No magic bullets to deal with snakebites

Ganesh V.S. from Chowdikatte, a village in Karnataka’s Mysuru district, had lost his wife to renal failure, a little over a year after she was bitten by a snake. In Karnataka, Rs. 200,000 (Rs. two lakh) is given as compensation for the loss of life from snakebite. However, Ganesh, who had spent Rs. 1.5 million of his money on his wife’s treatment before she died, had to jump through hoops to claim compensation because the hospital recorded the cause of her death as renal failure, and did not mention snakebite, as it is difficult to prove that death was due to snakebite.

Snakebite, in India, is a medico-legal case, where both medical and police departments are involved. In the case of a death from snakebite (in Sujatha’s case, the incident happened on the farm adjacent to her house), the revenue department that compensates the next of kin, demands an NOC (no objection certificate) from the police department, as well as clearance from the hospital to rule out any foul play. “There is a lot of paperwork, red tape and bureaucracy involved, all for a compensation of Rs. 2 lakhs when the family may have already spent much more than that for treatment,” said Sumanth Bindumadhav, director of Humane Society International India. According to him, some doctors even refuse to treat snakebite cases due to potential legal hassle in the event of a death.

India accounts for over half of global snakebite deaths

With an average of 58,000 deaths from snakebites annually, which is more than half of all snakebite deaths in the world (81,000–138,000), India continues to be the country most significantly affected by snakebite cases. According to a comprehensive study in 2020, eight states – Bihar, Jharkhand, Madhya Pradesh, Odisha, Uttar Pradesh, undivided Andhra Pradesh (which includes Telangana), Rajasthan and Gujarat carried the most burden of snakebite deaths accounting for more than 70% of deaths during the period between 2001 and 2014.

The experts Mongabay-India spoke to said that that was a conservative estimate since many cases go unreported, as snakebite is not a notifiable disease. “Some cases do not even get to hospitals. They go to faith and herbal healers and quacks,” said Karnataka-based snake researcher Gerry Martin. As a consequence, the real scale of the problem remains obscure.

“Most policymakers go by the Integrated Disease Surveillance Programme data or the Central Bureau of Health Intelligence data, which are inaccurate,” said Bindumadhav, emphasising the need to declare snakebite as a notifiable disease. The Central Bureau of Health Intelligence reported a total of 13,043 snakebite deaths in the country from 2010 to 2020, which is far removed from reality, say the experts. Apart from deaths, snakebite envenomation also causes long-term health effects and has a high social and economic impact on families.

Taking cognisance of the enormous health burden from snakebites, the World Health Organization (WHO) recognised snakebite as a neglected tropical disease in 2017 and in 2019, set a target to halve the global burden of snakebite by 2030. “Meeting the global target is possible only if India performs better, considering more than half of all snakebite deaths are reported from India,” said Soumyadeep Bhaumik, head of Meta-research and Evidence Synthesis Unit, Health Systems Science, George Institute for Global Health, India.

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Understanding the scale of the problem through surveys

India jumped on the bandwagon immediately with a national programme for prevention and control of snakebites that identified key areas of interventions and strategies to control cases in the future. The Indian Council for Medical Research (ICMR) set up a task force in 2022 and launched a nationwide survey to understand the incidence, mortality, morbidity and socioeconomic burden of snakebites in India. Dr. Jaideep C. Menon, professor of adult cardiology and public care at Amrita Hospital, Kochi, who heads the task force, said the survey has covered eight of the 14 states to be studied for the purpose and that the remaining states will be done by the end of this year. One of the takeaways from the study, according to him, is that the Indian polyvalent antivenom in the market doesn’t work across geographies and venom types, which points to a need for state-specific antivenoms. The study has various recommendations, including training community health workers, like Ashas, in carrying the messages of effective prevention and management to vulnerable populations, considering more than 70% of cases happen in rural India.

Early this year, the government also took the decision to appoint nodal officers in every state for snakebites. President of Mumbai-based Snakebite Healing and Education Society, Priyanka Kadam, said that the decision is going to be a game changer since there would be a better flow of funds for the purpose. “I’ve been working with the government on this issue since 2015, but there has never been funding for snakebites in the past,” she said. The states have also been asked to come up with action plans. Moreover, the Ministry of Environment, Forests and Climate Change (MOEFCC) released 10-species-specific guidelines to address human-wildlife conflict where snake is featured as an animal in conflict.

Policy gaps hamper effective interventions

Experts point to multiple gaps in policies that need immediate intervention. Bindumadhav finds the lack of quality control of the antivenom in the country worrisome. “A batch of antivenom may not be as potent as you think it is because the Central Drug Standards and Control Organisation (CDSCO) has no prescribed standard for potency for antivenom,” he said. Dr. Menon recommends extending the support of the government’s health insurance scheme, Pradhan Mantri Jan Arogya Yojana (PM-JAY) for those below the poverty line, to all snakebite cases and not just the critical ones needing ventilator support as is the case now.

Bhaumik, who was a part of the study on global mortality of snakebite envenoming, however, believes that the focus should be on preventing snakebite cases and a good portion of the global funding for the purpose must reach institutes, organisations and nonprofits as well as governments working on reducing snakebites in India. While focusing on better antivenoms and adequate compensation are essential, those expenses can be avoided by preventing snakebites, he said. He suggests community-based interventions like training the first responders of a community on prevention and making formal healthcare systems acceptable to community members.

The essentials for the prevention of snakebites in rural areas like boots, torches and mosquito bed nets, need to be made available to the vulnerable. Another intervention would be home environment modifications. “Ensuring logs of woods are not stacked near the house or food waste not lying around close to the house may seem simple but go a long way in preventing snakebites,” Menon said.

 A study conducted by Bhaumik and colleagues in West Bengal’s Sundarbans and Hooghly districts on snakebite care during COVID-19 found that communities affected by snakebite are immensely challenged by weak healthcare systems, which was accentuated during the pandemic. The study also revealed a strong need for community-based programmes on snakebites.

The conversation on snakebite management is often centred around better antivenoms or awareness building. While both are pertinent interventions, they are ineffective in the absence of an adequate healthcare system. “We can come up with very effective antivenoms but if there are no quality doctors or nurses to administer it or if the hospitals lack electricity or other facilities, these interventions are not effective,” said Bhaumik.

Bhaumik also recommends making first aid kits easily available to the first responders who are trained in administering them. “People’s faith in traditional healers is not just cultural. The common understanding that with better awareness, the affected will approach primary healthcare facilities is not always true. The outcome often depends on the location and accessibility of the primary healthcare facilities,” he said.

There are no magic bullets to deal with the burden of snakebite cases. The key, according to the experts, lies in a combination of interventions and sustained, collaborative efforts.

Banner image: A Russell’s viper inside a tube before a procedure to insert a radio telemetry transmitter into it. Photo by Abhishek N. Chinnappa/Mongabay.