The current study presents national suicide rates by various factors among immigrants from Ethiopia, as compared with immigrants from the FSU (characterized by a very different sociocultural background), and to the Israeli-born population. Spanning 33 years, despite wide fluctuations, the suicide rate remained much higher among EI than among the other examined populations. A suicide rate higher than in the local population was also found among Ethiopians who had immigrated to London [20]. Before examining risk factors for suicide among EI in order to develop adequate preventive services adapted to this population, we investigated the possibility that these high rates are primarily due to factors unrelated to life in Israel.
Differences in suicide rates may be an artifact if under-reporting of suicides differs in various populations. The reporting of suicides among immigrants and non-immigrants has been examined in the Tel Aviv area [21]. They observed no significant difference in under-reporting between Israeli non-immigrants and African-born immigrants, who were almost exclusively EI in the years of the study [22]. The high rate among EI cannot thus be explained by a higher reporting rate in this population. Suicides were found to be reported slightly more frequently for the European-born population, primarily consisting of FSUI during the years of the study [22]. Thus, the disparity found between FSUI and IB might, indeed, be slightly smaller, but our calculations indicate that the Israeli-born population would still have the lowest suicide rate.
Variable attitudes toward suicide among cultures have been identified as a critical factor in understanding why suicide rates vary across different cultures. Both in Israel and the FSU, as well as among FSUI, negative attitudes toward suicide have been reported [23,24,25], and there is no indication that suicide is less stigmatized among FSUI than among IB. Suicide is also considered a grievous sin among the Ethiopian Jews, both in Ethiopia [26] and in Israel [27]. Thus, differences in cultural attitudes toward suicide may be ruled out as a significant factor in explaining our results.
Suicide rates in the new country could also reflect the rate in the immigrants’ native country. There is, however, no evidence of elevated suicide rates in Ethiopia, although the rates may be underestimated due to the quality of vital statistics. Medical records from a general hospital in Western Ethiopia reported a mean annual suicide rate of 4.5 per 100,000 inhabitants between 1966 and 1972 [28]. The crude annual suicide rate in Addis Ababa was 7.8 per 100,000 population between 1974 and 1988, a period marked by unrest and war in Ethiopia [29]. Moreover, even according to more recent data [2], the age-adjusted suicide rate in Ethiopia (13.1 in 2000) was found to be much lower than among EI in the present study (33.9). It thus appears that high suicide rates for EI compared with IB cannot be attributed to higher rates in Ethiopia.
On the other hand, the WHO [2] reported that age-adjusted suicide rates per 100,000 population in 2000 for many FSU republics were much higher than for FSUI in Israel (12.0): 35.0 in the Russian Federation, 29.8 in Ukraine, 37.6 in Kazakhstan, and 49.9 in Lithuania It may be that among FSU Jews the rates were somewhat lower than among the general FSU population: It has been reported that the age-standardized mortality rate for an amalgam of homicide, suicide, and unspecified violent death is lower for Jews than for non-Jews [30]. While no data for suicide alone are available, suicide rates are unlikely to be lower for Jews in Russia than for FSUI. Thus, the higher suicide rate among FSUI than among IB cannot be attributed to the immigrants simply transplanting their native country’s suicide risk. Rather, immigration appears to have led to a decrease in suicide rate compared with the rates in their native country, or at least not to an increase.
The main risk factors of the high suicide rate among EI in Israel must, therefore, be sought in what transpires in the country of immigration. Several factors have been considered in the literature:
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a.
The disparity between the culture of origin and the culture of resettlement; this disparity is much greater for EI than for FSUI, resulting in EI having to endure a complex acculturation process [31]. Palmer [20], in his study on Ethiopian migrants to London, claimed a direct causal link between maladjustment in the immigration country and suicide.
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b.
Low consumption of mental health services [32]
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c.
Weakening of social support [15], while the latter contributes to suicide prevention [33, 34].
To further investigate the cause for the relatively high suicide rate among EI, the relationship between demographic factors and suicide rates was analyzed in this population. Comparing the EI rates with those of another immigrant population (i.e., FSUI) and of IB aimed to reveal some additional clues.
Suicide rates were higher for men than for women for all groups, ages, and years, as is the case worldwide, with few exceptions (e.g., China [35];). The rate ratio (RR) of male to female suicide rates was similar among EI (3.3) and IB (3.6), both close to the ratio (3.5) reported by WHO for high-income countries [2]; the high RR for FSUI (4.8) may be explained by an especially deleterious use of alcohol among men, as a high level of alcohol consumption is associated with increased suicide risk [36].
The similarity between male/female RR among EI and IB and of EI/IB RR in both genders is particularly interesting in view of the considerable difference of status of women in patriarchal Ethiopian society vs. liberal Israeli society. Youngmann and Shokeid [37] conducted interviews with key informants and in the format of focus groups, in the Ethiopian community concerning the causes of EI suicide and possible preventive methods. Both EI men and women agreed that men felt humiliated and threatened when EI women became involved in economic activities in their new country and benefited more than did men from public social agencies, which are mostly served by female professionals. EI men reported believing that social workers and police encourage women to apply for divorce and free themselves from their husbands’ control, which is the norm in patriarchal societies such as Ethiopia. One would therefore have expected a relatively very high male/female suicide rate ratio among EI. However, this rate ratio was found to be similar to that among IB. This could be explained by the heavy pressure and mental cost that Ethiopian women pay for their relatively rapid adaptation to Israel, which often leads to a crisis in their relations with their husbands. In these situations, traditional leaders, the elderly (Shmaglotch), and priests (Qessotch), who had traditionally intervened in family and personal crises, lost their authority [37]. The high levels of family conflict among EI [38], as reflected by a higher divorce rate among EI than among the total Jewish population [14], might also explain that marriage was less protective against suicide for EI than for the general population, as was also reported among Ethiopian immigrants in Toronto [39]. The conflicts even reached physical violence as indicated by a high prevalence of intimate partner homicide and the fact that EI are significantly more prone to commit suicide after killing their partner than are the FSU and IB [40]. Suicidality among Ethiopians also appear to be more violent, the proportion of completed suicides being higher, as we can see from the fact that while suicide rates among EI are much higher than other populations, suicide attempt rates in this population were reported similar to those among the Jewish population without EI and FSUI immigrants, during all the years between 2006 and 2017 [17]. However, it should be noted that the lower suicide attempt rate may also be due to under-reporting of attempts, since EI have lower total rates of visits to hospital emergency departments [41].
A comparison of age-specific suicide rates revealed substantially higher rates for EI than for FSUI and IB for all age groups. Among FSUI, the elderly had the highest suicide rate, and among IB, the age-specific suicide rates regularly increased with age, similarly to the trend found worldwide [2]. This has been explained by factors such as age-related decline, loss of autonomy, and a higher frequency of depressive symptoms among the elderly [42]. Surprisingly, among EI, the suicide rates did not increase with age. Seeking an explanation, we considered calculating suicide rates by time since immigration, but this step was precluded due to data limitations. Different periods can be used as a proxy since the mean time since immigration increases over the years. So, we compared age-specific rates for EI during three periods: one closest to the large immigration waves, the second during the 10 subsequent years, and the third during the final years of the study period. The suicide rate of the youngest age group had the lowest suicide rate in the first study period (1985–2000); in the following years (2001–2010), the rate almost doubled, and then in the following years (2011–2017), decreased very steeply to a lower level than in the first years, but not significantly so. Apparently the youngest EI adjusted more quickly than the older immigrants to their new life in Israel. However, those having immigrated as children likely expected the same opportunities as the IB youth of their age, but substantial differences remained in education, employment, and socioeconomic levels [43]. Gaps between expectations and reality have been identified as a risk factor for suicide [42]. In the first decade of the twenty-first century which corresponds to our second period, a sharp increase in high-risk behavior has been observed among young EI [44], while the needed parental support was unmet [37]. The sharp decrease in the subsequent 7 years of the study (2011–2017) may be due to the observed rapid acculturation of the young EI [14].
Among the elder EI (ages 45–64), the highest suicide rate was recorded in the initial period of the study. Whereas most Ethiopians having arrived in Israel as adults came with minimal education and high illiteracy rates, by 2007, 15% had achieved post-secondary education in Israeli institutions [45]. This enhanced education level may have contributed to decreased suicide rates among older EI in 2001–2017, and it may reflect adjustment to their new country.
It is worthwhile noting that, in parallel to the worldwide decrease in suicide rate between 1990 and 2016 [46], a general decline in the rate of suicide mortality was also found in the three populations of our study, but our results are not related to this decrease, since it was the same for EI and IB, leaving EI with a much higher rate than IB during all the years of the study. However, we observed large fluctuations in suicide rates over the years among EI, whereas FSUI and IB presented only minimal fluctuations. Ethiopian immigration to Israel occurred in three waves, each under very different circumstances, and thus, the proportion of EI from each wave changed over the years. However, since a similar secular trend was found among immigrants for each wave, this cannot explain the substantial changes in suicide rates over the years among EI.
Events in Israel during the examined periods may offer explanations for the changes in suicide rates. The decrease in suicide rates between 1992 and 2001 may reflect the EI’s progressive integration, along with some improved understanding of EI culture and idioms of distress by Israeli officials and professionals [47]. As noted, for EI women, this decrease in suicide rates began earlier and was more pronounced. The steep increase in suicide rates between 2002 and 2006 may stem from a drastic nationwide reduction in the monthly family allowances granted by the National Insurance Institute and in other social welfare benefits during the years 2002–2005 [48]. In 2006 suicide rates began to decline, likely due to the Israeli economic recovery, a restoration of some of the social welfare allowances and the increase in support of EI by NGOs [49]. It is noteworthy that the changes in social welfare allowances appeared to be linked to greater changes in suicide rates among EI men than among EI women, perhaps indicating men’s greater stress tied to their burden of responsibility to provide for their families.
Thus, socioeconomic status (SES) appears to be a risk factor for suicide in fragile populations, such as EI, unlike FSUI and IB. This hypothesis is corroborated by the fact that, in our study, changes in the National Insurance Institute policies primarily affect EI rather than the other populations. Low education, unemployment, and poverty, which are dimensions of social exclusion, have been identified as risk factors for suicide mortality [9]. Whereas FSUI were typically highly professionally qualified, EI arrived generally unskilled. More than 40% of FSUI who arrived in Israel between 1990 and 2007 possessed college degrees, versus 3% of EI [50]. Most Ethiopian immigrants had previously lived as peasants and artisans and endured considerable difficulty integrating into Israel’s modern labor market, as indicated by a much higher rate of unemployment than among FSUJ [51]. Consequently, due to their low SES, EI tend to live in towns or neighborhoods having poor schools, limited employment opportunities [52], and significantly lower average household expenditures in comparison with non-Ethiopian Israeli Jews [53]; this disparity would then make any financial assistance more critical for EI.
It is noteworthy that in 2009 the Israeli government ministries operated a suicide prevention pilot program for EI and FSUI immigrants, for teens, and for seniors in Rehovot, Ramla, and Kfar Kana [54]. It evolved into a national program in December 2013 under the name of the National Program for Suicide Prevention, continuing to this day [55]. To date, no evaluation of the program has been published, and no sudden decrease in suicide rates is apparent from the program’s inception. Consequently, this program cannot explain the steady decrease in the EI suicide rate since 2007.
Anyhow, both genders and all ages are likely to have been engaged in the process of adjustment to Israel over time, as documented by the fact that suicide rates were the lowest in Period 3 and by a steady decrease since 2006.
Strengths and limitations
The strengths of the study are that it is a national study encompassing entire populations and that data are related to an extensive period (33 years). A limitation of the study is that the examination of risk factors was limited to those derived from demographic data. A further study should explore other potential risk factors, such as time since immigration, SES, education, occupation, mental illness, and health service utilization.
