Snakebites and “Make in India”

Over the last two days I saw several mentions of the snake envenoming challenges in India on Twitter, and realized that we have the World Snake Day approaching (July 16th). I began writing about public health topics in 2015, and among my earliest published articles was in fact on the public health and policy aspects of snakebites in India. It was published in the Huffington Post (their erstwhile India edition) on June 1, 2016, and maybe it’s a good time to revisit it. What follows is a reproduction of that essay.

One risks being mocked for juxtaposing snakes with the “Make in India” initiative which recently was spoken of in the same (albeit a bit laboured) breath as Apple Inc. Inspired by ‘pop patriotism’ many Indians are eager to sever from popular imagination any associations India has with snakes. But of course, snakes aren’t going anywhere.

In fact, there are more than a million incidents of snakebite per year in India. Each hour snakes bite dozens of people and kill around five Indians (they kill about 45,000 annually) [Correction: More recent studies show that this number is as high as 58,000]. Tens of thousands lose limbs or are disfigured and disabled permanently. In comparison, there were 100,000 dengue cases last year, with 220 deaths. Which among the two gets more media coverage and political attention is anybody’s guess. While this comparison doesn’t intend to trivialize death, it helps us understand how we tend to prioritize India’s health crises by location: dengue is primarily urban, while snakebites are rural. No wonder even the World Health Organization (WHO) labels snake envenoming as a “neglected” condition.

Snakebites mainly affect children and young adults, age-groups which our Prime Minister supposedly has high hopes from. Though snakebites are an occupational hazard for farmers (a majority of bites occur while they are working in the fields), we rarely have public and political discussions on this daily danger they face. Imagine what a brouhaha would erupt if India’s urban IT personnel were battling a similar occupational hazard which killed dozens and injured hundreds a day, and was relatively easily curable and preventable.

I spent my childhood in Maharashtra’s Konkan region. Snakes abound there, and I remember several occasions of suddenly spotting them on a path, especially during the monsoon, and being both frightened and enamoured by their slithering forms. Years later, while working at the Ratnagiri District Hospital in the region, I wasn’t as enamoured: tens of patients, almost all of them villagers, would come in with excruciating pain from snakebites, and there would be occasional deaths. The most tragic thing with snakebite deaths, as against death from, say, dengue or most cancers, is that people die despite the presence of a proven and longstanding cure: the snake antivenom.

When snake venom enters our blood and tissues, the antivenom, which neutralizes that venom, becomes a life-saving medication. It saves thousands of lives and many more limbs each year. But India (and the world) possesses woefully inadequate amounts of it. Last year when the pharma company Sanofi Pasteur announced it would halt production of its antivenom for Africa, experts warned of consequent “unnecessary deaths”. Here is where Make in India comes in. The initiative has not yet been associated with any major public health project, and snake envenoming, a serious local as well as global problem, is one of the perfect candidates for intervention and innovation [Again, I would like to remind readers that this was written in 2016. Today, I would absolutely not expect any smart, evidence-based, grounded policy action from the Union government in India, especially one that makes major improvements in the lives of the marginalized and the poor.]

The production of high-quality and effective snake antivenom requires considerable investment and research. Our conventional antivenom is effective against the venoms of only four “medically most important” species of poisonous snakes of India. However, experts say either this number should be increased, or that we should have different antivenoms for different major regions of the country.

Around 80% of the entire country’s antivenom is made using venom of the snakes from, shockingly, just a few districts in Tamil Nadu (through the Irula Co-operative Society in Kancheepuram district). Hence, if you get bitten by a snake in Arunachal Pradesh or Bihar, chances are that the antivenom your doctor gives you might not work effectively — and with snakebites, this means flirting with death. Besides, Indian manufacturers haven’t yet embraced modern methods of production that reduce the occurrence of serious side effects to antivenoms.

In other words, we urgently need robust research on Indian snakes and their venom, as well as investment in antivenom production. For too long have we neglected this important need of rural India.

With the government being so loud about its Make in India agenda, the neglect of its own public sector pharma manufacturing is surprising. This April [2016], a Parliamentary Committee report urged the government to make fully functional its large sera and vaccine units in Kasauli, Guindy and Coonoor, some of which also produce antivenom. Since snake antivenom is often out of stock in government rural health centres, where it is needed the most, manufacturing high-quality antivenom in public sector companies needs to be a priority. This will not only save lives (particularly of young farmers), but also prevent thousands of villagers from slipping into poverty, since treatments with private sector antivenoms at private hospitals are enormously impoverishing.

In other words, Make in India must also strive to benefit the “other” India, the India of its villagers. Making state-of-the-art antivenom/s, which will be usable throughout India without any quality and efficacy issues, should become a high-priority project of the government. Through such needs-based (rather than only ambition-based) Make in India policies, more and more products could become valued desi commodities both within and outside the country.

Since low- and middle-income nations in Asia and Africa also require antivenom in huge quantities, investing in proper R&D can make India a world leader in snakebite saves, as against the currently dubious leadership in snakebite deaths. Last year, the British Medical Journal published an editorial titled “Snake bite: a global failure to act costs thousands of lives each year”. India, possessing appropriate experience and influence, has an important opportunity to help reverse this failure, and we shouldn’t let it go.

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Two of the many good papers on this topic:

Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study by WIlson Suraweers et al

Access to antivenoms in the developing world: A multidisciplinary analysis by Potet et al

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Flooding, snakes, and Mother India:

Being a Konkan native, I strongly associate snakes with rains and floods. As I was googling articles on snakebites in recent years, I saw that several mentioned significant rises in bites following the major flooding incidents we have witnessed across India of late. This is a real danger, and directly puts snake envenoming in the category of public health challenges exacerbated by climate change.

Which beings me to Mehboob Khan’s extraordinary 1957 magnum opus Mother India. Having first seen that film at a young age, I was very taken by the hair-raising flood scenes and the scary presence of snakes in one of those scenes.

You can watch that scene here: https://youtu.be/ii2OlEmzhJA?t=136