It takes a village to raise a child is an African proverb meaning a child’s upbringing belongs to the entire community
For some time I have been worried about New Zealand’s high rate of suicide. Initial investigations on how the new Covid-19 environment is affecting teenagers in the US is showing a dramatic increase in mental health symptoms. I have real concerns for New Zealand the fallout from Covid-19 means our awful youth suicide rate will get worse not better.
Back in 2017 there were some reports from UNICEF and the OECD showing how kiwi youth are struggling to cope. In particular that New Zealand youth were killing themselves at a world leading rate (see the blue line on the right of the below graph).
What made the statistics worse is that unlike many other countries, New Zealand’s youth suicide rate did not show signs of reducing.
This concerned me for several reasons. I am the father to two pre-teenage boys and I hope that they and their peers get the best start in life. I work in mental health and see the consequences of poor mental wellbeing. Finally, my private-time interest is advocating for affordable housing -something which I will explain has a connection to New Zealand’s poor youth well-being.
I am even more concerned now in 2020. A perfect storm of factors could be in motion to make the country’s already poor suicide statistics worsen. It is possible if there is no policy response that New Zealand’s suicide rate could double for some groups, like it did between the decades of the 1970s compared to the 1990s.
The trigger for the sudden change in young people committing suicide between the 1970s and 1990s that has never fully corrected itself was the neo-liberal free market reforms, which in New Zealand are referred to as Rogernomics. Whether these reforms were necessary or not is a debate for elsewhere, the issue this paper wants to raise was that insufficient care was taken to mitigate the negative outcomes.
It is possible the coronavirus pandemic will have a negative economic impact as bad as the 1990s when the unemployment rate peaked at 11% in 1992.
Negative economic indicators like unemployment are like stress waves going through community networks. The waves disrupt social networks which reduces the community support that vulnerable individuals receive. The effect is seen on all sorts of social indicators, such as the suicide rate.
The lesson of how the economic transition of the 1990s was associated with a wider social fallout needs to be considered for how the country responds to the current Covid-19 recession. The response to Covid-19 should address the wider social well-being issues rather than just having a narrow economic focus.
This paper does not take the position that New Zealand chose public health over the economy. The paper contends the economic shock was coming regardless and that it was right to go ‘hard and early’ on public health measures to save lives. The paper does though contend that in the future further public health policy work will be needed to save lives that are imperilled from the pandemic’s economic fallout.
The second factor of the perfect storm is evidence that youth around the world are not as resilient as previous generations. That the smartphone has resulted in less socially supportive face-to-face time with peers and adults, that smartphone use degrades genuine protective social connections and that more screen time only provides superficial support for users. Academics are increasingly looking at smartphones as a mental health/suicide risk factor for the youth population.
The third factor in the perfect storm is the needed public health measures used to contain the spread of covid-19 have increased online activities further while also reducing face-to-face social connections. There has been considerable funding allocated to keep adult workers connected to their employers but as far as I can see little consideration for how to keep youth connected to outside groups (other than to their schools) such as sport teams, drama clubs, cultural groups and other social activities.
Back in 2017 my concern about youth suicide resulted in me doing the initial examination of the issue which resulted in an earlier version of this paper. The examination is not exhaustive and although I have professional knowledge in the area I do not claim expertise status.
I looked at what doesn’t work, what has worked overseas, what might work in New Zealand and how much it would cost.
What does not work
What doesn’t work to improve youth wellbeing is victimisation.
Centuries ago when misfortune fell on a community -in some places a woman was singled out and punished for witchcraft. In the modern day -victimisation processes are more subtle -but they still occur.
Victimisation is often about making excuses and not honestly looking for evidence based causes. Unfortunately in New Zealand, victimisation is a common practise, even at the highest levels of society.
Bill English’s government at the time had been in power for nearly a decade and youth wellbeing had not improved in that time. So calling young men “pretty damn hopeless” and making unsubstantiated claims that young kiwis cannot fill job vacancies due to drug use was an indictment on Bill English and his government.
New Zealand needs a fresh approach that takes into account the current public health and economic stressors. In December 2018 the Mental Health Inquiry reported its findings.
The Inquiry did highlight the concerns of New Zealand’s high suicide rate. It explained that mental distress affects more people (up to 20%), than those formally diagnosed with mental illnesses (2%), and that addressing mental distress is an under resourced issue. Unfortunately the Inquiry did not lay out a clear pathway for reducing suicide caused by mental distress. It certainly did not advocate for the systematic strengthening of communities as the first line of mental health defence as promoted by this paper.
New Zealand has longed suffered from higher rates of ‘insanity’. In an 1870 inquiry into mental health, Dr M. S. Grace attributed the higher rate of insanity in New Zealand compared to Britain as being related to a “lack of sympathy for the loneliness and isolation” of New Zealand. Implying it was the loss of a supportive social networks that many immigrants experienced which resulted in more New Zealanders suffering from mental illness.
Hopefully New Zealand will look overseas to get a broad view of what works and what doesn’t.
What has worked overseas
In the above graph on youth suicide you can see that Iceland had the highest youth suicide rates in 1990 and 2000, but by 2013 it had one of the lowest. The OECD cautions that “due to small populations, suicide rates in Iceland and Luxembourg are likely to show high variability and outliers across the time series”.
What is helpful is that UNICEF have an index for child and youth health, averaging five indicators -neonatal mortality, suicide rates, mental health symptoms, drunkenness and teenage fertility rates. This indicates Iceland is a very good performer for ensuring health on these measures and New Zealand is performing very badly in comparison.
So given Iceland’s across the board good results for youth we can have some confidence that it’s low youth suicide statistic is not a statistical aberration.
Yet Iceland did have a problem with youth drug use twenty years ago -so the past bad figures are also likely to be accurate. In Iceland, the rate of teenage smoking, drinking and drug use have been radically cut in the past 20 years. The percentage of 15- and 16-year-olds who had been drunk in the previous month plummeted from 42 per cent in 1998 to 5 per cent in 2016. The percentage who have ever used cannabis is down from 17 per cent to 7 per cent. Those smoking cigarettes every day fell from 23 per cent to just 3 per cent.
In Iceland clinicians worked with the theory that alcohol and drug use was an inappropriate coping strategy -that alcohol and drug users were seeking artificially altered mental states -numbness or highs in response to stress. The solution found to counter this was to encourage more appropriate coping strategies -natural highs or natural calming activities -such as sport, drama and community groups. The breakthrough came when this theory was applied universally to the whole youth population of Iceland.
There is a full description in the below linked article of how Iceland made this beneficial social change.
Iceland knows how to stop teen substance abuse but the rest of the world isn't listening
In Iceland, teenage smoking, drinking and drug use have been radically cut in the past 20 years. Emma Young finds out…
To me the key initiatives were;
- Using an evidence based approach to ascertain/monitor the protective and risk factors -undertaken by professional clinical researchers.
- Actively engaging with the community -youth, parents and community organisations to create social networks which enhance the protective factors and reduce the risk factors. Leadership was demonstrated -a sensible mix of rights and responsibilities was used.
- The State providing institutional and financial support. For instance, creating a 250-euro activity card which families with youth could access to pay for club activities.
As a registered nurse with many years working in psychiatry this seems like a common sense approach to me. I am not surprised that when Iceland systematically applied this approach that it worked. This approach is also consistent with some newer studies on social networks.
What might work in New Zealand?
I think the Icelandic model could work in New Zealand if it was applied in a systematic way. It is really about using an evidence based approach to strengthen communities (post-Covid note; this is analogous to the Covid-19 ‘breaking the chains of transmission’ concept although for suicide prevention the idea is to enhance positive connections whilst minimising the negative connections for at risk groups/ ‘bubbles’).
Having worked for many years as a inpatient psychiatric nurse and also having done a stint as a counsellor in the community I can say the biggest support for people in mental distress is their family and community. The community is the first line of defence. In New Zealand it is this team of 5 million which can be the most effective. Professional health clinicians and counsellors in the community and hospital are back-up levels of support. My hospital has 64 beds that provides all the acute adult psychiatry inpatient care for the Canterbury community which consists of over 600,000 people. With the best will in the world we can only provide assistance to a tiny proportion of this population. Systems need to be in place to help the bigger mass of the people before they need contact with the health system.
New Zealand has some small scale strengthening community initiatives already. Christchurch City Council, for instance, has a $7.2 m strengthening communities fund that distributes grants. But these community initiatives are not as evidence based, systematic or as large scaled as what Iceland uses.
For the Iceland approach to improving youth wellbeing to be successfully applied in New Zealand, the first step would be undertaking an evidence based approach to ascertain/monitor the protective and risk factors.
Although the protective factors of increased social activities for youth are likely to be the same. Some of the risk factors might be different and therefore require adjustments to the model.
For instance, New Zealand might have a bigger problem with trauma and bullying (Covid-19 economic shock, Christchurch and Kaikoura earthquakes, high physical and sexual abuse statistics for instance).
Another risk factor which may be more present in New Zealand is the increasing numbers of renters and the difficulty renters have in settling into a community due to the shortness of New Zealand’s average tenancy. New Zealand’s home ownership rate has been falling since 1990, and by 2013 only 49.8 percent of people aged 15 years and over owned or partly owned the home they lived in.
On average, owner-occupiers live in each house for 5 years, compared to the average residential tenancy which lasts only 15 months. In Europe -Germany, for instance, due to more security of tenancy laws, the average tenancy period is more than double this amount, at 3 years.
John A Lee was responsible for housing in New Zealand first Labour Party -in the 1930’s famously saying -“it is well to remember that good housing is essential for a good community.” John A Lee started a big State house building programme as a practical expression of his government’s desire to create safe and secure communities for New Zealanders.
Unfortunately this practical support to community building faded out in the 1990s. State house numbers are static to falling, especially per capita. Social housing in New Zealand has not kept pace with the country's fast growing population. Given the declining numbers who own their own home, this means more and more kiwis are reliant on private rentals, which only provides transient accommodation and little ability to integrate into community life.
How much would it cost to implement Iceland’s model in New Zealand?
If families in New Zealand with youths (13 -18 year olds) could access a $250 activity card per child to pay for community activities, perhaps after attending a networking meeting where they agreed to the goals and responsibilities that went with this benefit, this would cost approximately $80 million (65,000x5x250) per year.
$80 million per year is not an small amount of money, and it may be necessary to expand the age up or down, which would raise the cost even higher, but if New Zealand could reduce youth suicide, youth cigarette consumption and drug and alcohol use, like Iceland achieve then this would be money well spent.