Welcome to the first post in the Neglected Tropical Disease Series! Check out my previous blog post here to find out what a Neglected Tropical Disease is and to learn more about this series!
Snakebite is a disease. It is a disease of poverty. What diseases do snakes spread, you may ask? Envenoming, which is the injection of venom following a bite or sprayed into the eyes, may not be the most obvious route of disease, but it certainly is one of the scariest and most gruesome. Yet, envenoming deaths are completely preventable, so why do the death statistics not reflect this?
Since 2017, snakebite envenoming has been classed as a neglected tropical disease. NTDs affect the world’s poorest people, who likely have limited access to healthcare and treatment. Whilst NTDs are not always killers, they can drastically impair physical and cognitive function. The impact of these disabilities often makes it very difficult for people to maintain their livelihood, attend school or carry out essential daily tasks. This is how easy it is to get trapped into the cycle of poverty and disease. Snakebite envenoming is an example of how devastating this entrapment can be. Deeper and deeper into the cycle you fall. Can the entrapment lose you, or is there a way out?
There are 250 medically important species of snake, meaning their venom is deadly. Snakes are classed as Elapids or Vipers.
Elapids, such as the Black Mamba or Bungarus snake, are often large, aggressive and live close to human habitats. A venomous bite by these types of snakes will cause neurotoxicity. Systemic envenoming, meaning the venom travels further than just around the bite site, starts with decreasing muscular control (ptosis). The toxins finally preventing chemical messages in the synapse between nerve and muscle by either binding to chemicals or causing anatomical damage to the synapse.
Vipers, such as Rattle snakes or Echis species, are often smaller, extremely aggressive and are located more in deserts. A venomous bite by these types of snakes will cause haemotixicity. Systemic envenoming starts when the toxin hits blood vessels and creates holes in blood vessels. Blood vessels become leaky and the body cannot plug them as the toxin prevents clotting.
Local effects can be a result of both types of snakebites, very commonly it is tissue destruction. Antivenom is the only effective treatment of systemic effects of snake envenoming. This is made by injecting venom into horses or sheep, and then routinely taking their blood and isolate the antibodies from their blood. The correct antivenom must go to the corresponding envenoming type. From a venomous bite, you will either bleed from the inside out, or lose all control of your body until you eventually die. It is a gruesome death. From the moment of the bite, time is ticking to access antivenom, otherwise it is certain death. In rural villages, hospitals are neither near nor well-equipped, so what do you do then?
An estimated 5.4 million people are bitten each year with up to 2.7 million envenomings. This difference is since a snake does not always release venom in their saliva every time they bite, but don’t let this lull you into a false sense of security. There are around 81,000 to 138,000 deaths and 400,000 amputations or other permanent disabilities each year due to snakebite envenoming. Most deaths occur in lower income countries in Asia and Africa, particularly in poor, rural communities. This post will explore three factors that highlight how closely linked snakebite is with poverty: occupation, housing and antivenom.
Creating and maintaining a source of income is a universal necessity. However, the choice of occupation varies significantly. The possibilities of becoming a doctor, a construction worker, or an architect are available to many. However, those living in countries affected by snakebite, especially in the rural areas, subsistence farming is often the only route to go down. Subsistence farming regards growing what you must eat and eating what you have grown. A lot of factors regarding the success of this job are out of one’s control, such as the weather and the subsequent harvest. Being bitten is completely out of one’s control, much like the consequences of this are. Subsistence farmers have no choice but to carry out this job. However, it is at these farms where snakes often reside, often camouflaged and difficult to avoid. The lack of appropriate footwear available results in farmers often only wearing flip-flops when they are working, offering no protection to snakebites. If bitten, it is unlikely that individual will ever return to work, as there is a high chance amputation is required. Disabilities like these can completely take away an individual’s responsibility and capability of providing for their family. The cost of these medical procedures risk children being taken out of school in order to replace the head of the family and work to ensure income is still coming into the household. There is no choice but to forfeit an education and the possibility of a job that gives them enough money to live. Many will have no choice but to enter the line of work that could expose them to the same risk that put them in this position in the first place. If a child is bitten, they could permanently be taken out of school and unable to work as well, leaving them completely reliant on others.
The fear around snakebite could cause long-term psychological effects that could be carried into adulthood. The stigma for girls is especially prominent, as disfigurement could stop them from marrying, which could have negative effects for the rest of their lives due to the differences in gender roles seen in many countries. Passing the burden of work onto their children could cause severe mental health problems. They may feel like they cannot provide for their family, or even the stigma around disfigurement could lead to social isolation. The fear of snakebite could heighten mental health problems. Multiple scientific studies have assessed the psychological impact of snakebite in victims. Delayed somatic symptoms, depressive order, PTSD and impairment in functioning among snakebite victims is common. Snakebite causes ongoing psychological morbidity. Stress and anxiety could lower immune systems, thus potentially leading to further infections. This is the cycle of poverty. A cycle in which many do not have the choice but to willingly enter.
I suspect that in your house, the only unwelcome visitor is either a noisy neighbour or a spider who has crept through the gaps. Nuisances like these are relatively easy to remove. Imagine if those gaps were big enough to allow the entry of a rattlesnake, at any point, especially when you are sleeping. Could you ever truly relax? This is not a question that can be asked for those living in an affected country, because if you cannot, you will not be able to provide for your family.
Many houses in lower-income countries are open or built with permeable construction materials. Thatched roofs and sleeping on floor mats are particularly common, and quite the attractant for a snake.
Entry into a home for a snake is easy through a thatched roof, and without that elevation that comes with the luxury of a bed, makes it easy for the snake. The inadequate storage of food attracts rodents, which will attract snakes. Often these families cannot afford protective nets or beds above ground, or more effective ways of storing food, which would in turn reduce their snakebite risk. Simple measures have the power to stop snakebite deaths, but only if these measures are affordable and accessible.
This post has so far explored how certain factors linked with poverty increases the risks of getting bitten by snakes. However, poverty can also affect the chances of survival post biting. For example, the transport to the hospital, which is necessary to receive antivenom and treat potential adverse local effects, can be costly. The time taken to go to the hospital will often require families to find temporary childcare in their absence. The reality of affording childcare, and the long journey outside of a village you may have never left before, are common contributions that discourage people from seeking treatment. Treatment which will determine if you live or die. Taking the decision to go to hospital also comes with consequences, it will be financially straining, assisting the fall further into the cycle of poverty. Life-changing decisions like these must be made instantaneously, as it will not be long before the venom takes over your body, and eventually takes your life.
It does not come as a surprise that many people will seek help from traditional healers, to save themselves from financial disaster. Therapies include black stone, oil therapy and electric shocks. It could be argued that the reason for seeking out these treatments are due to a lack of education, likely induced by poverty. Therapies seem to work, as 50% of snakebites are dry bites, meaning the venom has not been released in the first place. However, this gives the impression that it was the work of a traditional therapy that has cured them.
Many people do not know basic first aid due to lack of education inflicted by poverty. Therefore, many people will tourniquet the bite, yet this can actually increase the chances of amputation, leading to more social stigma.
Once at the hospital, the lack of beds due to the lack of funding is a problem. Additionally, the lack of antivenom due to its high cost, low dose efficacy, adverse effects and low motivation of pharmaceutical companies to produce it due to low profits for them to be made, also increase the risks of death to the snakebite victim. The wrong antivenom (ie African antivenom trying to treat Indian snake envenoming) could be delivered, which is due to a lack of education and trained staff. The lack of access to health care, such as fluid therapy, antibiotics and doctors/appropriately trained staff are all down to a lack of government funding. If synaptic anatomical damage has been done, artificial ventilation is required. Manual ventilation is often the only option in countries lacking resources, and requires other family members, who may have to come out of work, to run their ventilator and keep them alive. This heightens the financial strain.
Multiple studies have found that most patients coming into the hospital had attempted tourniquet or had ingested/carried out a traditional concoction. Those who had used a tourniquet or arrived late due to going to traditional healers first, required more antivenom, and had an increased risk of death or disability. Ingestion and application of traditional concoctions were associated with a higher cost of hospitalisation and increased risk of wound infection. Lack of education due to poverty can thus lead to increased costs at the hospital and contribute more to their poverty. Children often suffer more severe effects than adults, due to their smaller body mass, yet they still require the same volume of antivenom.
Poverty increases the risks of being bitten by snakes in the first place, and once bitten, the chances of death or disability are high. The aftermath of being bitten can contribute to the ongoing cycle of poverty, affecting physical and psychological well-being. Snakebite envenoming is a disease that affects some of the poorest people in the world, and its management has been severely neglected. These deaths can be prevented entirely through improved healthcare access and antivenom availability. Check out the links below to see what is being done to tackle snakebite! It is important that the increase in awareness recently observed in western media continues! We must remember that we are lucky enough to be able to appreciate the beauty of snakes, extra-terrestrial like creatures with intricate patterns, often only encountered for our own entertainment in wildlife centres. For some, this natural beauty is masked by the devastating effect they can have, and no wonder why.
Links to Organisations Currently Tackling Snakebite