Uttar Pradesh/ Madhya Pradesh/ Odisha

On June 26 last month, Mukesh Kumar, the 16-year-old son of Ramakant Maurya, was bitten by a snake in Jhaupur village of Lakhimpur Kheri district in Uttar Pradesh. By the time his family could reach him to a hospital, the teenager died.

"My son was returning from a shop at about ten in the morning when a snake bit him. We immediately took him to a tantrik (witch doctor) who said he could not help," Ramakant told Gaon Connection. The family rushed Mukesh to the government Community Health Centre (CHC) at Gola, about 16 kilometres (kms) away.

"There were no medicines available for poisonous bites. So, from Gola, we went to the district hospital at Lakhimpur, about 36 kilometres away. But by the time we reached there, Mukesh was declared dead," the distressed father said.

Like Mukesh, 45-year-old Gouranga Charan Das of Angelei village in Kendrapara district of Odisha was also bitten by a snake on June 2. He was taken to the CHC at Marsaghai. As he was in a critical condition, he was shifted to SCB Medical College and Hospital at Cuttack, nearly 70 kms away. Das fought for his life for nearly a month, but died earlier this month on July 4.

Time is of the essence, which is why the first hour after the snakebite is known as 'The Golden Hour' when with proper intervention lives can be saved. But, if there is a delay in administering the anti-venom drug, chances are the snake bite will cause grave organ damage, or prove to be fatal, like it did for Mukesh Kumar and Gouranga Charan Das.

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According to a July 2020 study titled Trends in snakebite mortality in India from 2000 to 2019 in a nationally representative mortality study, of the 2.8 million people bitten by snakes every year in India, 58,000 people die. And up to 94 per cent of the snakebite deaths are from rural India.

And, one of the main reasons for the deaths is non availability of anti-venom drugs in the primary health centres (PHCs), and sometimes even CHCs, that are closest to the villages. Additionally, there is misinformation about snakebites amongst the rural inhabitants because of which crucial time is lost.

Also Read: Rural India reports 94% of snakebite deaths in the country yet primary health centres lack antivenoms, treatment facilities

Ironically, India is one of the leading producers and exporters of anti-snake venoms. There are currently seven laboratories producing antivenom in India. A 2019 research paper titled Snake Venom Production for Antivenom in India estimated India's total production capacity at two million, 10-ml vials annually.

India is also the largest exporter of anti venom, as noted by Volza Grow Global, a trade expert company. It exports antivenom to Pakistan, Nigeria and Ghana. There are 59 suppliers in the country who export antivenom.

"Despite the fact that we are leading manufacturers of anti-venom and also its biggest exporter, our rural health centres report acute shortage of anti-snake venoms," Jose Louise, Kerala-based founder of the app 'Indian Snake', a leading platform with India's largest digital database for Indian snakes and related information, told Gaon Connection. He is also an International Union for Conservation of Nature (IUCN) expert in snakes.

Priyanka Kadam, founder, Snakebite Healing and Education Society, echoed what Louise said. "The problem is not with shortage of anti-venom drugs. There are more than four major companies that manufacture the anti-venom. The problem lies with its distribution by the health departments of state governments," the Mumbai-based snakebite expert with a background in community engagement and advocacy, said.

To raise awareness on preventing snakebite deaths, Gaon Connection has launched a month-long campaign titled 'The Golden Hour' on World Snake Day on July 16. As a part of the campaign, reporters from Gaon Connection visited several PHCs and CHCs across Uttar Pradesh, Madhya Pradesh and Odisha to check the availability of anti-snake venoms in its public health facilities. At a large number of these rural health centres, the antivenom was not available.

PHCs sans anti-venom

Anti-snake venom is listed as an 'essential' drug for primary health centres. According to the Indian Public Health Standard (IPHS) 2012 guidelines for PHCs, 24 hours emergency services include appropriate management of injuries and accident, first aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, in cases of dog bite/snake bite/scorpion bite cases, etc.

But, the reality is a sad commentary on the preparedness of the rural healthcare system to tackle snake bite related emergencies, Amarbara Biswal, a social worker in Kendrapara, Odisha, who is raising awareness on this issue, said. "Shortage of medical personnel, poor transport and next to no infrastructural facilities force many snakebite victims to seek quick treatment from quacks, who put them at further risk," he told Gaon Connection.

Gaon Connection visited several PHCs in Vidisha, Raisen and Guna districts of Madhya Pradesh and most of them did not have anti-venom drugs. A handful that did had kept the drugs along with other medicines, while it is clearly mandated that these drugs need refrigeration. And in some PHCs the drugs were long past their expiry dates.

The PHC at Dewanganj in Raisen district, had no anti-venom in stock on June 28, when Gaon Connection visited it. "We do not have any anti-venom drugs available at the moment, but we should have it," AK Mathur, the doctor at the PHC said.

Suresh Yadav, the doctor at the Mudiyakheda PHC in Raisen district, Madhya Pradesh also had the same thing to say. "You will not find anti venom drugs in any PHC. They are only available at the block and district level hospitals," he told Gaon Connection.

"It is not just enough to administer the anti-venom to a patient. The patient will have to be admitted into the ICU because he or she will need the ventilator," Yadav explained. "Not just that, there has to be trained medical practitioners to handle snake bite cases. The PHCs do not have those and that is the reason snakebite patients risk long journeys to district hospitals," he pointed out.

Over 160 kms away, in Guna district of Madhya Pradesh, the sub health centre at Umri also had no anti-venom on July 7 when Gaon Connection visited it. "The anti-venom drugs are available at the district hospital," Usha, the health officer at the sub health centre, said.

Apart from Uttar Pradesh, Gaon Connection also visited PHCs in Uttar Pradesh, which reports the highest snakebite deaths in the country. The story was no different there.

On July 8, when Gaon Connection visited the Jhaupur PHC in Lakhimpur Kheri district, the doctor was not present. But, the pharmacist Manoj Maurya was. "We have no cold storage facilities at our PHC. And we do not have the drug," he told Gaon Connection.

In Bihat Gaur PHC in Sitapur district, pharmacist SK Varma said that they had no electricity in the health centre and therefore vaccines could not be stored there.

However, Imran Ali, the doctor at the CHC in Maholi, Sitapur, said they had about 35-40 vaccines available. "Besides this, we have also allocated 10 vaccines each to the PHCs coming under us. And, the new kinds of anti-venom drugs that are coming now do not need special refrigeration," he told Gaon Connection.

And, not more than 12 kms away, another doctor, Sanjay Srivastava from CHC Pisawa, in Sitapur, had something entirely different to say. "The PHCs coming under this CHC have no anti-venom vaccines available in them. The PHCs have no facilities to store these drugs. The CHC has about 10 vaccines in stock," he told Gaon Connection.

In Kendrapara district of Odisha, A Beg, the additional district medical officer, said "Anti -venom drugs are available in the district headquarter hospital, nine community health centres and 45 primary health centres. But we have not stocked ant-venom vaccines in 227 Health and Wellness Centres in the district as these centres are being run by only health workers in rural areas."

The additional district medical officer went on to add: "Every year, twenty to twenty five people succumb to snake bites in the district. This year is no different. The state government provides Rs four lakh compensation to the family members of a snake victim."

The data from the Odisha State Disaster Mitigation Authority is telling. Snakebite deaths have doubled in Odisha. In 2015-16 it was 520 deaths. But, in 2018-19, 2019-20 and 2020-21, the annual snakebite deaths crossed the thousand mark.

Importance of The Golden Hour

In India, around 90 per cent of snakebites are caused by the 'big four'— common krait, Indian cobra, Russell's viper and the saw scaled viper. The July 2020 study shows that 70 per cent of the snakebite deaths occurred in eight states — Bihar, Jharkhand, Madhya Pradesh, Odisha, Uttar Pradesh, Andhra Pradesh (which includes Telangana, a recently defined state), Rajasthan and Gujarat. Uttar Pradesh tops the list with 8,700 deaths a year.

"Snakebites are common in rural India as many of the people work in fields and forests where chances of snake encounters are high,'' Joy Kumar Chakma, medical scientist at New Delhi-based Indian Council of Medical Research (ICMR), told Gaon Connection. "About a million snakebites are estimated in our country. In such cases, anti-snake venoms are administered. But, there was limited skill manpower and poor infrastructure in most rural health centres, which is why such cases were referred to district hospitals," the scientist added.

Chakma has authored a paper titled: White paper on venomous snakebite in India published last year in 2021. The scientific paper discusses the various reasons which could be attributed to the high mortality and morbidity due to venomous snakes and also provides recommendations on policy decisions, improvement on the quality of venom and anti-snake venom.

Delay in treatment during 'The Golden Hour' often means disability, or death. Meenu Kanoujia from Mehora village in Uttar Pradesh, Janaki Sahoo from Balia village in Odisha, and Harivati Adivasi from Patichakk village in Madhya Pradesh were all bitten by venomous snakes. While Janaki and Harivati (she was nine months pregnant), died, Meenu, was lying unconscious since June 30 when she was bitten, at a government hospital in Lucknow, with irreversible brain damage, the doctors say. The 55-year-old died two days back on July 14.

"We called up the nearest CHC at Malhour village, eight kilometres away from our village, and were advised to take her straight to the government hospital in Lucknow, about 20 kilometres away. It's been more than two weeks and she has been given more than 30 vials of anti-venom, but she is still unconscious or getting seizures and is constantly on painkillers," Dharmendra Kumar, Meenu's son told Gaon Connection on July 7 when Meenu was alive.

On July 12, Gaon Connection visited the CHC at Malhour village to understand why Meenu was advised to be taken all the way to Lucknow. Avinash Kumar, the doctor at the Malhour CHC, said that severe cases are routinely referred to bigger hospitals. "We do have antivenom, but if the symptoms are severe and may require oxygen support, we refer them to bigger centres," he told Gaon Connection.

The story of Harivati Adivasi from Patichakk village in Madhya Pradesh is even more tragic as she was nine-month pregnant when she died of snakebite. Her husband called the ambulance which never showed up. "I had to find a private vehicle which took valuable time, and by the time I got Harivati to the CHC Khaniyadhana that was 25 kilometres away, the doctor declared both my wife and my unborn child dead," he said.

"Every year, more than two thousand people like Harivati die of snakebite in Madhya Pradesh alone," Mukesh Ingle, director, Reptile Conservation Centre in Ujjain, Madhya Pradesh told Gaon Connection. "Most of the snakebites occur in the hinterlands of rural India and the huge number of deaths due to it is because the victims do not get the anti-venom on time," he added.

Why no anti-venom at PHCs?

ICMR scientist Joy Kumar Chakma explained how the anti-venom drugs were procured and distributed by the government. "The central government procures anti-snake venoms from the manufacturers at a subsidised rate and then provides them to the states. The vials of anti-venom are then supplied to health centres through a cold chain in adequate quantity depending upon the minimum requirement and incidences of snakebites in an area," the ICMR scientist said.

Bharat Serums and Vaccines Limited is one of the leading anti-snake venom producers in India. The cost of its one vial of anti-venom is about Rs 600. These are administered free of cost at government hospitals and rural health centres.

The Kerala-based Louise pointed out that it was not a problem of quantity but a matter of indifferent logistics management. "States buy antivenoms but distribution management is an issue. If there is a shortage, then the stock does not get replenished on time," he said.

According to Kadam, apart from the non-availability of anti-venom at rural health centres, there is also a huge discrepancy in the number of registered deaths due to snakebites and the actual deaths that happened on ground, most of which went unreported.

"This makes it more difficult to form any strong strategy to counter the problem. We think that the numbers (snakebite deaths) are a lot greater," the founder of Snakebite Healing and Education Society said.

Reported by Shivani Gupta in Lucknow (UP), Ramji Mishra in Sitapur and Lakhimpur Kheri (UP), Satish Malviya in Vidisha (MP), Brijendra Dubey in Guna (MP), Ashis Senapati in Kendrapara (Odisha). Written by Pankaja Srinivasan.