What India must get right

The Hindu

3 days ago

How do you know that a Russell's viper is knocked out from the anaesthetic it has been given, since snakes don't have eyelids that would helpfully close? You monitor the tail, always the last to stop moving, explains Lisa Gonsalves, curator at Karnataka-based The Liana Trust, a non-profit working on human-snake co-existence. She calmly strokes the sedated, highly venomous snake stretched out on a white table, its top half in a transparent tube. Once the tail stops twitching, Gonsalves and Gerard 'Gerry' Martin, herpetologist and founder of the Trust, move swiftly to de-worm, measure and weigh the snake.
The next step is heart-stopping. Martin starts blowing gently into the mouth of the Russell's viper — the species responsible for the highest number of snakebite fatalities in India — through a straw-like instrument. This, he explains, is to flush out the anaesthetic. Soon enough, the snake starts to revive.
The rescued viper is now part of a first-of-its-kind, research-based serpentarium near Hunsur, about 200 kilometres from Bengaluru, which aims to research and improve the way antivenom is made in India and study the behaviour of snakes, which Martin says can be 'a nightmare' in the wild. 'Snakes are difficult to work with. We can't study them using camera traps like with other species, for instance.'
The serpentarium houses seven venomous species and is set to have up to 400 snakes, with each individual in a separate enclosure designed to replicate its natural habitat to the extent possible, with lush flora and small pools of water in some, and enclosures with basking lights for species like the Russell's viper, which likes the warmth of the sun in cooler weather.
Set up by The Liana Trust with the Karnataka Forest Department, the serpentarium is one of several recent initiatives to mitigate the impact of human-snakebite conflict — responsible for the most number of human fatalities in human-wildlife conflict, yet long neglected. These include India's first National Action Plan on snakebites (launched a year ago), developing better alternatives to antivenom, multiple serpentariums, including one that will incubate startups working on antivenom, and apps for snake rescue.
All these and more are aimed at mitigating a public health issue which, till recently, did not get the attention it deserved. And which climate change is only set to exacerbate. A 2024 paper in The Lancet Planetary Health on how climate change will impact the distribution of venomous snakes predicts that while some areas such as the Amazon would see species loss, others like India with extensive agricultural area would see an increase in areas climatically suitable for snakes. Combined with India's large share of low-income and rural population, this would increase vulnerability to snake bite in a country that is already considered the snakebite capital of the world.
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India has more than 310 species of snakes. Of these, 66 are labelled venomous or mildly venomous. The 'Big Four' were considered responsible for most venomous bites in the country, but newer studies show other species also contribute to the snakebite burden, particularly in the Northeast.
Poor man's problem
Tackling snakebite envenoming — the technical term for the condition caused by the toxins in the bite of a venomous snake — poses a complex public health challenge which requires a sustained, multi-disciplinary endeavour.
In India, efforts to tackle snakebite are further complicated by the lack of data around it. Many victims die before reaching a hospital so no agency could capture the true burden, says Ravikar Ralph, professor, Clinical Toxicology Unit, at Vellore's Christian Medical College. Even when the deaths occur in hospitals, they would not necessarily be recorded with government authorities since snakebite was not a notifiable disease until recently.
Underpinning the invisibilising of the issue is the fact that victims typically live in rural areas and belong to low-income sections. 'We have six deaths every hour. But snakebite is a poor person's problem so it gets little attention,' says Sumanth Bindumadhav, director of wildlife protection at the non-profit, Humane Society International India. Additionally, the WHO estimates that while 81,410 to 1,37,880 people die each year because of snake bites globally, it also causes around three times as many amputations and other disabilities. Survivors also have to struggle with the financial impact, from the cost of treatment of conditions such as kidney damage and amputation caused by snakebite, to loss of income, which can be debilitating for low-income families.
'We need to acknowledge that humans and snakes will always share space. There will be co-existence, so it's very important to figure out how.'Sumanth BindumadhavDirector, Humane Society International India
Ramesh M. (name changed on request), a native of Hunsur, is one such survivor. When the 33-year-old stepped out of his house late one evening to move a big drum of water barefoot, a snake nestled underneath darted out and bit him. Poor first-aid, delays in treatment, and an infected wound meant he could not return to his factory job in Bengaluru for three months. When he recovered, the company would not take him back. He now works in a hardware store back home and as a farm labourer. 'From a salary of ₹35,000, his monthly earnings have now dipped to about ₹12,000. He has to support his family of four with it and also repay the loans he took for the snakebite treatment,' says Bindumadhav.
Gap in data
The scale of India's burden came to light with the Million Death Study, first published in 2011. It estimated that India sees about 58,000 deaths a year, close to half the global toll. In contrast, the Central Bureau of Health Intelligence pegs snakebite deaths at 2,000 a year.
This lack of accurate data is now starting to get plugged, with the country's first National Action Plan for Prevention and Control of Snakebite Envenoming in India (NAPSE), launched in March 2024, advising all states to make snakebite a notifiable disease. Karnataka had already done so in February 2024 while a few others like Tamil Nadu and Meghalaya began later in the year. 'It's one of the biggest impacts of the national action plan. This will answer a lot of our questions vis-a-vis deaths, bites, etc,' says Jaideep Menon of Amrita Vishwa Vidyapeetham in Kerala.
Lethal strike Snakebite kills about 58,000 people a year in India, close to half the global total. Snakebite deaths are more common (48%) during the southwest monsoon (June-September) Russell's viper contributes to most deaths at 43%, followed by unknown species (21%), krait (18%), and cobra (12%). (Source: WHO; Indian Million Death Study; Trends in snakebite deaths in India, 2020)
Dr. Menon began studying snakebite deaths in the early 2000s, and is separately leading an Indian Council of Medical Research survey on the incidence, mortality, morbidity and socio-economic burden of snakebites across 14 states, another first-of-its-kind effort which will improve understanding of the issue.
Close to 70% of snakebite deaths occur in nine states, including Uttar Pradesh, Bihar and Madhya Pradesh, according to a 2020 study on trends in snakebite deaths in India. However, it's yet to be declared a notifiable disease in these high-burden states.
In Madhya Pradesh, it is treated as a 'local tragedy', and compensation is disbursed for loss of life. The Uttar Pradesh government, in 2021, declared deaths due to snake bites as a state calamity following a significant number of fatalities recorded between 2016 and 2021. Families of victims are eligible for a compensation of ₹4 lakh, which must be provided within seven days of the death.
Confluence of factors
While snakebite envenoming is a global challenge, with the World Health Organization declaring it a neglected tropical disease in 2017, the number of deaths and cases of long-term disability are higher in India due to multiple factors. 'We have an extraordinary number of people coexisting closely with snakes, especially in rural and semi-rural areas,' says Gnaneswar Ch., project lead-snakebite mitigation at The Madras Crocodile Bank Trust & Centre For Herpetology in Tamil Nadu. 'Several parts of Africa have more venomous snakes than India. But the numbers [of envenoming] are not as high because of lower population density.'
Secondly, medical treatment is often delayed, either due to lack of access to healthcare facilities in rural areas, poor availability of anti-venom or, as it often happens, because patients first approach traditional healers. Gnaneswar recalls a recent incident where a farmer from Kanchipuram who was bitten by a Russell's viper first went to a faith healer. 'The healer gave him something to put in his mouth, something to put in his eyes, then took him to the spot where he was bitten and conducted a ritual, all of which took an hour-and-a-half. When the victim lost consciousness, the healer said it was not his responsibility,' he says. The farmer was finally rushed to the hospital but by the time he reached, he was brain dead.
Even when the patient manages to reach a healthcare facility in time, other complications can arise. Administering antivenom quickly is the universal life-saving treatment for snakebite envenoming. But because antivenom is made of antibodies generated in an animal, it can trigger adverse allergic reactions in humans, which can sometimes be severe, even life-threatening. 'The fear of developing an allergic reaction is heightened in a small hospital in the periphery,' says Dr. Ralph. Doctors then end up referring patients to larger facilities, which means precious time is lost. Many primary health centres (PHCs) also don't have qualified doctors, says Priyanka Kadam, founder of Mumbai-based not-for-profit Snakebite Healing and Education Society (SHE-India).
When Dr. Sadanand and Dr. Pallavi Raut opened their clinic in Narayangaon in Maharashtra in the mid-90s after the former witnessed an eight-year-old girl lose her life to snakebite, these issues were rampant. 'Doctors at PHCs and medical centres in our area were initially reluctant to give antivenom because of the risk of anaphylaxis and death,' says Dr. Sadanand. But years of working with communities, building awareness and giving training has made a difference in the area, he says, underlining the importance of scaling these measures. 'Critical patients now come to us within 20 minutes and the survival rate is 100%.' Kadam says her organisation is training ASHAs (accredited social health activists) in places like Bastar in Chhattisgarh to spread the message that victims must immediately go to the hospital.
One size doesn't fit all
Antivenom everywhere is made using the same century-old method: by injecting tiny doses of venom into a large animal like a horse and then using the antibodies that are generated. Antivenom can be monovalent, targeting a single species, or polyvalent, for multiple species. In India, antivenom is made using the venom of four species considered responsible for most cases of envenoming. Termed the 'Big Four', these are the common krait, the Indian cobra, the Russell's viper and the saw-scaled viper.
But this approach is now being questioned, particularly since there are regions where other venomous species dominate and where the current antivenom is less effective, as multiple studies have now shown.
Venom also varies within species, depending on age and climatic conditions, recent research has shown. A study conducted among snakebite victims in Rajasthan published in January this year found poor antivenom response, because the venom of the saw-scaled viper in the region was more potent than its counterpart in Tamil Nadu, from where much of the country's venom is sourced.
One solution is to have antivenoms for different regions instead of a single one for the whole country, an approach the national action plan now recommends. Different research groups are working on this, including the Evolutionary Venomics Lab at the Indian Institute of Science (IISc) in Bengaluru, which has been testing regional antivenoms for western India with an antivenom manufacturer. Results are set to be published soon. Another group in Tezpur University is working on an antivenom for the Northeast.
Quality issues
But Indian antivenom also suffers from quality issues. At present, the bulk of venom is collected by the Irulas, a marginalised tribal community in Tamil Nadu historically skilled at catching snakes. With the help of conservationist Romulus Whitaker, they formed the Irula Snake Catchers' Industrial Cooperative Society and are today licensed to catch snakes for venom.
The Irulas keep the captive reptiles in pots in sand pits, milk them for venom to sell to manufacturers, and then release the snakes back into the wild. However, this process does not adhere to WHO protocols and good manufacturing practices, which impacts the venom quality, says Gnaneswar. Humane Society's Bindumadhav says there is a big policy gap in the fact that the antivenom used in India has never undergone clinical trials and there are no minimum quality standards.
This is one of the issues The Liana Trust's new serpentarium aims to tackle, by taking venom from snakes housed in the facility in controlled, hygienic conditions to be supplied to antivenom manufacturers for free. 'This will set a precedent for region-specific antivenom centres. It will also help us understand the local venom landscape,' says Martin.
Tamil Nadu, too, is considering setting up a modern serpentarium, though Gnaneswar says progress has been slow. The most ambitious of the new facilities will be the Venom Institute for Snakebite Health and Advanced Medicine (VISHAM) coming up in Bengaluru, funded by the Karnataka government and developed in collaboration with the Evolutionary Venomics Lab (EVL) at an initial cost of ₹7 crore. Kartik Sunagar, associate professor at IISc and head of EVL, says the serpentarium aims to be one of the best globally, housing species from across India, and producing high-quality venom. 'We will also have labs for collaborative research with manufacturers and an incubation centre that will house startups interested in working on antivenoms,' says Sunagar.
Modernising treatment
Critically, Sunagar and his team are also working on bringing snakebite treatment into the 21st century. Last year, scientists at EVL along with researchers at Scripps Institute in the U.S .and the Liverpool School of Tropical Medicine published their discovery of a new recombinant antibody (produced using genetic engineering; it was tested and selected from a 'library' of millions of lab-made antibodies), which can neutralise a whole group of toxins across multiple species, holding out promise of a universal or at least pan-continental antivenom.
While progress will take time, Sunagar's team is working on other synthetic antibodies specifically against Indian snakes. Since these antibodies are not generated in animals, it will also minimise adverse reactions. 'Regional antivenoms can at best be a stop-gap solution — we need modern solutions, which will be more effective,' says Sunagar.
The other promising avenue is repurposing existing drugs such as varespladib and marimastat, found to be potent inhibitors of specific toxins in snake venom. Success would mean a drug that can be taken orally as opposed to antivenom given intravenously in a healthcare setting. This will at the very least buy victims time to reach a hospital. U.S.-based Ophirex is currently conducting trials in India and the U.S. Sunagar is separately set to publish results of trials of orally-administered drugs in Russell's viper bites, which successfully neutralised venom in mice. A diagnostic test to identify a Russell's viper bite, which would help in targeted treatment, is also in the works.
Rescue app
Others are using technology to mitigate the conflict between snakes and humans. For instance, the Sarpa (short for Snake Awareness Rescue and Protection App) app, which has enabled the rescue of 50,000 snakes in Kerala, connects the closest snake rescuer with those who need one, much like an Uber or Ola connects passengers to taxi drivers. Says founder Jose Louies, who is also CEO of Wildlife Trust of India, 'We can keep track of what species we've found in which season, in an area. We can also generate predictive data.' Other states have expressed interest in replicating this model, adds Louies, before cautioning that apps should not be seen as a magic bullet. 'It's the system and networks behind it that make it work.'
The best mitigation, says conservationist Whitaker, is prevention. But that's difficult in India, where people work in fields barefoot and with bare hands, and step out at night without a flashlight. 'Education and awareness are key. The government would only have to spend a fraction of what it ends up paying as compensation,' he suggests.
Being at the frontlines of human-snake conflict, Martin says the challenges often seem formidable. 'But the momentum is growing and the problem is getting acknowledged. Every step forward is heartening,' he says.
We need to acknowledge that humans and snakes will always share space, adds Bindumadhav. 'There will be coexistence, so it's very important to figure out how.'
The question gathers urgency if India is to meet the WHO target of halving snakebite mortality by 2030 and adapt to the impact of climate change.
With inputs from Mehul Malpani (Madhya Pradesh) and Mayank Kumar (Uttar Pradesh).
The Bengaluru-based independent journalist writes on gender, labour, ecology and business.