In 235-37 B.C., when Alexander the Great invaded India, his army was terrified. They were terrified, not because of the opposing army, but because of cobras with “eyes the size of the large round Macedonian shields”. Alexander dealt with the issue head on – he hired skilled Indian physicians and made it mandatory for all snake bites to be reported immediately to the royal tent.
In modern India, the Million Deaths Study in 2011, estimated that snakebite envenomation kills more than 46,000 Indians every year; about 30 times higher than the official figures of the Government of India. Apart from deaths, snake bite envenomation (the clinical condition after the bite of a snake), is known to cause long-term neurological and musculoskeletal disability, chronic kidney disease and even depression and post-traumatic stress disorder. In spite of this, snake bite envenomation is largely not seen as a major public health problem.
Late last month, the World Health Assembly (the principal policy-making body of the World Health Organisation) passed a resolution to address the burden of snakebite envenomation. Despite having the highest burden of snakebites globally, India continues to neglect the issue. The resolution in Geneva should provide some impetus for change.
Snake bite envenomation: a neglected public health problem
Unlike communicable diseases like tuberculosis or malaria, snakebite envenomation affects only certain communities – it affects rural and tribal communities, particularly those where agriculture, tea-leaf picking, and firewood collecting are primary sources of livelihood.
In spite of the huge burden, there is no comprehensive programme or concerted action to address snakebite envenomation. This is because, communities affected by snakebite are disenfranchised politically – they are poor, rural and tribal. While farmers have always constituted a vote bank in India, the focus has narrowly been on farm loans and support prices (which affect rich farmers) and not on their health problems.
Children in the age group of five to 14 years are known to have the highest risk of dying from snakebite – and many of them are probably child labourers engaged in agricultural work. However, most snakebite deaths occur in the 15–29 year age group. Deaths of young adults, who are often the sole breadwinners of families lead to prolonged suffering for the entire family, the social and economic impact of which is yet to be documented.
Snake anti-venoms (SAV), the only effective treatment for snake envenomation are often not available at primary health centres. Even if available, many doctors are afraid to treat with SAV due to inadequate training and fear of adverse reactions.
Snakebites are unexpected events. Many snakebite victims do not go to health facilities but to ‘ojhas’ or snakestone healers for several cultural and religious reasons. Even if a snake bite victim decides to go to a health facility, it might be non-functional.
In a study conducted in Tamil Nadu, arguably one of the states with better public health systems, three-quarters (75%) of snakebite victims had to seek treatment from the private sector with just direct costs (transport and medication) amounting to Rs 3,50,000. Long-term physical and psychological effects also mean chronic health costs and loss of livelihood, leading to forced borrowing and debts. The Tamil Nadu study showed that 18% of families sold crops worth nine months of income; another 14% sold valuable items worth 3.6 years of income; another 9.3% sold livestock worth one year’s income and 3.9% sold land worth 14 years of personal income.
What can we do to address snake bite envenomation?
The recent World Health Assembly passed a resolution sponsored by the Government of Costa Rica and Colombia and backed by 25 other member states including India, to address the burden of snake bite envenomation. The WHO is required to provide support to countries and foster technical cooperation between different countries.
With the highest burden of snake bite, it is high time for India to accord high priority status to snake bite envenomation nationally.
The glaring anomaly between official statistics which still captures around 1,000-1,200 snake bite deaths annually and the estimates of Million Deaths Study of 46,000 deaths annually is a cause for major concern and a reflection of how much more we need to do in India.
Firstly, the government of India should make snake bite a notifiable disease – this will help better capturing of official data. Public health institutes and organisations need to focus research on epidemiological studies and understanding of non-fatal consequences of snake bite. The economic and social burden of snake bite needs to be better understood too.
Community efforts or social marketing approaches to improve awareness and addressing myths and stigma around snake bite is very much doable. Prevention approaches for snakebites happening in the first place (long boots, gloves etc.) are also very important from the health systems perspective. This is because even cases of non-venomous snakebites come to the health facilities.
Opportunities to address the disease burden and economic costs related to snakebite envenomation exist through flagship government programmes like the Ayushman Bharat and upgrade of sub-centres to health and wellness centres. We are at the design and inception phase of these programmes – free access to quality SAV, supportive treatment as well as long-term rehabilitation should be a part of the comprehensive primary healthcare agenda in these programmes.
Developing digital solutions to smoothen supply chain and logistics problems related to availability of SAVs should be relatively easy for India to achieve. Building governance and financing mechanisms to support such digital initiatives in the remotest corner of our country might be challenging, but is in the current ecosystem wherein large-scale changes are actually happening in several sectors. Being a time-sensitive condition (just like road traffic accidents) it is also important to develop transportation and referral links with higher levels of care. Removing structural barriers such as these, along with proper training and evaluation of implementation of snake bite guidelines through clinical audits can significantly bring down mortality due to snakebites envenomation. It is time we end the neglect.
Soumyadeep Bhaumik is a medical doctor and international public health specialist. He is a Research Fellow at The George Institute for Global Health, India and Associate Editor, Evidence Syntheses at the BMJ Global Health. He tweets at @DrSoumyadeepB. Views and opinions expressed in the article are the author’s own and do not necessarily reflect the opinion of his employers.