I wrote this in 2011 at the request of the film production company that produced ‘One Million Snakebites,’ a BBC Natural World documentary. Wasn’t published then so here it is –
If you are a young farmer in India, your chances of succumbing to snake bite are greater than anywhere else in the world. The country has made impressive strides in several fields of endeavour, including putting satellites in orbit, but in the case of snake bite casualties, we appear to be mired in the Dark Ages.
According to the World Health Organization (WHO) between 35,000 to 50,000 Indians die every year, but in 2008, the Government of India reported a dramatically low 1400 mortalities. Apparently six of the worst affected states never sent their death toll figures.
Finally, a path-breaking project code-named ‘The Million Death Study’ provides a more realistic handle on the impact of venomous snakes. The research team comprises experts from institutions in Canada (the Centre for Global Health Research at St. Michael’s Hospital and University of Toronto), UK (Nuffield Department of Clinical Medicine, University of Oxford) and India (the Registrar-General of India (Delhi), S.C.B Medical College (Orissa), Indian Institute of Health and Family Welfare (Hyderabad), St. John’s Research Institute (Bangalore) National AIDS Control Organization (Delhi) and Madras Crocodile Bank Trust (Tamil Nadu). By a process of extensive interviews called “verbal autopsies”, the study found that as many as a million Indians are bitten by snakes every year while almost 50,000 people die. Indian mortalities are a third of the globally estimated snake bite deaths. In other words, for every two people who succumb to AIDS in India, there is one snake bite fatality!
This is no surprise when you consider that Indians seem quixotically prone to high snake-bite-risk behaviour such as walking barefoot without a torchlight at night and sleeping on the floor, while also creating ideal cover for rodents and snakes in their midst. Once bitten, they further reduce their chances of survival by going to a witch doctor first rather than seeking the only cure, antivenom, from a hospital. There is very little understanding that a venomous snake injects its virulent muscle-eating, nerve-damaging, blood-destroying venom deep into body tissue that no amount of superficially applied ‘black stones’, herbal poultices, or eating bitter roots can hope to counter. For years, Indian herpetologist Rom Whitaker has evangelized to country folk that only an injection can counter the snake’s injection, but clearly vast areas of the country remain to be covered.
Do snakes especially target Indians? Surely our neighbours who share the same farming patterns, life styles, and medical practices are equally doomed. Perhaps there are just too many of us crammed on a land where agriculture is still the majority occupation?
Both India and Sri Lanka have about 300 people per sq.km while Pakistan has 214 and Nepal 200. But Bangladesh blows us all off the South Asian density chart with 1100 people compressed in every square kilometre. It stands to reason that Bangladeshis are more likely to trip over snakes than Indians. And they do. A recent survey reported 700,000 snake bites and 6000 deaths a year.
Across South Asia, the picture-perfect rice fields are highly productive food bowls. Herpetologists such as Rom Whitaker, however, see an ideal snake-rich landscape. The flooded fields are demarcated by raised embankments that are perfect for housing high densities of rodents and snakes. For nocturnal, rodent-eating, farm-living snakes, life can get no better. At dusk, cobras and Russell’s vipers emerge from rat burrows and dense undergrowth to start hunting for prey, just when barefoot farm workers are likely to step on them. It appears that this is when and how the bulk of the snake bites occur.
In ‘One Million Snake Bites’, an hour long BBC Natural World documentary, Rom Whitaker uses high speed photography to illustrate that despite the bad rap, the cobra doesn’t bite most of the time. It first relies on its ability to make a quick getaway to avoid confrontations. When cornered, the defensive snake sits with its hood spread looking beautifully dangerous. But in take after slow-motion take, every cobra strikes with its mouth closed, its dangerous toolkit safely sheathed, consistently punching but not biting. Now you know why Rikki Tikki Tavi, the mongoose always wins its bouts with Kipling’s hooded death. Whitaker surmises that the cobra is reluctant to bite because producing venom demands a lot of energy, and no snake in its right mind would want to physically tangle with an animal as deadly as a human.
Even the small, feisty saw-scaled vipers and the larger, fat Russell’s vipers are prone to swift departure in some cases. But in others, they open their jaws wide and sink their fangs up to the hilt. All these species of snakes are common to most South Asian countries which heightens to mystery of why India bears such a high burden.
Is it the quality of healthcare? The Million Death Study found that only 23% of the deaths occurred in a hospital. Perhaps another reason for the very low official snake bite toll figures. Even the Irula tribals with whom Whitaker has had a long collaboration, set great store in their native treatments. In one gory episode in the film, the swollen finger of an elderly Irula lady who had been bitten by a saw-scaled viper is sliced with a broken piece of glass and the whole hand packed with green plant material. Had it been a lethal dose of venom, the outcome would not have been happy.
Clearly, belief in herbal medicine and magic is high, and when the condition of such a patient takes a turn for the worse, he/she is rushed belatedly to a hospital. Doctors have a hard time distinguishing the symptoms of snake bite from complications caused by local treatment thereby losing critical time. This is compounded by people’s poor knowledge of appropriate first aid measures. For instance, wrapping tight tourniquets causes more harm than good.
Even if snake bite victims and their families chose to seek treatment from a hospital, not all hospitals stock antivenom. The patient has to be transported over long distances to reach one that can treat him/her. Most doctors know little about snakes and are unable to tell venomous from non-venomous snakes. Some unfortunately rely on anecdotal mumbo-jumbo such as pattern of the bite mark and number of fang punctures to differentiate between venomous and non-venomous bites. Other problems include administration of insufficient doses of antivenom, lack of supportive care such as ventilators (in the case of krait and cobra bites) and dialysis machines (to treat Russell’s and hump-nosed viper bites).
To add tragedy to injury, antivenom manufactured in India is of low potency, and huge doses may be required to neutralize the effects of venom. Whitaker collected a venom sample from one black cobra in Rajasthan that yielded 198 milligrams, while one 10 ml vial of antivenom can only neutralize 6 mg of venom.
To top these challenges, there is an additional whammy: the venom of some species of snakes varies from one place to another. For instance, venom of the Russell’s vipers of east and south India are nerve-affecting in addition to the blood-deranging effects elsewhere in its range. This might mean that the antivenom made using the venom of south Indian Russell’s vipers may not neutralize a bite from the same species in north India.
Besides, antivenom is made from the venom of four of the commonest snake species: spectacled cobra, common krait, Russell’s viper and saw-scaled viper. However, India has four species of cobras, eight species of kraits, two sub-species of saw-scaled vipers and one species of Russell’s viper. We just do not know how effective the available antivenom is against the venom of all these species.
During the course of the film, Whitaker travels across India collecting venom samples from different species of snakes. Collaborating with toxinologists, who work in the laboratory, he hopes to try to answer these complicated questions in order to produce a truly life-saving antivenom that is widely available and is effective throughout the country.
While ruminating over the 50,000 poor souls a year who never make it, I realized this was spread over a very large country. Perhaps the best way of seeing this in the all-Asia context was to break it up into units. India’s 5 deaths per 100,000 people is high compared to the South Asian average of 0.91-2.21. But it appears to be similar to the lower-human-population-density countries of Pakistan and Nepal that suffer 4.8 and 3.5 deaths per 100,000 respectively. Surprisingly, Sri Lanka’s human density figures are almost the same as India’s, but it suffers a mere 0.63 deaths per 100,000 people. [These are back of the envelope calculations based on guesstimates. So please take it with a large pinch of salt.] This kind of comparison is interesting but still needs fine-tuning when better snake bite statistics become available.
The Million Death Study provided another clue to India’s snake bite problem: religion. A Hindu has a higher chance of dying from snake bite because his/her reverence for cobras has fostered a higher degree of tolerance toward the presence of snakes as well as a belief system that sets great store in village cures. But, the Islamic Republic of Pakistan ranks second in severity.
At every turn a poor snake-bitten farmer is conspired against – by his own occupation and behaviour, the snake’s potent venom, and the insufficient medical care delivery system. Solving this, one of the worst public health crises caused by vertebrate animals, needs a radical change in attitude to an age-old problem. It needs large-scale public awareness campaign, clinical training and good quality antivenom.
A public awareness campaign, that employs the best techniques of the advertising industry, should educate people on how to avoid snakes and highlight that antivenom is the only antidote to a venomous snake bite. Wearing adequate covering for the feet and ankles where most bites are inflicted, sleeping on cots and under mosquito nets will greatly reduce the incidence of snake bite. Keeping the immediate surroundings clear of garbage, firewood piles, and straw heaps will discourage both rodents and snakes. Using a torch and being aware of snakes when walking at night would probably halve snake bite mortality.
In Madurai, a group of voluntary snake rescuers provide rapid transport to hospital for snake bite victims. They also counsel patients and help in obtaining prosthetic limbs when a snake bite victim is disabled. In the Nepal Terai, where the road network is rudimentary, volunteer village-based motor cyclists have proved effective in transporting snake bite victims to medical care. Programs like this have to be scaled up to enable victims to live as full a life as possible.
On the medical side, monitoring the incidence, mortality and disability rates is important so improvements in dealing with the problem can be tracked. Rural health workers and doctors not only need training to adequately diagnose and treat snake bites, they also require access to antivenom and a range of basic resources such as ventilators and dialysis machines. Venom and antivenom manufacturers have to raise their standards to those established by the WHO.
We have the knowledge and the technology to make this happen; all the government needs do is push the concerned departments into high gear. In addition, key stakeholders in herpetology, medicine, toxinology, venom collection and antivenom manufacture recently met to form a South Asian Snakebite Initiative, so there is light at the end of this horrendous tunnel.
Written by Janaki Lenin