Snakes and Ladders
Snakes and ladders: the race to curb snakebite mortalities in Central India
This longform article covers roughly 150 years of research into snakebite mortalities, snake envenomation, and the reasons of snakebite-related deaths in central Indian states of Madhya Pradesh and Chhattisgarh – known to have among the highest death rate in India, majorly because of lack of effective medical care/availability of antivenom, treatment of resulting complications, time taken to reach healthcare centres, and beliefs in traditional antidotes. It also discusses the large gap in monitoring the mortalities and how researchers are innovating medical, ecological, and taxonomic studies of snakes and snakebite envenomation, tied in with my experiences of snake rescue and snake awareness in and around Kanha Tiger Reserve. This is a part of a larger piece tracing the ecological history of central India being presented here for its relevance, since the formal publication is under process, references are withheld for the time being.
With monsoon around the corner, and predictions of new and old lands coming under tillage with returning residents in the wake of the covid-19 pandemic, snakebite-related mortalities may see a sudden rise if preventive care is not taken and post-bite care is not timely provided.
Snakes in the middle
The lower jaw of the Indian rock python (Python molurus) was split open, a pool of blood forming underneath it. The python lay motionless in a big clearing, several people forming a large circle around it as a few dogs barked from a distance. This python got hold of a goat kid on a hill ending into this plain. Hearing its cries, the shepherd rescued the kid by hitting the snake several times on the head, tied a rope on its tail and dragged it down to the plains. We were called to take it away. We carried it for a quick check-up and after dressing its bleeding mouth, contemplated whether it would survive. I asked the shepherd if the goat was alright; except for a sprain in the neck, she was okay. I also wanted to ask why he didn’t kill the snake, instead of letting it go once it loosened the grasp, but refrained.
|This python was rescued after it was injured for strangulating a goat kid on the edge of Kanha Tiger Reserve|
For years this eight-foot long python stayed near human settlements, feeding on rodents, hare, and possibly small domestic animals. And in those years, she never encountered a human. On this fateful day they both met, man and snake, by a mere accident.
On the other side of the equation, not far from this village, Rangaelal ventured into his overgrown badi in the morning – like any other day – to harvest vegetables for the market. He cultivated rice for subsistence, herded his animals before dark, ventured into forests for firewood and forest produce, and tended to his backyard garden to sell the vegetables at a weekly market. That morning he stumbled back home mumbling of pain in his foot. Within a few hours he lost control of his motors and collapsed. He was declared dead on arrival at the hospital. A snake, most likely the Indian cobra (Naja naja), had bitten him when he stepped into the thicket. His was one of eight cases of death due to snakebite on the record in Balaghat that year.
India ranks first in terms of snakebite-related deaths in the world – an estimated 10,000 to 50,000 people die every year out of an estimated 2,00,000 snakebites, disabilities due to snakebites not accounted for. In other words, about five to twenty-five out of every hundred persons bitten die. The WHO had estimated the higher side of the mortality for the whole world, and has since increased to global mortality rate per year to 100,000. According to the Million Death Study (MDS), the national average mortality rate is between 3.6 to 4.5 per 100,000 persons, with the rate much higher in rural areas at 5.4 per 100,000 persons. If we go by the National Health Profile (NHP), number of snakebite incidences (averaged for ten years) is about 1,40,000, with about 1,100 deaths per year – that’s about one death per hundred snakebites, compared to five to twenty-five deaths per hundred persons according to other estimates. This discrepancy in varying estimates has put our relationship with snakes in the middle of conflict and resolution.
In central India, the NHP puts annual deaths due to snakebites between 35 and 114 for the states of Madhya Pradesh and Chhattisgarh, respectively, whereas other estimates put the deaths between 1,000 and 4,000. Even one soul lost is an irreplaceable loss. Considering the estimate of 1,000 deaths per year – snakes surpass any other wild animal by fifty times: In Madhya Pradesh, records tell us that 67 people died because of sloth bears, 63 because of jackals, 41 because of tigers, 40 because of wild pigs, and 21 because of leopards – all in a span of fifteen years (2001-2015); that’s fifty deaths due to snakes for every one death by large mammals each year.
With a mortality rate of 5.9 and 4.4 per 100,000 persons every year, Madhya Pradesh and Chhattisgarh states rank second and eighth, respectively, in India. That’s quite a high mortality rate in the modern era. These numbers, however, ask more questions than provide answers. Have mortalities always been this high, are our interactions with snakes increasing, leading to more people dying? To get to the bottom of these estimates, we need to travel back in time.
Snakes in the 19th Century
Sir Joseph Fayrer was 26 years old when he joined the Indian Medical Service in 1850 as an assistant surgeon. He went back to England for a couple of years and returned in 1958 with a Doctor of Medicine, then joining the Medical College and Hospital, Kolkata as a professor. His interest for wild animals and medicine saw him take keen interest in snakes. Venomous snakes, in particular, and the effect of venom is where he led the snake-related studies in India, and is the first person to have studied in detail the effects of venom.
The publication of The Thanatophidia of India being a description of the venomous snakes of the Indian peninsula, in 1872 – the same year as Forsyth’s Highlands of Central India – came on the heels of Gunther’s study in taxonomy and ecology of reptiles published in 1864. Both, Gunther and Fayrer put emphasis on the first aid treatment of snakebite, including physical processes to remove venom from blood. This involved what we now frown upon: making incisions and sucking blood through the wound, binding tightly above and below the wound, and cauterization with burning hot iron.
Thanatopidia is an education in death, a learning which was the turn of the tide in the medical study of the snakes of India. Just as Gunther introduced the world to the amazing diversity of reptiles of India, Fayrer introduced the world to the alarming interactions between humans and snakes. His longest section dwells on this subject, which he introduces as “experiments on the influence of snake poison on the lower animals, and on the value of certain modes of treatment and reputed antidotes.”
Fayrer experimented with snake venom on various animals. From ox and horses to goats, to civets and mongoose, rats, and birds such as domestic fowl, kites, herons, to lizards, frogs, snails, and venomous snakes themselves, limiting his observations to the physiological effects of venom. The experiments went thus:
“Oct. 21st, 1867. Experiment No. 1. A full-grown Pariah Dog was bitten by a large Cobra at 12.36 P.M. Just before he was bitten five large leaves of the Aristolochia indica, beaten into a pulp, were administered to him through a tube. The snake was made to close its jaws on the inner part of the thigh, which was at once drawn up and became partially paralysed. The Aristolochia leaves, made into a pulp, were applied to, and rubbed into, the bites.”
Excuse the explicit description of the experiments, but going ahead, we will look at herbs being used an antidote to envenomation.
“At 12.41 the Dog began to stagger, and at 12.42 he lay down. The respiration became much hurried. He got up and lay down again, and was intensely restless. There was a profuse flow of saliva, and slight twitching of posterior extremities. 12.47. – Salivation very profuse. 12.50. – Vomited some rice tinged green by the Aristolochia. 12.56. – Convulsions; pupils dilated. Involuntary discharge of feces and urine. Profuse salivation continues. Irregular contraction of limbs. 12.58. – Breathing now becoming slow, and slightly stertorous. Lies motionless, with dilated pupil and glassy eye. 1.2 P.M. – Died in twenty-six minutes after being bitten.”
In another experiment, a cobra was made to bite a dog without the treatment of Aristolochia indica leaves. Fayrer concluded: “In this case a full-grown Dog, severely bitten by a vigorous full-grown Cobra, died in thirty minutes from the effects of the poison, showing that the Aristolochia could have had little or no effect in the first experiment…” He also provided a detailed account of the effects of venom on various organs.
Being a surgeon, Fayrer also treated patients brought to his hospital, and sometimes his home, for snakebite treatment. He also meticulously kept records of snakebite cases and treatments from across northern India, including parts of central India wherever the district surgeons could provide the case information. He recounts a report of one Dr. Thompson from 1865, who was brought a patient with “some root to his nose, supposed to be an antidote, and small portions of which has been given to the boy to chew”. The boy was apparently bitten on the tip of his fingers while asleep in the cook-house, and was awoken by pain. A krait was found in the cook-house and captured. Dr Thompson found a minute puncture on a finger, like a prick of a very fine needle. The boy’s hand was puffy and swollen. Three hours had passed since the boy was brought to the doctor. “The boy’s countenance was anxious, and his breathing short and hurried; he complained of uneasiness and constriction across the chest.” Thompson applied counterirritants to the chest, stomach, legs, and administered ammonia doses through brandy. As the boy became drowsy, Dr Thompson found the he was becoming weaker in the limbs, and slapped his calves and thighs to elicit a response. The boy died two-and-a-half hours later.
In 1870, Dr. Ewart was informed of a man being bitten by a krait. Ewart notes, “The man, it appears, had been sleeping and on awaking he found something crawling over the right shoulder, and immediately experienced a stinging sensation about the middle of the acromion process. He was then under the impression that he had been bitten by a snake, and on procuring a light, a very lively snake was captured.”. The doctor found a small puncture with a bit of coagulated blood, and the site of bite puffy and swollen. The patient’s pulse was recorded irregular, body cold, but normal pupils and conscious. The patient was administered ammonia with rum, with efforts made to keep him awake. The snake was submitted to Fayrer, who identified it as Lycodon ailicus, the Indian wolf snake – “perfectly innocent”. He adds, “It is something like the Krait (Bungarus caeruleus), and often gets blamed accordingly.”
One-and-a-half century later, we are still faced with the dilemma. Those of us who rescue or take interest in snakes know how confusing it can be at times when faced with a krait and a wolf snake in the dark of the night.
The foundations of snakebite mortality studies
Fayrer made remarkable observations on snakebites, there are four that stand out to me. One is on fear, second on the effect of antidotes of those times – mostly herbal remedies – used traditionally, third on the effects of venom, particularly of what we now refer to as the big four, and fourth, the when-and-where of snakebites.
On fear, Fayrer had a lot to say: Referring to the confusion between a krait and a wolf snake, he writes, “The effect of fear was well shown in this case, as producing several of the symptoms met with in men and animals poisoned by snakes. This fear was intensified by his having seen the reptile, and being under the firm belief that it was a Krait, well known by every native to be poisonous to a deadly degree. Had the snake not been identified by unimpeachable authority, the notion might have been entertained that the patient had recovered, under the influence of cupping, ammonia, and rum, from the effects of the bite of the deadly Krait.” A false-positive success in such a case, which, in a slightly different context, has afforded the panda baba to promote enchantments as treatments.
Ewart also made a similar conclusion: “They show how the symptoms of venom from poisonous snakes may-be unintentionally simulated for a time by the influence of the fear of certain death, and how easily the practitioner may be deceived unless he is on the alert.”
On herbal antidotes, Ewart adds, “The results of the experiments made by Dr. Fayrer have all tended to prove that when the venom of the poisonous snakes of India has penetrated beneath the integument of such large animals as the horse, it inevitably causes death, in spite of the administration or application of reputed remedies. After a prolonged and patient trial of supposed antidotes, he has been reluctantly compelled to arrive at the conclusion that for the poison of Indian venomous snakes at least there has not as yet been discovered an antidote. Through his kindness, I have witnessed a large number of his experiments, and, so far as my observation goes, I am constrained to concur in the conclusion at which he has arrived with regard to the question of antidotes […] that most, if not all, of the reputed cures from the bites of poisonous snakes have been quite as deceptive and illusory” And he finally adds, with emphasis mine: “I am convinced that we have not as yet found out any medicine which can be fairly looked upon as possessing in the least degree the virtues of an antidote.”
On the effects of snake venom, Fayrer inadvertently identified the ‘big four’ venomous snakes of India attributed with most mortalities: the Indian cobra, the Indian krait, the Russell’s viper (Daboia russelii), and the saw-scaled viper (Echis carinatus). Of the eight type of snakes Fayrer experimented with, he says, “In point of relative deadliness, I should be inclined to consider that the cobra, Ophiophagus [the king cobra], and Daboia [Russell’s viper] are very nearly on par. They are quite capable of destroying a full-grown Dog in half an hour, sometimes in much less time; and very frequently I believe Man has succumbed within an equally short period, though generally the time is much longer.” He compared the banded krait (Bungarus fasciatus) and the common krait (B. caeruleus) and found that the latter as deadly as the king cobra and Russell’s viper but does not kill quickly, while the former is less fatal and kills less quickly than the common krait. The saw-scaled viper (Echis sp.), he says, are also deadly to a certain extent, and that it should be regarded with peculiar dread. The coral snakes (then Callophidae) and the pit vipers (then Crotalidae) “are certainly not so deadly […] though capable of inflicting a painful, and in some instances no doubt a dangerous bite, they are not so much dreaded as the other snakes.” Finally, of the sea kraits (Hydrophidae), he says much less is known, adding, “I should think human life would be in great danger from their bite” – and he is right. He does not discuss the cobra (Naja tripudinas – now N. naja), explicitly, but his experiments show that the cobra venom is also potent.
In 1882, he wrote; “I pointed out that the snakes which are so destructive to life are the cobra, the bungarus or krait, the echis [saw-scaled viper], and the daboia or Russell’s viper” – what we now call the big four of India’s venomous snakes causing most number of deaths.
On the situation in which snakes are encountered, Fayrer meticulously maintained an account of cases he documented himself and though his surgeon colleagues from across northern India. With over fifty cases on record in his thanatopidia, it gives us an important insight into the causes as well as the spatial and temporal patterns of snakebites of that era. For some reason we can only glimpse at four records from central India, from Seoni and Chhatarpur. Most of the recorded cases elude to some form of a trend: most were men, some as young as two to twelve years of age, the median age was 30, with an average age of 22 for men and 36 for women.
There appears to be no difference in the number of snakebite incidents between night and day. Most of the snakebites in the night occurred in the house while the person was asleep, whereas almost all of the snakebites in the day were when the person was engaged in outdoor activities in farmlands, while cutting grass or fetching water.
Snakebites when a person is asleep are generally, if not always, associated with Indian krait and Indian cobra. These nocturnal snakes occasionally enter homes to hunt in the nooks and corners. While krait primarily preys on other snakes, like the wolf snake which are also nocturnal, the cobra stalks rodents. A krait’s bite is considered like a pin-prick, or an ant’s bite, which is usually not felt by a person fast asleep. Since people slept on the floor with a blanket, these snakes would sneak inside seeking prey, biting in defense if the sleeping person moved. These attacks, like those occurring outdoors, are also accidental and are not intentional strikes.
It goes without saying that all the incidents recorded were from rural India. Most of the patients died in the cases discussed, with a large number of those receiving charms as a treatment. However, those treated with medicine also succumbed since there were no foolproof treatments available. Seasonally, the distinction between monsoon and summer months was low with slightly more cases in monsoon – the mode of months were July and March – much fewer cases were registered during winters. Snakes were not identified in a majority of the cases, the doctors speculating cobra and krait as primary suspects.
The counting of snakebite-related mortalities
Since late 1860s, Fayrer had been asking secretaries of the provincial governments for information on the subject of loss of life from snakebites. He gained much success in this pan-India effort; excepting a few provinces, he received response from most, writing, “Had similar information been obtained from these Provinces, the list of mortality would doubtless have been much larger”. In 1869, central India reported 696 deaths, but the data lacked in details. Most of cases were from Bengal, including Assam and Odisha which came under his reach of medical work, followed by the North-west provinces, the Oude (Awadh, a region in present-day Uttar Pradesh), and Punjab.
|Mortality of snakebites per 100,000 persons (population of 1866 and 1881) after Fayrer (1872 and 1882)|
Fayrer left for England the same year of his publication, but set in place a protocol to study envenomation in India. By 1880s, his data collection picked pace with more regions added, including southern India. Between 1869 and 1881, over 1,886 cases of death due to snakebites were registered in central India; the increase within a decade attests to the efficiency of data gathering when letters were mailed and telephones were only being set up the same year. Cumulative for the entire country, Fayrer recorded between 18,000 and 19,000 deaths within a year, and about 150,000 to 200,000 lives lost between 1870 and 1882. He had this to say on this count: “[…] as it is, the number of deaths is perfectly appalling, and the subject merits close consideration, with the view of discovering, if possible, some remedy.” He estimated that not less than 20,000 people die every year because of snakebites in India – remember this death toll, and remember the year he said it in.
The reportage of cases continued after Fayrer’s death in 1907. A large volume of valuable data remained in gazetteers, medical records now lost in dust, and probably did not even move out of districts. While an estimated 20,000 people died each year of preventable snakebites in the country, it appeared, after Fayrer’s efforts, to have gone back into the recesses of our attention. Even as regional and medical studies advanced the production of anti-venom serums, the attention to this interaction remained shrouded unlike the fabled man-eater tigers. Scientists, however, trudged on. Swaroop and Grab, nearly 70 years after Fayrer, published an account of ‘Snakebite mortality in the world’ under the WHO. They state that the number of snakebite incidences between 1896 and 1909 could be in the order of about 200,000 – about 15,000 cases per year.
Little is known from the thickly wooded mountains of central India; the knowledge of how snakes and humans interacted left to our speculations and deductions from studies from elsewhere in the region. The area of Chhattisgarh recorded 138 cases of snakebite deaths in fourteen years (1895-1909) – or about ten deaths per year, whereas the district of Seoni recorded over 700 deaths in fifteen years (1892-1907), about 47 deaths per year. In the Central Indian provinces, Chhattisgarh Division was at least five-times the size of Seoni district, indicating that these numbers were skewed underestimates of the real extent of the problem.
Fayrer does not dwell much upon his decades-long research on snake venom and snakebites in his autobiography. Amidst stories of hunting tigers in the terai of Uttar Pradesh and his memorabilia of acquaintances over his lifetime, snakes appear only a few times. This intrigues me, because a reflective piece on one’s life should, or may, have a more elaborate take on one’s passion. The thanatophidia is humbly only mentioned once, although Fayrer continued to give talks on venomous snakes. The reason why this intrigues me is that Fayrer was more than a researcher or a doctor. He advocated the Government of India to look into the seriousness of this interaction, even admitting that the government took efforts to address it to an extent.
The management of the problem
In his treatise, Fayrer dedicated a section to “suggestions for the immediate treatment of persons bitten by venomous snakes” with the subtext “intended for the guidance of police officers and others.”. In addition to advocating awareness among medical and police officers and the public using his well-illustrated, coloured diagrams of snakes – their morphology and anatomy published in spreads in his treatise, he drafted a protocol to be followed by first-responders to the situation, writing, “It is, I believe, usual to supply the police thannahs with liquor ammoniae to administer to those who are bitten, and who come under the notice of the police before they can be brought under any medical treatment.” Remember, this was at a time when primary healthcare facilities were few and far between. His first aid protocol is short but crisp, albeit now outdated. He likens this to general instructions for the first aid treatment of drowned or suffocated persons put up in the police stations in England. In India, he says, a translated version “might be hung up in every police thannah and other public place”; with this next line holding true to this day, “The people should be warned against incantations, popular antidotes, and loss of time in seeking for aid.”
|Plates of the 'big four' of the 29 species illustrated by the students of the|
Government School of Art and Craft, Kolkata. Fayrer, 1872.
“ […] not until a system of organised, determined, and sustained efforts for the destruction of the snakes is adopted and carried out […] will the evil be fairly grappled with and overcome. But I repeat it is only by the destruction of the snakes that the evil can be mitigated.” Fayrer advocated a rewards system on the lines of the rewards provided by the government for hunting large animals such as tiger, leopard, dhole, and others deemed destructive to human life and property. Referring to the big four and the banded krait, the king cobra, and the pit vipers, he writes, “By offering a larger reward for these only, their numbers would soon diminish, and the people would be made acquainted with the characters that distinguish the venomous from the harmless snakes, and would learn to avoid them”.
He suggested rewards from 2 annas (₹ 0.125) up to 8 annas (₹ 0.5) per snake, adding, “the sum disbursed would no doubt be large, but the results in the saving of life and destruction of snakes would compensate for the expenditure.” Awards for hunting any problematic animal– whether a snake, a tiger, a buffalo, or an elephant – were a common practice in colonial India, and was considered an effective strategy to control the losses. Just as a shikari with a gun hunted tigers, Fayrer advocated snake-catchers with a certificate from the government to hunt down snakes and provide it for the reward. Many thousands of snakes were killed. Between 1880 and 1881, the awards amounted from ₹ 11,663 to ₹ 11,961 – that’s over 467,755 snakes killed within a year. Reportedly, he also noted a short fall in the number of snakebite mortalities between the two years.
But his advocacy was not a blanket hunting permit on all snake species. He advocated hunting of the seven venomous species that are common and interact most with humans. He also suggested that through awareness the people would “gradually become convinced of the futility of all antidotes charms or spells to protect them” – hinting that no treatment yet could counter the effects of the venom, and stated, “should they ever alter their present mode of living in huts which have the floor on the ground surface, to huts with raised floors – a consummation devoutly to be wished, not only on account of snakes, but of malaria – but hardly likely to be realised.”
I know what you must be thinking; what is the point of all of this? Times have changed, and we all know that people and sometimes traditions change with time too – take the case of people preferring cots to sleep on more now than earlier, or the whole architecture of the modern houses – mud or concrete – being more-or-less snake-proof. Before we come to discuss this, bear with me a while longer with some more numbers.
Snakes in the 20th century
We will take a look at snakebite cases from 1940 to 1949 as we return to the present age. An effort made by Swaroop and Grab in 1954 fills the missing pieces of this period, and the numbers largely remain consistent. India’s mortality because of snakebites was recorded to be around 13,000 deaths per year – an estimate not far from Fayrer’s. We have better estimates for central India here than we did before. In this decade, the estimates for mortality put Bihar first – at 9 per 100,000, followed by Madhya Pradesh at 7.9 per 100,000. “In Madhya Pradesh”, writes Swaroop and Grab, “the highest snakebite mortality is found in Mandla (8.2 [deaths per 100,000 persons]), the rates being relatively high for districts at lower altitudes.” The region they refer to is the forests in and around present-day Kanha Tiger Reserve. Surprisingly, this figure is at par with death rates for eastern India and south-east Asian countries which are known for dense human populations and a larger diversity of venomous snakes.
|Mortalities of snakebites per 100,000 persons as reported by Swaroop and Grab (1954)|
Between 1946 and 1952, central India showed a wide range of mortality rates related to snakebites. The region north of Mandla, such as Shahdol, Katni, all the way up to Rewa to the north and Ambikapur to the east in Chhattisgarh showed low mortality rates (less than 1.9 per 100,000), whereas regions of Balaghat and Seoni, all the way to Melghat, showed mortality rate between 4.0 to 7.9, and that between Jabalpur and Sagar in Madhya Pradesh and Korba to Kanker in Chhattisgarh between 2.0 to 3.9. If you overlay the forest cover map on the mortality rates, two things become clear: that mortality rates are higher where forests are denser, especially in the hilly country, and second, that these regions are also where tribal and agrarian communities still practice traditional farming, and live in close proximity to forests. However, what we don’t know is how meticulously every region is represented, something left to our speculation.
Snakes in the 21st Century
Within the last 150 years, from Fayrer’s prediction of 20,000 human lives lost to snakebite, the only aspect to have improved, or broadened, are the estimates – the modern estimates stand between 10,000 and 50,000 deaths every year.
Much happened between now and then, from herbal antidotes to single-species anti-venom serum, to polyvalent anti-venom serum, from sleeping on the floor to using cots, from mud to concrete houses, to raised floors, to covered shoes, yet the numbers more-or-less remain the same. Just as the doctors of old, some of the modern doctors with keen interest in snakebite treatments have studied and analysed the reasons for such high mortality – and the similarities between then and now are startling.
|Mortalities of snakebites per 100,000 persons for the year 2005 as reported by Mohapatra et al., 2011|
The MDS for the year 2001-2003 provides an overview of the scale of the issue across the country. The study informs that 97% of the cases occur in rural areas, with the vulnerable age group of 15–29 years – with slightly older age group from Madhya Pradesh and Chhattisgarh. A majority of the patients are represented by men (59%) than women (41%). They found that the risk of snakebite death was significant among farmers and labourers who work outdoors especially between the monsoon moths of June and September.
In central India, doctors closely monitored over 800 snakebite patients between 2006 and 2014, focusing largely on the southern central Indian region. The central Indian figures, deduced from these fine-scale studies, are not far off the findings from the pan-Indian study. Their observations are comparable with Fayrer’s findings as well. Most were men (65%). The ages ranged between 21 and 35 years. Almost all incidents occurred in agricultural fields, and over 70% in rural areas. Over 70% of the bites were on legs – below the knee, and only 30% were on hands, below the elbow. Over 60% to as much as 83% of the attacks took place in the monsoon season, and very few (10–23%) in summer and winter months, and a majority of the incidents (66%) took place in the day. Unlike Fayrer, no one really dwells on snakebite incidents taking place while the victim is asleep.
|Snakebite incidents in percentage for the year 2018 (mortality rate at 2 per 100,000 persons) as reported by Salve, Vatavati and Halland, 2019|
The modern findings provide us better figures to save lives, but this is also something Fayrer already mentioned, in spite of having no foolproof treatments available then. The studies show that mortality increases as time taken to reach a treatment facility, or ‘door to needle time’ increases by as much as 67% with a delay of 25–36 hours, to as low as 7% with a delay of under 6 hours. A delay of 24 hours saw mortality rate between 17–31%. These delays are largely attributed to the preference to charms and herbal treatments, the distance from hospital, and unavailability of mode of transport. While modern India is fast closing the gap in the latter two, charms used by shamans and quack doctors – or what is locally called jhaad-phoonk – is a part of the culture of central India.
It has remained unchanged for many decades. The panda baba, as shamans in central India are called, uses parts of plants as plaster or oral antidotes. The victim lying upright on the ground is given the antidote to eat, the wound plastered with herbal pulp, and a broom of leaves and blades of grass used to ‘sweep’ the venom out of the victim’s body. About 34 floral species, from trees to herbs, are known to be used in snakebite treatment, usually as paste or pulp of roots, leaves, and whole plant. Most of the antidotes are applied physically at the site of bite. In one case in Chhattisgarh, a woman taken to a shaman to treat a snakebite wound died in the process. The shaman recommended covering her body in cow dung to bring her back to life. Her body was kept for several days until the police intervened. Using cow dung as a plaster is one of the common ways prescribed by the shamans in northern India.
And it works, perhaps a majority of the times, because of chances. Of the 25-odd snakes found in central India, five are venomous enough to cause death. If we exclude the banded krait for its restricted eastern and the saw-scaled viper for its restricted northern distribution – that’s one in every eight snakes. In addition, about one to twenty-five of a hundred persons bitten by a snake die – this often than not works in favour, or against, the victim. While the herbs do exhibit some antimicrobial and pain suppressing properties, Fayrer has been right all along, they cannot react with toxin in the bloodstream. Enchantments are considered as leading reasons for the delay in anti-venom treatments.
The only part Fayrer could not account for to further his point on the inefficiency of herbal treatments is that mortality rate goes down nearly 90% if the victim is treated with anti-venom serum at the primary healthcare facility before being transferred to a hospital for treatment. Now replace Fayrer’s police stations with PHCs, and update his snakebite treatment protocols with modern treatments – and perhaps we are in a better position to save lives.
The doctors also list a set of complications which increase chances of mortality. Vomiting is considered a risk factor. Bleeding, especially from venom-induced consumption coagulopathy (when the ability of clotting is impaired) also increases chances of mortality, followed by acute renal failure – both results of a viper’s bite. Neurotoxins of krait and cobra causes neuroparalysis which in turn affects breathing. In such complications, only anti-venoms do not work, dialysis and respirators need to be provided to the patients, equipment often in short supply and expertise lacking in primary healthcare facilities. To counter this, transfer to hospitals is paramount. The doctors suggest that the average time to take the patient to the hospital should be within twelve hours of the incident, the shorter the better. While Fayrer found cobra and krait to be the most common suspects, the present-era studies attributed over 25% to vipers (mostly Russell’s but also saw-scaled) and a small number to cobra and krait. On an average, without effective treatment, death can result within eight hours from the bite of a cobra and 18 hours from the bite of a krait, to 3–5 days from the bite of a Russell’s and saw-scaled viper’s bite.
Snakes in the backyard
It would seem that we know everything about snakebite causes and effects today – but I think we have known it for the last century-and-a-half. We now possess fine-scale data for the entire country, with little effect on the number of estimated deaths. Perhaps there are other reasons we aren’t looking into. It is true that lifestyles have changed to an extent, but the exposure of populations has remained the same. India is an agrarian nation – the agricultural ecosystems are also the abodes of snakes, a large number of which come seeking rodents.
I’ve been asked on several occasions, why do I rescue snakes, followed closely by what is their importance in an ecosystem? One of the many reasons why I rescue snakes is to reduce the tension between people and the snakes. Our fear of snakes is not instinctive, the fear is cultured in us as we grow up. Most of us carry this fear – no, not the heart-clenched-in-fists fear, but the fear of stay-away-from-me which compels us on to destroy the problem. As for the importance of snakes, I avoid being philosophical (well, you know, everything in this universe exists not because it is important to us) and tell everyone that frankly, there is a cobra in your granary because your grains are being eaten up by rats, and there are pythons in your fields because there are rats eating up your crop.
|This Indian cobra sought sanctuary in a six-feet deep granary where it moulted and possibly hunted rats.|
It was rescued and released nearby.
Some conservative estimates put damage to standing crop by rodents between 10% and 20%, and for postharvest between 25% and 30%. While several mechanical and chemical ways of rodent control exist, snakes and birds-of-prey are important parts of an ecosystem in managing populations of rats which see a sudden, unnatural spurt in population growth on the heels of a surplus food source, attracting their predators into our backyards.
|A young python, not four-feet in length, had consumed a rat in this paddy field right outside a farmer's house. He called us to take it away, thanking the snake for getting rid of rats, and us for getting rid of the snake.|
Snakebite mortality, compared to mortality due to other wild animals, is different in the way we treat it. The MDS was initiated to understand the underlying causes of premature mortality in the world, starting with India since over 75% of deaths in the country occur at homes without medical attention. It was launched in 1998 in collaboration with the Registrar General of India which also conducts the nation-wide census surveys. The study is still ongoing, with a focus on deaths due various reasons related to maternal and child health, cancer, cardiovascular disease, injuries, alcohol, malaria, HIV/AIDS, suicide, road traffic, and snakebites.
In 2017, WHO added snakebites as ‘other neglected conditions’ under the neglected tropical diseases – the only vertebrate animal among several parasitic, bacterial infectious diseases. Perhaps I can say that the human-snake interaction issue was of numbers all along. Did it have to take a million deaths to warrant the world’s attention? What did we miss amidst our obsession with man-eater tigers and leopards in over a century? Perhaps Fayrer was right about another thing; he called venom a virus, perhaps for the lack of a better name in his era, but as much as human-snake interaction is an issue of human-wildlife interaction, the higher mortality rate is an issue requiring expert medical attention.
Scientists are expanding in their quest for solutions on three fronts now; to understand who the vulnerable populations are, where they are (in terms of how far they are from a hospital with provision of anti-venom treatment), and the effectiveness of anti-venom serums. A global study of snakebite envenoming by Longbottom and colleagues identified populations which share habitats with venomous snakes for which anti-venom may or may not exist. They represented it based on the distance from the nearest healthcare facility (mostly the nearest major cities).
Longbottom and his colleagues used the HAQ index (Healthcare Access and Quality Index) to identify global hotspots where “the intersection of population who live within the range of venomous snakes that have no anti-venom available, cannot easily access healthcare, and have poor quality healthcare in delivery of anti-venoms or ensuring necessary stocks.” HAQ Index is calculated on the premise that humans have access to quality health care. It is generally represented in ten equal portions, called deciles, ranking them from low (decile 1) to high (decile 10) scores. India’s overall rank has been in the second decile, moving up from 153 in 1990 to 145 in 2016 out of 195 countries.
The authors used the HAQ index to understand vulnerable populations living more than three hours from nearest major cities with population of around 50,000. A majority of India’s population falls in the fourth decile near the medium risk category, second highest in the second decile near the high-risk category, followed by third and fifth decile. A large population falls within the first four deciles with a higher risk of snakebites. In India, excepting the mountainous belts of the Himalaya and parts of the Western Ghats, vulnerability to medically important snake species appears lower. In central India, risks show up as low because of connectivity with major cities. Global studies like this help identify vulnerable countries in need of medical facilities to reduce snakebite mortalities, but fine-scale studies which account for regional specificity are the need of the hour.
A study by Senji Laxme and colleagues recommends profiling venom of medically important yet neglected snakes from various geographies. The authors state that the anti-venom manufacturing protocols “have remained unchanged for over a century”, with the polyvalent anti-venom for the ‘big four’ being used routinely for snakebite treatment across the country. The study highlights “dramatic inter- and intraspecific differences” in venom profiles of medically important snakes, linked with their ecologies and diet.
Some of these differences are physical visible. For instance, five subspecies of the saw-scaled viper are recognised. Parts of central India are represented by the species Echis carinatus, which are much smaller and darker in appearance than their counterparts the eastern saw-scaled viper (E. c. sochureki) that have more of a sandy hue with prominent white patches and are bulkier in stature, found in the drier states of Rajasthan, Gujarat, parts of Punjab, and further west.
|The saw-scaled viper (Echis carinatus) (1, 3, 4) and the eastern/Sochurek's saw-scaled viper (E. c. sochureki) (2).|
1 is found in the drier parts of central India, 2 is found in western India, and 3, 4 are head-shots of individuals from the Western Ghats shown here for comparison. Image 1 and 2 © Vivek Sharma, indiansnakes.org
Depending on prey availability and the habitat suitability, these physiological differences hint at the differences in the potency of their venom. The authors ran sulphate-polyacrylamide gel electrophoresis which separates protein molecules using an electronic charge – forming a unique signature as the molecules flow (the lighter the molecule, the farther it would travel). For snakes belonging to the same species, one would expect similar signatures in toxins, but both the subspecies show distinguishable signatures – with the eastern saw-scaled viper having 33% more PLA2 protein, among other varying protein compositions. PLA2 is a commonly found venom protein which leads to muscle necrosis. The authors also tested various polyvalent anti-venoms available in the market for the treatment of venom belonging to different subspecies of snakes. In case of the two saw-scaled vipers, they found most binding well with the venom of E. carinatus to neutralise it, but only one antivenom exhibited increased binding with E. c. sochureki.
A diversity of physical variations among the same species are found in central India. There are the brown and black morphs of both, the Indian cobra and the Indian rat snake (Ptyas mucosa). There is a belief that the black morphs of both the species are extremely venomous, and that when a brown-morph cobra, locally called bhura naag, mates with the dark-morph rat snake, locally called kariya asadiya, the progeny of black-morphed cobras, or kariya naag, are among the most venomous snakes. Both these morphs are common to both the species, and while the Indian cobra is among the most venomous, the rat snake is not, and the species do not interbreed.
|The dark and brown morphs of the Indian cobra are both common in central India|
The authors highlight there are “Dramatic differences in venom composition and biochemistry of the ‘big four’ and the ‘neglected many’”, warranting regional venom collection centers for the development of antivenoms that accounts for other venomous snake species and regional specificities within snake populations.
The race to zero snakebite mortalities
Humanity has come a long way in this snake-and-ladders game of life. In India, we’ve probably only reached half-way through it, but we can shrink the next half with better-informed science – use a ladder, if you will. Perhaps we were lacking in two aspects, the count and the outreach. We have been counting for the last century-and-a-half, but we need to get better at it to narrow down the broad range of snakebite mortalities, and put more emphasis on region-specific mortality rates. In addition, we also need to be transparent about it – this factor ties up with our second aspect, the private aid assistance. Today, many individuals and non-governmental organizations are joining hands with district administrations, the health departments, and the local communities on snakebite prevention and treatment. But down at the household-level, many people still visit private untrained practitioners for snakebite-related treatments, some still believe in physical suction of venom out of the bloodstream. Some still give priority to the panda baba. While I write this, I feel I am repeating Fayrer, because the foundations he led down to make people aware remain the same. We do have better photographs of specimens now; we have active internet-based groups to provide answers and help. I have seen this change in the remote corner of Balaghat, close to Kanha in Baihar. Once, anti-venom was only available at the government hospital of Baihar and the hospital of Hindustan Copper Limited in Malanjkhand, both at a distance of about 23 km. A snakebite incidence in Garhi, a small village north of Kanha, would take more than an hour to reach Baihar – time to find transport and bring the victim to the main road not accounted for – with high uncertainty of foolproof treatment. Besides physical distance, awareness was a key determinant in seeking proper and timely care. The administration of Kanha Tiger Reserve has started stocking anti-venom and providing quick transport for the patients to reach hospitals. This was possible only when electricity-provision improved in the little village of Mukki, and now Kanha has effectively saved lives by providing timely treatment before transferring the patients to hospitals. If this outreach continues to expand to every corner of the country, I strongly believe that we have already crossed the peak of the mortality curve. Today, the forests around Kanha which showed mortality rates of 8–15.9 per 100,000 persons is down to around 2 per 100,000 persons, with a death toll of around 30 in Madhya Pradesh and 140 per year in Chhattisgarh in 2018.
As a mechanism to cope with the loss of a family member, the government, through the National Health Authority, launched a compensation programme under Ayushman Bharat – the Pradhan Mantri Jan Arogya Yojana. It is geared towards treatment and ex-gratia support costs for below-poverty line and vulnerable families in rural and urban settings. Snakebite-related treatment costs are also covered under Pradhan Mantri Suraksha Bima Yojana which primarily covers insured people. The nominee is paid an amount of ₹ 200,000 in case of death or ₹ 100,000 in case of permanent disability on presenting the medical records. The annual premium one has to pay to be insured is ₹ 12 excluding service tax. All these schemes are managed through the district administration. State governments also provide ex-gratia compensation under the Chief Minister’s Disaster Relief Fund for snakebite injuries. These compensatory programmes are relief-aids and do not directly help reduce the interactions, but they fill in a gap left behind by the colonial-era rewards-system.
You may ask what makes me say that we’re past the peak in the curve. Estimates, low or high, generally lead us to some factual information. After Fayrer (1872), Swaroop and Grab (1954), and the scientists-cum-researchers who led us to the root of this interaction (2000s), snakebite mortalities found a place in reportage under the NHP. An annual report of the Central Bureau of Health Intelligence, the publication came into circulation in 2005. The discrepancies between government-led and private-led figures of snakebite mortality aside, NHP has been reporting on snakebite incidences on the lines of other diseases. This forms an important baseline to study trends in this interaction.
|A composite map showing refinement in snakebite mortality rate studies from late 1800s to early 2000s|
|Snakebite mortality rates per 100,000 persons between late 1800s and early 2000s in central India|
Just as Fayrer’s numbers saw a jump between 1869 and 1881, we see a ten-fold jump in numbers between the 1940s and the 2010s from an average 13,291 cases to 140,230 cases of snakebites. This jump doesn’t mean that cases have increased, but our efficiency of recording cases has certainly improved. The outreach of awareness, lifestyle changes, accessibility to treatment facilities and approach to such facilities, has led to changes I see as a silver lining. In central India, the mortality rate of eight has come down to nearly two for every 100,000 people within half a century. Overall, central India has also seen a decline in deaths per person bitten to 1:126 from 1:17 – a seven-fold drop between 2009 and 2018.
Where does this leave us in understanding the negative human-snake interactions? Snakes are perpetually hunted across the country. I’ve witnessed them being speared, or beaten, or burned alive, but there is another side of this equation. I have said that we destroy our problems through our fear, but that narrative is changing, too. Wherever snake rescue and rehabilitation are actively undertaken by passionate people, snake deaths eventually decrease and snake rescues go up. People’s fear is taken over by fascination. While I rescued only a handful-few snakes in Kanha, state-supported snake rescue teams, such as the flying squad of Seoni Forest Circle, rescued hundreds, saving lives of both the snakes and the people. Many snake rescuers have also, unfortunately, lost their lives during snake rescue operations. In addition to strengthening PHCs and hospitals to treat snakebite patients, government should also recognize individuals and communities in snake rescue work through insurance mechanisms such as the Pradhan Mantri Suraksha Bima Yojana.
What made the shepherd spare the python when almost all the snakes in conflict situations are inevitably killed made all the difference. The reason lies in an ancient tradition. In the southern parts of central India, pythons are revered as an avatar of Goddess Lakshmi who brings good fortune, who visits homes after the harvest is stored in granary and rests there guarding the grains from rodents and bad omen. This simple belief has saved this snake from its doom, and perhaps has saved many in the past. It is no wonder that we’ve received most calls to rescue pythons during monsoon than most other, especially venomous, snakes.
|Providing respite to the rescued python with the officials of Kanha Tiger Reserve during the release|
Once the wound was cleaned and the snake examined for other injuries – which fortunately were none – it was bathed with water a number of times.
The deputy ranger told us of his encounters with these giants in the forests of Kanha. Once he saw a python being kicked by a group of Hard-ground Barasingha while it curled around a new born calf. It endured many kicks for a long time till it let go of the calf and moved away smeared in its own blood. Pythons are extremely strong, he assured.
It was unanimously decided that the python would be released that night itself, so we carried it deep inside the protected forests, away from any human interactions where it could find peace of mind earnestly required for healing. That was all we could do.
To watch this eight-foot python weighing eight kilograms slither smoothly on the moist earth as it vanished into the darkness was a hopeful sight. We saw it gently raise its head and flicker its tongue as it made its way through the thicket. It would find shelter, and rest there for days until the wounds healed and its teeth grew back, and I hope is remembered as a goddess again.
See indiansnakes.org for more information on snake identification and DOs and DON'Ts of snakebite treatment.