Sulekha Sasmal remembers the day her 10-year-old daughter died in front of her, lying on a stretcher in the back of an ambulance, on the way to a hospital. Five years ago, Sutapa had been sleeping in her parents’ semi-permanent house made of mud, in Nabin Manua village in West Bengal’s Paschim Medinipur district when a snake bit her twice within a span of hours.
“We heard her call out to us around 4 am in the morning. The first time the snake bit her, it did not wake her up. But the second time, she woke up and saw the snake slither away. We had not realised that the snake had been hidden deep inside the mosquito nets covering the bed,” Sulekha says.
Sutapa’s parents borrowed a relative’s car and took her to the nearest district hospital, an hour from their village. Ill-equipped to handle a case like Sutapa’s, the district hospital advised taking her to one in Kolkata, the largest city, some three hours away, where she would receive the treatment she required. But just as the ambulance was about to reach the hospital’s doors in Kolkata, Supata died.
India accounts for almost 80% of global snakebite deaths, with over 64,000 people dying every year, according to a recent study conducted by a group of researchers from 22 countries, says Dr Soumyadeep Bhaumik, a public health specialist at the George Institute for Global Health in India, who was a part of the group. The study shows that Uttar Pradesh, followed by Madhya Pradesh and Rajasthan, reported the highest number of deaths. But experts say that actual numbers are likely higher because of unreported cases.
“Deaths due to snakebites are very high in West Bengal as well but they don’t get reported in hospitals and hence don’t feature on official lists,” says Dr Dayal Bandhu Majumdar, an ophthalmologist by profession, who is among the state’s leading experts on snakebite treatment.
Kalkutta, Giftentnahme. (Wikimedia Coommons)
Two weeks ago, on October 19, the Directorate General of Health Services at India’s Ministry of Health and Family Welfare sent a notice to surveillance officers and mission directors at the National Health Mission’s state offices across the country, directing them to appoint a nodal officer in each state who would oversee the execution of the central government’s snakebite prevention and control programme. Under this programme, the Indian government has also allocated funds for training for snakebite treatment in each state.
For decades, snakebites have been a serious tropical health issue and a neglected public health disease in many countries across the global south. So much so that in 2017, WHO reinstated it to its list of category A neglected tropical diseases. But in India, it is still not categorised as a notifiable disease. That means, despite its prevalence in the country, it is not officially considered a disease that is required by law to be reported to government authorities. “It is considered a problem that needs to be addressed by the state governments. It is not a matter of national concern,” says Vishal Santra, a West Bengal-based herpetologist.
Dr Majumdar says it is easy to understand how neglected the issue is when compared to how the government tackles malaria in the country. “Look at malaria deaths in the country. They are 1/10th of the number of deaths that happen in India due to snakebites, but for malaria, there are government officers monitoring statistics and treatment plans at every level, right from the bottom,” he says.
Over a decade after Dr Majumdar and a group of experts, along with some non-governmental organisations, first wrote to the central government to include snakebite prevention under a national programme, this past month, New Delhi finally gave it a go-ahead for execution in 2023.
The neglect and lack of attention on snakebites as a pressing public health issue in India are in part because of the socio-economic backgrounds of victims, experts say. “It is considered a poor person’s disease or a rural problem. People who get bitten by snakes are usually from marginalised communities, rural backgrounds, women and children,” Santra explains.
Bungarus Caerulus. (Wikimedia Commons)
Dr Majumdar says that one reason why dengue and other similar public health issues in India get the attention that they do is that they also impact the country’s urban population. “In the cities, people create a ruckus when even one death due to dengue occurs. But go into the interiors of Bengal and you will see how many deaths happen due to snake bites, but there is no public outcry for these victims. In West Bengal alone, we have 400-500 deaths per month,” he says.
Between April to October, almost all hospitals across rural West Bengal will have snakebite patients, with one hospital admitting at least 50 patients in one month, says Subrata Kumar Burai, in Purba Medinipur district’s Daspur (Block II) village. In addition to his day job as headmaster at Gomakpota Gunadhar Vidyamandir High School, Burai also works as a village-level administrator for a local ground-level campaign generating awareness of snake bites and snake bite treatment across villages.
As part of this campaign that was devised by Dr Majumdar, Burai travels from village to village across Purba Medinipur district holding screenings in the evenings of presentations prepared by Dr Majumdar in Bengali, urging villagers to seek immediate treatment in the nearest medical health centre available.
“I show the presentations to people so that people don’t go to ojhas and there are fewer snake bite deaths,” Burai says. In villages across India, people turn to ojhas and gunil or traditional faith healers for medical treatment, especially because of a paucity of accessible medical health facilities and high medical costs when health centres are available.
“If you look at the success rate of the ojha, it is statistically higher than hospitals. The answer lies in the number of non-venomous snake bites that the ojha gets to treat. So it is likely that the ojha just treated a bite by a non-venomous snake, where the patient did not die, and the family believed that the ojha ‘cured’ the patient,” says Santra.
In India, he explains, the majority of snake bites occur by non-venomous snakes simply because their numbers are higher than venomous snakes. Even when people do get bitten by venomous snakes, it is likely that they were not injected with venom, as a result of which the patient did not experience any impact typically associated with venom. “Twenty per cent of cobra bites are dry bites, which is a very good number,” Santra explains.
Saw-scaled Viper (Echis carinatus). (Wikimedia Commons)
The dependency on traditional faith healers is also rooted in the trust that villagers have in them. “Whatever the time of the day or night you go to an ojha’s house, whether his technique is effective or not, he will accommodate you, unlike doctors who are known to turn patients away. So dependability is important for the community. Ojhas have no knowledge about snakebite treatment,” he adds.
For over three decades, Dr Madhusudan Bhowmik has been treating snake bite patients at the Ghatal Sub Divisional Hospital in Paschim Medinipur. “Snake bites to a large degree, are not taken seriously by many people. In rural parts, people believe they recognise different snake species and then self-diagnose claiming that the snake that bit them was not venomous and therefore did not require medical treatment, resulting in medical complications. So there is a lack of awareness,” he says.
When treatment is required, they prefer traditional faith healers. Across rural West Bengal, and in several other parts of India, faith healers advertise their services on flyers and posters, encouraging patients to turn to them for treatment. “If 100 patients visit a faith healer, the healer will claim 1 has died but 99 have lived. What they do not say is that the 99 who survived were bitten by non-poisonous snakes,” Dr Bhowmik says.
Although awareness is growing, especially in bigger villages and towns, patients who do come to local hospitals find that they cannot get adequate medical help. “We do not have dialysis and ventilation machines required for snake bite treatments. In some cases, patients need dialysis machines and intensive care units. District and subdivision hospitals do not have medical equipment required for treatment, forcing patients into hospitals in big urban centres. We have to send them to Kolkata and many die on the way,” he explains.
It is not that the Indian government has not done anything, sources interviewed for this report told indianexpress.com. “At least now, every village-level health centre has anti-snake venom (ASV), which is the first stage of treatment, something that was not easily available in rural India before. But anti-snake venom is not enough by itself. You also need other equipment,” Dr Bhowmik says.
In the field of snake bite treatment, snake species that are of medical significance are those that live in a built environment or environments where people live and survive. “A bite from a snake that will require medical attention is the one that we consider a medically significant species,” says Santra.
Several years ago, he says, discussions started in government and academic circles, focusing on what were called the ‘big four medically significant snakes’, a theory which claims that four species of snakes in South Asia — Russell’s viper, saw-scaled viper, spectacled cobra and the common krait — bite people the most in this region. But this was not a scientifically sound argument, Santra explains, because in northeast India, starting from the Malda district of West Bengal, these species cannot be found. A lack of focus on species distribution and genetic diversity among snakes when creating action plans for tackling snake bites make control programmes redundant, experts say.
Naja-naja-kobra. (Wikimedia Commons)
Despite being a country with the highest numbers of deaths due to snake bites, in India, there is no academic specialisation for treating this medical problem in the country, doctors interviewed for this report said. “Look at the MBBS curriculum. In the fourth semester, students read a book on forensic medicine and toxicology, and in that there is a chapter dedicated to animal stings and poison. In that, the amount of information given to medical students is scarily less. Someone who has studied that curriculum and is posted at a rural hospital will have no idea about what to do with a snakebite patient. So these doctors would say, ‘we don’t have ventilator machines’, and refer the patient to an urban hospital. What follows is a trial and error process and a high number of patients die in transit,” says Santra.
The problem starts at the ground level and in the seven decades since Independence, it has not been addressed in the country in any meaningful way, experts say.
In Nabin Manua village, 10-year-old Sutapa Sasmal was a victim of not just a snake bite, but also the lack of access to adequate medical treatment required for her condition, her parents say. On the way to Kolkata, the ambulance carrying Sutapa passed by a small temple dedicated to the Hindu goddess Manasa, the snake deity.
Sitting in the ambulance with her daughter writhing in pain before her, Sutapa’s mother prayed to the goddess to save her child, promising to offer prayers once she was cured. “My daughter was a big devotee of the goddess. She religiously prayed to her. But the goddess did not save her,” Sulekha says, her voice breaking with emotion. “If the local hospital had the necessary equipment, my daughter could have been saved.”
