Print Email to Friend| From Tehelka Magazine, Vol 9, Issue 41, Dated 13 Oct 2012

CURRENT AFFAIRS   WHAT ON EARTH

Snake bites and poisoned stats

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 percent of the deaths showing up in official records, the State refuses to fight the epidemic killing its rural poor

By Jay Mazoomdaar

Photos: Indiansnakes.org, Tubai Biswas, Dharmendra Khandal, Krushna Ghule, Umakant Chavan

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.

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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 5,000-6,000 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, 3-5.5 million people are bitten by snakes in self-defence every year. Many of these bites are harmless because only around 600 of the 3,000-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 1.5 lakh 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 the Public Library of Science Neglected Tropical Diseases journal 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 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 1,440 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 2004-09.

Evidently, very few snakebite victims reach hospitals. No statistics are available for India but the magnitude of invisible victims can be gauged by the fact that in rural Nigeria and Kenya only 8.5 percent and 27 percent of snakebite victims, respectively, sought hospital treatment. But ASVS is the only cure for snakebite and, if administered in time, can be effective.

Spectacled cobra Russell’s viper

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 expensive, unavailable and ineffective in India.

Common krait Lesser black krait

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 hyperimmunity 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 $1,000, 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, which are supposed to offer ASVS free of cost, 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 3 lakh 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 four 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 sideeffects of ASVS.

Rapid technical advancements in the production of ASVS have not entered the Indian industry. Those made here frequently cause 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 victims treated with Indian ASVS showed side- effects.

Saw-scaled viper Malabar pit viper

The Irula Snake Catchers Industrial Cooperative Society (ISCICS) is licensed by the Tamil Nadu Forest Department to capture 8,000 snakes per year. The 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.

The ASVS produced with venom collected from one geographical pocket 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.

India’s three cobra sub-species 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 not effective against three species of krait, two species of cobra and three species of viper among the 12 high-priority species listed by WHO for South Asia.

Deadly bites Tissue damage caused by a Russell’s viper Photo: Abhijit Chavan

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 1.78 lakh incidences of cholera, 4,000 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 2.6 million with 1 lakh 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 hazard for the farmers, plantation workers, fishermen and other rural workforce. Not surprisingly, it fell off the radar.

The hump-nosed pit viper Photo: Amrut Singh

There are a few positive initiatives. West Bengal has designed treatment protocol posters for snakebite management 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 past 60 years, we have had enough of both.

Jay Mazoomdaar is an Independent Journalist.
jaymazoomdaar@gmail.com