Man and animal

Children in rural India are left to depend on a 125-year-old medicine when bitten by snakes

About 14% of children in Erode, Tamil Nadu have been bitten by snakes. But there is little awareness or medical research for snakebites.

Nandana Shanmugam, an 11-year-old girl, runs on four toes in a muddy field outside her house in Vadugapatty village in Erode district of Tamil Nadu. She was 18 months old when a cobra bit her leg, and since then she could not walk normally.

“My daughter was walking down the steps when this happened. We rushed her to the government hospital, where the first surgery happened. But that was not the end,” her mother Shanti Shanmugam recalls. “We visited almost 11 hospitals in a year for her treatment. In one hospital, they asked us Rs 14 lakh, and in another one, they said her leg has to be amputated. Finally, we found a doctor in Erode who charged Rs 50,000 for skin grafting.”

Nandana was born to a farmer. After five days in the hospital and spending a lakh on their own, Nandana showed some sign of improvement. It has been more than a decade since the snakebite, but the treatment is not all over yet. Nandana had to miss six months of school last year for another surgery. “More than the money, the child’s suffering is painful,” Shanti told VillageSquare.in. With limited financial resources, the family is still battling to save Nandana’s future.

In India, awareness about snakebites is limited. The major snakes known as Big Four are responsible for most snakebite deaths in India. These include the Russell’s viper, the Saw-scaled viper, the Indian cobra, and the common krait.

The children in the country are more affected by snakebites than adults. “Snakebites affect children more than adults because their body mass is smaller,” says Sakthivel Vaiyapuri from the Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, University of Reading, the UK, who published a paper titled Snakebite and Its Socio-Economic Impact on the Rural Population of Tamil Nadu, India.

Community survey

Vaiyapuri’s research data was collected through a detailed community survey. Such surveys are crucial for collecting accurate data from the ground, which is not available otherwise. The villages were divided into three on the basis of population and size. The community survey in Erode district revealed that almost 13-14% of children between 0-10 years in all the three villages suffered snakebites. The numbers increased to almost 19% in the age group of 11-20. “The numbers are high among children. We never expected this to be as high as 14%,” Vaiyapuri told VillageSquare.in.

The National Snakebite Initiative conducts training workshops in schools to raise awareness. (Photo: National snakebite Initiative)
The National Snakebite Initiative conducts training workshops in schools to raise awareness. (Photo: National snakebite Initiative)

Snake envenomation in children has high morbidity and mortality rate, and is life threatening. This demands timely administration of Anti Snake Venom or ASV. In a paper titled Anti-snake venom induced reactions among children with snake envenomation, V Poovazhagi, Department of Paediatrics, Chengalpattu Medical College, looked at what happens to children after a snakebite. It was found that children were commonly bit on foot with 55.5% having nocturnal bites. Further, children sleeping outside or lying on the floor indoors face a higher risk of snake bites.

ASV, a 125-year old medicine is still the only treatment given for victims at government hospitals, Poovazhagi says. “In most developing countries you identify common snakes, common venom, and antidote for snakes that fall in the group. ASV is a life saviour right now. However, there is a need for venom detection kits, after which monovalent antivenom for the specific bite from a snake must be given.”

ASV is not available in the private hospitals easily. Families, without knowing where to go, rush the victims to private hospitals. Robin Bernard, who runs the NGO National Snakebite Initiative in Erode, says, “An eighteen month old baby was bitten by Russell’s Viper, and her parents took her to a private hospital. After a few days with no proper treatment, she died.”

Unfortunately, developing countries still depend on ASV, and no medical research is happening despite the fact that India has the largest number of snakebites in the world.

Lack of data

Further, there is no appropriate data on snakebite victims. “There is no data or reporting system. We need to generate this and make them available for researchers,” Shyamala Robin of NSI told VillageSquare.in.

For this, the team visits the general hospital every day and finds out the number of ASV vials given, the situation in which snakebite happened, and follow the victims till they recover or die. For this task, they engage the youth in the villages. Training is given to them to find snakebite incidences in the neighbourhood, and this helps in pooling victim data.

Robin says, “Where is the death record of the victim? After the victim dies, it is only mentioned that the patient died due to renal failure or respiratory failure, and not that he or she has died or snakebite. There is no link of snakebite to his or her death.”

Lack of exclusive envenomation units in Indian hospitals is a cause of major concern. Robin says, “There are very few experts, no improved medicines for treatment, and no skill development training for doctors to handle bite victims. They should know what needs to be done in an emergency situation, and precautions that need to be taken.”

NSI took steps on the ground to combat the human-snake conflict in rural areas. In 2013, the NGO won recognition from the UN Habitat. The funds were utilised to run rural snake safety campaigns. These campaigns were done among rural communities and rural schools.

Robin says, “In schools, we had an informative session on snakes- what are snakes, what should be done and what should not be done when snakes come in direct conflict with humans, what are the myths and superstitions, differentiating poisonous and non-poisonous snakes, and so on.”

What’s needed

For people’s personal safety, there is a need to have snake safety equipments like tongs. Robin says, “In tribal regions where we have worked, reaching the forest department or the nearest hospital takes hours. In such cases, the community has to solve this issue on their own. Having equipments to capture snake will help the locals in taking swift action.”

People living in vulnerable regions need to have an information centre in place. Robin says, “We need a hospital, first aid awareness campaign, and mobile ambulance for immediate action. Along with these facilities, if there are improvements in medicines, and regular check-up for victims, it will be better. Fear of death is common among such victims, and counselling is crucial for victims under rehabilitation.”

Vaiyapuri says, “Children living in vulnerable areas must wear boots as they play in bushes. Awareness should happen at a school level where they must be taught not to pick rocks as snakes could be found under them. Parents and teachers should take a lead in imparting this information to children. Children should know first aid measures, and this will have a direct impact.”

Though corporate social responsibility is pacing up in India, there are no funds going into this neglected issue. Robin says, “For even printing information pamphlets that differentiate venomous and non-venomous snakes, immediate action to be taken after bite, there is no support at the grassroot level.”

Vaiyapuri adds, “If people get access to simple things torches and tongs, it will prevent snakebite incidences. Further, there should be support from the government in promoting research on snakebites as if affects our country the most.”

This article was first published on Village Square.

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Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.