slim cigarettes -- have helped increase the rate at which girls smoke to the same rate as boys do in more than 60 percent of countries surveyed in the Global Youth Tobacco Survey conducted by the WHO, U.S. Centers of Disease Control and Prevention(CDC), and the Canadian Public Health Association.

In the world's poorest countries, where tobacco has not been consumed historically, multinational cigarette companies use investments in local tobacco production and corporate social responsibility programs to win new friends and future customers. These tactics have increased tobacco use throughout Asia, Eastern Europe, and Latin America. Many expect Africa will be next. Tobacco use is currently relatively low in Africa -- 20 percent for men and much less for women -- but there will be dire consequences if it increases: Many African governments lack the ability to implement effective national tobacco-control programs and the health-care resources to cope with a pandemic of tobacco-related diseases.

Multinational tobacco companies are exploiting U.S. and other affluent countries' trade policies to pursue these tactics and outmaneuver developing-country regulators. Increasingly, multinational tobacco companies use dispute resolution under trade and investment agreements to block labeling and advertising restrictions in low- and middle-income countries. Free trade agreements reduce tobacco product tariffs before developing countries can introduce adequate domestic tobacco control and taxation programs to compensate for the lower price of imported cigarettes.

Smoking-control efforts in developing countries are stalling in the face of fierce industry opposition. Tobacco industry promotional investments dwarf expenditures on tobacco control in these countries. In 2009, the WHO reported that less than 10 percent of the world's population is covered by any of the WHO-recommended measures to reduce demand for tobacco and regulate tobacco-industry marketing.

Some policymakers in Washington make the argument that American jobs depend on tobacco companies' free access to developing countries. But that's a false choice: Doing more for international tobacco control would not put U.S. jobs at risk. The United States currently exports significant volumes of high-quality tobacco leaf and premium cigarettes to Japan, Europe, and affluent Middle Eastern countries, but hardly anything at all to cost-sensitive developing-country markets. Moreover, cigarette production has largely shifted to overseas factories. With domestic consumption declining, the tobacco industry now provides less than 2 percent of the jobs in the six southeastern U.S. states most associated with tobacco growing and product manufacturing.

In fact, taking the lead on international tobacco control would clearly be in the national interest of the United States. In a recent speech before the United Nations, President Barack Obama cited global health and development as not only moral imperatives, but U.S. strategic and economic imperatives. U.S. investments in global health are visible, concrete, and highly valued; they save lives and enhance America's credibility around the world. Few global health threats can compare with the human and economic toll of tobacco-related diseases in developing countries. If disease prevention and global health are strategic U.S. priorities, then global tobacco control must be as well.

Fortunately, it's an especially opportune moment for U.S. leadership on international tobacco control. The scientific consensus that to­bacco use and secondhand smoke cause a plague of terminal and disabling diseases no longer faces serious challenge. The WHO Framework Convention on Tobacco Control is among the most widely subscribed treaties in the world and provides a blueprint for acting on the most evidence-based and cost-effective strategies for global tobacco control. A $500 million, multiyear commitment from the Bloomberg Initiative and the Bill and Melinda Gates Foundation has injected sorely needed resources into tobacco-control programs in 20 priority developing countries. Anti-smoking NGOs like the Campaign for Tobacco-Free Kids and the Framework Convention Alliance are doing groundbreaking work on global tobacco control and would be capable U.S. government partners. Increased U.S. engagement on global tobacco control can transform this momentum into sus­tainable progress.

A foundation for change exists within the U.S. government. Obama supports ratification of the WHO Framework Convention on Tobacco Control. The senior leadership at the State Department, the FDA, and the CDC include individuals with distinguished track records on tobacco control and prevention. Last year, the U.S. trade representative resisted congressional pressure to challenge other countries' tobacco-control regulations. Where the United States has engaged on international tobacco control, such as the CDC's efforts on global tobacco-use surveillance, it has made a significant difference.

The United States must not wait another 10 years to demonstrate internationally the same leadership it has shown on tobacco control domestically. Obama has said he supports the WHO framework convention; but he should not wait for the Senate to ratify it before integrating tobacco control into existing U.S. efforts on maternal and child health, disease control, and health-systems strengthening. The U.S. Treasury Department and FDA have extensive technical expertise that should be shared with develop­ing countries seeking to improve tobacco taxation, fight cigarette smuggling, and regulate tobacco products and their advertisement. The U.S. trade representative should stop seeking tobacco tariff reductions and cease including tobacco-related investments in trade and investment agreements with developing countries. This year's G-20 meeting in France and the upcoming U.N. High-Level Summit on Non-Communicable Diseases provide excellent opportunities for the United States to motivate other governments to likewise prioritize tobacco control.

Washington has already shown great courage and leadership in protecting its own citizens from the perils of tobacco. It's past time that the United States support the world's poorest countries in their efforts to do the same.


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