BHUBANESWAR: On Wednesday last, Shiba Patra, a native of Ganjam’s Buguda was bitten by a venomous snake. Instead of rushing him to a hospital, his family members took him to nearby Baladevjew Temple for a special ritual.
The temple priests poured 82 pitchers of water on Patra and performed a puja to cure him. When his condition deteriorated, he was shifted to Buguda Hospital but by then, they were 12 hours late. Doctors declared Patra brought dead.
Eight km away, Sujata Pradhan was taken to a witch doctor after she reported snake bite the same day. When the sorcerer failed to revive her, Sujata was rushed to a hospital where she succumbed.
In large parts of Odisha, sorcerers not only get the first call in snakebite cases but are also expected to revive the dead in many instances, such is the sway of superstition over basic medical science in this age.
On June 23, a sorcerer tried to resurrect a 40-year-old woman near postmortem wing of Padampur Sub-Divisional Hospital in Bargarh district. The woman Saptashila Bhoi, a native of Changria village, had already died of snakebite.
When the sorcerer failed in his attempt, he told the family that he should have been intimated earlier. Another such sorcerer was even allowed to enter District Headquarters Hospital (DHH) in Bhawanipatna to try his ‘mumbo jumbo’ to bring a snakebite victim Satish Gopal (21) back to life right inside the mortuary.
Calamity Vs Snake
In a natural disaster-prone State like Odisha, snakebites claim more lives every year than calamities like floods, cyclones, drowning and fire mishaps. Declared a State-specific disaster in 2015 under which family of the victims are entitled to a compensation of Rs 4 lakh, snakebite deaths account for 40 per cent of total disaster deaths.
An official estimate states that 811 people were killed in snakebite in 2018-19 which makes it two deaths every day. In first four months of 2019-20, as many as 237 deaths were registered. In the last five years, a massive 2,954 snakebite casualties have been recorded.
And the number is on the rise, improvements in health care services and their coverage notwithstanding.Fourteen districts recorded more than 100 snakebite deaths each during the period.
About 85 per cent deaths occur between May and October - either peak heat or monsoon seasons. Special Relief Commissioner (SRC) Bishnupada Sethi explains that maximum number of deaths are reported in July and coastal districts like Balasore, Ganjam and Bhadrak - primarily flood-prone - report more deaths.
The reptiles are not the villains though. Superstition kills more. If that is not bad enough, non-availability of adequate anti-snake venoms (ASVs) at grassroots health care centres, poor understanding of treatment system, abysmal road network coupled with fractured ambulance service have added to the toll.
On August 11, two siblings - Barsha Dandasena (13) and Abinash (8) were bitten by a snake while they were sleeping in their house at Subulia village in Sundargarh district. By the time they could be taken to Ispat General Hospital (IGH) in Rourkela, the two had died.
The Roadblocks
High fatality due to snakebite is attributed to non-availability of ASV at rural health facilities, delayed and inappropriate administration of ASV, lack of standard protocol for management and inexperienced doctors and non-availability of ventilator facility in PHC or CHC level.
Twenty-six year-old Tribikram Oram of Bhaluduguri village in Sambalpur was rushed to Paramanpur PHC after he was bitten by a snake. Since there was no ASV available, he was referred to Sambalpur DHH before being shifted to Veer Surendra Sai Institute of Medical Science and Research, Burla but doctors could not save him.
Additional District Medical Officer (Public Health), Sambalpur Dr Panchanan Nayak admits that ASVs are not supplied to PHCs primarily because these units are not equipped to manage snakebite victims if they develop complications after drug administration.
Adequate numbers ASVs are available in CHCs, SDHs and DHHs, he said.
Though ASVs are supplied by Odisha Government free of cost, its non-availability in remote and rural pockets where snakebite cases are aplenty is attributed to a spike in snakebite deaths in the state.
In Rangamatia Sahi of Keonjhar district, a 14-year-old Daktara Munda suffered a snakebite on August 8. He was initially taken to nearby Phulajhar PHC where ASV was unavailable.
The desperate family tried two sorcerers but in vain. “Had ASV been available in the hospital, my son could have been saved,” Daktara’s father Dambaru Munda laments.
Associate Professor of Forensic Medicine and Toxicology at AIIMS-Bhubaneswar, Dr Sudipta Ranjan Singh points out that awareness among people to check intrusion of snakes and prevent deaths is negligible.
Patients, instead, depend more on traditional healers and sorcerers for which precious time is lost.“Most deaths are reported during transit and referrals because confidence level of treating doctors in rural areas is low.
They express reluctance to admit and treat snakebite cases fearing medical complications and reactions to ASV,” he said.
Apprehensive, doctors in rural pockets refer cases to urban and semi-urban centres as supporting services like ventilators and oxygenation systems in periphery hospitals are next to nil.
Just about 10 District Headquarters Hospitals in the State are equipped with ICU and ventilator systems, forget about the CHCs and PHCs.
“Delayed administration of ASV or waiting the victim to develop symptoms results in systemic envenoming and high fatality. Apart from availability of ASVs in rural centres, focus should be on identification of snakes and proper training of doctors for management of snakebite cases,” Dr Singh suggests.
Response time plays a great factor in cure of snakebite victims. Even the largest venom dose of any snake can be neutralised by anti-venom but the Golden Hour must be kept in mind.
General Secretary of Snake Help Line Subhendu Mallik, also a honourary wildlife warden, says deaths are on the rise due to prevailing superstition among rural populace. “When medical science has definite treatment for snakebite cases, people first visit faith healers or sorcerers.
Timely treatment only can prevent snakebite deaths,” he points out.Inadequate infrastructure in rural areas such as lighting, sewerage systems and roads co-contribute to snake bites. Habit of people sleeping on the floor, presence of livestock and agricultural fields near human habitations which attract prey for snakes are add-ons.
State must act
With snakebite deaths emerging as a major headache, the State Government has decided to scale up deployment of doctors at primary health centres in vulnerable areas and make ambulances available for swift transfer of patients to hospitals.
“We have asked Health and Family Welfare Department to ensure availability of medical officers at PHCs in snakebite-prone areas. Districts have been directed to sensitise people to bring victims to nearest health institutions at the earliest and ensure they are not treated by sorcerers and quacks,” SRC Sethi says.
Though production and distribution of ASV in the country remains a matter of great interest, Odisha provides it free of cost. Managing Director of Odisha State Medical Corporation Limited (OSMCL) Yamini Sarangi says health centres up to block level are adequately supplied with ASVs.
"As many as 37,066 vials of ASV are in stock with 37 warehouses in the State. Snake venom antiserum (polyvalent) with diluents in plastic container, 10 ml/vial (Lyophilised powder form) is now available. The ASV in powder form does not require refrigerator for stocking.
As per requirement, PHCs can also pick it from block warehouses,” she informs.
ASV not good enough
Grey areas still exist. A study on Venomous Snake Bite in India by cardiologist Jaideep C Menon, nephrologist Joseph K Joseph and herpetologist Romulus E Whitaker says that ASVs available in India may not be ideal for treating venomous snakebite in the East, West and Northern parts of the country.
The standard ASV neutralises the venom of Russell’s Viper, Common Cobra, Saw-scaled Viper and Common Krait. However, the study published in the Journal of The Association of Physicians of India claims a significant number of bites by Banded Krait, Hump nosed Pit Viper, Malabar Pit Viper, Bamboo Pit Viper, Sochurek’s Saw-scaled Viper, Monocled Cobra, Sind Krait and King Cobra are also reported and venom of these snakes is not neutralised by the standard ASV available.
“Since it is difficult to distinguish the species of snake at the primary level and PHCs lack expertise in identifying the snake on the basis of signs and symptoms, the ASV administered are mainly polyvalent.
Though ASV is the only scientifically proven treatment for venomous snakebite, it is not effective for all venomous snakes found in Odisha,” Dr Singh points out.
Focus on curriculum
As per the prevailing medical curriculum, venomous snakebite is covered in Forensic Medicine and Toxicology subject. Identification of venomous species symptomology is covered from a forensic angle.
The focus of medical education should shift from knowledge-based approach as taught in most of medical colleges from Western texts to a more practical one based on the disease conditions medical graduates are likely to encounter during their practice, the study stated.
A person in respiratory distress due to a neurotoxic snakebite (especially krait bite) is unlikely to survive a one-hour journey to a tertiary care centre without ventilator support. Doctors in PHCs, especially in areas where neurotoxic bites are common, should be trained to maintain oxygen saturation till definitive treatment is given, the study added.
Snake Help Line General Secretary Mallik says, awareness campaigns apart, stringent legal action against sorcerers will help bring snakebite cases to hospitals. He feels that the number of reported cases is on the rise after the state government hiked the ex gratia amount to Rs 4 lakh in 2015.
“Nearly 3,000 people are reported to have died of snakebite since the ex gratia was enhanced and government has shelled out Rs 120 crore. If doctors are properly trained to manage the cases and hospitals are well equipped, the problem can be mitigated,” Mallik added.