Due to poor quality and unavailability of anti-venom serum,
snakebites kill nearly 50,000 people in India every year. But with not even 3%
of the deaths showing up on official records, the state refuses to fight the
epidemic killing its rural poor.
Two
years after Rajasthan health minister Digambar Singh launched a snakebite
treatment initiative in 2007, I spent a week in the desert looking for a snake
vilified in local myths. The first and last resort for many snakebite victims
in central Rajasthan, I found, was the Kesariya Kanwarji temple near Ajmer
where blessed threads were tied on them with more resignation than hope.
Further
west, in the Bikaner-Jaisalmer-Barmer region, dubious practitioners of unani
medicine enjoyed a mass client base. While many government health facilities
stored anti-snake venom serum (ASVS), the training was minimal. Young doctors
admitted that their MBBS course did not quite cover snakebite treatment.
Not
much has changed since. Rajasthan still loses up to 6000 people to snakebites
each year. This July, rural belts of Kanpur in Uttar Pradesh, the state that
accounts for the highest number of snakebite deaths in the country, suffered an
acute shortage of ASVS. In August, a farm labourer died in Bengal’s Burdwan
district because neither local hospitals nor pharmacies had any ASVS because of
“weak supply”. Few such stories make it to the mainstream media.
Several studies
estimate that globally, 3 million - 5.5 million people are bitten by snakes in
self-defence every year. Many of
these bites are harmless because only around 600 of the 3000-odd snake species
are venomous. Even venomous snakes are often reluctant to inject precious venom
into humans. Yet, 2-3 million cases of envenoming occur annually, of which up
to 150,000 turn fatal.
In 1869, Joseph Fayrer of the Indian Medical
Service tracked 11,416 snakebite deaths across half of British India, ranging
from Pakistan to Burma. In 2005, the World Health Organisation (WHO) estimated
35-50,000 snakebite deaths in India alone. A report published in PLOS
Neglected Tropical Diseases in April 2011 put the toll at 45,900 on
the basis of the Million Death Study (2001-03) that surveyed 1.1 million
households across the country.
In comparative terms, there is one snakebite death for every two AIDS deaths in India. When not fatal, venomous snakebites often cause permanent disability for which no data is available. With the majority of victims being typically young, this has a significant impact on our rural economy.
Yet, the deaths remain
invisible in government reports. Union Health Minister Ghulam Nabi Azad told
the Lok Sabha this April that there had been a total of 1440 deaths due to
snakebites in India in 2011. This startling statistical gap is consistent with
the Central Bureau of Health Intelligence reports that recorded an annual
average of 1,350 snakebite deaths during 2004-2009.
Evidently, very few
snakebite victims reach hospitals. No statistics is available for India but the
magnitude of invisible victims can be gauged by the fact that in rural Nigeria
and Kenya only 8.5% and 27% of snakebite victims, respectively, sought hospital
treatment. But ASVS is the only cure for snakebite and, administered in time,
can be very effective.
Only last week, a teenager
bitten by an inland taipan — the world’s most venomous land snake — was treated successfully at a small
town hospital north of Sydney in Australia. In India, the Central Research
Institute began producing ASVS as early as in the 1920s. So, a century later,
why do so many Indians continue to die of snakebite?
Basic precautions such
as using shoes, torches and mosquito nets, avoiding sleeping on the ground or
ridding the household of garbage and courtyards of piled-up debris can
drastically reduce instances of snakebites. In terms of cure, rural witch
doctors stay in business because of their “success” in treating non-venomous
and dry bites. There has been no campaign on the lines of family planning to
educate people about ASVS. Nor has the government criminalised mumbo-jumbo —
some of it, such as the brand Tirhakah, available off the shelf — in snakebite
treatment that kills thousands of people.
But superstition and
lack of awareness are not the only reasons for such a staggering death count. A
large number of victims who actually seek proper medical care also end up dead.
Unfortunately, life-saving ASVS is costly, unavailable and ineffective in
India.
Only mass production
can bring down the cost of ASVS, which involves procuring snake venom,
injecting small doses into horse or sheep till the animals attain
hyper-immunity and making a serum of their blood. Since it is difficult to
ascertain which species is responsible for a bite, polyvalent ASVS, produced from
the venom of the cobra, krait, Russell’s and saw-scaled viper, is administered
to victims and is effective against each of the “big four”.
Venom is a rare
commodity and official restrictions on snake capture make it exorbitant. One
gram of krait or saw-scaled viper venom costs $900 and $1000 respectively. This
pushes the average cost of one vial of polyvalent ASVS to Rs 500. The excuse of
low demand for high-priced ASVS in poor rural markets discourages mass
production which in turn further shoots up the cost.
Government hospitals
that are supposed to offer ASVS for free face erratic supply. Few private
hospitals in rural areas store it because patients can rarely afford it. Nine
companies produce ASVS in India. There has been no estimate of the total demand
or requirement for ASVS in the country. But the supply gap is evident. In Tamil
Nadu, for example, the King Institute is supposed to be distributing 300,000
vials but only one-third of this requirement is actually produced.
Extrapolating these figures, the national demand for ASVS should be between 4
and 5 million vials but the production remains less than 1.5 million vials.
Worse, the government
inexplicably lowered the required strength of ASVS in the 1950s. So while 4
vials of ASVS produced by CroFab can neutralise a viper bite in the US, a cobra
bite at home can require anything between 13 and 165 vials of made-in-India
ASVS. This not only pushes up the medical cost but also over-exposes the victim
to potentially dangerous side-effects of ASVS.
Rapid technical
advancements in the production of ASVS have not entered the Indian industry.
The ASVS produced here frequently causes severe side-effects — including temporary arthritis and
kidney disease — and can have
potentially fatal consequences at high doses. In Sri Lanka, four out of every
five snakebite victims treated with Indian ASVS showed side-effects.
The Irula Snake
Catchers Industrial Cooperative Society (ISCICS) is licensed by the Tamil Nadu
Forest Department to capture 8,000 snakes per year. ISCICS sells about 600 grams of venom
annually. This limited supply does not meet the huge ASVS requirement of the
rural market. As a result, it is alleged that illegally procured venom is often
used. The quality of such venom remains suspect due to unscientific collection
and compromises the quality of the ASVS.
ASVS produced with
venom collected from one geographical pocket down south often fails to
effectively neutralise snakebites across the country due to the geographic
variation in the composition of venom within the same species of snake. Indian
ASVS failed to treat Russell’s viper bites in Sri Lanka adequately. Similarly,
Thai ASVS could not neutralise Indian king cobra venom and Indian ASVS peddled
in Africa by unscrupulous traders caused scores of deaths.
The three cobra
sub-species of India have now been re-classified as three separate species.
Indian ASVS is produced using venom only from the spectacled cobra and its
effectiveness has not been tested against the venom of other cobra species.
Similarly, there is no evidence that ASVS produced from common krait and
saw-scaled viper work against other Indian variations such as Sindh krait or
Sochurek’s saw-scaled viper. Moreover, ASVS produced in India is in any
case not effective against three
species of krait, two species of cobra and three species of viper among the
twelve high-priority species listed by WHO for South Asia.
Herpetologist Romulus
Whitaker and his team is presently conducting lab tests to check how Indian
ASVS works against venom collected from different species across the country.
He says India must expand the scope of the Irula cooperatives to other parts of
the country and bring more snake catching communities under its wing. This will
ensure the quality of venom, incentivise marginal snake catchers and cover
regional venom variations. Simultaneously, we need to increase the potency of
our ASVS and introduce contemporary technology to reduce side-effects.
So what is stopping
us? The politics of medicine, it seems. In 2009, Ian D. Simpson and Ingrid M
Jacobsen published a paper, Anti-snake
Venom Production Crisis—Who Told Us It Was Uneconomic and Unsustainable?
The myth of unviability, it appears, is to disown the predominantly rural and
poor victims of snakebite.
In 1998, a WHO
analysis of global tropical illnesses put snakebites in perspective. Against
178,000 incidences of cholera, 4000 deaths were recorded. Japanese encephalitis
infected 44,000 and killed 14,000 while 73,000 cases of dengue caused 19,000
deaths. Snakebite incidences were 2,682,000 with 100,000 deaths. But the research
investment even in amoebiasis far surpasses the funding in the study of
snakebite.
Due to the geographic
variety of venom, no single ASVS can be promoted for a global market. The
limited purchasing power of the majority of victims has discouraged development
of private medical infrastructure for treating snakebite. In India, too,
snakebite is predominantly an occupational disease of farmers, plantation
workers, fishermen and other rural workforce. Not surprisingly, it fell off the
radar.
There are a few
positive initiatives. West Bengal has designed treatment protocol posters for
management of snakebite and is also drafting a training module for medical
officers. A compensation of Rs 1 lakh has also ensured that most snakebite
deaths in the state are reported and recorded.
But to effectively
combat the menace of snakebite, the union government must first acknowledge the
crisis. It must be declared a notifiable disease that makes reporting of deaths
mandatory. We need resources to promote research, spread awareness, develop
quality serum, ensure its availability in remote villages and build medical
infrastructure to handle snakebite.
The biggest reasons of
snakebite mortality are delay and indecision. For the last 60 years, we had had
enough of both.
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