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Suicide in Hong Kong, 1981-1991 : a social and spatial analysis Lee, David J. 1993

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SUICIDE IN HONG KONG 1981-1991:A SOCIAL AND SPATIAL ANALYSISbyDavid Jerald LeeB.A., The University of British Columbia, 1987THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENT FOR THE DEGREE OF MASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(Department of Geography)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAOCTOBER 1993© David Jerald LeeIn presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission. (Signature)Department ofThe University of British ColumbiaVancouver, CanadaDate^Cd (4,q3DE-6 (2/88)ABSTRACTThis thesis is a social and spatial study of suicide in Hong Kong's three subregions: HongKong Island, Kowloon, and the New Territories for the period 1981-1991. The primarydata used are official suicide statistics; these are supplemented by descriptivenewspaper accounts of suicide. Over time, the suicide rate for Hong Kong as a whole, aswell as for each of these subregions, increased during this period. Over space, the ratewas highest for Kowloon, a core urban area with the highest degree of socialdisorganization. The New Territories, a recently urbanized subregion, had the lowestbut increasing rate. Moreover, it has been found that the suicide rates for all subregionsincreased lineally with age. It is hypothesized that the relatively high suicide rate forthe older population is related to the inequitable social-wealth redistribution stemmingfrom Hong Kong's laissez-faire economic policy, in particular, inadequate socialservices, inefficient public-sector medical services, and formal and informal suicide-intervention opportunities. It is also observed that Hong Kong's media provide most ofits suicide coverage to the age group with the lowest suicide rate—school age people,while coverage given to elderly suicides is relatively rare and usually brief; thisperpetuates public ignorance of elderly suicide as a problematic social issue. Increasedequity in social-wealth redistribution and increased public awareness of depression andsuicide are proposed as means of reducing suicide in Hong Kong.TABLE OF CONTENTSAbstract ^ iiTable of Contents ^List of Figures viAcknowledgements ^ viiDedication ^ viiiCHAPTER ONEINTRODUCTION^ 1CHAPTER TWOLITERATURE REVIEW^ 4The Biological Perspective 5Genetics Research^ 5Biochemical Research 5Psychological Perspectives^ 7The Psychoanalytic (Freudian) Perspective^ 9The Psychosocial Perspective^ 11The Humanistic Perspective 1 2The Behavioural Perspective^ 1 2The Cognitive Perspective 1 5Summary of Psychological Theories of Suicide^ 1 7Depression and Hopelessness in Suicide^ 1 7Depression in Suicide^ 1 8Hopelessness in Suicide 1 9Depression Causation^ 1 9Depression alleviation or treatment^ 2 0The Sociological Perspectives^ 2 0Durkheim's Suicide 2 1ivStatus Integration Theories of Suicide^ 2 4Status and Anomie Theory of Suicide 2 5Status-Change Theories of Suicide^ 26Aggression in Suicide^ 2 7Gold's Theory of Suicide 32Ecological Theories of Suicide^ 32Summary of Sociological Theories of Suicide^ 34The Prevention and Intervention Perspective^ 35Suicide Prevention^ 35Suicide Intervention 3 7A Personal Account in Intervention^ 39Social Support in Hong Kong^ 4 1Suicide Prevention in Hong Kong 42Welfare Services and Suicide Prevention in Hong Kong^45Summary of Prevention and Intervention Perspective 48Summary^ 48CHAPTER THREESTATISTICAL ANALYSIS OF SUICIDE IN HONG KONG^ 50Hong Kong's Socio-Economic Landscape^ 5 0Hong Kong Island^ 5 1Kowloon^ 5 7The New Territories^ 60Summary^ 61Data Limitations 62Raw Suicide Data^ 62Population Data 6 6Suicide Rate Computation ^ 66VData Interpretation^ 67Suicide in Hong Kong—An Overview^ 6 7Spatial Variations Between the Three Subregions^ 70Summary^ 77CHAPTER FOURANALYSIS OF SUICIDE IN HONG KONG AND ITS THREE SUBREGIONS^78Analysis of Suicide on Hong Kong Island^ 78Analysis of Suicide in Kowloon^ 79Analysis of Suicide in the New Territories^ 82Analysis of Suicide by Age Group^ 84Summary^ 86CHAPTER FIVEDISCUSSION AND CONCLUSION^ 88Appendix 1^ 92Appendix 2 93Appendix 3^ 9 4Appendix 4 95Appendix 5^ 98Appendix 6 99References^ 1 0 11List^of^Figures^Rate of Suicide for Selected Countries^ 42 Legal Aggression in Hong Kong: Disregard for the Stranger ^ 313 Map of Hong Kong^ 524 A Typical Lower-Middle Income Apartment ^ 535 A Typical Low-Income Public Housing Estate 546 Affluence ^ 557 A Not-So-Private Display of Personal Wealth ^ 568 Two Cage "Flats" ^ 589 A "Cage Man" 591 0 A Camera-Ready Suicide ^ 6411 Some Suicides Are Less Equal Than Others^ 651 2 Rate of Suicide by Sex for Hong Kong 1981-1991 ^ 691 3 Rate of Suicide by Age group for Hong Kong 1981-1991 ^ 691 4 Suicide Rate for Hong Kong Island, Kowloon, and the new Territories(1981, 1986, and 1991) ^ 711 5 Suicide Rate by Sex for Hong Kong Island ^ 711 6 Suicide Rate by Sex for Kowloon ^ 721 7 Suicide Rate by Sex for the New Territories ^ 721 8 Suicide Rate by Area for the 10-19 ^ 731 9 Suicide Rate by Area for the 20-29 7320 Suicide Rate by Area for the 30-39 ^ 742 1 Suicide Rate by Area for the 40-49 7422 Suicide Rate by Area for the 50-59 ^ 7523 Suicide Rate by Area for the 60 and Over 7524 Just Another Druggie Who Refuses to Make Money Like the Rest of Us  ^81viACKNOWLEDGEMENTSI would like to thank Richard Copley and David Edgington for their patience inreading and commenting on the several drafts to this thesis. The former should,moreover, be thanked for the years of career guidance he gave to me and the months ofsuicide-intervention assistance he gave through me to my suicidal friends while I waspreparing this thesis.The suicide-intervention experience I accrued during those few months hasdemonstrated to me the importance of social support in suicide prevention andintervention. This is why I would also like to thank the following friends of mine: ScottHayward, Sean Lerner, Pedro Ong, Bob Taylor, Dave Winter, as well as everyone who"lived," panicked, and learned about the ephemerality of life in the snack-bar section ofSedgewick Library in the fall of 1991. In addition, I would also like to thank Dr.Farquhar at Student Health Services and John Schneider at the Student CounsellingServices at the University of British Columbia for their help as professional caregiversduring this crisis period. All of these friends—and many others too numerous tomention—and professionals not only have contributed generously toward those in need ofsocial and emotional support, but have taught me to regard suicide and its preventionfrom a different, and certainly more optimistic, viewpoint.Lastly, I would also like to expression my appreciation for the Dr. C. K. Leung inthe Department of Geography at the University of Hong Kong and Jeremy Austin for theirhelpful hints on doing research in Hong Kong.v i iTo mom (1921-1992) and dad (1911-1991)v iiiCHAPTER ONE: INTRODUCTIONSuicide is a universal phenomenon (Stillion et al. 1989, 18), a phenomenonwhich is found in societies of all social and economic conditions. Suicide causation cannotbe reduced to any one factor to the exclusion of other factors; it is not a mental illness oremotional disorder; it is a potential outcome of a self-destructive behaviour related to,or resulting from, depression and a number of other factors, such as biological,psychological, social, and environmental factors. This thesis is a spatial analysis ofsuicide in Hong Kong's three subregions of Hong Kong Island, Kowloon, and the NewTerritories, for the period 1981-1991. It focuses primarily on the relationshipbetween the rate of suicide on the one hand, and the socio-spatial and environmentalcharacteristics of these subregions on the other hand. Chapter Two of this thesis willbegin with a brief review of suicide literature from a selected number of non-spatialand non-sociological research perspectives, such as psychology, biology and genetics,and medicine and psychiatry. This is to familiarize readers from social sciencedisciplines who are not suicidologists with some of the established findings and currentdebates in suicidology.One of these major findings is that the affective disorder called clinicaldepression, as it is known in the West, is thought to be present in a sizeable majority ofpeople who complete suicide. Although many studies have revealed biochemical changesin the brain among the clinically depressed, clinical depression is not caused exclusivelyby biological, genetic, or psychological factors; these factors, as many have argued, canonly predispose certain individuals to develop depression.Since most of the people who suffer from clinical depression do not die bysuicide, many suicidologists have focused on the roles of other additional factors insuicide causation. Some have argued that certain environmental and social factors canaccelerate the onset of clinical depression among people predisposed to developing it(Stillion et al., 57-58), while others have asserted that environmental and socialstressors can increase the likelihood of suicide completion among people who are alreadyclinically depressed (Stillion et al., 57-58). This thesis supports the significance ofboth of these probable causal relationships.The objective of this thesis is to identify, analyze, compare, and contrastenvironmental and sociological factors related to completed suicides in Hong Kong'ssubregions. A measure of the level of importance of suicide in Hong Kong is that morepeople died by suicide than by accident in Hong Kong in 1990. This made death by suicidethe second largest cause of death—next to death by natural causes (Hong Kong Government121990).1 A total of 747 people died by suicide in Hong Kong in 1991, resulting in anaggregate suicide rate of 13.52 per 100,000. Although this is a relatively low ratecompared to those in many Western nations and Japan (Figure 1), it represents,nevertheless, a 38 per cent increase from a rate of 9.82 per 100,000 for 1981; inabsolute terms, the number of completed suicides in 1991 increased by 50 per centfrom a total of 497 suicides recorded in 1981, while the population increased by 11 percent from a total of 5,109,892 in 1981 to a total of 5,674,114 in 1991 (Census andStatistics Department 1992). It is also evident that a more balanced sex ratio exists inthe rate for Hong Kong, as well as that for the largely ethnic-Chinese city-state ofSingapore. Spatial variations in the suicide rate are evident between each of Hong Kong'sthree subregions of Hong Kong Island, Kowloon, and the New Territories. While theaggregate suicide rate for all of Hong Kong in 1991 was 13.52 per 100,000, the ratefor each of these subregions was 14.33 per 100,000, 15.24 per 100,000, and 11.72per 100,000, respectively.2 These and other data will be presented in Chapter Threeand analyzed in Chapter Four.What are some of the factors which have lead to these spatial variations betweenthe core urban area of Hong Kong Island, the core urban area of Kowloon, and therecently urbanized New Territories in this modernized and deindustrialized colonialcity-state? After the research methodology has been presented in Chapter Three, thesuicide statistics used in this study for the period of 1981-1991 for these threesubregions will be presented. The penultimate section will compare and analyze thesubregional differences between the suicide rates in terms of spatial variations in ageand sex, and in terms of the social, economic, and environmental conditions of thesesubregions; the major factors identified in the literature review are applied to thefindings on suicide in Hong Kong throughout this section. Further discussion, prospectsfor suicide prevention in Hong Kong, and concluding remarks will be offered in the lastsection.1Suicide incidence supplied by Hong Kong Coroner's Office. Rate derived from incidenceand 1991 census.2See Chapter 3 for the sources and method of calculation of these rates.3^Philippines^Figure 1 Rate of Suicide (per 100,000) for^Greece Selected CountriesThailandArgentinaEngland and WalesI-01G KONGSingaporeUnited StatesCanadaSwedenJapanFinlandHungary0^10^20^30^40^50^60^70^80^90 100M Female 111 MaleSource: World health Organization Annual 1987.CHAPTER TWO: LITERATURE REVIEWMuch debate has taken place among genetic-, biological-, medical-, andpsychological-perspective suicidologists over the significance of genetic, biological,psychoanalytic, developmental, social learning, and psychopathological factors in theshaping of an individual's suicidal proneness. Although this thesis is not focused on theseperspectives, the prevalence of depression and hopelessness among suicidal peoplealmost universally renders it a necessity to understand more about depression; this isparticularly true because the treatment of depression and alleviation of hopelessness arecrucial to an immediate reduction of suicide lethality in suicidal individuals. Thisliterature review will begin, therefore, with a selection of findings by these non-sociological researchers—findings which led to the recognition of clinical depression andhopelessness as two antecedents to suicide. Since ethnic-Chinese make up 98 per cent ofHong Kong's population, attempts will be made throughout the literature review chapterto apply Western suicide-research findings to suicide in Hong Kong, and to compare,contrast, and synthesize these Western findings with traditional Chinese concepts ofhealth and illness.The review of selected literature on the social, economic, and environmentalcauses of suicide which follows will examine factors external to the individual psychethat can affect the proneness of suicidal individuals to complete suicide: it is here that asection on the mobilization of social and economic resources for suicide prevention andintervention will also be presented.Finally, the utility of each of these bodies of literature in enhancing theunderstanding of suicide causation and in increasing the effectiveness of suicideprevention will be evaluated at the end of this literature review chapter. It will bedemonstrated throughout this chapter that although completed suicides are individuallyinitiated acts, these sum total of these acts—the aggregate suicide statistics—for a givengeographical area can reflect, and also be a result of, its social economic, andenvironmental characteristics. What will be discussed later in this review, then, are therelationship between depression and the emotional state of suicide ideation on the onehand, and 1) the psychosocial factors leading to the manifestation of one of the associatedbehaviours—a suicide attempt, and 2) the social, economic, and environmental factorsleading to the completion of the attempt on the other hand. The suicide data for HongKong's three subregions for the period 1981-1991 will be introduced in the nextchapter for the purpose of making spatial comparisons and analyses of completedsuicides in those subregions. The following section begins with a review of thebiological-perspective findings pertaining to suicide.4The Biological Perspective The assertion that suicide has both organic and inherited causes was first made bythe German psychiatrist Emil Kraeplin at the turn of the century (Kushner 1989, 80).Until the 1950s, depression and many other mental illnesses were thought of as purelypsychological (Kushner 1989, 203). Today's biological research on suicide focuses onthe physical or physiological composition or attributes, especially those of the brain, ofhumans capable of making them depressed and suicidal. Research in this perspective canbe broken down into 1) genetics research and 2) biochemical research.Genetics ResearchFor some time, genetic factors have been thought to be responsible for thetransmission of affective disorder and suicidal tendencies, such that "a family history ofsuicide significantly increased the risk for a violent suicide attempt" (Roy 1990, 50).Blumenthal and Kupfer (1986) found that "suicidal behavior is higher in relatives ofpersons who exhibit suicidal behavior." Kallmann (1947) found "high concordancerates for schizophrenia and manic-depressive illness in monozygotic twins, [but] noconcordance at all for suicide." Twenty years later, Haberlandt "found a significantnumber of concordant monozygotic twin pairs with suicide" (Haberlandt 1967). On thecontrary, Kety found that "in no series [of studies] is the concordance rate as high [insuicide] as it is for depression or schizophrenia' (Kety 1986, 41).Genetic research has not been able to adequately demonstrate that it is thegenetic, rather than other factors—such the socialization-experience and environmentalfactors—that is accountable for this phenomenon. Research findings on purely or largelygenetic factors in suicide remain inconclusive.Research conducted for this thesis failed to reveal any genetic study of suicideamong the Chinese.Biochemical ResearchAn organic basis for the etiology of melancholia, as well as a somatic etiology ofsome suicides, were suggested in the nineteenth century (Kushner 1989, 80). Coltreported recently that more than three-fourths of suicides are by people who sufferfrom affective disorders and/or alcoholism" (Colt 1991, 202).Modern biochemical research in depression and suicide is built on the basis thatchemical changes at the synaptic junction in the brain between the transmitting andreceiving neurons can affect the synaptic transmission processes, and that depression,5among other mental illnesses, results from the inhibition of normal synaptictransmission processes (Stillion et al. 1989, 54). This inhibition can be caused bypsychological factors (such as the death of a close person), by natural biochemicalchanges due to senility, by physical trauma like a blow to the head, or by certainmedication used to treat physical or other mental illnesses. In fact, it was one of the sideeffects of the drug Reserpine, used to control or treat high blood pressure, that led to thediscovery of this relationship between the two neurons in the 1950s: a high percentageof patients on this drug reported depressive symptoms while on the drug (Stillion et al.1989, 54).By now, biochemical research in suicide has established a relationship betweenserotonin (as measured by one of its metabolic products called 5-HIAA) and dopaminedeficiency in the brain on the one hand, and poor impulse control, aggressive behaviour,and violent suicide attempts on the other hand (Asberg, Nordstrom, and Traskman-Bendz1986; Colt 1991, 203-04; De Leo 1988, 114; Korn et al. 1990, 57-70; Lester1988a, 57; Roy 1990, 40-49; Stillion et al. 1989, 54-55). The use of psychoactivedrugs, such as monoamine oxidase inhibitors (MAO) and tricyclic antidepressants, tocorrect chemical imbalances thought to cause depression can largely be attributed tobiochemical research. No link, however, has been established directly betweenbiochemical factors on the one hand, and suicidal proneness as well as the less violentsuicides on the other hand.Not all biochemical researchers dismiss the possibility that suicidal behaviourmight be learned; many of them are aware that "the family member who has . . . [diedby] suicide may serve as a role model to identify with when committing suicide entersone's mind as a possible solution to the alleviation of intolerable psychological pain"(Korn et al. 1990, 57; Roy 1990, 54-55). In fact, suicide as a learned behaviour willbe presented in a subsequent section of this review. While many biochemicalresearchers have been criticized for their slighting of non-organic, such as social,causes of suicide (Colt 1991, 204-05; Conroy 1991, 80; Kushner 1989, 80), thisfollowing explanation by Akiskal and McKinney (1973) should help to demonstrate thatnot all biochemical researchers neglect the role of other factors in suicide causation:There is a "final common pathway" which results in thetransformation of loss experiences and other negative lifeevents into physiological functioning at the chemical levelin the brain. Thus, regardless of the environmental causeof depression, whether the death of a loved one, a brokenhome, divorce, child abuse, or the negative self-conceptand learned helplessness accumulated during a lifetime, at6some point physiological changes occur in the brain.(Stillion et al. 1989, 56)To examine the universality, if any, of this final common pathway, psychologicaland emotional disorders, as they are called in the West, tend to be somatized intraditional Chinese society. This is still evident in Hong Kong today, where a study onuniversity students found that common health or mental health problems are describedas "weakness and fatigue, tension and anxiety, difficulty in sleeping, 'hollow emptiness,'and headache" (Cheung, Lee, and Chan 1983). Symptoms such as these, as well as "lackof vital energy, lack of blood, . . . and shen kui OW [kidney deficiency]," often resultin a diagnosis of neurasthenia by Western medical practitioners in Hong Kong (Cheung1986, 179). This is a diagnosis which has been loosely applied by patients, theirfamilies, or professionals to refer to a variety of symptoms of both a somatic andpsychological nature without incurring the stigma associated in Chinese society withbeing mentally ill (Cheung 1986, 179).The few studies conducted on the correlation between Chinese psychopathology andphysical and physiological attributes have revealed the following. Unusually quickelectroencephalogram (EEG) reactions to external stimuli and delayed after-effectreactions were observed among neurasthenia patients (Kung 1963).Ewing, Rouse, and Pellizzari (1974) found more face-flushing and higher heartrates among Asian students in the United States after consuming alcohol, and attempted toattribute these Asians' lower rates of alcohol abuse to their aversive physiologicalreaction to alcohol. A similar study was done by Sue and Nakamura (1984); theseresearchers concluded that socio-cultural, rather than biological, factors wereresponsible for differences in the rate of alcohol abuse.Two Hong Kong studies found that compared with normal Chinese population,"Chinese schizophrenic and neurotic patients had smaller body size and higher linearitywhereas, among affective patients, males had larger body size but females had smallerbody size. The authors concluded that the correlation they obtained for these variableswere similar to those reported for Caucasians" (Singer, Chang, and Hsu, 1972; Singer,Lieh-Mak, and Ng, 1976). No study can be found, however, on the biological orchemical characteristics of the Chinese to account for differences, if any, in thesusceptibility to suicide between the Chinese and other populations.Psychological PerspectivesMany people consider psychology the most appropriate field in which to study thecauses of suicide. This is because suicide is generally seen as an exclusively human7behaviour (Asberg, Nordstrom, and Traskman-Bendz 1985, 47), and that psychology isoften defined as the study of behaviour. Proponents of this view include psychoanalystAlfred Adler, who argued that "suicide can be understood only individually, even if it hassocial preconditions and social consequences" (Colt 1991, 194), as well as Richman andEyman, who expressed the view that psychology held the most promise in treatingsuicidal people:Suicide is the only form of death whose classification isdetermined by a psychological variable, that of themotivation or intent of the deceased. It therefore seemsfitting to use psychological forms of treatment withsuicidal patients. (Richman and Eyman 1990, 139)The number of psychological works on suicide, however, is dwarfed by those comingfrom sociology (Lester 1988b, 3-4). This is in part because while sociologicalresearchers can gain access to suicide and other social data with relative ease for thepurposes of establishing numerical facts and making sociological inferences,3 thestandardized information on the psychological state of suicide attempters required bypsychological researchers is rarely collected from suicide attempters by means of astandard questionnaire in the wake of suicide attempts. Asking direct questions about thepsychological states of completed suicides becomes altogether impossible: the subjectsare dead and not available to interviewers.Another type of study method used from time to time in psychology is thelongitudinal method. This type of study often tracks twins from the time of birth untilwell into adulthood; it has been used to determine, for instance, the role of the genes andthe environment in the onset of disease, such as schizophrenia and alcoholism. But thestatistical rarity of completed suicides, compared to the prevalence of schizophrenia andalcoholism, makes longitudinal studies of suicide extremely costly and next toimpossible.Yet another method, commonly used in experimental psychology, is to manipulatethe emotional condition of experiment subjects in a controlled laboratory setting in3It must be stated that many suicides are masked, for example, as single motor-vehicleaccidents and accidental drug overdoses, to the extent that the number of "real" suicideshave been estimated to range between four to eight times the number of officiallyclassified suicidal deaths worldwide. The continued reliance on and use of official suicidestatistics by suicidologists is based on their confidence in the overall consistency ofdeath-classification standard and practice over time within most jurisdictions. Thisconsistency facilitates the comparison of changes over time in the suicide rate for anarea—such as Hong Kong.8order to elicit a response or behaviour, such as an erection. Manipulating humansubjects to the point of making them suicidal is certainly ethically unacceptable.In spite of these limitations, psychology has contributed significantly to theunderstanding of the processes which lead to the presence of suicidal thoughts in aparticular person's mind. This review now begins with Freud's psychoanalytic school ofinterpretation of suicide causation.The Psychoanalytic (Freudian) PerspectiveThe psychoanalytic perspective, derived from classical Freudian and neo-Freudian theories, holds that each individual has a finite amount of psychic energy(libido). Libido is made up of the dichotomous entities of the life- and pleasure-seekingenergy of eros, and the naturally occurring death-instinct energy of thanatos; suicideoccurs when the amount of thanatos becomes so high that it becomes the dominant energyin the mind of a person. An excess of thanatos can be caused by factors such as"prolonged intrapsychic conflict, . . . regression or fixation at a particular psychosexualstage" and unconscious hostility (Stillion et al., 35).Freud's theory assumes that the mind of all individuals across time and space aredeveloped and shaped in chronologically structured stages early in life. These stages—oral, anal, phallic, latency, and genital stages of development—last only up to about theage of 18. For fear of emotional pain, individuals instinctively store the unpleasantexperiences (such as excessive beating, sexual abuse, and frequent neglect) which theyreceived between birth and late adolescence in a "region" of their mind that is notidentifiable physically, a region Freud called the unconscious, and by a process calledrepression. Repression, according to Freud, is an unconscious act people are capable ofperforming universally (T'ien 1985, 78). The higher the number of negative eventsexperienced early in one's life, the more libido would be required to repress theseevents; this would result in an insufficient amount of libido left for normal development.Such deficit could then result in inadequate ego development, a condition which thengenerates an excess of desires and behaviours governed by the id (such as the need forfrequent approval and those behaviour required to procure the approval), and to apathologically strong superego, which can make an individual develop pathologicalperfectionism, or become obsessed with retaining independence, leadership, control overevents and other people, etc. From a Freudian perspective, the suicide of Vincent J.Foster in July, 1993 in Washington, DC, can be seen as the result of a strong superego,which rendered him vulnerable to negative criticisms, perceived loss of control andfailure.9The arrest of ego development, according to Freud, is also responsible for a hostof psychological malaise, such as narcissism and self-directed anger. Suicide, inparticular, is anger turned inward, which has been triggered by, say, the loss of, orrejection by, a significant and highly cathected object (i.e. a person) (Leenaars 1990,1 5 9 ) :Probably no one finds "the mental energy to kill himselfunless, in the first place, in doing so he is at the same timekilling an object with whom he has identified himself and,in the second place, is turning against himself a death wishwhich had been directed against someone else" (Freud1920, 162; Leenaars 1990, 159).The Freudian perspective asserts, then, that individuals who kill themselves do so out ofanger which was initially directed externally (at the lost object), but was subsequentlyprojected onto themselves.It was not until the 1930s that Zilboorg—a "neo-Freudian"—added experiencesacquired by one later on in life, such as a broken-home environment in one's teenageyears, and an individual's suicidal proneness (Zilboorg 1937). Still later, Litman addedthe significance of emotional states, such as rage, guilt, anxiety, dependency,helplessness, and hopelessness to the suicidal process (Colt 1991, 201-02; Litman1967, 70).In spite of these modifications, the psychoanalytic theory of suicide is still ill-suited to the prevention of suicide (Stillion et al., 35). This is because it attributes thecauses of suicide—as an outcome (death) of a pathological behaviour (self-destruction)--to repressed and unconscious motives of an individual whose emotions wereinsufficiently developed, rather than, for instance, to depression induced by organicbrain-disease or to social problems. Its high degree of reliance on the retrieval ofrepressed early experiences also necessitates lengthy and costly in-depthpsychoanalysis, which rarely brings about a quick reduction in feelings of hopelessnessor the severity of depression. This pessimistic view of the psychoanalytic approach wasechoed by Conroy—a depression and suicidal-pain sufferer with over ten years ofsuicide-intervention experience. He attributed the popularity of the psychoanalyticmodel to a desire on the part of the mainstream members of American society to blamethe suicidal person, instead of acknowledging "social complicity in the causation ofsuicidal pain" (Conroy 1991, 54).A Freudian interpretation of suicide in Chinese culture might be focused on therole of shame or loss of face; these are some of the traditional means of moral- and1 0social-control mechanisms instilled into the Chinese at an age as young as Freud's firstof three stages of development. Instead of being socialized to feel guilty of their immoralacts, Chinese children are taught to avoid bringing shame or causing a loss of face to thesocial unit to which they belong which, in Chinese society, is the family with theparents—especially the father—at its helm (King and Bond 1985, 37; Wu and Tseng1985, 7). School-age individuals who receive demerit points for misconduct or failinggrades in school, or breadwinners who lose their families' life savings in badinvestments, might well be blamed by other family members for their academic failureor investment loss. This is because the poor academic performance or investmentmiscalculation, once leaked to people outside the family unit, can tarnish the image of,and incur shame to, the entire family unit (Lin and Lin 1981).In the case of individuals whose emotional development prior to adulthood havebeen pathological, such set-backs can easily be construed as events causing the loss oflove or approval of the significant other. This rejection, coupled with the typicalambivalence of people with inadequate emotional development, can lead to an ambivalentfeeling of both affection and hostility toward their significant others. These individuals'pathological development also make them identify with the significant other. This is tosay, then, that although they are angry or vengeful toward a significant other for theirrejection, their identification with and their erroneous projection of the significantother compel them to act out to themselves as if they were acting toward the significantother. The anger and the murderous wishes initially targeted at the parents or at thespouse have now become anger turned inward. And when these individuals'overwhelming shame, harsh self-criticisms, and impaired personal-organizationabilities compel them to destroy the "real" object of their hostility, they killthemselves. These might be one of the numerous processes, according to classicalFreudian theories of suicide, for the failing Hong Kong student and financial risk-takerto commit "murder in the 180th degree."4The Psychosocial PerspectiveWhile Freud stressed only the childhood and adolescent experience of individuals,Erik Erikson, the founder of the psychosocial school of psychology, argued that theshaping of the human experience of individuals is not limited to the early years (Stillionet al., 35-39). He asserted that individuals are continually modified by their4This application of the psychoanalytic approach to suicide in Chinese society is based onthe 10 protocol sentences or aphorisms on the psychoanalytic approach to suicide asproposed by Leenaars 1990, p. 161.1 1experiences throughout their lives, and are capable of developing, maintaining, orincreasing their sense of self-worth (as well as, for example, self-doubt, inferiority,and despair—feelings which could eventually lead to depression and suicide). From thestandpoint of devising psychotherapy, the psychosocial school provides a more optimisticframework for the understanding and alleviation of psychological malaise and suicidallethality compared to that of the psychoanalytic school. The psychosocial school assertsthat negative self-image is a psychological state found in most suicidal people, and thatthe development and retention of personal integrity lessens the likelihood for one to formsuch a negative self-image. However, little research directly on suicide from thisperspective has been produced.Popular perception in the West, but also from within Chinese society, that theelderly in Chinese society are well looked after. Given that the elderly has the highestsuicide rate in all the three subregions of Hong Kong, a high prevalence of despair amongthe the elderly population would be suggested by psychosocial theorists. Thisphenomenon will be examined in detail in Chapters Three and Four.The Humanistic PerspectiveThe humanistic perspective believes that suicide occurs when individuals, havingfailed to discover meaning in their lives, begin to experience a sense of uselessness,hopelessness and, in the end, depression (Stillion et al., 39-42). This type of condition,seen as pathological, has been described as "noogenic neurosis: . . . one of the mostwidespread illness of Western societies in the twentieth century" (Stillion et al., 43-44). It is one of the psychological perspectives which acknowledges the presence of arelationship between social factors and depression. According to this theory, it is whenindividuals realize their unique potential—a process called "self-actualization"—thatthey then become capable of reaching the highest level of human attainment and, in turn,become less prone to suicide (Stillion et al., 45). Applying this theory to Hong Kong, itmight be hypothesized that the spatial or social area with the lowest suicide rate shouldbe the least Westernized area, while the area with the highest rate should the mostWesternized area.The Behavioural PerspectiveThe behavioural, or learning, perspective discussed in this section and thecognitive perspective (discussed in the next section) are two of the psychologicalperspectives on suicide whose research and application have provided effectivepsychological therapy for suicide prevention (Clum and Lerner 1990). Behaviourists12believe that most observable behaviours—both the statistically normal and devianttypes—can be learned by classical conditioning, operant conditioning or modeling(Lester 1988b, 23-27; Lester 1987 [throughout]; Stillion et al., 39-42). The kind ofconditioning, or learning, perhaps most well known is classical conditioning. The originof this model is attributed to Pavlov at the turn of the century, when he conducted aseries of experiments with dogs, in which the offer of food was always preceded by theringing of a bell. After having repeatedly presented this pair of stimuli in the samesequence, the dogs learned to associate the bell-ringing to the imminent availability offood. By association, these dogs later learned (or were conditioned) to manifest thebehaviour of salivating to the sound of the bell alone.In a more recent experiment, heterosexual college males who were repeatedlyshown pictures of boots, together with erotic pictures of attractive women, learned byassociation to exhibit sexual arousal when they were subsequently shown pictures ofboots alone (Lester 1987a, 11; Rachman and Hodgson 1968). Similarly, behaviouristsbelieve that most types of anxiety, such as claustrophobia, can be acquired by classicalconditioning, for example, by frequent confinement to a tight space in early childhood(Stillion et al. 1989, 39), a process which leads to the mere association of confinedspace with anxiety. Unlike the psychoanalytic school, behaviourists hold the view thatall pathological behaviours have demonstrable antecedents.In addition to acquiring behaviour by mere association, behaviour can also belearned by reinforcement or rewarding—a learning process called operant conditioning.An example of operant conditioning is that hungry animals left alone in a controlledphysical environment can learn, by trial and error, that food (a positive reward) can bemade to appear whenever a certain lever is pushed (a behaviour); subsequently, theseanimals engaged in the same button-pushing behaviour whenever they wanted to berewarded with food. Reinforcers (or rewards) can be positive or negative, as thefollowing description of operant conditioning on a human being demonstrates:A baby is left alone in his crib, and the light turned out ashis mother leaves his bedroom. He cries and, after awhile, his mother returns and turns the light on to see ifhe is all right. The response of crying has been rewarded,both by the positive reinforcer of his mother's presenceand attention, but also by the negative reinforcer of theending of darkness and of being alone. His mother isteaching him to cry at night [by operant conditioning].(Lester 1988b, 24)13According to the operant-conditioning model suicide can be seen as an act which providesa negative reinforcer: death provides an end to unbearable psychological pain, .Another type of learning is called social learning. Unlike animals, humans havecomplex problem-solving abilities (such as piecing together a jigsaw puzzle) whichenable them to learn by using solely internal thoughts:Thoughts can provide stimuli, responses can be imaginedand reinforcers can be cognitions (such as self-praise).Thus, for example, a person can engage in trial-and-errorproblem solving tasks using solely internal thoughts, sothat an observer would observe no stimuli, responses, orreinforcers. Social learning theory accepts too thathumans can learn by watching others (by modeling).(Lester 1987, 12)Modeling is a learning process whereby from observing others, one forms an idea of howcertain new behaviours are performed, and that this coded information serves as a guidefor action on later occasions (Bandura 1977, 22). Lester argued, for example, that thesuicide of writer Ernest Hemingway could be explained from the standpoint of modeling.Hemingway had learned, from the numerous suicides by firearms in his family, toassociate his own depression-induced emotional pain with the behaviour of suicide(Lester 1987, 105-118).The timing, method, and location of suicide can also be learned by modeling. Someexamples of modeling in suicide are as follows: suicides which take place on theanniversary of the suicide of a significant other (such as a parent, sibling or lover),suicides which occur in a cluster, for example, shortly after the suicide of a rock star ora charming and admired high-school group leader, and suicides at highly symboliclocations, such as the Eiffel Tower or the Golden Gate Bridge (Stillion et al. 1989, 40-41 ) .One sub-type of social learning theory—learned helplessness—is most pertinentto the understanding of depression and suicide (Stillion eta!., 41-42). This is when onehas learned to believe in an external locus of control, rather than an internal locus ofcontrol, over events in one's life; it is a belief learned earlier in one's life that one'sresponding is independent of reinforcement (Seligman 1975, 93). In other words, it isa belief that one is unable to change the course of events in one's life regardless of whatone tries to do.From a behaviourist standpoint, this passive acceptance of an external locus ofcontrol over events in life results from a passive acceptance of painful stimuli (forinstance, noxious, unpleasant, disturbing, or stressful stimuli) in one's life. The14founding of this theory of behaviour-learning can be credited to Seligman, who conductedan experiment on dogs restrained in harnesses. Seligman applied repeatedly, first, atone, followed by an electric shock to these restrained dogs. As soon as the dogs learnedto associate the tone with imminent pain, they attempted to break themselves free uponhearing the tone. However, once they have learned over a prolonged period of time thatthe shocks were inescapable, they ceased making any attempts at all to escape uponhearing the tone—even after their harnesses have been untied (Seligman 1975, 23-27;Stillion et al., 41-42). Together with the findings of a series of experiments studies onhumans, Seligman believes that unavoidable traumatic events suffered earlier in life cancontribute to some types of depression found in suicidal individuals (Seligman 1975,93-106; Stillion et al., 41-42).The effectiveness of behavioural therapy rests upon the behaviourists' optimisticview that most behaviours learned by classical conditioning, operant conditioning, ormodeling can be un-learned by these same processes. In other words, the likelihood ofsuicide can be decreased by strengthening suicidal individuals' belief in an internal locusof control, and to develop "new and healthier ways of coping" (Stillion et al., 42). Thisprocess—called behaviour modification—offers greater, and more immediate,therapeutic value than does the psychoanalytic approach in reducing the level of suicidalpain.This kind of therapy, sometimes called "talk therapy," is rarely practiced inHong Kong (Cheung 1984). The Chinese prefer discussing their psychological problemswith friends and family members (Cheung 1984, Tsoi and Tam 1990, 211-12). Themore serious affective disorders come to the attention of medical physicians as somaticcomplaints (Kleinman 1977; Marsella 1980; Tseng 1975); it is important, therefore,for professionals, friends, and family members to be aware of the potential affectiveproblems often associated with somatic complaints. These findings indicate that one ofthe very few effective means of suicide prevention is not being used in Hong Kong(Cheung, Lau, and Wong 1984).The Cognitive PerspectiveThe cognitive perspective on depression and suicide is most often associated withthe research of Aaron Beck in the 1960s and 1970s (Leenaars 1990, 161-62). Hisresearch established the role of hopelessness, a cognitive state, as a variable betweendepression and suicide: a topic to be presented in the next section.In contrast to the behavioural perspective's emphasis on observable behaviour,the cognitive perspective in suicide studies and attempts to modify the pathological15cognition—the thinking process and perceptions—of depressed or suicidal individuals,such as inexact labelling, selective abstraction and over-generalization (Stillion et al.,50-51). Cognitive theories also try to integrate psychoanalytic, psychosocial andbehavioural theories. They assert that it is the cognition that creates, in certainindividuals, the often-erroneous perception of rejection or neglect by others; if theseindividuals can change their views they can improve their mental health (Stillion et aL,4 5 - 5 1 ) :From the point of view of suicidal patients, cognitivetherapy offers hope that they can be taught to see the worldin a more rational, less hopeless manner and that a changein worldview will result in a change in suicidal attitudesand behaviour. (Stillion et al., 51)In other words, cognitive therapy is focused on changing individuals' subjective—andnegative—interpretation of their painful situations. The inclusion of behavioural viewsalso enables cognitive therapy to aim at bringing relatively immediate changes to thebehaviour of the suicidal.Even when anti-depressant use is called for, a combined program of cognitive andbehavioural therapy is most crucial in reducing suicidal pain during those initial weeksrequired for antidepressants to reach their minimum level of effective dosage.Continuation of cognition- and behaviour-modification therapy reduces the likelihood ofrecurrent negative views and destructive behaviours (Clum and Lerner 1990).It was stated in the previous section that the emotionally disturbed in Hong Kongprefer informal peer counselling to formal therapy. Since cognition-modification callsfor persuasion and reasoning, it is important that people who are called upon by theirdepressed friends to listen, to persuade, and to reason be well-informed of the symptomsof depression, and the important skills of listening, focusing, and mutual problem-solving.Some studies have argued that the Chinese prefer to have an authority figure,such as a licensed medical doctor, instruct them on the means to get well; others haveargued that authoritative instructions to get well psychologically work well only in theshort term (Cheng and Wu 1977). The articles in the Appendices to this thesis provideexamples of informal "counsellors" in Hong Kong attempting to moralize with thedepressed about how wrong it is to feel suicidal, as in the case of the school principalwho, following the suicidal death of one of his students, stressed the importance of"appreciating the preciousness of life" as a means to avoid feeling suicidal (Appendix 1).If Ming Pao can be considered a newspaper with an authoritative voice, its uncritical use16of popular Chinese idioms in reporting suicides can only prolong public ignorance ofdepression and suicide. For example, part of the headlines of a special column written toanalyze the suicide of a 10-year-old student read "Inadequate Communications betweenParents and Children Could Easily Make Children Do Silly Things" (Ming Pao, 17 May1991, 2. Emphasis added). In Hong Kong as elsewhere, suggesting to depressed peoplethat it is immoral for them to refuse to "snap out" of their depression, hopelessness,helplessness, and self-destructiveness can add to the depressed a sense of guilt, whichcan worsen their depression. Public education in depression is urgently needed in HongKong.Summary of Psychological Theories of SuicidePsychological theories of suicide stress the importance of the role of suicidalindividuals in suicide causation, and attempt to change their views in order to produce inthese individuals less pathological emotional conditions, which in turn reduce theirlikelihood of engaging in suicidal behaviours. Some schools within this perspective,such as the psychosocial and humanistic schools, are more theoretical in nature; theyalso provide some insight into the social causation of suicide ideation in individuals. Thepsychoanalytic, behavioural, and cognitive schools are more active in researching andpreventing suicide. The psychoanalytic school, however, has produced few effective andimmediate means of reducing the suicidal proneness of individuals; its therapy tends tobe lengthy and costly. The behavioural and cognitive schools have provided moreeffective therapy in suicide prevention and intervention, through long-term behaviour-modification and cognitive therapy.Before embarking on a review of suicide literature of the sociologicalperspective, the role of depression and hopelessness in suicide will be presented in thenext section. While depression and hopelessness are not major perspectives bythemselves, their near-universal presence among the suicidal are widely acknowledgedby suicidologists. To recap, it is the research from medicine and psychiatry thatestablished clinical depression as an affective disorder strongly related to suicide, whileit is Beck's research in cognitive-behavioural psychology that established hopelessnessas a pathological emotional state as a significant determinant in suicidal proneness amongthe clinically depressed.Depression and Hopelessness in Suicide Even though suicidologists from psychology, psychiatry, and medicine do notalways agree on the origin of individuals' suicidal proneness, they agree that depression17plays a significant role in the causation of suicide. This section discusses andsummarizes the role of depression and hopelessness in suicide, to which some referenceshave already been made earlier.Depression in SuicideDepression is "something which is very different from [merely] sadness orunhappiness" (Sainsbury 1985, 73); it consists of not just one painful emotion, but "ahost of painful emotions that painfully interact" (Conroy 1991, 85). The list ofemotions, behaviours, and psychosomatic symptoms of a depressed person often includessome of the following: self-pity, shame, envy, grandiosity, anger, frustration,indecisiveness, submissiveness, social withdrawal, mental constriction (for example,cognitive distortion, dichotomous and rigid thinking), negative self-construing (forexample, low self-esteem), changes in appetite (usually a reduction, which results inweight loss), changes in sleeping pattern (usually in the form of early-morningawakening), helplessness, and hopelessness (American Psychiatric Association 1987,218-24; Conroy 1991, 83-114).The latest manual used to diagnose psychiatric disorders in Western psychiatry—The Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R, third edition,revised (DSM-III-R) states that "the most serious complication of a Major DepressiveEpisode is suicide" (American Psychiatric Association 1987, 221). Recent researchhas not only found that probably the majority of suicides suffered from an unequivocaland treatable depressive illness, but that most of them also contacted their doctorsduring the period immediately preceding their death (Robins et al. 1959; Sainsbury1986, 73). Hagnell and Rorsman (1978) reported that a diagnosis of endogenousdepression was found in half of the suicides. Furthermore, 64 of 100 suicides in a studyconducted by Barraclough were found to have an uncomplicated primary depressiveillness. This percentage is increased to 77 per cent when those suicides whose principaldiagnoses was alcoholism, but who also had a severe depression, are included(Barraclough et al. 1974; Lester 1988b, 30; Sainsbury 1986, 75). The reluctance onthe part of many depressed and suicidal people to seek professional help and the failureof professional caregivers to diagnose depression are probably why these estimatedpercentages are not even higher than they are.5 Moreover, the standard DSM-Illdiagnostic procedure does not allow for a diagnosis of major depression when the5For a study and discussion of the failure of heath care professionals to detect depressionand to ask patients whether or not they have suicidal thoughts (in the United States), seeCoombs et al. 1992, and Maltsberger 1991 (in the West).18depression is complicated by something more severe, such as schizophrenia, or byorganic factors, such as senile dementia; in either case, an official absence of depressiondoes not automatically mean an actual absence of depression.The majority of the people diagnosed as depressed, however, do not completesuicide; only a small proportion-15 per cent—of people diagnosed as such die by suicide(Lester 1988b, 30; Miles 1977; Sainsbury 1986, Table 5.1). Researchers andinterventionists are faced, therefore, with the challenge of explaining why only a fewdepressed people complete suicide while the majority do not, and, more important, oftrying to identify those depressed individuals who are at high risk for suicide. One of themany identification studies was conducted in 1971 in Sussex, England; these researchersreported that depressed suicides were "significantly more often male, older, separated,socially isolated, and recently bereaved" (Bunch, Barraclough, Nelson, and Sainsbury,1971). Since the majority of the clinically depressed people in Sussex (as elsewhere)who fit this profile do not complete suicide, the major weakness in this type ofretroactive studies of completed suicides is that they provide little in the way ofpredicting which depressed individual would complete suicide within, say, a period ofone year. As a result of this drawback, it contributes little to increasing the efficiencyin the use of suicide-intervention resources.Hopelessness in SuicideIn the mid 1970s, Beck and his associates found that a high score on an objectivescale-of-hopelessness test by the depressed was a stronger correlate of suicidalintention than a diagnosis of depression alone (Beck, Kovacs, and Weissman 1975). Thissuggests that even though it can take months or years to treat depression satisfactorily, areduction in the perception of hopelessness by clinically depressed individuals (oftenachieved by informal social and emotional support, and by formal cognitive therapy) iscrucial to the immediate reduction of their suicidal proneness.Depression CausationNo consensus exists on the cause of depression. Its etiology, as discussedpreviously, has been attributed to the role of nature (for example, genetically-predisposed organic disease, which then results in brain-chemistry changes), the roleof nurture (for example, neurochemical changes due to toxins in the physicalenvironment, and depression as a learned behaviour, regardless of whether or not it isassociated with neurochemical change), and to a combination of many bio-psychosocialand cultural factors.19Depression alleviation or treatmentThere is more agreement, however, on the treatment of depression and suicidalpain. These include the use of psychoactive medication, cognitive therapy, andbehavioural therapy where appropriate, and the provision of a socially-supportiveenvironment. A glance at the number of predisposing factors to depression presented anddescribed in the DSM-III-R should imply the importance of social support at all levels:Chronic physical illness and Psychoactive SubstanceDependence, particularly Alcohol and Cocaine Dependence,apparently predispose to the development of a MajorDepressive Episode. Frequently a Major DepressiveEpisode follows a psychosocial stressor, particularly deathof a loved one, marital separation, or divorce. Childbirthsometimes precipitates a Major Depressive Episode.(American Psychiatric Association 1987, 221)An increase in the level of public-education and social-service expenditure in theprevention and treatment of chronic illness, substance dependence, and—moreimportant—in making available formal and informal social support after people indistress have received yet another psychosocial stressor, can be very instrumental tothe prevention of a Major Depressive Episode and, hence, to reducing suicide.In summary, research on depression and hopelessness vis-a-vis suicideindicates that clinical depression and hopelessness are present in most suicidalindividuals. An immediate reduction in the sense of hopelessness by cognitive therapy,and long-term treatment of depression, often by a combination of cognitive, behavioural,and drug therapy, are essential to suicide prevention. In Hong Kong as elsewhere, thedegree to which a depressed and suicidal person can access family, social, and medicalresources for the alleviation of depression and hopelessness should be inversely relatedto that individual's likelihood of completing suicide. Since the level of family, social, andmedical resource rests more in the hands of the society in which the suicidal individualis merely one small part, the understanding of suicide is not complete without anunderstanding of social factors—factors which are external to the psychological make-upof the individual. This review now turns to some of the major sociological researchfindings on suicide.The Sociological Perspectives While psychological theories of suicide stress the role of the mind of theindividual in suicidal behaviour, sociological theories of suicide emphasize the role of20external social factors in determining the proportion of individuals in any given societywho will engage in suicidal behaviour (Taylor 1990, 225, 228). These theoriessuggest that society can affect the prevalence of stress, depression, hopelessness, suicideideation, and suicide completion. This is because the prevailing political ideology affectsa country's domestic economic policy, which has a direct bearing on the generosity andefficiency of its social programs. The characteristics of these programs then determinethe level of services available to support the depressed, as well as the extent to whichthe public is educated on recognizing depression in themselves and in significant others.Recognizing and acknowledging depression in others, as will be discussed later in thisand other sections, is crucial to suicide prevention: the depressed, who are almostalways confused, anxious, resigned, helpless, and guilt-ridden as well, are often unableto communicate their emotional state to others clearly. Since the sociologicalperspective deals with socially-shared and environmentally-sensitive factors—factorsexternal to the individual, related to his or her immediate environment, and presumablyvarying over space and time—it lends itself to geographical analysis in a superior way.Beginning with Durkheim's Suicide, this section provides a review of the majorsociological theories of suicide.Durkheim's SuicideIt is only appropriate for a review of sociological theories of suicide to beginwith Emile Durkheim and his Suicide: a Study in Sociology, originally published in1897. Durkheim's use of statistics in examining a social phenomenon—suicide inwestern Europe—later made him one of the founders of modern sociology. In addition, hisinter-regional suicide-rate comparisons rendered his method and findings valuable tosubsequent spatial analyses of suicide.One of Durkheim's main assertions in Suicide was that the incidence of suicide ina society was associated with the degree of social integration in that society (Durkheim1951; Hassan 1983, 2). He stated, for example, that a society's suicide rate varied"inversely with the degree of integration of the social groups of which the individualforms a part" (Colt 1991, 194; Durkheim 1951, 209). This is to say that the morethat people are integrated into, or the stronger that they feel a sense of attachment to,the society to which they belong, fewer people there would become detached or isolatedenough to complete suicide; this process would lead to a relatively low suicide rate inthat society. Durkheim did not explore the psychological or emotional condition ofsuicide-prone individuals vis-a-vis their degree of social integration.21Durkheim argued that different types of society generated different social causesof suicide; he classified these social causes into four major categories. The first wasegoistic suicide. According to Durkheim, this type of suicide was found in societies withexcessive individualism, a condition which led to the detachment of individuals fromsocial life or communal activities. Mapping the suicide statistics that he collected,Durkheim demonstrated that the predominantly Protestant countries of western Europehad higher suicide rates than the predominantly Catholic countries. He argued that thiswas because the higher degree of social support provided by the Catholic Church toCatholic communities created more social integration. In contrast, Durkheim felt thatthe more individually orientated Protestant church provided a lower degree of socialsupport, and achieved a lesser degree of social integration (Colt 1991, 191-92;Durkheim 1951). Durkheim then used this typology of egoistic suicide to account forthe higher suicide rate in Protestant countries, which according to him had a largernumber of socially isolated or emotionally isolated people. Conversely, he argued thatCatholic countries had lower suicide rates because the strong social cohesion found inCatholic societies was beneficial to the psychological and moral health of the individual.(Colt 1991, 191-91; Durkheim 1951, 152-216; Hassan 1983, 5, 76; Shneidman1985, 24; Stillion et al. 1989, 51-52; Taylor 1990, 226).Durkheim also used egoistic suicide to account for the higher suicide rates hefound in urban areas than in rural areas; he asserted that people who lived in cities weremore socially detached (Durkheim 1951). However, Iga reported higher suicide ratesfor the Japanese countryside than the big cities in the early 1970s (Iga 1986, 19).This occurred at a time when many of the young in Japan migrated to urban areas forhigher-paid employment in industries, leaving a large number of elderly people inrural villages with reduced financial and emotional support. lga's finding suggests socialattachment cannot be taken for granted in all rural areas in the world. According to thistypology, given that Hong Kong society—apart from family or clan networks—is nothighly cohesive to begin with (Lau and Kuan 1988), it might be expected—all thingsbeing equal—that if increased urbanization would break down family ties, the highurbanization rate of an area such as the New Territories would increase the degree ofsocial detachment and the rate of suicide in that subregion.Durkheim called the second social type of suicide altruistic suicide. Whileegoistic suicide was a result of inadequate social integration, Durkheim thought thataltruistic suicide occurred because individuals were so excessively integrated into thenorms, expectations, discipline and regulations of society, to the extent that they neverreceived sufficient individuation (Colt 1991, 193). Examples of this type of behaviour22are those exhibited by the elite troops in the French military in Durkheim's time and,more recently, those by the kamikaze pilots in the Japanese air force during World WarII (Durkheim 1951, 217-40; Hassan 1983, 3-4; Stillion et al. 1989, 52). Accordingto this typology, Hong Kong's culture of economic individualism, as suggested by Lau andKuan (1988) should result in such a low level of social cohesion that the prevalence ofaltruistic suicide should be keep to a minimum. On the other hand, excessive integrationinto the family by the Chinese of Hong Kong could result in more altruistic suicides inHong Kong than in countries where familial cohesion is disintegrating. Nevertheless, ifthe cohesion of the traditional Chinese family unit in Hong Kong's New Territories havebeen weakened by the urbanization of that area in the 1970s and 1980s, it might beexpected that this type of suicide would have decreased in that subregion.Durkheim's third type of suicide was anomic suicide. This kind of suicide wasthought to occur when individuals were confronted by changes in life fortunes too suddenand drastic for them to cope with (Colt 1991, 193; Durkheim 1951, 241-76; Hassan1983, 5-6; Kushner 1989, 2-3; Stillion et al. 1989, 52). Suicide resulting fromeconomic anomie was thought to occur when individuals suddenly became poor orwealthy, to the point that their lives became so de-regulated that their needs were nolonger in harmony with their means (Durkheim 1951, 241-76, 403; Shneidman1985, 24). According to this typology, the prevalence of financial speculation in thelaissez-faire capitalistic society of Hong Kong would suggest that horse-race gamblersand stock-market speculators—people who are vulnerable to sudden financial gains andlosses—are most susceptible to anomic suicide.Durkheim's fourth type of suicide was fatalistic suicide. This type of suicideoccurred, according to Durkheim, when people are driven to desperation andhopelessness, such as when soldiers in a losing battle realize that their destruction andtorture by their enemies are imminent. It might be argued that Hong Kong's politicalstructure might be increase the prevalence of fatalistic suicide among the poor, in thatthe Hong Kong Government has coopted a local merchant-class Chinese elite since the late19th century primarily for its wealth, economic leadership, and political acquiescence,rather than for its espousal of any Chinese or Western moral values (Lau and Kuan1988). Without an indigenous leadership acting in the interests of the poor, the poorhave become passively tolerant of Hong Kong's economic inegalitarianism (Lau and Kuan1988). They maintain this fatalism by rationalizing that they have become affluentrelative to the friends whom they have left behind in China. The political acquiescence ofthe poor and the political apathy of the more affluent in Hong Kong have slowed theintroduction of a fully representative government in Hong Kong. This has in turn slowed23the implementation of a more equitable wealth-redistribution policy.6 Durkheim mighthave asserted, then, that the poor of Hong Kong who feel helpless, hopeless and desperatecan be prone to fatalistic suicide.Durkheim did not incorporate psychological factors into, for example, thesuicides of people in anomic or de-regulated societies. The was done by "post-Durkheimian" researchers and, vice versa, by psychological scholars in the decadessubsequent to the publication of Durkheim's Suicide . Advances in the collection andmanipulation of statistics also enabled later researchers to operationalize Durkheim'stheories.Status Integration Theories of SuicideGibbs and Martin are two of many of these "post-Durkheim" scholars whoattempted this operationalization Durkheim's theories. Their work was a theoreticalextension of Durkheim's sociological theory of suicide (Gibbs and Martin 1958; Gibbsand Martin 1964). Using the concept of status integration, they operationalizedDurkheim's theory into the following theorem:The suicide rate of a population varies inversely with thedegree of status integration in that population. (Gibbs andMartin 1964, 27)In order to measure the degree of status integration, Gibbs and Martin chose a number ofofficially created social classifications (such as the categories of being "married" and"divorced"). Like Durkheim, however, they did not relate the role of status integrationto suicide precipitation.According to this theory, it might be expected that the modernization and thecapitalistic nature of Hong Kong society would increase the prevalence of role conflict,for example, as in the case of a married and employed middle-age woman occupying theroles of wife, mother, tutor, employee, and currency speculator. Each of these rolesexerts competing demands and potentially conflicting duties from her, and increases thenumber of incompatible statuses occupied by her. Singer, for example, has suggestedthat "urbanization together with the ensuing housing problems, the increased value ofthe conjugal family and of individualism, and the greater independence of women, have6It can also be argued that this apathy has been cultivated deliberately by the Hong Konggovernment and condoned by the Chinese government, both of which believe that it is intheir own political and economic interest that Hong Kong does not develop full democracy.See Benjamin K. P. Leung, "Political development: prospects and possibilities."24created more conflict in the family, particularly between children and parents, andmothers- and daughters-in-law" in Hong Kong (Singer 1976).Pearson described another role of the Hong Kong mother not often prescribed tomothers elsewhere, that of preparing their children for Hong Kong's competitivestandard examinations:[In Hong Kong], the major burden of supervisinghomework tends, in most households, to fall on the mother.Both she and her child are tired after a long day at workbut homework fills the gap between the end of dinner andbedtime. In otherwise happy families this factor seems tocause more distress than any other. Even the difficultrelationship with the mother-in-law may pale into secondplace beside it. (Pearson 1990, 128)If the number of people in Hong Kong occupying incompatible statuses have, in fact,increased along with modernization, the theorem of Gibbs and Martin would suggest thatthe suicide rate should have increased at the same time.Status and Anomie Theory of SuicideLike Gibbs and Martin, Powell's status and anomie theory of suicide was also anattempt to operationalize Durkheim's theories (Douglas 1967, 93). According toPowell, individuals are simply more prone to suicide "when they cannot validate their'selves' through the normally approved form of status activity" (Douglas 1967, 93).Powell, however, did not suggest any provisions for the testing of the relationshipbetween this self-invalidation and the tendency to . . . suicide, or to account for anycognitive variations in the definition of social phenomena, such as "failure," by differentindividuals (Douglas 1967, 93). Nevertheless, Powell opened the door to later studiesin the role of cognitive perception vis-a-vis depression and hopelessness withinparticular social settings. For instance, most of the people who fail school exams or losehalf of their life savings in Hong Kong as elsewhere do not perceive themselves ascomplete failures in life and, as a result of it, become clinically depressed and suicidal.Two important research question raised, then, were these: In what ways might some ofthe social values which lend one to harsh self-invalidation be learned socially? And inwhat ways might psychological, such as cognitive, factors and perhaps even biochemicalfactors interact with socially learned self-invalidation to make one depressed andsuicidal?25Status-Change Theories of SuicideIt was stated earlier that one of the fundamental components of Durkheim'stheory of anomic suicide is that downward mobility leads to deregulation, which in turnincreases the probability of suicide (Douglas 1967, 109). While status-changetheorists assert that any change in the status of individuals can be a "burden badlytolerated" (Douglas 1967, 111), it is particularly downward change, that can inducesufficient stress to lead individuals to desperation and suicide (Douglas 1967, 111).For example, Sainsbury found in a study in London that poverty in itself did relativelylittle to render individuals more suicide-prone. Rather, it is when poverty befell thosewho were used to a better standard of living that it became a burden badly tolerated—especially among those in the upper occupational classes during economic depression—that made them more suicide-prone (Sainsbury 1955, 19).Maris found that most male suicides in the United States had also experienceddownward occupational mobility, as indicated by "developmental stagnation,unemployment, and erratic [recent] work histories (Maris 1981, 156). He also foundthat and one-fifth of [suicide] completers were disabled and retired (Maris 1981,169). Similar findings have been made by Breed in New Orleans (Breed 1963). Platt(1984) also hypothesized that unemployment or loss of employment was "a principalcausal agent of the current rise in suicide mortality" in the countries of Northwest andcentral Europe undergoing important socioeconomic development. Lo and Leungdemonstrated in their recent study that while 4.1 per cent of Hong Kong's economicallyactive male—suicidal and non-suicidal—population was unemployed, 36.6 per cent ofmale suicidal subjects between 20 and 65 years of age were unemployed (Lo and Leung1985, 288). Unfortunately, neither Platt, nor Lo and Leung, provided data on howrecently the suicidal individuals had become unemployed.Rao's study in India also confirm that "poverty and unemployment are definitecauses of suicide and suicidal attempts" among members of one occupational group whoexperienced the badly tolerated burden of downward status change (Rao 1975, 237):Often entire families have put an end to themselves bypoisoning or by other means because of being unable to livein poverty. There was a wave of suicide a few years agoamong the goldsmiths in India when they found themselvessuddenly unemployed as a result of the promulgation of theGold Control Order by the Government of India. (Rao1975, 237)Critics of status-change theories have questioned whether or not any additionalevent, such as the loss of a loved one, might have preceded the loss of status (which may26lead, for instance, to depression and job loss). Some have even suggested that the"discovery" of statistically significant relationships between social-status variables andsuicide are not necessarily any more significant than the "discovery" of relationshipsbetween suicide and visits to the zoo (Douglas 1967, 119-20). These are validcriticisms, considering that the relationship between downward status change (or,"drift," as it is known today) and suicide completion usually contains many interveningvariables. Indeed, the state of "desperation" that lies between unemployment and suicidecompletion certainly comprises those mental and emotional conditions described bypsychological-perspective researchers as decreased self-esteem, helplessness,hopelessness, and depression. For instance, while Lo and Leung confirmed a correlationbetween suicide and unemployment in Hong Kong, they also indicated that a highproportion of the completed suicides in their study had suffered from a physicaldisability or psychiatric illness; they argued that it is the disability or illness ratherthan unemployment per se, that is, downward status change, that precipitated thesesuicidal acts (Lo and Leung 1985, 291).In summary, while status-change theories of suicide facilitate the mapping andexplaining of the suicide phenomenon—perhaps for the use of health-care policyplanners, it is less useful to individual cases of suicide prevention and interventionagainst individual cases of suicide. A large majority of people who lose jobs or receivedemotions do not complete suicide, and these theories alone do little to help the familymembers of a "clammed-up" unemployed breadwinner realize this person's suicide-proneness, let alone initiate an appropriate course of action.Aggression in SuicideAccording to Henry and Short, suicide—like homicide—is directly related toaggression (Douglas 1967, 132). The introduction of the element of aggression to asociological theory of suicide made this the first major psychosocial theory of suicide.In general, the theory of Henry and Short is based on the following assumptions:1. An increase in frustration will cause an increase inaggression, and a decrease in frustration will cause adecrease in aggression.2. For a given population (especially a class group),an increase in aggression leads to an increase in homicideor an increase in suicide; and a decrease in aggression leadsto a decrease in homicide or a decrease in suicide.27283. An increase in general economic gains will lead to ageneral decrease in frustration; and an increase in generaleconomic losses will lead to an increase in frustration.4. An individual will express (or direct) hisaggression against (or toward) the object(s) to which heimputes generalized responsibility for his frustration.5. The direction of the imputation of generalizedresponsibility is determined by the degree of externalrestraint on the actions of the individual, such that a highdegree of external restraint will lead to the imputation ofgeneralized responsibility to others and a low degree ofexternal restraint will lead to the imputation ofgeneralized responsibility to ego.6. The degree of external restraint varies inverselywith the social strata. (Douglas 1967, 133-40)Henry and Short were recognized for their formulation of "a definite, hypothesized orderof interdependency" between psychological and sociological variables which causevariations in the suicide rates (Douglas 1967, 132). They have been criticized,however, for having failed to consider that "the imputation of responsibility amongpeople of a specific social stratum might well be the result of subculture differences"(Douglas 1967, 142). Douglas argued that instead of being restrained externally,upper-class individuals might shoulder more responsibility not because of their highstatus, but simply because upper-class parents, more then their lower-classcounterparts, tend to teach their children that they are responsible for what happens tothem (Douglas 1967, 142). Furthermore, Douglas criticized Henry and Short for theirreliance on data from two dichotomous categories comprising the rich and the poor: theyfailed to notice a strong U-functional relation with respect to social class, in that theupper class and the lower class have roughly similar suicide rates and the middle classhaving a considerably lower rate (Douglas 1967, 143).Hassan dismissed in his Singapore study this simplistic U-f unctionalrelationship—at least for suicide—by arguing that "not all high prestige occupations havehigh suicide rate and not all low prestige occupations have high suicide rate," and thattwo occupational factors were related to suicide: the level of external social constraintby one's employer and the public, and the level of social and economic reward from one'semployer and the public (Hassan 1983, 73). According to Hassan, most prone to suicideare individuals whose occupations "have high regulations of social behaviour [but] withrelatively low economic rewards and social prestige, such as working proprietors ofcatering and lodging establishments, hairdressers, bankers and beauticians; employeessuch as domestic servants, caretakers, cleaners, cooks, waiters and bartenders, andpolicemen and other protective service workers" (Hassan 1983: 73). He added that thisexternal-restraint stress factor can be moderated somewhat, however, by an increase ineconomic reward. For instance, Hassan thought that although administrative andmanagerial workers also have a high degree of external restraint, their tendency tosuicide is lower than those who face both high external restraint and low income (Hassan1983, 73). Hassan also stated that clerical workers, agricultural workers, and fishingpeople had only a low level of external restraint exerted upon them, and that they had thelowest suicide rates in Singapore (Hassan 1983, 73).Yap reported only one case of suicide among what he called "farmers," and noneamong "fishermen" in an 18-month study period in Hong Kong in the mid 1950s (Yap1958, 33). As in Hassan's Singapore study, the low suicide rates among people in thefishing and agricultural occupations could probably be attributed to their greaterinsulation from cultural change, and a less degree of external restraint and economicuncertainty. Among the urban population of Hong Kong, Yap found that the unemployed(under 60), the "unemployed over 60," entertainers (mostly low-paid female tea-house singers and "dancing-parlour girls"), shop assistants, coolies (streetside anddockside piecework labourers) and amahs (female live-in domestics)—occupationssubject to a high degree of economic insecurity and uncertainty—had some of the highestsuicide rates. The police had the lowest suicide rate among all of the occupationalcategories discussed by Yap (Yap 1958, 32-37, 77). This is probably because thepolice was largely a "top-down" policy-implementation instrument of the colonialgovernment, and was mandated to control—rather than to be accountable to—the public.Most of the individuals who entered the police department had the assurance of somethingakin to lifetime employment, and were consequently relatively sheltered from economicstress than were individuals working in the private or, often, the informal sector.Newspapers in the 1980s and 1990s however, did report accounts of police-officersuicides (Ming Pao, 8 March 1991, 5; 30 September 1991, 4). Although theseunquantified accounts cannot be used to argue for an increase in the suicide rate amongthe police, they do challenge Hassan's assertion that the external social constraint of theemployer could be compensated by economic reward.Others have simply argued that suicide is democratic:Suicide is . . . the one continuous, everyday, ever-presentproblem of living. It is a question of degree. I'd seen themin all varying stages of development and despair. The failedlawyer, the cynical doctor, the depressed housewife, theangry teenager . . . all of mankind engaged in the massive29conspiracy against their own lives that is their dailyactivity. (Daniel Stern, in Hassan 1983, 53)But since real or perceived failure, cynicism, and anger all are common symptoms ofdepression, Stern's finding might well be interpreted in a way which suggests thatmental state, rather than occupation, is the more important factor affecting the suicidalproneness of these individuals.In any case, while Hong Kong's aggregate suicide rate increased gradually almostlinearly between 1981 and 1986, the aggregate homicide (labelled officially as"manslaughter") rate decreased gradually almost linearly as well, suggesting that thereis prima fade evidence of an inverse relationship between the rate of homicide andsuicide in Hong Kong. Before the aggression theory of Henry and Short can be fully testedfor Hong Kong, however, it will be necessary to confirm the socio-economic status of allof the suicide completers and homicide perpetrators. Data on the latter can be difficultto obtain, considering that not all of the identities of homicide perpetrators are known tothe police. Moreover, it should also be considered that, in Hong Kong as elsewhere,members of the upper class who take overdoses can also be more likely to have deathresulting from "internally directed aggression" certified as accidental (Slaby 1992,157-58). This process can cloud suicide statistics, as well as the attempts to analyzethe imputation of blame and the role of economic reward in suicide.It should also be added that acts of aggression, in Hong Kong as elsewhere, rarelybecome entries in suicide or crime statistics (Figure 2). Apart from the few relativelyclosely knit villages in the distant parts of the New Territories (mostly those onoutlying islands such as Cheung Chau and Lantao), "legal" aggressive behaviour is thenorm, rather than the exception, in Hong Kong. Aggressive behaviour—rationalized bythose who express such behaviour as "something we all have to do to get anywhere"—canbe observed in the way taxis are snatched, often by young and able-bodied men andwomen from the frail elderly or parcel-laden hailer. It can also be seen in the mannerin which many young and able-bodied travellers run—like race horses do—for trains andimmigration checkpoints at the border with China, and, with little fore-thought orafter-thought, colliding against the baggage-laden, slow-moving elderly, and the child-carrying travellers. More of this type of anxiety induced aggressive behaviour in HongKong will be examined later in the section on the statistical analysis of suicide in HongKong between 1981 and 1991. Suffice to indicate for now that studies on therelationship between aggression on the one hand, and suicide or homicide on the otherhand are inconclusive. Future studies will need to consider and perhaps even quantify30Figure 2^Legal aggression in Hong Kong: Disregard for the stranger.Source:^W.H. Kwan, 1992.those aggressive behaviours which are culturally condoned, and not only the "pent-up"ones that culminate in suicide or homicide statistics.Gold's Theory of SuicideWhile Henry and Short "merely provided a juxtaposition of psychological andsociological variables [in suicide and homicide], rather than some kind of synthesis ofthe two . . ." (Douglas 1967, 145), Gold offered the following synthesis:1. The socialization of aggression is the fundamentaldeterminant of the preference for homicide or suicide.2. The type of socialization normally associated withthe outward expression of aggression is found more amonglower-class individuals than among upper-classindividuals, and the type of socialization normallyassociated with inward expression of aggression is foundmore among upper-class individuals than among lower-class individuals.3.^Therefore, lower-class individuals will show apreference for homicide over suicide and upper-classindividuals will show a preference for suicide overhomicide. (Douglas 1967, 145-46)In spite of these refinements, Douglas suggested that Gold's attempt at synthesizing thenumerous psychological and sociological variables fell short of taking into account themany . . . socially determined meanings of immediate situations" (Douglas 1967, 150-51). For instance, "Gold does not attempt to show that the social position of individualshas any causal effect on their socialization process, . . . [in the sense that] it is possiblethat individuals with a tendency to express aggression outwardly and to socialize theirchildren to do so are lower class precisely because of this tendency, rather than that thetendency to express aggression outwardly is caused by their social-class position"(Douglas 1967, 146). Any attempt to test Gold's theory for Hong Kong will also requirethe type of approach and data suggested earlier for testing the aggression theory ofsuicide and homicide of Henry and Short.Ecological Theories of SuicideThe ecological approach emphasizes largely the causal dependence of social actionon the physical environment of society or social groups (Douglas 1967, 96-97). Usingthe social areas approach, Zorbaugh found that "the cold, unsociable atmosphere" of therooming-house district of Seattle was related to the suicide rate there (see Schmid321928, 20-21). Like many of his predecessors and contemporaries, Zorbaugh has beencriticized for having relied on the homogeneity of a population contained in officiallyclassified areal statistics.Later ecological studies downplayed slightly the ecological aspects andendeavoured to make the ecological theory more determinate. Cavan, Schmid and Farispostulated the existence of predisposing factors which, in most Western societies, gavenegative social meanings to suicide. According to these researchers, it is the acceptanceof negative social meanings of suicide by certain individuals that render them, whenfaced with a crisis (a precipitating factor), more likely or less likely to "opt for"suicide as a way out (Douglas 1967, 108).Hassan found in his Singapore study that the suicide rate was high in the central-city area with a high concentration of poor and single elderly people, and also in thephysically and socially alienating environment of high-rise public housing areas(Hassan 1983, 161). Hassan further commented that the social anonymity and thearchitectural design and layout of the buildings reduce opportunities for social andcultural intervention after frustrated housewifes have "decided to kill themselves on thespur of the moment" (Hassan 1983, 65-66).It will be stated in the next section of this review that suicide only appears to bea rational option in the confused and constricted state of mind of the clinically depressedperson. Established well before the current knowledge of depression and hopelessnesshave been acquired, the line of reasoning used by many of these earlier ecologicalresearchers run contrary to the assertions of suicide interventionists that most suicideattempts are cries for help. As for completed suicides, they are cries that wentunheeded, in the sense that bio-psychosocial intervention was not available in theimmediate environment of the completer. Analyzing the availability of such interventionopportunities is a useful approach and important research question for ecological studiesof suicide. These studies, however, must be cautious of the pitfall of attributing suicidesby the people of a certain social area to such rationalizations by the suicidal as "Societyconsiders suicidal people as losers. Since I'm poor, unemployed, old, useless,miserable, and have become a loser already because of these factors, what other ways doI have to end my pain than killing myself?"Any ecological studies of suicide in Hong Kong, as elsewhere, will requireapproaches to suicide and the geography of suicide that have rarely appeared in thesuicide literature on Hong Kong. As Ferenc Moksony stated: "influences stemming fromthe local community have not only to be established; they have to be explained as well bydeveloping causal theories about how the environment sets limits to the individuals33living in it, how people perceive those constraints, and how they respond to them."(Moksony 1990, 134 ). The importance of individual cognitive perceptions andbehaviour in suicide is why socio-spatial studies of suicide must incorporate theories ofsuicide introduced by the cognitive school in psychology, and revelations of the cognitivestate of suicidal people as reported by suicide interventionists, and by those who haverecovered from depression and suicide ideation.Summary of Sociological Theories of SuicideSociological theories of suicide began with Durkheim's observation and analysisof socio-spatial variations in suicide rates of different societies and geographical regionsin western Europe about a century ago. The growth of psychology as an academicdiscipline in 20th century led to considerable cross-fertilization between psychologicaland sociological theories of suicide. This is evident in such examples as the imputation ofpersonal aggression to certain members of a spatial unit or socio-economic category.The significance of sociology in the study of suicide can best be summed up as follows:The sociological view of suicide calls for a broaderperspective than that found in most psychologicalapproaches. It challenges people to look at conditions intheir cultures at any given point in history as factorswhich can directly influence the suicide rate. In this way,sociologists provides a major service to students of suicide.An analogy that is useful in understanding the utility ofthis perspective is that of the ant hill. A child watching anindividual ant busily wander back and forth across a pathcarrying a bit of sand can infer little meaning from thebehavior. If, however, the child stands up and regard thebroader scene, he or she may observe a nearly finished anthill. While the individual behavior is not explainable, itbecomes meaningful as a part of a larger picture. In justsuch a way, individual suicidal behavior may become moremeaningful when examined against the social fabric ofsociety. (Stillion et al. 1989, 53)The study of suicide as a social phenomenon is less effective in preventing thesuicide of specific individuals; it is more useful to the reduction of the total number ofsuicides in society, as long as the political will to do so and the necessary economicresources are present. The extent to which public suicide-intervention services areavailable in Hong Kong will be discussed briefly below after an introduction to theconcept of suicide intervention.34The Prevention and Intervention PerspectiveThe following passage is perhaps a concise summary of the causes of suicide:Stressful environments change body chemistry. Insusceptible people, increased stress can result in changesthat increase the likelihood of depression. When thesechemical changes occur, an increase in depression relatedcognitions . . . may result. Such negative cognitions maywell increase the subjective impression of stress, whichin turn will have a continuing effect on the chemistry ofthe brain. In short, personality, environment, biology,and cognitions may interact to produce a suicidalindividual. (Stillion et al. 1989, 57-58)This section will examine the role of the social mechanisms available to prevent theproduction of suicidal individuals and to prevent them from carrying out their suicidalacts. It includes an introduction to suicide prevention, and an account of my personalexperience in suicide intervention in Canada. The purpose of this account is todemonstrate the importance of social support and easy access to the services ofcompetent professional caregivers. Discussion of long-term comprehensive suicideprevention methods will be provided at the end of this section and, in the manner thatthey can be applied to Hong Kong, in the last chapter of this thesis.Suicide PreventionIt needs little emphasis here that all of the literature reviewed so far, regardlessof the perspective from which it was written, has one common purpose—to preventsuicide. Apart from humanitarian concerns, suicide prevention is important because thepsychological effects of one's suicide on surviving family members can be devastating:the thought of using suicide as a means to escape intolerable pain can be learned moreeasily by those—especially the young—with a history of suicide among family membersor peer groups than by those who do not have a family history of suicide.1 In order toenhance social and economic stability, and to reduce the prevalence of suicides resultingfrom learning by today's survivors, it is clear that the significance of suicide preventioncannot be slighted.Much has been done in biology and pharmacology to delay the onset of depression-inducing organic brain disease, and to control the symptoms of these disease by1For example, a young relative of an eight-year old girl who jumped to her death from apublic housing building had done the same two years earlier. See appendix 6.35medication after their onset. Much has been discussed about the role of social,environmental, and economic factors in shaping the developmental process ofindividuals, which may lead to the development of pathological personalities andpsychological disorders.The number of developmental experiences which can make it easy for people tobecome depressed, hopeless, and helpless, etc. are infinite. These are but a fewexamples: people who grew up in a domestic environment in which they were required toact as mediators between warring parents; people who, for fear of parental rejection,were coerced to settle for course marks no less than 100 per cent, to diet or to exercisefervently in preparation to win the elusive Olympic Gold, or to conceal physical andsexual abuses done to them by family members. It goes without saying, then, that thetask of suicide prevention begins with teaching parenting skills which include makingonly realistic expectations of themselves and their children, and not using children ascommodities for the parents' own gains in prestige, status, and other superficialrespectability in the name of "This is done for the good of all for 'us'—the family." Thetask continues with ensuring the availability of adequate social support for parents,whether they are single, common-law, or "married and intact" parents. These are onlysome of the numerous social changes which can help reduce the number of suicide-proneindividuals; they are presented here merely to demonstrate how much more society needto do to prevent suicide and where society can begin to focus to prevent suicide.One area of suicide prevention which has been researched frequently and appliedmore widely is the restriction of the means of suicide. For example, the detoxification ofhome gas in England in the 1970s resulted in a drastic reduction in suicides by gaspoisoning in subsequent years—without incurring any significant increase in suicide byother means. Increased difficulty in access to potentially lethal drugs, such astranquillizers and sleeping pills, has also made suicide completion by these drugs moredifficult. These means alone, however, are no substitutes for social support for thesuicidal.Ultimately, social support can best be increased by a dedicated effort to educatethe public about depression and suicide to the point that it knows what they are, and tothe extent that these no longer remain taboo conversation topics. To say the least, thismeans that the public must be as aware of depression and suicide as the Western publicis of the ways in which AIDS is transmitted and, more important, the ways in which AIDSis not transmitted.The amount of popular television air time spent on the edcation of depression andsuicide in Canada and the United States is, unfortunately, next to nil in the four years36since I began my research on this thesis. Many university counselling offices havecopies of pamphlets on these topic stacked next to those on stress, dieting, weightproblems, and perfectionism, etc. In this university, they are placed in the waitingroom in the counselling office, which can hardly be considered a thorough effort inpublic education. Most suicide prevention pamphlets contain a "What to do" checklistand a "What not to do" checklist. They advise helpers, for example, not to tell suicidalfriends to "snap out of it," or to say things like "Come on. Things can't be that bad!", or"Stop whining!". Instead, befrienders are advised to use both verbal and body languageto listen, to reflect non-judgementally, to empathize, and to show support.Unfortunately, these pamphlets alone were far from being effective when they were putto test among many of my non-suicidal university friends, as the section following thenext should amply indicate. In the meantime, this next section will introduce one of themost crucial component of suicide prevention—suicide intervention.Suicide InterventionSuicide intervention is another components of suicide prevention. Unlikeprevention, suicide intervention mobilizes all available and necessary social and medicalresources in an effort to stop individuals on the verge of attempting suicide from doingso. One type of social support in most modern countries comes from public suicide-intervention services. These are important because family members and relatives maybe in the immediate vicinity of suicidal people to offer support. Moreover, "culturallyapproved" significant others can often be contributors to the emotional malaise ofsuicidal individuals.Public phone-in and volunteer-staffed suicide intervention services is often saidto have begun in the 1950s, with the founding of a crisis centre in Los Angeles in theUnited States and a similar one by the Samaritans in England (Lester 1990, 183).Since that time, such crisis hotlines have proliferated to the extent that they can befound in the telephone directory of almost every community in the West. The Samaritanshave been providing their services in Hong Kong since the mid 1960s.The effectiveness of these hotlines have often been questioned, especially bygovernment fund-allocation agencies and by biomedical researchers in depression andsuicide, who argue either that most of the calls received are merely for information, orthat professional medical treatment are available to the suicidal. It is true that mosthotline services provide information and referrals in order to demonstrate their utilityto funding agencies. It is also true that referrals to the services of other providers, suchas social-welfare, debt-counselling, and prenatal-care agencies, are often what is37needed to reduce the level of frustration, anxiety, or depression of the callers—whetheror not they are suicidal. As stated earlier, it is also sadly true that most of the suicidalhave made contact with the medical system in the weeks prior to suicide completion, butonly to have physicians miss making the diagnosis of depression; it may also be that anevent perceived to be catastrophic enough by callers to become a precipitating factor insuicide has occurred when their medical doctors are asleep or on vacation. In any case,no medication-use can, and should, replace the prevention of illness by maintainingphysical and emotional health. This is especially true for suicide intervention, where itmust be pointed out that in spite of advances in the development of psychoactivemedications for the immediate alleviation of panic, anxiety, and schizophrenichallucinations, biomedical and pharmaceutical research has not yet developed one singlepsychoactive medication that can control depression or reduce suicidal pain immediately.Until this kind of medication is developed, hotlines will remain the last and only sourceof round-the-clock emotional support available to the suicidal caller.Most interventionists, whether they are hotline volunteers, clinic counsellors,or researchers, operate on the premise that peak-level suicide lethality in people lastsfor only about a week or two, and it is during this period that maximum medical,psychological, and social resources must be mobilized for suicidal individuals in order toprevent their suicide. They argue that the cognitive state of severely depressed andhighly suicidal individuals are constricted, and that the "decisions" they make to die arelogical and rational only to people in such a psychological state. Rather than honouringindividuals' irrational decisions to die, suicide interventionists interpret suicidalpeople's "rational decision to die " as a cry for help in seeking a solution to endintolerable psychological pain (Shneidman 1985, 3-5).From the perspective of interventionists, even acknowledging the existence of"rational suicide" or manipulative motives (other than an instinctive motive ofcommunicating intolerable psychological pain) is detrimental to raising the level ofpublic support for suicide-intervention education. Instead of seeing suicidal people asangry, frustrated, and hopeless individuals formulating plans to punish themselves orothers, interventionists suggest that suicide occurs simply because these individuals'aggregate level of psychological pain—intensified by an endless array of bio-social,cultural, and environment factors—has exceeded the aggregate level of their copingresources.In order to alleviate suicidal lethality, interventionists argue that the aggregatelevel of suicidal pain—regardless of its antecedent—must be reduced by any availablemeans (Conroy 1991; Shneidman 1985, 13-14). Typically, these include increasing38the level of formal and informal social support for suicidal people and treating theirclinical depression of, during the critical week-long period. Longer-term goals includecounselling and therapy for the suicidal, de-stigmatizing depression and expressions ofsuicidal feelings, as well as increasing public awareness of the signs of depression andsuicide (Shneidman 1985, 15-16). The importance of these short- and long-termobjectives cannot be overemphasized, considering that most completed suicides couldhave been prevented with timely social intervention.A Personal Account in InterventionWithin a two-month period recently, two university-student friends of mineexpressed suicide ideation to me. The first friend had already visited the studentcounselling office and a psychiatrist in the student health service on enough occasions tofeel that the visits "were getting nowhere," and that he was given the "run-around." Heinformed me that he felt that his depressed state was not being completely understood byothers, including the caregivers at student health services. He reminded me that he hadbeen suffering from gastro-intestinal problems for several months, that he had beenwaking up late at night and unable to return to sleep, and that his inability to eat hadbrought significant weight loss. In retrospect, it became clear to me that his perceptionof the unresponsiveness of the professional caregivers resulted partly from thedepression itself: uncomplicated unipolar depression has on its list of symptoms the lossof assertiveness, which in this case meant the lack of the very assertiveness needed inorder for him to inform his medical practitioners of his suicide ideation and plan. Hisreluctance to volunteer his suicide plan also resulted from his faith in the ability ofmembers of an reputable authority—medical practitioners—to "know enough" and to askhim.The second of my two friends imparted to me one evening in a cocktail lounge thathe felt sad, depressed, rejected, and misunderstood by the world, that he had beensleepless and losing weight for over a month. He had not made any attempt to contactstudent health services.Up to that moment, I did not have any clinical experience in counselling orsuicide intervention; my understanding about suicide was limited to about a year'spreliminary reading of suicide research written from various perspectives found in theuniversity library. It was from this literature that recalled the "motto" that askingwhether a person was suicidal or not would not put the "wrong" idea in the head of a non-suicidal person; I also recalled that the degree of suicide lethality is positively related tothe firmness of a suicide plan.39Upon asking, I was told by my first friend that he had a symbolic place in mind tocut his wrist, and by the other that he had a symbolic date planned on which to take anoverdose of sleeping pills.I was more than willing to take time off from research to support thememotionally. I was also most concerned that they get professional help immediately,which meant that they communicate their suicide plan to the caregivers like they did tome. This required several days of emotional support by me and another mutual friend, astudent of medicine, before our first friend could be motivated sufficiently to do so.My second friend, on the other hand, adamantly refused to approach theprofessionals for fear of being stigmatized as a "wacko"; he also insisted that there wasno turning back from his suicide plan: it was the only means available to him to provethat he was not a "total loser." It became necessary for my supportive friend and me tode-stigmatize depression. This task took several days—and many sleepless nightswondering if we were going to see our friend again—before he approached theprofessional caregivers voluntarily.My attempts to rally social support from other mutual friends were moreproblematic. Even after I have distributed the suicide prevention pamphlet from thecounselling office to many of them, most of them displayed many of the behavioursitemized on the "What not to do" list. Some of them expressed to me that they haddifficulties in applying abstract terms like "empathize," and "being non-judgemental,"citing that it was because they had never taken a course in psychology! Some asked me ifthey were just looking for attention, and whether or not getting each of them a girlfriendmight help. They found it difficult (and probably fearful) to take personalizedapproaches suited to the unique nature of their friendship; it appeared that some wishedthat there had been a script for them to rehearse and recite. Some even avoided facingthe pressure altogether by avoiding our suicidal friends, citing they were fearful of thewhole university becoming suicidal because these two cases had occurred within a month.Their avoidance, an act clearly indicated on most "What not to do list," could beinterpreted as a disservice, rather than a positive contribution, to the emotional well-being of their depressed friends.As a postscript, neither of them attempted suicide, nor are they suicidal now.These reactions to depression and suicide are not isolated ones. The experiencesderived from these two incidents are, indeed, that suicidal people need both socialsupport and easy access to well-trained professional care. Social support can best beassured when society—the suicidal and their would-be supporters—are well educated indepression and suicide, so that they are not apprehensive in seeking treatment or40showing support. Access to professional help can best be ensured, to say the least, whenit is not dependent on the ability of the suicidal to pay for such services. The quality ofcare for the suicidal can best be achieved by training all professionals to ask patients orclients with depressive symptoms whether or not they are suicidal.The reluctance of the depressed to seek treatment and the difficulties theyencounter in obtaining social and emotional support are, unfortunately, still the normrather than the exception in Canada, in spite of its relatively generous socialized-medicine and public-health education spending. The following section will examinepublic understanding of suicide, and the availability and the quality of suicide preventionservices in Hong Kong.Social Support in Hong KongThe findings in this section are based on observations made during my 15 yearsof residence in, and subsequent annual visits to, Hong Kong. The literature on the viewsof Hong Kong people toward strangers and mental illness in general will also beexamined.Hong Kong's culture of fervent materialistic pursuit and apathy toward strangershas been well documented:Individual and family interests are without exceptionranked above societal or collective interests. In fact,society is seen as an arena where individual interests arepursued, and social interests are important to the extentthat this arena has to be preserved for the sake ofindividual interests. (Lau and Kuan 1988, 54)This view is supported by another student of Hong Kong:The ideology which can be found in Hong Kong . . . ischaracterized by the people's emphasis on economicpursuits and a general apathy toward . . . matters outsideone's personal orbit. Hong Kong has often been described asa city where no one is concerned about the well-being ofother people . . . People are only interested in what theycan obtain and not in what they can give. (Chow 1986,4 0 7 )To date, public education on mental illness has been scarce (Tsoi and Tam 1990,209); on suicide, it is limited to superficial training for school teachers—in light of afew highly sensationalized student suicides. Otherwise, no systematic effort has beenmade to educate mental illness or mental health (Chen 1981). Where mental illness wasincluded in the school curriculum, "mental illness was described as a 'sickness' and 'an41inability to solve life's problems and to overcome anxiety' without any attempt tosynthesize the two" (Tsoi and Tam 1990, 209-10).Chinese society has traditionally regarded mental illness as a misfortunebefalling families in which one of its members must have done wrong in a previous life.In Hong Kong, for instance, "mental illness has often been associated with manslaughter,running amok or long-haired beggars" (Tsoi and Tam 1990, 213). It has been arguedthat depression tends to be somatized in Chinese culture (Cheung 1985); it is probablythis type of stigma that forces depressed Chinese to report only physical symptoms: thesufferers reject their illness themselves (Ma 1974). Given these views of Hong Kongsociety toward the mentally ill, having a mentally ill family member can stigmatize theentire family; this can force the family to overprotect, collude, and conceal this"blemish" in the household, and reduce its access to non-judgemental social support insuch times of crisis (Lin and Lin 1981). For example, a study conducted on families ofschizophrenic patients in Hong Kong found that 60 per cent of them were not receivinghelp from relatives (Pan 1987); the immediate family members struggled on their own.This is not to say that the Chinese are by nature less caring. In fact, Okenberg(1970) found in a study conducted on Hong Kong secondary-school students that thosestudents who had received a relatively traditional Chinese education tended to be lessMachiavellian than those students who had received a Western education. These findingsled Yang (1986) to suggest "it appears that Westernization, in the Chinese context, willstrengthen Machiavellian attitudes." Neither of these authors clarified if"Westernization in the Chinese context" was limited to Westernization in the context ofHong Kong's laissez-faire capitalism, its preoccupation with wealth (Lau 1981; Lee1985, 199-208), and its relatively limited social-wealth redistribution. The ways inwhich this redistribution is manifested in the health-care and social-welfare systems,and the effectiveness of these system in treating depression and preventing suicide willbe examined below.Suicide Prevention in Hong KongThe extent to which suicide intervention services are available and accessible, inHong Kong as in other modernized societies, are dependent upon the funding priorities ofa government; these are, in turn, dependent upon society's overall economic conditions,and the characteristics of the political ideology which shape social-wealth redistributionpolicies. In this section, we will first examine the role of Hong Kong's health caresystem in suicide prevention.42Hong Kong's health-care system can best be described as a two-dimensionalsystem. One the one hand, Hong Kong has a public medical-care system which isnominally free for all; this publicly funded sector is poorly managed, resulting inbureaucratic rationing of outpatient-clinic services by means of service limitations andlong waiting time (Hay 1992, xxiv/35). In 1991, a public hospital refused to performthe frequent and medically required cleaning of a patient's kidney, citing that limitedfunding by the government compelled it to refuse providing such a service to patientsover 55 years of age. The hospital insisted that this was done to make more efficient useof its limited resources, in that money spent on treating younger patients could benefitmore people; the husband of the patient was in no mood to consider this aggregateutilitarian argument. He reported the incident to the press, and explained that becausehis family could not afford to obtain the same treatment from private-sector providers,this public hospital was in fact committing premeditated murder (Ming Pao, 23September 1991, 1).Rationing policies can also make the public stay away from public-sectorproviders voluntarily. Since time—a "commodity" required to accumulate wealth—ishighly precious in Hong Kong, even those who can just barely afford to pay for privateconsultations prefer spending a little money in order to make more money, rather thanwaste time and money—since time equals money—in the queues public clinics. Inpatientservices at government hospitals are known for their high patient-to-doctor and staffratio, the inadequate training of emergency-room doctors, the absence of the latest high-tech imaging technology, the poor morale of doctors and nurses, and the perpetualcongestion of the wards whose halls are filled with camp beds (Hay 1992; Yuen 1992,288-90). It has been argued that some aspects of Hong Kong's unique social structurerender the people of Hong Kong quite tolerant of high-density living (Lee 1985, 196-99; Millar 1979). This tolerance between healthy Hong Kong urbanites, however, oftendiminishes among the sick in the congested hospital wards, where poorly attendedpatients often break into verbal and fist fights. These factors act as disincentive toprevent all but the poor and those requiring lengthy hospitalization to use governmenthospitals (Hay 1992, 35-36). Very little research data on the government's provisionof heath services have been made public (Hay 1991). Judging by the overall quality ofthe public-sector heath care, however, public-sector health-care services for theclinically depressed and suicidal cannot but be as inadequate as those for the physicallyill. Suicides by jumping out of hospital windows are not unheard of in Hong Kong (MingPao, 15 April 1991, 4); this suggests that the minimum precaution of restrictingmeans of suicide is not observed by hospital administrators or staff.43On the other hand, the highly efficient health-care services provided by theprivate sector in Hong Kong have lured an increasing number of patients (Hay 1992,41), such that 80 per cent of outpatient care in 1992 was delivered by the privatesector (Yuen 1992, 287). Private out-patient medical practices are so numerous thatresidents in the congested areas of Hong Kong Island and Kowloon can usually find onewithin a five-minute walk from home. The waiting time is minimal, usually less than10 minutes. These doctors are also licensed to dispense prescription drugs, so it iscommon for patients diagnosed with a flu to receive several little bags of drugs, such aspainkillers, antihistamine, and a small bottle of cough syrup with codine after a one-minute check of the throat and the chest on the stethoscope. For those with sick-leavedocuments to be signed, it can even be done at a discounted rate without a medicalexamination.8 This speedy and apparently personal service provided by private-sectordoctors—at prices way below that charged for an office visit in the United States—attractall but the poor and the economically less-active to the private doctor. Since nocentralized records on office visits are kept, no mechanism exists to prevent patients insearch of lethal dosages of sleeping pills or tranquillizers from visiting as many doctorsas they can afford to (Hay 1992, 44).The same level of efficiency can be found in Hong Kong's private hospitals, alongwith sophisticated treatment technology (Hay 1992, 41-45). For most middle incomepeople, a week-long stay in an eight-patient ward in a private hospital for the removalof a benign tumour or gall bladder is not financially threatening. A chronic or terminalillness requiring stays of several months, however, can lead to a financial crisis andsevere psychological stress for most except the rich in Hong Kong. This has seriousimplications, of course, for the clinically depressed and suicidal. For instance, what isthe best immediate course of action to take for suicidal people whose constricted thinkinghappens to be "telling" them that they are failures because they are poor (because theyhave only the "wrong" amount of $3,000,000 in savings, and not the "right" amount of$5,000,000)? Will the thought of having to spend $1,000 on whatever type of initialtreatment to alleviate that constricted thinking become a precipitating factor in suicide?What if a suicidal person is feeling guilt-ridden and worthless for having alreadybrought financial ruin to the family? Will more guilt arise if another $10,000 is spenton treating this highly stigmatized illness called depression, along with the extra8A 40-year-old doctor received a two-year suspended sentence for signing sicknesscertificates required by employers for four "customers" for a fee ranging from $20 to$30 (US $3-$4) each without even having examined the "customers." See Ming Pao,21 February 1991.44pressure exerted on family members to lie to their friends in an attempt to conceal thepatient's true whereabouts?As for public health education in general, apart from posters and advertisementon the prevention of the spread of infectious disease, such as AIDS, tuberculosis, andcholera, public health education in Hong Kong is next to non-existent. Public ignoranceof the nature of disease compel many to adhere zealously to the practice of refusing to sitdown immediately after a seat on board a public conveyance has been vacated by astranger, for fear of catching venereal disease. Ignorance of healthy eating patternsresults in such erroneous beliefs in many people as "weight loss can be achieved byeating meat alone without any intake of cereal." When the significant others of post-stroke patients are called into the (public) hospital to attend a free one-hour lecture bya dietician on how to prepare low-sodium meals, it is often the first time they learn thatthe patients should have avoided such things as dim sum, roast duck, preserved duckeggs, and soya sauce for the previous 20 years or so (Ming Pao, 20 January 1991, 19).It is not unlikely, then, that the first time that most people in Hong Kong areinformed about clinical depression is after their significant others have survived asuicide attempt serious enough for them to be hospitalized for at least several days.Based on the information available on Hong Kong's medical and health services, their rolein suicide prevention is insignificant and inadequate.Welfare Services and Suicide Prevention in Hong KongHong Kong has never been a welfare state (Chow 1993, 92). Recent figures onHong Kong's income distribution indicate that while the richest 20 per cent of Hong Konghouseholds claimed 49.3 per cent of Hong Kong's income in 1971, the share of thepoorest 20 per cent of households amounted to only 6.2 per cent (Leung 1990d: 70). Atthat time, the common rationale cited by the government for its refusal to provide thekind of comprehensive welfare program found in many of the industrialized nations ofthe West was simply because such generous programs would add to the already large flowof refugees from China (Hodge 1981, 6-7).Opposition to the introduction of generous welfare benefits have come largelyfrom the business community, which denies the accusations that this is done for selfishmotives. Instead, business asserts that the opposition comes from its far-sightedrecognition that any increases in taxation for welfare funding would drive awaybusiness, which would then reduce trickle-down benefits (Hodge 1981, 12). Othermembers of the rich have voice opposition to any concept of giving away "free lunch"(Leung 1990c, 78). By 1991, the share of the richest 20 per cent in Hong Kong has45increased to 50.4 per cent, while that of the poorest 20 per cent has decreased to 4.6per cent. In spite of such glowing inequities, the Governor has reaffirmed recently thatHong Kong still will not become a welfare state (Chow 1993, 92). In sum, Hong Kong'swelfare policy is that of benign neglect, marketed in the rhetoric of stimulating self-help.Government and business have repeatedly asserted that any generous welfareprogram would erode Hong Kong's diligent work ethic (Chow 1981, 120-21). It hasalso been argued, however, that it is the lack of a social safety net that forces the poorinto low-wage labour with little job security and even dangerous working conditions forfear of economic hardship (Levin 1990, 94); it is their fervent struggle to survive thathas created this work ethic. An example of this culture of struggle can be seen from acommon Cantonese saying unique to Hong Kong: kou ting shou ting ( nr;aç )—the handcan only stop working if and when the mouth is willing to stop eating (Smart 1991,129). Moreover, this kind of fervent struggle has led to or increased economicindividualism, utilitarian familism, instrumental social relationships and a lack ofconcern for strangers (Lau and Kuan 1988; Figure 2).The Hong Kong Government, meanwhile, follows socioeconomic policies whichhave been described by many as laissez-faire, but also by others as a total absence of anyofficial ideology: the government merely "muddles through" by trial and error, beingcautious at every step to prevent or contain unrest, so as to enable it tax base—business—to prosper (Wong 1980, 65). In order to ensure an adequate supply of labourfor the smooth operation of business, the government has clearly been willing toredistribute some wealth in such areas as public housing, basic education, and basichealth and medical service. This is to say, the, that the basic welfare needs of the able-bodied can be met, by and large, through the government's basic social expenditures.It is when the needs of certain segments of the population exceed what thegovernment considers to be basic that a woefully inadequate picture emerges. WhileHong Kong does have a universal pension plan nominally, the amount of monthly benefitis barely enough for an elderly single recipient to pay for the rental of a bed space in adormitory-type flat.9 This kind of financial hardship forces many of Hong Kong's9In a Ming Pao (May 13, 1991, 4) news article on the killing of one old-age resident byanother in a senior-citizen dormitory located in a resettlement-estate-turned-old-agehome in the Sau Mau Ping District in northern Kowloon, it was revealed that both thevictim and the assailant were unemployed. Each of them survived on $725 (US $93) ofsocial assistance per month. The monthly charge for staying at the dormitory was $296(US $38) in rent for those who were physically able to shop for their own groceries andcook their own meals, and $893 (US $114) for those who required full bed and board.46elderly to continue working. For example, in 1986, 35 per cent of the poor elderlybetween the ages of sixty and seventy surveyed in a study were working, mostly in low-wage jobs (Chow 1990).10 Others work as self-employed scavengers in search of tincans and cardboard boxes left on the street by hawkers in an attempt to get spendingmoney, if not merely to stay alive.11 In the event that such a person is physically ormentally handicapped, additional benefits in the form of a disability pension can justbarely cover the extra rent charged for board by equally congested retirement or resthomes, many of which have waiting lists of up to three years (Ming Pao, 6 May 1991,7). Thrust together among strangers in their old age many to a room, "unrests" breakout in these poorly attended rest home just like they do in the congested and poorlyattended public hospital wards. For example, a man in his 705, probably suffering fromsome delusion, hacked a roommate with a cleaver without warning (Note 9; Ming Pao, 18May 1991, 5). The staff, obviously insufficiently trained to deal with suchemergencies, did not attempt to intervene. They stayed clear of the room in which theassault took place for the police to find the victim dead. In a similar incident a few dayslater, an argument between two old men in a similar type of "rest" home in the KwunTong District of Kowloon saw the victim seriously injured, and the assailant jump to hisdeath after the attack. The idiomatic headline dismissed the social significance of thistragedy by stating that the attacker had jumped to his death "because he was afraid of[legal] retribution" (Ming Pao, 18 May 1991, 5). The condition of the poor elderly inHong Kong can best be described by this observation by Chow:The elderly in Hong Kong today no longer hold a prestigiousposition in either the family or the society. In otherwords, filial piety, once regarded as the prime virtue inChinese culture, now plays only a minor role in family lifeand society in general. (Chow 1990, 167)The same study on the self-image of the elderly in Hong Kong from which the aboveanalysis was derived also revealed that 24 per cent and 43 per cent of those surveyed"agreed strongly" and "agreed", respectively, that they were just "waiting for death toThe 69-year-old assailant had unexpectedly become violent, and hacked the victim in his70s—one of the assailant's four roommates in a cramped room-13 times with a Chinesecleaver. The assailant was also reported to have had a history of epilepsy but not mentalillness, suggesting that a diagnosis of some form of psychosis might have been missed bypublic-sector health-care providers, or simply because the human resources requiredto take the assailant to a clinic for regular check-ups were unavailable.10See Nelson Chow, "Ageing in Hong Kong" for the growing need for public interventionin caring for Hong Kong's increasing elderly population.11See the budget of an unemployed elderly person presented in Note 9.4748come (dengsi^)" (Appendix 2; Chow 1990, 168). Such a gloomy view of life andthe overall deprivation of those dependent upon social services suggest that Hong Kong'ssocial services have been negligent in suicide prevention efforts.Summary of Prevention and Intervention PerspectiveThe suicide prevention and intervention perspective draws from the research ofall other perspectives, as well as from experiences in current prevention andintervention efforts, in order to prevent suicide. One of the most important means ofpreventing suicide is to increase the level of public awareness of clinical depression andsuicide among the public, medical practitioners, and social-service providers. The goalsof researchers and practitioners in suicide prevention are to prevent clinicaldepression, suicide ideation, and suicide attempts, using all available social,psychological, and medical resources. The literature on suicide prevention in Hong Kongis almost non-existent. Based on the sparse amount of literature on the provision ofmedical services, the relative abundance of literature on social services, and personalobservation made, on Hong Kong, it appears that Hong Kong lacks an adequate public andprofessional education program in depression and suicide.S urn maryThe literature reviewed in this chapter indicates that suicide is a complexuniversal phenomenon which cannot be explained thoroughly by any one theory or anyone type of study. Most psychological theories of suicide agree that clinical depressionand hopelessness are the mental and emotional conditions common in most suicides, andthat it is the difference in the ways in which individuals perceive their experiences thatrender some of them more prone to depression and suicide than others. Sociologicaltheories of suicide emphasize the relationship between socially induced stress—such asunemployment, poverty, migration-induced loneliness, and rigidity of social roles—andthe suicide rate of a society. Many of these research findings have contributed to anotherperspective in suicide research: suicide prevention and intervention. Researchers inthis perspective attempt to reduce suicide by putting to practice various measures whichmake individuals less likely to make suicide attempts and to complete suicide. Inparticular, suicide interventionists attempt to find the most effective and immediateways to alleviate suicidal pain—regardless of the causes of the pain. The findings fromeach approach are beneficial to the understanding of every aspect of suicide, whether itis causation, suicidal-proneness evaluation, or effective prevention and intervention.The understanding of suicide is enriched—and the prevention of suicide is made moreeffective—by multi-disciplinary research. The data on suicide for Hong Kong will bepresented in the following chapter; they will be analyzed using many of these multi-disciplinary research findings in Chapter Four.49This chapter begins with an introduction to the landscape of each of the threesubregions of the British Territory of Hong Kong. It will be followed by an explanationof the manner in which these data were obtained, as well as their limitations; it is hopedthat this information will ease data procurement by future researchers of suicide inHong Kong. The first set of data to be introduced will be the suicide data for theTerritory as a whole in order to provide an overall picture of suicide; these will befollowed by the suicide data for each of Hong Kong's three subregions: Hong Kong Island,Kowloon, and the New Territories in order to facilitate a spatial analysis. Aninterpretation of these data of all of these data will be made after all data have beenpresented. An analysis of these data, as seen from many of the various perspectives onsuicide presented in the literature review, will follow in the next chapter.Hong Kong's Socio-Economic Landscape In spite of Hong Kong's "miraculous" economic performance, the redistributionof social wealth is far from equitable. The ability of the poor in making thisredistribution more equitable is hampered by their lack of political power. Forced towork hard just to subsist, members of this large workforce has helped create what hasbeen presented in Chapter Two as the diligent work ethic of the Hong Kong people; theiracquiescence have also helped maintain the economic, political and social status quo.Although social welfare programs do exist, the unemployed and the unemployablemembers of Hong Kong society cannot expect public assistance beyond the level ofsubsistence; those who cannot count on the additional financial support of familymembers are likely to be waiting for death to come to them in the midst of economicprosperity for others.Hong Kong has a total land area of just over 1,000 square kilometres. (SeeFigure 3 for a map of Hong Kong.) This has result in a high overall population density ofmore than 5000 persons per square kilometre. Eighty per cent of this 1000 squarekilometre of land is considered to be too steep or otherwise too costly for residential orcommercial development. This uneven distribution of land suitable for residentialdevelopment has resulted in a highly uneven spatial distribution of the population of theTerritory. In 1981, 74 per cent of the Territory's population lived in the core urbanarea of Hong Kong Island and Kowloon. Furthermore, this core urban area populationwas not spread out evenly across Hong Kong Island and Kowloon; it was highlyconcentrated in areas on both sides of the harbour, whose total land area comprised only12 per cent of the total land area of all of Hong Kong Island and Kowloon. Moreover,numerous pockets of extremely high population densities, some measuring more than50100,000 persons per square kilometre (including one in north-central Kowloon with165,445 persons per square kilometre), could be found in the low-lying and poorersections of this urban core (Figures 4 and 5). Juxtaposed against some of these poorerneighbourhoods on Hong Kong Island and in Kowloon are some of the Territory's mostaffluent residential areas. It should be stated, therefore, that substantial variations ineconomic conditions exist even within each of these two subregions.Hong Kong IslandUntil the end of the 1960s, more than 80 per cent of Hong Kong population livedin the core urban area on the north shore of Hong Kong Island and the southern tip ofKowloon Peninsula (Lo 1986). Today, most government, financial, and corporate officesare situated in the core business area on the north side of Hong Kong Island. On the restof this thin strip of land on the north side of Hong Kong Island are a variety of low- tomid-income high-rise residential buildings, mostly in areas of extremely highpopulation density. Some of the Territory's most expensive housing is located high onthe north-facing hill slope above this coastal strip, as well as on south-facing slope ofHong Kong Island (Figures 6 and 7); both of these areas provide the kind of quieter andmore spacious living environment not found along the busy streets by the waterfront.A few public-housing estates were built in a few pockets of land within, and onboth extremities of, this narrow strip in the 1960s and 1970s. Hong Kong's stringentimmigration regulations in the 1980s have stemmed the flow of refugees and illegalimmigrants from China. This reduction in population pressure and the limiting of mostnew social housing projects to the New Territories have relocated much of theterritory's population of childbearing age to the New Territories. This reduced rate ofpopulation growth on Hong Kong Island enabled the government to rebuild, upgrade, orreplace many of these old, high-density housing estates on Hong Kong Island. By 1991,relatively few low-income housing estates remain on Hong Kong Island, and anincreasing number of privately developed (and higher-cost) housing complexes havebeen built. Coupled with a territory-wide declining birth rate throughout the 1980s,the population of Hong Kong Island has been reduced to a level which made it the lowest ofall three subregions in 1991.51Figure 3^Map of Hong KongCHINA.1wAEW TERRITOTuen MunNew Town100eocif44C0 1NRailways--F— New Towns1-1-1 Scale0 1 2 km53Figure 4^A typical lower-middle income apartment buildingin the core urban area of Hong Kond Island and Kowloon.Source: Max Lawrence, n. d. (a)54Figure 5^A typical low-income public housing estate.Source: Max Lawrence, n.d. (b)55Figure 6^Affluence: A role model for Hong Kong's diligent work ethic?Source:^R. Ian Lloyd, n.d. (a)56Figure 7^A not-so-private display of personal wealthSource:^R. Ian Lloyd, n. d. (b)KowloonMost of the Territory's night life activities are found on the Kowloon Peninsula,where "world class" hotels for the entertainment of the affluent, British-style pubs forthe ex-patroit community, sex-for-hire services mostly for heterosexual men, andopen air "night clubs" comprising whole streets full of food vendors and export-unfitmerchandise hawkers for those with low income are concentrated. Apart from thehomeless, most of the poor live in crowded tenement flats on the upper floors ofbuildings in the vicinity of the open air "night clubs" in southern and central Kowloon,as well as in the densely populated public housing in northern Kowloon (also known asNew Kowloon). Also found in northern Kowloon, however, is one small area with theTerritory's highest-priced real estate called Kowloon Tong.Most of the public housing in northern Kowloon comprised high-densityresettlement housing estates built in the 1950s and 1960s for the resettlement ofsquatters. During the period 1981-1991, some of these seven-storey resettlementestates were also upgraded, much like their public-housing counterparts on Hong KongIsland. This usually meant that elevators were installed in these buildings, that thenumber of residential unit in each building was reduced, that private kitchens andbathrooms were installed in each individual unit, and that the amount of rent charged toeach household has been increased to reflect the increased affluence of their former-refugee residents. This modest gentrification in Kowloon (as well as on Hong KongIsland) was also achieved by the promise of lower-density and higher-quality housing inthe New Towns in the New Territories to the more economically productive population.The buildings which remained "as is" became the shared dwellings for some of theTerritory's poorest members of society: single elderly people on social assistance anddisability pension who have waited for years to be assigned one such shared flat in whichto wait for death. Their less fortunate counterparts, on the other hand, await theirdeaths in the privately operated wired bedspace cages in other parts of northern Kowloon(Figures 8 and 9), while the least fortunate ones get by as street-sleepers.Lo and Leung reported in the mid 1980s that northern Kowloon was an areacharacterized by social disorganization, an area whose suicide rate-21.7 per 100,000among population aged 15 and over in 1985—was the highest in all of Hong Kong (Lo andLeung 1985, 291). In 1991, the size of Kowloon's population remained the higher ofthe two core urban areas. The density of the population in some of its districts remainedthe highest in the Territory. Its suicide rate has also stayed the highest of the threesubregions.5758Figure 8^Two cage "flats"Source:^C.W. Wong, 1992.Figure 9^A "cage man"Source:^C.L. Cheng, 1992.The New TerritoriesUntil the 1960s, most of the plains and valleys of the New Territories were usedfor agriculture, handicraft and construction-material production, while the coastalareas on the New Territories provided moorage, trading facilities, and services for thefishing population. The physical, social, and economic landscape of the New Territorieshave changed drastically since the late 1960s and the early 1970s, after the governmentintroduced a series of urban development programs designed to house Hong Kong's low-to mid-income residents in conditions less congested than those of the public housingbuilt earlier in the core urban area (Hong Kong Government 1981).This program called for the construction of high-rise residential apartments tohouse mainly nuclear families, industrial buildings, schools, and community centres, atthe sites of a number of coastal and inland market towns (Bristow 1989). The designs ofthese new towns were derived, to a certain extent, from the planned and self-containedtowns, called New Towns, which originated in post-War Britain (Bristow 1989; Leung1986). The program called for the public sector to provide most of the housinginitially, to be followed by private investment in industry, business, and additionalhousing, in the hope of attracting a variety of people to live and work in the NewTerritories (Bristow 1989; Leung 1986). The government had expected to disperseabout half of Hong Kong's total population of up to six million to the New Territories bythe early 1990s, so that the traffic, population density, and congestion in the core urbanarea could be reduced. It is obvious today that the goal of population dispersal wassuccessful, and that the promise of less-congested living space has been fulfilled: thehighest population density was only 31,575 persons per square kilometre in one of therecently developed New Towns (Lo 1986, 148). But the majority of the employed NewTown residents, especially those in higher-paid information and white-collar servicesector jobs, continue to work on Hong Kong Island and in Kowloon. This suggests that thegoal of self-containment has not been achieved in the New Towns (Bristow 1989; Leung1986).In the meantime, the changing economic structures of Hong Kong and China andthe increased trade between Hong Kong and China since the late 1970s have also changedthe landscape of those areas of the New Territories outside New Town boundaries. Theneed for goods storage space has transformed most of the New Territories' crop land andfish ponds to warehouses and truck-trailer parking lots. It is true that the loss of theNew Territories' young to the core urban areas and to emigration overseas is not a newphenomenon, but this accelerated modernization in the 1970s and 1980s has certainlyquickened the pace of physical, demographic, and social changes in the New Territories.60The transformation of the New Territories from a close-knit agricultural andfishing society to a more individualistic and urbanized society also brought various typesof pathogenic social conditions, such as social isolation, loneliness, and violence (Caritas1986), and teenage alcohol and drug abuse (Furlong 1993); the New Territories'suicide rate of 8.7 per 100,000 in 1954 (Yap 1958, Table 2) increased to about 12per 100,000 in 1991 (Figure 14).SummaryWith the highest population density still found in Kowloon, followed by Hong KongIsland, and then by the New Territories, the subregional rank order in terms ofpopulation density has remained unchanged between 1981 and 1991. The New TownProgram has succeeded, however, in changing the spatial concentration and distributionof the Territory's population, such that the New Territories has become the subregionwith the highest population in 1991, followed by Kowloon, and then by Hong Kong Island.For the period 1981-1991, a large majority of the households in the NewTerritories comprised a relatively socio-economically homogeneous group of young,low- to mid-income urbanites in conjugal relationships, who were more likely to becommuting to work in Kowloon or on Hong Kong Island than working in their own NewTowns. The inequity of Hong Kong's social-wealth redistribution is perhaps least visiblein the New Territories. By comparison, more variations can be found in the socio-economic characteristics of the residents of Kowloon. They range from the few affluentones in Kowloon Tong's garden villas, to the poor in dormitory cages nearby, and to thedestitute street-sleepers in alleys and staircases between "world class" hotels.Dormitory cages and street-sleepers could also be found in the urban area adjacent to theharbour on Hong Kong Island, though the overall economic condition of the population onHong Kong Island rendered it the most affluent of all three subregions. Many of thosewith middle income lived in relatively spacious flats in large, privately developed,apartment complexes, while the rich and senior government officials lived higher up onthe hill slope above the central business district, and in luxurious resort-likeapartment complexes, complete with uniformed security guards, on the south-facingslope of Hong Kong Island. Having provided this brief view of the socio-economiclandscape of Hong Kong as a whole and by its three subregions, the following section willintroduce and then examine the suicide data for the Territory as a whole, and those foreach of these subregions.61Data Limitations Four major types of data were used to compile the suicide rates used in thisstudy:1) The total number of cases of suicide for Hong Kong as a whole for eachyear between 1981 and 1991, inclusive, as provided by the Registrarof the Supreme Court in Hong Kong.2) The total number of cases of suicide for each of Hong Kong's threesubregions for the years 1981, 1986, and 1991, as provided by TheCoroner of Hong Kong.3) Census population data for each of the three subregions for the years1981, 1986, and 1991.4) Mid-year population estimates for Hong Kong as a whole for each yearbetween 1981 and 1991.Raw Suicide DataStatistics on the number of suicides were obtained in the following manner. In1991, two editions of Hong Kong Coroners Report—Hong Kong Coroners Report for theYear 1989 and Hong Kong Coroners Report for the Year 1990—were found in the libraryof the University of Hong Kong. Each of these publications contains, for thecorresponding year, four two-part tables of suicide data, one for all of Hong Kong, onefor Hong Kong Island, one for Kowloon, and one for the New Territories. The top half ofthe sheet for each subregion lists the number of suicides between January 1 andDecember 31 by age group, sex, and method in that subregion; the bottom half of thesame sheet lists the number of deaths resulting from "injury undetermined whetheraccidentally or purposely inflicted" between January 1 and December 31 by age, sex,and method in the corresponding subregion. In order to maintain consistency, only thosedeaths classified by the Coroner as suicide (and listed in the table at the top half of eachof these pages) have been counted in this analysis.Attempts were made to locate earlier editions of the Hong Kong Coroners Report,but it was learned that this publication did not exist prior to 1989. In December 1990,a phone call was then placed to the Coroner's office for the purpose of requesting suicidedata for years prior to 1989. The staff there indicated that all public inquiries werehandled only through the office of the Registrar of the Supreme Court. A phone call wasthen made to the Supreme Court Registrar's office, requesting suicide data for the threeseparate subregions "in a format similar or identical to that found in the Hong KongCoroners Report for the Year 1989 for as far back as possible." The staff there62indicated that something would be made available for pick up later that day. Uponexamination of the content of the envelope picked up later that same day, it wasdiscovered to contain only aggregate suicide data for Hong Kong as a whole for each of theyears between 1981 and 1991. A verbal request for separate data for each of the threesubregions was rejected due to "lack of manpower and undue expense to the public." Atthis time, it was also added that any additional requests be made in writing. A writtenrequest, which indicated a willingness to pay for overtime work at a "reasonable rate,"was then made and delivered personally to Mr. Julian Betts, the Supreme CourtRegistrar. A written denial, signed by Mr. Betts, was received three days later,indicating that no further assistance could be expected from him. A phone call was thenmade to the Samaritans—Hong Kong's crisis-intervention and service referral centre.Staff members there did not know where spatial suicide data for each of the threesubregions could be procured.In order to determine whether or not the total number of cases of suicidereported in any daily newspaper matched the number of suicide published in the HongKong Coroners Report, several weeks were spent examining three of Hong Kong's dailynewspapers for the year 1991. Only a handful of suicides were reported by the English-language daily South China Morning Post, and about a quarter of those published by theCoroner were reported in the Chinese-language daily Ming Pao : Hong Kong's daily readby academics.Although the numerical discrepancy confirmed that these newspapers could not beused as a statistical source, the number of suicides reported and details on these suicidesas mentioned in the newspaper reports led to some useful observations. For example,the majority of the cases reported by Ming Pao were completed and attempted suicides bythe young. In addition, the amount of detail in each report tended to be related to the ageof the suicide and the degree to which the attempt or completion was sensational: theyounger an attempter or completer was, the larger the size of the story and the greaterthe depth of its coverage. This is most noticeable either when a young suicide attempteror completer had created news-worthy footages by holding suicide-interventioncounsellors at bay from the edge of a roof for several hours (Figures 10 and 11), orwhen a fall from a great height provided a "picture-perfect" shot of mangled flesh andblood on the street. Conversely, elderly suicidal deaths were given very brief coverage,it at all (Appendix 3).6364Figure 10^A camera-ready suicide.Source:^T.Y. Lo, n.d.Source:^W.K. Yu, 1987.Figure 11^Another camera-ready suicide.In March 1992, a thorough examination of the government telephone listings inthe Hong Kong telephone directory revealed a potentially useful source listed as the"Senior Statistician of Social and Economic Statistics." A phone call was made to theswitchboard there to verify its mailing address. A written request for spatial suicidedata for the census or by-census years of 1971, 1976, 1981, 1986, and 1991 wasaddressed to the Senior Statistician of Social and Economic Statistics, who must have thenforwarded it to the Coroner. A speedy reply from Mr. H. Y. Lam (Clerk to Coroners) wasreceived. It contained spatial suicide data for the three subregions for 1981, 1986, and1991; Mr. Lam apologized that "this sort of statistics" have been kept only since 1981,thus limiting this study to the period 1981-1991.In sum, data on the number of suicides by age group, sex, and suicide method foreach of the three subregions of Hong Kong Island, Kowloon, and the New Territories for1981, 1986, and 1991 were provided through the assistance of Mr. H. Y. Lam in theCoroner's Court in early 1992, and through the referrals made by the SeniorStatistician. In relative terms, the Supreme Court Registrar was less helpful inproviding the spatial statistics needed for this study.Population DataAggregate population data for the years 1981-1991 were obtained from the table"Estimated Mid-Year Population by Age Group by Sex" in various issues of the Hong KongAnnual Digest of Statistics published annually by the Census and Statistics Department inHong Kong. Population data by age group, sex, and census area for the by-census year of1986 and the census years of 1981 and 1991 were obtained from government censuspublications, whose titles are indicated at the bottom of each figure. Although the elderlypopulation has been broken down into age groups of 60-64, 65-69, 70-74, and 75 andhigher in the 1986 and 1991 census data, the elderly population data published in the1981 census is available only as a single group of 60 and higher. In order to ensureconsistency and comparability, the oldest age group presented in this study will be theage group of 60 and over.Suicide Rate ComputationSuicide rates for each of the three areas of Hong Kong for 1981, 1986, and 1991were computed using this formula:Number of suicides during the calendar year divided bycensus population and multiplied by 100,00066Aggregate suicide rates for all of Hong Kong for each year, 1981-1991, were computedusing the formula:Number of suicides during the calendar year divided bymid-year population estimates and multiplied by 100,000Data Interpretation Like coroners in many Western jurisdictions, Hong Kong's coroner's officeclassifies all deaths brought to its attention under the four major categories of deaths: 1)natural causes, 2) accident, 3) suicide, and 4) indeterminate causes. Information on thedefinition of suicide used by the Coroner in Hong Kong was not available for this study.However, the centralized processing of Cause-of-Death verdicts should ensure a highdegree of uniformity in death certification among these areas.The data analyzed first will be the aggregate data for all of Hong Kong as a whole.These will be followed by a spatial analysis of the data for Hong Kong Island, Kowloon,and the New Territories.Suicide in Hong Kong—An OverviewFigure 12 indicates that the male suicide rate has remained consistently higherthan the female rate, and that a gradual increasing trend for both sexes is evident for theperiod 1981-1991 for Hong Kong as a whole. More fluctuations can be observed in themale suicide rate than the female suicide rate over time. A substantial increase can benoted in the male suicide rate throughout the early and mid 1980s. This is followed by asizeable decrease for two years, and then by a period of accelerated increase toward1991. On the other hand, the rate for females also shows a sizeable increase during theearly and mid 1980s, but has remained relatively stable since the mid 1980s. Overall,the suicide rate ranges from a low of just under 8 per 100,000 (for females in theearly 1980s) to a high of slightly over 15 per 100,000 (for males in 1991). Thesedata also indicate that the increase in the aggregate suicide rate in the period 1981-1991 resulted from a rise in both the male and female suicide rate.Elsewhere, Stillion et al. reported that three times as many men complete suicideglobally (Stillion et al., 1989, 17). Lester reported a suicide rate of 19.3 per100,000 for males and 5.1 per 100,000 in the United States for 1986 (Lester 1990,182-83), and and Hassan reported a rate of 11.4 per 100,000 for males and 7.7 per100,000 for females in Singapore in 1970 (Hassan 1983, 69). Yap reported a rate of16.3 per 100,000 for males and 12.0 for females in Hong Kong in 1954 (Yap 1958,679), a period when homelessness, unemployment, and starvation, that is, absolutedeprivation, were more prevalent than in the 1980s. The higher rate found in males isa gender-specific characteristic also found in the suicide statistics reported by mostcountries to the World Health Organization (Figure 1).Figure 13 reveals year-to-year fluctuations in the suicide rate for some of theage groups; it also clearly shows rate increases over time in each of the groups 20 yearsof age and over. Increases over time are especially pronounced for the older age groups,with the rate for the 60-69 rising from about 20 per 100,000 in 1981 to higher than25 per 100,000 in 1991, and that for the group 70 and over increasing from just over35 per 100,000 in 1981 to over 50 per 100,000 in 1991. Yap, Lo, and Leung alsofound that Hong Kong's suicide rate increased with age (Lo and Leung 1985, 288; Yap1958, 13).Elsewhere, Yampey stated that suicide among the elderly became more prevalentthan among the young in Buenos Aires as the size of that city's elderly populationincreased in the 1960s (Yampey 1975, 61). Rao also reported an increase in theincidence of suicide among the elderly in India; Rao attributed it to an increase in the thesize of the country's elderly population (Rao 1975, 237). McIntosh found that whilethe suicide rate among the 15 to 24 age group in the United States has increased inrecent decades to 13.1 per 100,000 in 1986, a suicide rate of 21.5 for those 65 andover for the same year was almost 50 per cent higher than the rate for the 15 to 24 agegroup (McIntosh 1991, 60-63). Hassan found that elderly ethnic-Chinese and ethnic-Indian people 60 years of age and higher in Singapore are six times more prone tosuicide than their counterparts 59 years of age and under (Hassan 1983, 61). Apartfrom a smaller peak in the suicide rate for those between the ages of 20 and 24, thesuicide rate for Japan also peaked among those 70 years of age and over (Iga 1986, 13,15; Iga and Tatai 1975, 255-56).These findings and the characteristics indicated in Figure 13 are consistent withthe finding that the rate of suicide completion increases with age in most countries(Durkheim 1951, 324-25; Hassan 1983, 60-62; Leenaars 1992, v; Lester 1991,73-77; Miller 1979, 1; Osgood 1986, ix; Stillion et al. 1989, 159; Yampey 1975,60; Yap 1958, 13). The elderly in Hong Kong not only have the highest suicide rate,those 60 and older—when classified as one single age group—also complete the highestnumber of suicides compared to all younger age groups. The elderly suicide rate did notdecrease along with the modernization and increased economic prosperity of Hong Kongbetween the mid 1950s (the period covered by Yap's study) and the 1980s; it has, infact, increased.681 81 614121086Per100,00087' 88' 89' 90' 91'0^I^I^I^I^I^1^1^1^1^i81'^82'^83'^84'^85'^86'Year42-7777°Per100,000 302040Figure 13 Rate of Suicide (by Age Group) for Hong Kong 1981-19916 0 — 5 0^10 ^0 ^81' 82' 83' 84' 85' 86' 87' 88' 89' 90' 91'Year4I"' 10 - 19-0- 20 - 29•1- 30 - 39•0- 40 - 4941"" 50 - 59-6,- 60 - 6970+Figure 12 Rate of Suicide (by Sex) for Hong Kong 1981-19914- Male^-0- Female .•- M & F69Source for both figures: Raw suicide data provided by HongKong Coroner's Court, see Hong Kong Coroner's Court1992. Population data from mid-year populationestimates, Census and Statistics Department, Hong KongAnnual Digest of Statistics 1990 and 1992.Spatial Variations Between the Three SubregionsFigure 14 provides a spatial breakdown of the overall suicide rate for Hong KongIsland, Kowloon, and the New Territories for the 1981, 1986, and 1991. It is evidentthat the suicide rate for all three areas has increased over time. The rate for Kowloon isthe highest, followed by Hong Kong Island, and then by the New Territories; this rankingorder is identical to that reported by Yap (1958, Table 2), and similar to that reportedby Lo and Leung (1985, Table 1). 12 .Accounting for gender (Figures 15, 16, and 17), rate increases over time arestill evident for all areas and both sexes. One exception is that the female suicide rate inKowloon decreased slightly between 1986 and 1991, though the rate for 1991 is stillhigher when compared to that of 1981. These figures also reveal that males have highersuicide rates than females in all three subregions and time periods; they also indicatethat the rate for females was consistently but only slightly lower than that for males forthis period.Figures 18 through 23 are then presented in an attempt to verify whether or notthis general increase is spread across people of all ages; they show the rate of suicide byage group for each of the three areas of Hong Kong Island, Kowloon, and the NewTerritories for 1981, 1986, and 1991, respectively. A comparison of the value of thex-axis of these six figures reveals that the value generally increases with age; thisindicates that the aggregate phenomenon noted earlier that suicide increases with age isapplicable to all three areas.More variations can be observed, however, in the ranking of the rates betweenthe three subregions. For example, for the 10-19 age group, the suicide rate washighest in the New Territories in 1981 and 1991, while the rate for Hong Kong Islandpeaked in 1986, but decreased drastically to become the lowest of the three areas in1991 (Figure 18). Meanwhile, the rate for Kowloon began at just below that for HongKong Island in 1981, increased to match that of the New Territories in 1986, butsubsequently fell back to its 1981 level. For this age group, the high-to-low rankingorder in 1991 was the New Territories, Kowloon, and Hong Kong Island (Figure 18).12Lo and Leung counted only incidence of suicide of those 15 years of age and above, andcomputed all of their rates using population figures of those 15 and over. Furthermore,spatial data were broken down into the four areas of Hong Kong Island (with a suiciderate of 17.6 per 100,000), Kowloon (10.4 per 100,000), New Kowloon (21.7 per100,000), and the New Territories (18.4 per 100,000) (Lo and Leung 1985, Table1)701986 1991161412108642o19814- Hong Kong.0- Kowloon'Mk New Territories1 986 19911816141210864201981- H. K. (M).0- H. K. (F)Figure 14 Suicide Rate (per 100,000) for Hong Kong Island, Kowloon,and the New Territories (1981, 1986, 1991)71Figure 15 Suicide Rate (per 100,000) for Hong Kong Island by Sex(1981, 1986, 1991)Source (for Figures 14-17): Raw suicide data from Hong Kong Coroner's Court 1992.Population data from the following publications by the Census and Statistics Departmentof Hong Kong. Hong Kong 1981 Census: Basic Tables (Table 1); Hong Kong 1986 By-Census—District Board Constituency Area: Population by Age (Area Tables for Hong KongDistrict Boards on p. 11, Kowloon District Boards on p. 12, and New TerritoriesDistrict Boards on p. 13); Hong Kong 1991 Population Census—Tabulations for DistrictBoard Districts and Constituency Areas: Population by Age and Sex (Summary Tables forHong Kong Island on p. 28, Kowloon and New Kowloon on p. 29, and the New Territorieson p. 30).50199119861 9812 52 0 -1 5•1 0Figure 16 Suicide Rate (per 100,000) by Sex for Kowloon (1981,1986, 1991)724- KLN (M)-0- KLN (F)Figure 17 Suicide Rate (per 100,000) by Sex for the New Territories(1981, 1986, 1991) 4- N. T. (M)-0- N. T. (F)1981^1986^19910811 86 9 1 '3.53 T^•2.521.510.5Figure 18 Suicide Rate (per 100,000) for the 10-19 Age Group for HongKong Island, Kowloon, and the New TerritoriesFigure 19 Suicide Rate (per 100,000) for the 20-29 Age Group for HongKong Island, Kowloon, and the New Territories731412106420 .•— HK-Or- KLN.0- NT8 1' 8 6' 911Source for Figures 18-23: Raw suicide data from Hong Kong Coroner's Court 1992.Population data from the following publications by the Census and Statistics Departmentof Hong Kong. Hong Kong 1981 Census: Basic Tables (Table 1); Hong Kong 1986 By-Census—District Board Constituency Area: Population by Age (Area Tables for Hong KongDistrict Boards on p. 11, Kowloon District Boards on p. 12, and New TerritoriesDistrict Boards on p. 13); Hong Kong 1991 Population Census—Tabulations for DistrictBoard Districts and Constituency Areas: Population by Age and Sex (Summary Tables forHong Kong Island on p. 28, Kowloon and New Kowloon on p. 29, and the New Territorieson p. 30).64208' 8 6 ' 9 1 '1 8 1 1 6 •1 41 21 08Figure 20 Suicide Rate (per 100,000) for the 30-39 Age Group for HongKong Island, Kowloon, and the New Territories7418161 4 ik 012108642o8 1 '•- HK-0- KLNm- NT86 9 1 'Figure 21 Suicide Rate (per 100,000) for the 40-49 Age Group for HongKong Island, Kowloon, and the New Territories4- HK.0- KLN.0- NTFigure 22 Suicide Rate (per 100,000) for the 50-59 Age Group for HongKong Island, Kowloon, and the New Territories752 52 0 1 51 04- HK.o- KLNNTo81^86^91Figure 23 Suicide Rate (per 100,000) for the 60 and Over for Hong KongIsland, Kowloon, and the New Territories4 035302520151050- HK-0- KLNa- NET8 1 '^8 6 '^9 1 'The pattern in Figure 19 reveals that the suicide rate among the 20-29 agegroup was was the highest in the New Territories in 1981; it then decreased for 1986and 1991, to the extent that the New Territories had the lowest suicide rate of all threesubregions for both 1986 and 1991. The rates for Hong Kong Island and Kowloon forthis age group were similar to each other in 1981 and were both lower than that for theNew Territories, but both exceeded that for the New Territories in 1986 and 1991. Thesubregional rank order for this age group was, in 1991, Kowloon, Hong Kong, and theNew Territories, which is identical to the aggregate picture.Figure 20 indicates that the suicide rate for the young middle-age people 30 to39 years of age in the New Territories was consistently the lowest. As for the twotraditional urban areas of Hong Kong Island and Kowloon, the rate for Hong Kong Islandwas slightly higher than the rate for Kowloon for both 1981 and 1986. While the ratefor Hong Kong Island remained stable for all the three time periods, it was exceeded bythat for Kowloon for 1991. The increase in the rate for Kowloon between 1986 and1991 brought, in 1991, a rank order for this age group identical to that of the aggregatepattern.The pattern for the older middle-age group (40-49 years of age) is that the ratefor the New Territories was the highest for both 1981 and 1986, but fell to the lowestof all three areas for 1991 (Figure 21). The rate for Kowloon was the lowest for 1981,but increased steadily to surpass that of Hong Kong Island in 1986, and those of bothsubregions for 1991. Again, the ranking of the suicide rate of the three subregions for1991 conforms to the aggregate order.Among those aged 50-59 years, the rate for Kowloon simply remained thehighest for all three time periods (Figure 22). The rates for the other two subregionsfluctuated somewhat, with the rate for Hong Kong Island being the lowest of the threesubregions for 1981. This was exceeded in the 1986 by a substantial rise in the ratefor the New Territories. Hong Kong's rate surpassed that of the New Territories again,however, as it began to rise while the rate for the New Territories fell between 1986and 1991. Once more, the spatial rank order for this age group is identical to that of theaggregate for 1991.Lastly, the suicide rate for those 60 years of age and higher was the lowest onHong Kong Island for both 1981 and 1986 (Figure 23). It rose, however, to a levelbetween those of the other two subregions in 1991. The rate for this old and the very-old age group in Kowloon was higher than that for Hong Kong Island in 1981 and 1986,but fell to become the lowest rate found in the three subregions for 1991. As for theNew Territories, its rate began from being the highest of all three subregions in 1981,76which was exceeded slightly by Kowloon for 1986 because the increase for the latter wasgreater than that for the New Territories. Between 1986 and 1991, the rate forKowloon fell slightly while that for the New Territories continued to increase. By1991, the old and the very-old in the New Territories not only had the highest suiciderate of this age group in all three subregions, they had the highest suicide rate for anyage group anywhere. Figure 23 also indicates that the high suicide rates among theelderly population demonstrated earlier in the aggregate data in Figure 13 is a result ofhigh suicide rates among Hong Kong's elderly population in all three subregions.Summary To summarize, Hong Kong's aggregate suicide rate increased between 1981 and1991. The aggregate suicide data reveal two patterns similar to those found in mostcountries: 1) the rate increases with age and 2) the rate for males is higher. Spatially,the suicide rate is the highest in Kowloon, followed by Hong Kong Island, and then by theNew Territories—except for the young and the elderly populations, whose rates werehighest in the New Territories. These statistical data will be examined further in thenext chapter, where a socio-spatial analysis of suicide in each of these three subregionswill be provided.77CHAPTER FOUR: ANALYSIS OF SUICIDE IN HONG KONG AND ITS THREESUBREGIONSThis section will analyze the suicide data presented earlier. Attempts will bemade to explain them in the context of the socio-economic environment of each of thethree subregions.Analysis of Suicide on Hong Kong IslandThe Territory's social, demographic, and economic changes, especially thosewhich have taken place on Hong Kong Island, have probably attributed to Hong KongIsland's relatively low suicide rate compared to that of Kowloon (Figure 14). In fact,the data in Figures 18 to 23 indicate that the suicide rate in 1991 for those 20 and olderon Hong Kong Island remained at a level lower than that for Kowloon, and higher than thatfor the New Territories. Even though the presence of the wealth of the Territory's smallhandful of rich households is most evident in this subregion, the relative affluence of themajority of people on Hong Kong Island reduces the likelihood of psychological malaiseresulting from a sense of gross self-inadequacy; this relative economic sufficiency andstability is probably a significant protection against suicide resulting from deprivationof basic material needs.Compared to those 20 years of age and older, the number and the rate of suicidesby those 10 to 19 years of age are both low. The small size of statistical sample forthose of this age group reduces the representativeness of the changes in its suicide ratebetween 1981, 1986, and 1991. Namely, was 1986 an unusually high year and 1991an unusually low year (Figure 18)? In any case, if the low rate for 1991 is typical ofthe early 1990s, it might be hypothesized that this rate also resulted from the generaleconomic affluence of this subregion. In particular, most of the people in this age groupare certainly to be students. The relative affluence of their elders increases thelikelihood that they can afford to hire tutors and domestic help. This should decrease theworkload and the level of stress and frustration on the part of the elders, who mightotherwise have to struggle long hours every day to make ends meet. It should alsoincrease their physical and emotional availability to their children, so that theirchildren would more readily approach them to discuss their social and academicdifficulties, rather than avoid them in guilt or shame for fear of parental rejection.On the other hand, except for the relatively stable rate for the 30-39 age group,increases over time can be observed in every age group 20 and over. Moreover, the rateof increase itself tends to accelerate with increases in age. For instance, while the ratefor those 20-29 increased by 15 per cent from about 10.5 per 100,000 in 1981 to78about 12.1 in 1991, the rate for the 60 and higher increased by 68 per cent from about22 per 100,000 to about 37 per 100,000 during the same ten-year period. This highrate of increase among the elderly population of Hong Kong Island suggests either that thehypothesized economic protection against suicide available to the young was not extendedto the elderly, or that the aggregate pain experienced by the elderly simply overwhelmedwhatever economic protection that was available to them. No spatial data is available onthe income of the elderly, but if the social and psychological condition of the elderlydescribed in Appendix 2 is representative of the condition of the elderly on Hong KongIsland, it can only be concluded that they walk a financial tightrope in the midst of theaffluence of others; their psychological state can best be described as feeling lonely,hopeless, useless, and disillusioned.Analysis of Suicide in Kowloon Except for the suicide rate among the 10-19 age group, the suicide rate inKowloon has increased for every age group between 1981 and 1991. As in the case ofHong Kong Island, the rate for the school-age population peaked in 1986, and thendecreased in 1991. In Kowloon's case, however, the decrease was not as substantial asthat on Hong Kong Island: the rate only went down to its 1981 level. Again, it can only behypothesized that a general Territory-wide increase in overall affluence and a decreasein the size of the households to which the young belong have reduced economically inducedstress among the 10-19 age group of Kowloon.This thesis of affluence, however, cannot be generalized to the middle-agepopulation, since worldviews and their socially and cognitively constructed means ofappraising their self-worth are more likely than not to differ from those of the 10-19age group. In other words, different sets of environmental stressors, as well as theirgreater vulnerability to physical and mental illness, can generate more stress for theolder individuals than for those of school age. The increase in the suicide rates for themiddle age groups in Kowloon, like that for similar age groups in other subregions,might be a result of a realization in their adulthood the inability to reach the goal ofaccumulation which they had set for themselves, a relative lack of interventionopportunities in the single-person and public-housing home environments, and agreater reliance on the relatively inefficient public health providers to detect, diagnose,and treat mental problems.Appendix 4, the account of an attempted suicide by a poor middle-age man in the"high-rise jungle" or urban Kowloon, provides an excellent example of cognitiverigidity, insufficient drug-addiction (and probably metal-illness) treatment (Figure7924), and inadequate early recognition of suicidal intentions by a good friend. Theunwillingness to partake of Hong Kong's meagre welfare benefits by this suicideattempter and Tsui Chun as described in Appendix 2 probably resulted from theirinternalization of the prevalent view in Hong Kong society that to accept welfare is toacknowledge one's failure and uselessness. This is also because the government, in nothaving enshrined in legislation most of the social services it provides directly orthrough subventioned voluntary agencies, has created the public perception the socialservices are charity rather than rightful entitlement (Jones 1981, xiii).The high suicide rate for the 60 and over in Kowloon, which increased from about30 per 100,000 in 1981 to about 34 per 100,000 in 1991, might be attributed to thelarge number of poor single people of this age group in this subregion. Although some ofthe world's highest-priced real estate is located in a very small part of northernKowloon (an area known as Kowloon Tong) with pseudo-English garden-city landscape,within a kilometre or two of it can also be found some of Hong Kong's highestconcentration of Hong Kong's poor, single, childless, and unemployed.Some of them went to Hong Kong from rural villages in nearby GuangdongProvince several decades ago in their prime. Having severed their emotional ties to aChina in political, social, and economic turmoil, they toiled as labourers or domesticservants in the Territory until they became too frail to work—never having earnedenough money to establish a family. Many of these residents sleep in congested bed-space units in high-rise flats in the Tai Kok Tsui area in northwestern Kowloon and theKowloon City area in north-central Kowloon. Each of these units is enclosed by meshwires designed to prevent theft of their scarce personal belongings by other residents.Most of the tenants of these "cages" are single elderly men. This high-density livingenvironment among strangers fosters tension and suspicion; it rarely creates goodwilland mutual support. The funds they use to pay for such accommodation come partly fromHong Kong's meagre universal pension, designed nominally to "thank" them for thedecades of services which they provided to society in their prime, but often dispensed tothem in a pitying manner that insults their dignity. For many, the funds also comepartly from doing odd jobs or from scavenging.Those who are too mentally ill or physically frail to supplement their pensionincome with their own labour, as well as those who have been evicted by the re-development of their bed-space buildings into higher-standard residential complexes,simply sleep under cardboard boxes in public areas. For the relatively healthy street-sleepers, the occasional near-freezing temperature experienced in Hong Kong duringpassages of cold fronts in the winter drives them to the warmth of community centres8081Figure 24^"Just another druggie who refuses to make money likethe rest of us." Graffiti at top reads "This way (left) to hell."Source:^K.M. Mak, 1991.serving as temporary street-sleepers' quarters in cold weather; for those who are toofrail or disorientated to find their way to a community centre, they become statistics ofthose frozen to death amidst the affluence of Hong Kong. In sum, poverty and illness inold age, as well as the absence of a socially supportive environment, are factors whichfoster or intensify the loneliness, depression, and hopelessness of the elderly inKowloon. These are likely the social and environmental factors associated withKowloon's high elderly suicide rate.It can only be hoped that the slight reduction in their suicide rate between 1986and 1991 was the beginning of a decreasing trend. If further studies can confirm thisencouraging trend, the trend might be attributed to the positive effects of the WelfareDepartment's outreach programs, which have been found to be more effective and lessdemeaning to their users (Chow 1990). If this is indeed the case, it can only be clear tothe government that more social service provided with dignity to the poor elderlypopulation is required to enable them to live in more humane conditions.Analysis of Suicide in the New TerritoriesExcept for the youngest and the oldest age groups, the suicide rates for the NewTerritories were the lowest of the three subregions in 1991. Moreover, the rates forthe 20-29 and 40-49 age groups have decreased between 1981 and 1991—a trendopposite to the trend for the Territory as a whole. The rate climbed for those in their30s, though only by 18 per cent from about 11 per 100,000 in 1981 to about 13 per100,000 in 1991.Members of these 20 to 49 age groups in the New Territories die as tragically asthose in the other subregions. An examination of the newspaper articles on suicide in theNew Territories for 1991 also revealed suicides resulting from stress, helplessness,and hopelessness, which were in turn precipitated or aggravated by such events as failedromance or by threats of loss of face made by loan sharks,13 as indicated by the tragedyof this family, originally from Kowloon, which had just been assigned a flat in a housingestate in Shatin New Town a year earlier (Ming Pao, 11 October 1991, 2). The wife andmother, a 35-year-old housewife addicted to gambling, lost money and then borrowedfrom loan sharks. When the creditor threatened her family for the non-payment of131he relative importance of saving face and avoiding shame (or maintaining a sociallyacceptable reputation) for the family or household in Chinese culture and Hong Kongsociety enables loan sharks to intimidate delinquent borrowers by threatening to post orspray-paint overdue notices on the doors of indebted households. It is hoped that theurge to avoid incurring shame would compel debtors to pay up.82several tens of thousands of dollars, a heated argument broke out between she and herhusband. She was stabbed over 30 times to her death by her husband, a man whomneighbours thought of as civilized and gentle. He then jumped to 10 floors to his deathfrom their high-rise housing-estate flat. Their two daughters subsequently complainedof nightmares, and were likely to be emotionally scarred for life (Ming Pao, 12 October1991, 4).Following the suicidal death of a woman in Tuen Mun New Town, a warning wasissued by the Tuen Mun District Board about the danger of lonely and friendless NewTown residents falling prey to the unscrupulous practices of loan sharks (Ming Pao, 25November 1991, 6). The Hong Kong Government, however, fell short of announcing anynew social policies designed to enhance the social cohesion of New Towns. Nevertheless,the relatively low rates of suicide of these age groups probably are a reflection of therelative affluence and socio-economic homogeneity of the New Town environment. TheNew Territories did not have as high a proportion of the destitute and struggling poor asthe core urban areas had in the period 1981-1991.Two disturbing trends of increase, however, are evident in the New Territoriesfor this period: the increase in the suicide rates for both the school-age and the elderlypopulations. They also reached levels which were the highest among the threesubregions. The school curriculum is standardized throughout the Territory. It islikely for many students in New Territories schools, however, to have moved to thatsubregion in recent years. They have severed their social ties with former classmatesand neigbourhood playmates, but have not yet established new ones. The relativelyunsupportive school environment, when coupled with their small families and parentsworking outside the home for long hours on most days, reduce parent-childcommunication and intervention opportunities should social, academic, or emotionaldifficulties arise. The suicide reported in Appendix 1 is typical of a suicide by a 10-19year-old in the New Territories.As stated earlier, the slighting of elderly suicides by the press imposes a sizeablehandicap to to the understanding of suicides by this age group in all of Hong Kong, butespecially in the New Territories: none of the 92 suicides by those 60 and older in theNew Territories were even reported at all by Ming Pao. Two hypotheses, however, canbe provided for the time being. First, the high rate might be a result of the urbanizationof areas which have become new towns; this process increased the number andproportion of elderly people who have been physically or emotionally neglected bychildren who were employed for long hours in Kowloon or on Hong Kong Island. Thesecond might be that the en-masse conversion of agricultural village land into concrete-8 3filled shipping-container parking plots, the depopulation of the peripheral areas of theNew Territories, and a large-scale emigration of the young contributed to theabandonment of the elderly long-time residents of the New Territories. It is likely,then, that these factors, along with the absence of younger family members to detectdepressive symptoms, might have contributed to elderly suicides in the New Territories.Although the tragedy reported in Appendix 5 is not a suicide, it nevertheless provides aglimpse of the plight of one elderly couple in the New Territories. The scarcity ofnewspaper reports to account for the group with the highest suicide rate in theTerritory suggests that this vacuum needs to be filled by case files from the Coroner.Analysis of Suicide by Age Group The statistical evidence presented so far indicates that suicide rates haveincreased for most age groups between 1981 and 1991 in all three subregions of HongKong. Judging by the suicide completers' home addresses and their suicide locations asreported in Ming Pao for 1991, it is clear that a large majority of them had low tolower-middle socio-economic backgrounds. Assuming that the newspaper reports wererelatively representative of all of the suicides in Hong Kong that year, it can betentatively concluded that economic stress in the household played a significant role increating, increasing, or maintaining the overall level of psychological stress among thesuicide completers in all three subregions.Among older and poorer single adults, prolonged economic stress can directlyincrease their level of psychological stress, which makes them more vulnerable tofeeling depressed, particularly if they are chronically ill or disabled, and are forced todepend on Hong Kong's meagre pension and welfare handout for their subsistence. Underthese conditions of extreme relative economic deprivation, physical and financialhelplessness, and the loss of hope that their condition would ever improve, one additionalstressor—such as the death a close friend or the eviction from a familiar residentialenvironment to make way for the profit of affluent investors—could lead to suicideideation. Ideation develops into suicide attempt without adequate social and medicalintervention. Based on the literature reviewed so far, it is clear that both types ofintervention are kept to a minimum by the lack of concern for others in modern HongKong, by the unsupportive residential environments of cage flats and "rest" homes, andby the unintentional neglect on the part of the overworked personnel of Hong Kong'sunderfunded and inefficiently operated social and medical services. When this type ofattempts become completions, they become contributions to statistics of what Durkheimcalled fatalistic suicide.84Among middle-age adults in Hong Kong, prolonged economically induced stress isless likely to result from severe financial deprivation. For those working as busdrivers, office clerks, or junior bureaucrats, wholesale internalization of Hong Kong'ssocial norm of fervent accumulation can result in, or strengthen, an insatiablecompulsion to measure self-worth in terms of the wealth accumulated. This can in turnlead to or strengthen a perpetual cognitive perception of imperfection or personalfailure. The perennial urge to become successful by such measures can easily lead tosuch risky financial ventures as race-track gambling in Hong Kong, or pawning andlosing one's return jetfoil ticket in the casinos and dog track of Macau. In an attempt torecover from the "bad Luck" or simply to procure the lost food and rent money for thefollowing month, many such risk takers turn to borrow from loan sharks. Interest onthese loans compounds quickly when repayment cannot be made quickly. When extendedperiods of non-payment results in the harassment of the debtors family members byloan sharks, tension and more stress develop among household members. The heatedarguments which ensue, and the reluctance of newly and barely acquainted neighbours tomeddle in the affairs of strangers, can often precipitate the suicide of individuals whoalready feel helpless and hopeless in ever recovering from their shame and failures. Thesuicide by these individuals—individuals unsure of the meaningful ways in which tomeasure their success or self-worth—results in what Durkheim called egoistic suicides.On the other hand, it might also be said that these are anomic suicides, in that they occuras a result of the badly tolerated burden of financial loss by people accustomed to ahigher standard of living.Among the school-age population of Hong Kong, prolonged economically inducedstress on the part of their adult family members can also lead to psychological stress.The adults' struggle for basic material needs and for relative materialistic gains (for theenhancement of their own prestige) often requires them to be physically absent fromhome for long hours; this absence reduces their emotional availability to their children.This can lead to their children feeling distanced from and outright contempt for theirparents, as well as feeling lonely, rejected, helpless and depressed. Being at adevelopmental stage in which peer approval is eagerly sought for and highly valued, apublic scolding by a teacher for a missed assignment or humiliation by peer-groupmembers in school can aggravate these negative feelings enough to produce suicideideation. This can materialize into an attempt when overworked adults at home, ignorantof depression and suicide themselves, dismiss their children's wish to be dead asmanipulative whining or downright trivial. It might be argued, from a classical85Freudian perspective, that these suicides occurred when the hatred felt by Hong Kong'semotionally abandoned children for their parents are turned in the 180th degree.SummaryThe statistical evidence available to this study indicates that suicide rates haveincreased between 1981 and 1991 for all age groups in Hong Kong as a whole, and for allage groups in each of Hong Kong's three subregions. Furthermore, this evidence alsoindicates that the level of the suicide rate for each subregion remained in the same rankrelative to the other two subregions, with Kowloon having the highest rate during thisperiod, followed by Hong Kong Island, and then by the New Territories. In other words,the same pattern of spatial variations in the suicide rates between the three subregionsremained throughout the period 1981-1991.While the rank among these three subregions did not change, it is important tostress that the steady increase in the New Territories' suicide rate during this periodsuggests that the kind of social organization structure which kept its suicide rate low—ashypothesized by Yap in the 1950s—was no longer in place in the modernized andurbanized New Territories of the 1980s. This is to say, then, that the New Territoriesprovided a greater degree of protection against suicide for its population in the period1981-1991 in relative, but not in absolute, terms. Based on these statistical data andthe news reports in Ming Pao, it has been suggested that this relative degree ofprotection resulted from the relative economic sufficiency and socio-economichomogeneity of its population, and that the absolute increase in its suicide rate resultedfrom the increased anonymity and the decreased social support in the physical and socialenvironment of an urbanized New Territories. As for the other two subregions, it hasbeen hypothesized that their rates remained higher by comparison because theycontained a higher proportion of the Territory's elderly poor population, many of whosemembers lived in an economically deprived, socially unsupportive, medically neglected,and psychologically stressful environment.Furthermore, it has been argued that the economic factor was the mostsignificant factor in directly causing or indirectly developing suicide ideation inindividuals of all three subregions, and that certain socio-economic factors foundthroughout the three subregions for the period 1981-1991 significantly affected theavailability of suicide intervention opportunities in all of Hong Kong. From a suicideprevention and intervention standpoint, these findings suggest that the causes of suicidein Hong Kong are more similar—rather than varied—across space: an economic policywhich promotes the fervent accumulation of wealth for its own sake, a culture of86extreme selfishness, and a social policy which neglects and discards economicallyunproductive members of society.87CHAPTER FIVE: DISCUSSION AND CONCLUSIONIt is assumed that all humane societies are willing to reduce the prevalence ofsuicide, and that all willing societies, as long as their basic needs of food and shelter arebeing met, are capable of reducing suicide. It is also argued here that an economicallyaffluent society like Hong Kong can afford to modify the social, economic, andenvironmental conditions of society in order to reduce suicide. Even though depressionand suicidal deaths can never be completely prevented in Hong Kong, a number of socialactions can be undertaken to reduce suicide in Hong Kong. This section contains asummary of some of the causes of suicide in Hong Kong. It also includes some of themeans by which suicide can be reduced in Hong Kong.At present, the quality of the nominally "free" universal medical services doesnot reflect what an economically prosperous Hong Kong can afford to provide. Theinefficient operation of outpatient clinics force them to ration consultations, thusrequiring the sick to stand in line at dawn to "take a number." This practice discouragespoor people without a visible life-threatening condition—which usually means aphysical illness—from seeking medical aid; it can only be too effective in deterring thosewho are depressed and suicidal from seeking medical treatment. Even if contact is madewith the medical system, the oversubscribed facilities keeps to a minimum the amount ofinterview time, and the low morale among the professionals reduce their sensitivities tothe needs of the patient, both of which can easily result in a missed diagnosis ofdepression.The underdiagnosis of clinical depression among the Chinese in Hong Kong is alsocaused in part by the absence of the concept of clinical depression in Chinese culture. Ithas been a long-standing policy of the colonial government to allow Chinese culturalcharacteristics and social institutions to co-exist with Western ones for as long as theformer are not deemed to be detrimental to the interests of the government. One of theChinese institutions which has been allowed to exist is the unregulated practice ofChinese medicine. It is not the intention here to argue that Western medicine isabsolutely superior to Chinese medicine; it important, however, to point out thatclinical depression is not recognized as such in Chinese medicine. The absence of itsexpression in popular Chinese language and the expression of its symptoms inpsychosomatic terms enable the the Chinese in Hong Kong to avoid telling others openlythat they have a "mental illness," which in Chinese culture can be attributedpejoratively to wrongdoings in the past lives of the sufferer or their ancestors. Whilethe concealment of depression by psychosomatic terms allows the depressed and theirfamily to keep their condition from being known by people outside the household, it88reinforces the stigma attached to depression, increases the misunderstanding ofdepression, and encourages public avoidance of the depressed. The negative attitudetoward the depressed taxes heavily on the coping resources of families with a depressedmember, which may in turn cause caregiving family members under stress to expressanger and frustration at the depressed. Feeling unwanted by their family, avoided by thepublic, and rejected by doctors, the depressed are likely to internalize their suffering,resulting in a strengthening of their belief that they are indeed a useless burden to all,which is one of the major precipitating factors of suicide, especially among the elderlyor the terminally ill.It is reasonable to argue, then, that Hong Kong's public medical services—usedmostly by those who cannot afford private-sector medical care—are inadequatelyequipped to detect depression among the poor. Changing Hong Kong's source-specificuniversal health-care system to allow a covered person access to any doctor shouldincrease accessibility to medical care for more people. It should also increase theincentive for doctors to see, as well as get to know, their patients, thus increasing thelikelihood of detecting depression and any potential suicide plans. Still, whether or notimprovement in medical service occurs soon—as a revamping of the public health careservice in 1992 was designed to achieve, a relatively low-cost way of reducing suicide,for the time being, is to increase the awareness of clinical depression among doctors andnurses, and to reduce any reluctance on their part to ask depressed patients specificallywhether or not they are suicidal.At the same time, it must be emphasized that health care comprises more thancorrective medical care, and that the detection of depression and suicide plans must bethought of as a last line of defence in suicide prevention. Long before the elderly developsevere clinical depression, the sense of uselessness, and the feeling of hopelessness,steps should have been taken to prevent these negative conditions from having arisen inthe first place. It is not that loneliness and widowhood in old age were unknownphenomena in Chinese society. Rather, they were probably perceived by many of today'selderly in Hong Kong as conditions associated with a poor China "in the bad old days,"conditions which inspired them to move to Hong Kong in the first place. Having arrivedin a capitalist and consumption-oriented Hong Kong at the prime of their life, most ofthem were able to work hard, and to enjoy a comparatively comfortable lifestyle thelikes of which was beyond their imagination. They were probably unaware, however,that the same social and family social network on which most of the elderly in China haddepended could not be transplanted to Hong Kong. Dazzled by the government's subtlecivic-pride campaigns, such as its promotion of Hong Kong as the shoppers' paradise and89the culinary heaven, images of spending their old age alone—rather than among well-acquainted neighbours and respectful grandchildren—were probably beyond their mostvivid imagination. It is therefore important that the social consequences ofindustrialization and de-industrialization, the emigration of the young, the prevalence ofthe nuclear family, the widespread use of technology in everyday living, must not onlybe recognized by today's planners, they must also be materialized in actions designed toalleviate the negative outcomes of what might be called the "obsolescence of the elderly."To begin, the public must be taught that welfare is a right, not charity. Theamount of pension paid to the elderly must then be increased from the current level,which is just a little more than what an elderly person pays in rent for a bedspace in acage flat. This is because increasing the income of the elderly can reduce their feelingsof being a burden, and increase their sense of independence, productivity, and self-worth. In addition, instead of inducing the elderly to search in vain for physical andemotional security from the ideal child instilled with Confucian "family values," acampaign which suggests to the elderly that living alone is the norm, rather than theexception, needs to be introduced to prepare the aging population against disappointmentand psychological devastation. Of course, this campaign must be accompanied byincreased social expenditures on the expansion of community, social, health, andrecreational services for the elderly. This will enable more of Hong Kong's aging peopleto reduce their fear of losing face just because they are establishing a social networkamong strangers, rather than counting on the existence of the idealized version of thecaring and respectful offspring. The cost of these programs will necessarily beshouldered by the young, especially the affluent young. Even if funding must come fromtax increases instead of wealth redistribution, it is not difficult to market such asincrease in laissez-faire capitalist Hong Kong. It needs only be suggested to the publicthat such an increase represents a shift of the costs of caring for the aged from the handsof the young and busy members of society, to an account designed to provide "world class"old-age care designed specifically to allow the elderly to live in dignity, and to free theyoung to accumulate more wealth or capital for themselves.A social program like this one probably will not quell the zeal and anxiety amongthose middle age people who have already learned, through early social conditioning, tomeasure their self-worth and social status solely on the basis of their ability to increasetheir personal holding of capital and material wealth. The security provided by such aprogram for Hong Kong's senior citizens can, however, reduce the anxiety among themiddle age people who, fearful of financial insecurity in their old age, are caught up inhigh-risk financial venture, or are simply over-exerting themselves to the detriment90of of their own and their family members' physical and emotional health. Having hadsome of their fears for the future alleviated, the middle age will be more physically andemotionally available to their aging parents. Increased face-to-face contact can in turnreduce the loneliness and helplessness experienced by the elderly, and the likelihood ofdeveloping depression among the elderly. The middle age will also have more timeavailable to themselves, which can enable them to pursue less stressful, spirituallyrewarding, and socially productive activities. This will reduce their own vulnerabilityto anger and the development of any pathological perception of failure and hopelessness.They will also have more emotionally constructive moments with their spouse andchildren. This will enable them to enhance the intimacy of their relationships amongeach other, be more accessible to those members who experience academic- or work-related stress, and be more readily available to those who might have become frustratedor depressed.Lastly, the amount of pressure which they exert on their children to succeed vis-a-vis other children will also be reduced, thanks to the reduction of their own fears ofhaving to depend on their children's financial and emotional support in later years. Thiswill decrease the likelihood of their children developing pathological perfectionism,helplessness, and depression.The factors which can improve the mental health of the people of all age groups inHong Kong are as multi-dimensional as those which can worsen it sufficiently tointensify depression and to lead to suicide. Suicide results from an extensiveculmination of social and psychological factors, and deconstructing these social andpsychological conditions is a lengthy but not impossible task. Collectively, Hong Kong isa society affluent enough to enable all of its citizens to meet their basic needs. Whetheror not they can meet their emotional needs, such as care, understanding, and dignitywill, of course, be dependent upon the spending priorities of the present and theincoming government.91Appendix 1A teenage suicide in a New Town in the New TerritoriesThis report on the suicide of a 14-year-old student at her public-housing flat in a New Town inthe New Territories reveals a moralizing and resigned editorial tone, implying that "its just toobad that another tragedy as sad, unpreventable, and unpredictable as this has happened again."The views expressed by the school principal is slightly more encouraging, though he did notappear to know that moralizing about the preciousness of life to depressed and suicidal cannotalleviate their depression and suicide ideation. His attitude of leaving all suicide preventionwork to the experts indicates his ignorance of the crucial role of social support in suicideprevention. Note the extended absence of busy double-income nuclear-family parents, bothstruggling to make ends meet by working in relatively low-wage jobs. Also note suggestions ofthe suicide's pathological perfectionism, and the school's misinterpretation or missedinterpretation of the suicide's decline from top rank to 15th place, which probably resultedfrom cognitive distortion, inability to concentrate, and interruption to regular sleepingpattern—all symptoms of clinical depression.Dissatisfied With Declining School GradesFemale Form 3 Student Dies Tragically After Fall From BuildingNumerous child suicide cases have taken place since the beginning of this month; this ill windshows no sign of abating. Another such suicide happened this morning, this time to a female 14-year-old Form 3 student at Po Lam Estate in Junk Bay. The student died immediately afterhaving fallen from building. No suicide note was found, but the death is thought to be related toacademic problems. The school principal has indicated that guidelines set by the EducationDepartment will be adhered to; namely, all students will be duly notified of the death, and timelycounselling services will be provided.Dead is Chan Fung Yee, aged 14. Chan lived with her family in Hong Lam Building in Po LamEstate. Chan's parents are both employed in the restaurant business. Chan was the eldest of fourchildren; Chan had two younger sisters and one younger brother. Chan was enrolled in Form 3in a Protestant school in the Estate. As usual, she left home for school in her school uniformthis morning at about 7:30. She was found shortly afterwards, however, lying in a seriously-injured condition on the ground floor of her building. Upon notification, police arrived to rushher to hospital, but her life could no longer be revived. Police believe she had fallen from a highplace. While investigate along the staircase, police found the school bag of the deceased on the21st floor. Afterwards, police contacted the family and the school of the deceased.Based on information provided by Mr. Lau—the principal of the school attended by the deceased,Chan had maintaining herself as one the highest-ranking students ever since she enrolled in thatschool in Form 1. Although her academic performance had fallen somewhat during the currentacademic year, she still ranked about 15th among the 200 or so students of her grade. Chan hadfrequently expressed anxiety over her grades, so it is believed that this tragedy is related tothis matter. The principal stated that ever since directives from the Education Departmentwere received last month,the school has increased the amount of counselling to students, and hasbeen emphasizing the preciousness of life in school assemblies. Accordingly, the school intendsto notify all students of this incident, and will be providing the necessary guidance andcounselling. Meanwhile, Chan's father blamed himself. He added that both he and his wife havebeen compelled to work long hours every day in order to make a living, and he feels that theymust have neglected the duty of looking after their children.Source: Sing Tao Daily (British Columbia ed.), 19 January 1993.92Appendix 2Go kick the bucket, now! Ni kuai dian-er Si! (4itnk9d3t!)This special report on the social and economic conditions of Hong Kong's elderly peoplereveals some of the negative financial and psychological pressures experienced by one ofHong Kong's many single elderly women. In spite of the meagreness of the welfaresupport to which they are entitled, some tend to refuse it because they perceive it ascharity rather than entitlement.Cursed to Death by Her Vicious TenantTsui Chun Really Wants to Die SoonMs. Tsui Chun is 87 years old. Other than one younger sister, the rest of her familymembers all died during the Japanese occupation of Hong Kong [between 1941 and1945]. The two sisters have had only each other to lean on for almost thirty years, thatis, until the sister also left this world. Tsui Chun lives alone in a residential unit in aprivate building of the old type [the dark and dingy type constructed before the War] inthe Kennedy Town district on Hong Kong Island. That unit is partitioned into three roomsand eight bedspaces. She rents one of the three partitioned rooms, and ekes out a livingby renting out, or subletting, two bedspaces to two tenants and by collecting pensionsubsidies.Tsui Chun's financial condition is just sufficient for her to fill her mouth. She said,however, "I've eaten food that's been leftover [unrefrigerated] for as many as four days."She said that she was not happy in the 20 or so years that she has lived there. In fact,she has often been abused by others.She stated, for example, that administrative and maintenance charges for the building iscollected on the 20th of every month. Once, one of her tenants went away from HongKong, and stayed away till after the 20th of that month. When she attempted to collectthe overdue fees, the tenant insisted that it had been paid on the 20th. An argumentensued, and her opponent insisted that Tsui Chun kneel on the floor and swear in thename of her family honour before she would pay. And so Tsui Chun did it.She said that the same tenant, when praying to Buddha, frequently cursed Tsui Chun, andurged god to take her back to the western heaven as soon as possible.Tsui Chun rarely converses with her neighbours. She said, "If I had a bowl of congee, Ican take it to my neighbours. But what do I have. If all I tell my neighbours every day isa bellyful of my anger, even if I don't think that's too troublesome, they will certainlyget fed up with me!"Tsui Chun rarely participates in senior citizen activities. She said that other seniorslike to go there because they know that the activities there are free of charge. Shewondered if they would keep on going if a charge is made for the activities! She said it isprecisely because they are free that she refuses to participate."When asked if Tsui Chun had a wish, she replied, "I'd like to die soon."Translated from: Ming Pao, 16 December 1991. 3.93Appendix 3The brevity of this report on two elderly suicides is typical of the length of reports onelderly suicides. Its tone implies that suicide resulting from chronic illness in old age isinevitable and unpreventable. It also fails to suggest that being tired of and depressed bya lack of social life and social support—rather than being tired of living—are more likelyto be the causes of these suicides. For arguments and prevention against "rational"suicide by or euthanasia for the terminally ill, see Joseph Richman, "A rationalapproach to rational suicide."Tired of Life Due to IllnessTwo Old Men Over 70 Leap to DeathFed up with life due to illness, two old men jumped to death in two separate incidents onHong Kong Island yesterday morning.One of the dead was 73-year-old Mr. To who, afflicted by kidney disease, had to enterhospital for treatment last month, where he stayed until four days ago. Having returnedhome to rest, it was suspected that he became tired of living. At 10:30 A.M. yesterday,he waited for the moment when his wife was not paying attention to leap out of thekitchen window at a residential unit on the 13th floor at 4 Park Road on Hong KongIsland. Residents nearby noticed the fall, and contacted police to have him rushed tohospital, at which time he was certified dead. When news of his death reached his wife,she was so shocked and saddened that she lost consciousness, and had to be sent to hospitalfor a check-up.The second dead old man was 79-year-old Mr. Yung Yan Tak, who lived with familymembers in a flat on the 9th floor at 151 Jaffa Road in Wanchai on Hong Kong Island. Ithas been learned that he was ill. At about 11 A. M. yesterday, his 39-year-old daughternoticed that he jumped out of the back of their residence, and landed in the alley behindthe apartment building. She immediately notified Mr. Man, the watchman of thebuilding, who in turn contacted police. Mr. Yung was rushed to hospital, butunfortunately could not be revived. Family members were extremely saddened by thenews of his death.Translated from Ming Pao, 2 January 1991. 6.94Appendix 4This man could easily have died and become another suicide statistic for Kowloon in1991. As it was, social intervention came too late, and he was only saved by technologyand the "precision" of his fall. There is hardly any evidence to suggest that he wouldreceive sufficient social and medical assistance to prevent him from making anothersuicide attempt. He is another example of a Hong Kong residents who has internalized thesocial norm that receiving welfare is receiving charity and is, therefore, a confirmationthat one is a "loser." His rejection of such a label and the inadequate help he receivesmade him one of the many street-sleepers amidst the open-air "night club" district ofKowloon.Thought to Have Incurred Debt to Loan SharksIndebted Man Slightly Injured After Fall from 19th FloorA 41-year-old man, suspected of owing large amounts to loan sharks and of robberywith violence, jumped from the roof on the 19th floor of Man Wai Building in the JordanDistrict [of southern Kowloon] yesterday. Before this, negotiation experts, reporters,and a good friend persuaded him to the point of exhaustion—to no avails—for four hours.Fortunately, the air mattresses placed on the ground by fire services enabled him toescape with only minor injuries.While negotiation experts were in the process of persuading this man at Man WaiBuilding yesterday, he asked to meet with a news reporter, to whom he narrated a littlestory. He stated that he borrowed $2,000 [US $250] from a loan shark about three orfour years ago at the request of a friend who needed money. But this friend did not havemoney to pay him back, so he ended up owing the loan shark $40,000 [US $5,000] inprinciple plus interest. He has also been beaten on numerous occasions, and hasrequested help from police, but police refused to handle the matter.While on the roof, he also revealed to the negotiation experts and the police, that herobbed and hit the head of an old man in the pedestrian tunnel at the intersection of ChingPing and Tung Kun Streets at about 10 A. M. yesterday.After investigation, police confirmed that a 75-year-old man, Mr. Sun X Chuen wasrobbed in the pedestrian tunnel at the intersection of Ching Ping and Tung Kun Streets atabout 10 A. M. yesterday; his head was hit and injured.14 Subsequently, police believedthat Mr. Lau Shek Chuen was involved in this robbery.At about 10:30 A. M. yesterday, Lau Shek Chuen went to a restaurant on the ground floorof Man Ying Building in Jordan District to look for his good friend Mr. Lau Yiu Ho (38years old). After having chatted harmoniously for a while with his good friend, hesuddenly announced to Lau Yiu Ho, "Someone's cornering me, 'So what if I stumble on thestreet and die; it's no big deal for me to jump off a building and die."At the time, Lau Yiu Ho did not give the matter any thought, and did not pay any attention.thereafter, he left his seat to get some dim sum.When Lau Yiu Ho returned to his seat, Lau Shek Chuen had already left the restaurant, soLau Yiu Ho went out of the restaurant to look for him. When Lau Yiu Ho reached Man Wai14..x.. is a common device used by the Hong Kong's Chinese press to indicate that the fullname or address of a victim, witness, or suspect has been omitted intentionally.95Building by way of Man Ying Building, he saw a large number of police and firepersonnel racing to the scene. At the same time, he heard from bystanders that someonewas trying to jump from the roof of Man Wai Building.After checking with police at the scene, Lau Yiu Ho was able to confirm that the manattempting to jump from the roof was his good friend Lau Shek Chuen. Subsequently, heasked police for him to be allowed on the roof to persuade Lau Shek Chuen. But he wasrefused by police.After a few detectives and non-Chinese police officials saw that Lau Shek Chuen wasstanding on a metal cover which extended beyond the concrete edge of the building on theroof, they deemed the situation extremely dangerous. They then immediate notified firepersonnel to set up some inflated foam-cushions on the street, and negotiation experts togo there to persuade Lau Shek Chuen.Three negotiation experts took turns in persuading Lau on the roof. At one point Lauasked to meet with a reporter, in order to pour out his bitter predicament.Simultaneously, he even at one point raced toward the edge of the roof, and wanted tojump right over. Witnessing this critical scene, the negotiation experts immediatelyuttered for him to stop. He finally obeyed, and returned to stand on the metal cover.At 1:45 P. M., police arranged for a reporter to arrive on the roof, and allowed him tostraddle one set of fences, in order to persuade Lau Shek Chuen to return to the roof.While the reporter was attempting to persuade him, he asked for the reporter's presscard and business card to examine. While persuading him, the reporter even passed acigarette to him.At 2:45 P. M., Lau accepted the reporter's persuasion, and walked from the metal coverback towards the roof, but he wanted a certain distance be kept between them.At the same moment, his good friend Lau Yiu Ho obtained permission from a fireman atthe scene to go to the roof to try to persuade Lau Shek Chuen. When Lau Yiu Ho arrivedon the roof to persuade Lau Shek Chuen, he asked to negotiate in private with Lau Yiu Ho.Police subsequently allowed Lau Yiu Ho to climb over the fence on the roof in order toconverse with Lau Shek Chuen. Lau Yiu Ho first poured a glass of water and passed it toLau Shek Chuen and, while preoccupied with drinking the water, jumped forward andgrabbed both of his hands. Witnessing this opportunity, police took quick action, but itwas too late. He shook off Lau Yiu Ho and jumped straight down. Fortunately, he fellright on the upper right-hand corner of the air cushion, and sustained only minorinjuries.The ambulance attendants and fire service personnel on alert on the street immediatelytook him down from the cushion and took him to hospital, where he was listed insatisfactory condition.Lau Shek Chuen is a casual labourer in soldering and peeling off paint on board ships.But he has been unemployed for three weeks. His friend Lau Yiu Ho revealed that he hasa stubborn character. Even when he has no money and no work, he still refuses to applyfor public assistance. His parents, older and younger brothers, and grandmother alllive in Hong Kong, but he has not been home for over 10 years. For years, he has beensleeping under the overpass at Ferry Street.Lau Yiu Ho also indicated that at the time he met Lau Shek Chuen 10 years ago, Lau ShekChuen was addicted to drugs [heroin], and has entered drug-rehabilitation centres on96numerous occasions. He has just recently left a rehabilitation centre, and has not beenseen doing drugs since then.Translated from: Ming Pao, 12 August 1991. 2.97Appendix 5This article exemplifies the environment of pathological codependency which some, if notmany, of Hong Kong's elderly couples live in. It indicates that even the "traditional"rural social structure of the New Territories has been significantly altered in recentyears.Afflicted by Stubborn illnessMutually Dependent for SurvivalLoyal to Each Other Till DeathOld Woman Falls, Hurt Head While Trying to Save HusbandBled Till Unconscious and Too Late to Be RevivedA tragic accident happened at noon yesterday to a mutually dependent elderly couple in KoPo Village in the Kam Tin area of the New Territories. After the husband lost his balanceand fell on the ground, and when the old wife, in a panic, went up to try to lift him, sheunfortunately also lost her balance and fell. Moreover, she even struck her head, beganto bleed, and soon lost consciousness. In this state they remained—until the two old oneswere discovered by their daughter, who just happened to have decided to pay them a visit.By the time police had been notified and the couple rushed to the hospital, then old womanhad unfortunately died; the old husband was a satisfactory condition.Dead is Wan Kwon Tai, aged 76. She lived with her husband, Ho Cheuk Sang, in a two-storey village-house in Ko Po Village in Kam Tin. They raised a son and a daughter, butthey did not live with them in Ko Po Village; they only went back home to visit the twoold ones occasionally.According to their daughter, her father is afflicted with diabetes, and has difficultywalking, while the mother had high blood pressure for many years. The two had retiredfor many years, and had been mutually dependent on each other to survive. They reliedon the children's financial support and the sale of their own home-grown vegetables tosurvive.At about 3 P. M. yesterday, Ho's daughter took some groceries with her to visit herparents. The moment she stepped through the gate to the yard, she unexpectedly saw hermother lying in a mud pool by the fish pond outside the house. Her head was bleeding andher face had already turned dark, and her father was leaning against her. He wailed tohis daughter to rush her to the hospital, so the daughter immediately notified police.Translated from Ming Pao, 23 August 1991.98Appendix 6A possible case of suicide as a learned behaviour: one of these two suicides lost a relativeof about the same age to suicide two years earlier.Two Girls Leap to Death on Same Day: Holiday School Assignment TurnsInto Pressure UnexpectedlyWho can fathom the world of the inner hearts of children? Soon after the jump of aneight-year old girl from a building at Pak Tin Village at 9 AM yesterday, another jumptook place at 12:45 PM. The second jump resulted in the suicidal death of an 11-yearold girl.Dying tragically from the fall is 11-year old female student Lau Ka Man. Preliminaryinvestigation led to the belief that the wish to trivialize life arose from problems relatedto academic exercises due to be completed during the school holidays. It is also known,however, that one of the paternal elder male cousins of about the same age as the deceasedalso leaped to his death two years ago; it is thought that this event generated somenegative influence in the small and tender heart and soul of Lau.The deceased lived with her parents and a younger sister in Flat 1X5 in Leung FatBuilding in Cheung Fat Estate. 15 Her father is a day shift taxi driver, who has to beginwork every day at dawn. Her mother is a housewife who, in addition to looking after hertwo small daughters, has to accept at-home light-industrial assembly consignments inorder to remedy the financial insufficiency of the household. It is known that Mr. andMrs. Lau loved their daughters dearly. They rarely scolded their daughters; in sum,family relationships were very cordial. Moreover, neighbours also indicated that theyhave a very good impression of the family; many of them expressed shock and regretover news of the death.Ka Man attended the afternoon section of Primary 6-C at the nearby Tsing Yi Island LuiMing Choi Chinese Methodist Primary School. According to school principal Wong KokKong, that school has always emphasized the importance of its relationship to thestudents. Wong also added that the scarcity of homework given to its students can even beconsidered one of the notable features of that school.Lau Ka Man's classes normally started at 12:45 PM. Yesterday was the first day of classafter the Christmas and New Year holidays. After having had her hunch at home, Ka Manleft her residence at Leung Fat Building with her school bag. In no more than tenminutes' time, however, residents in the neighbourhood saw a girl in white athleticoutfit and a red school blazer falling from a high place. The body landed on the publicsquare outside the main entrance to the building; blood splattered everywhere.On the other hand, after having heard a loud thump coming from the street into herapartment, Lau's mother immediately went out to investigate. She first found herdaughter's black school bag in the staircase on the 10th floor. She then rushed down thestairs in a panic and full of fear. After having confirmed that the fallen girl was herloved daughter, she became so grieved that she wished life would end. She embraced herfatally injured daughter and wailed, refusing to let go of her body. Witness at the scenefound it hard to hold back their own tears. Afterwards, other residents in theneighbourhood notified police. Lau Ka Man was pronounced dead upon arrival at hospital.15A public housing estate in Tsing Yi New Town in the New Territories99According to police investigation, the mother of the deceased indicated that uponinquiring into the status of her daughter's holiday assignment, the deceased had repliedthat it was incomplete. She then urged her to hurry up and finish it. In addition, justprior to leaving home for school yesterday, the deceased had revealed to Mrs. Lau thather homework, though completed, had been misplaced. The deceased also added that shefelt guilty over the matter. 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