After the Serpent’s Sting

Maria Benedict, almost 11, was one of the 50,000 odd Indians who died of snakebite last year, but it was not the venom alone that killed her

On the evening of 19 September 2011, Maria Benedict made the fatal mistake of turning around midway and going back home for her Catholicism Studies textbook. An orderly student, Maria did not like to be late for her after-school tuitions. At the convent across the village of Kodathi on the outskirts of Bangalore, Sister Mary Thomas would not be cross at Maria, but she would be saddened, which was worse. So, instead of keeping to the main road of the village, Maria took a shortcut through a ragi field, one that lay behind her two-room cottage where her parents Sagairaj and Annie and her three siblings lived. The ragi crop was calf-high as Maria walked with her errant textbook clutched in one hand.

Around 5:30 pm, the evening was overcast. Maria, 10 years and 11 months old, was probably wearing her usual pigtails and attired in a comfortable top with a knee-length skirt; two months after her fateful detour, her mother and father do not remember the colour of her dress.

Just minutes after entering the field of ragi (there is maize growing there now, and no one but the farmer goes that way anymore), Maria presented herself at her neighbour’s house, a one-room cottage next to the field. She is said to have hugged her matronly neighbour, Renuka, though Maria’s family and Renuka were by no means close. “Aunty,” Maria said, according to her mother Annie, “I’ve been bitten by a snake. I don’t know if I’ll live or die.”

Making her way through the ragi crop, Maria had passed a patch of bare earth in a tearing hurry. The textbook had slipped from her hands, landing on the bare patch. Maria never saw the snake. It was either warming its curls in what sunlight there was, or hunting rodents. Perhaps the textbook had fallen on its twists, obscuring all peril from view. Perhaps it had startled the reptile. However it happened, Maria was bitten. The strike must have taken a second or two.

This was not a venomless ‘dry bite’ or a partial dose of venom. She must have felt the punctures on her left foot, on the outer side, just below the knob of her ankle-bone. Forty-eight hours after the snakebite, Maria Benedict met her end in Bangalore. Her death was not inevitable. It came of organ failure: her kidneys shut down. One of the hospitals she had the misfortune of going to did not have a dialysis machine that was suitable for use on children, though it had a well-

equipped ICU for patients with disorders brought on by wealthier pursuits. Also, the Anti-Snake Venom (ASV) serum she was given did not prove effective enough as an antidote.

In a country where an estimated 49,500 people die of snakebite annually, most of them adults, what chance did Maria’s small little body have?

Maria Benedict’s father Sagairaj, a water tanker driver who does not use a second name, tells Open how he and his neighbours rushed Maria in a borrowed car to the government-run Public Health Centre in Domsandra, a neighbouring village. The doctor on duty flatly refused to believe Maria’s account of events. Sagairaj describes how the doctor asked him, “Who is the doctor, you or me?” before giving Maria a tetanus shot and sending the party away. Maria insisted that she had been bitten. The doctor attributed the stab on her leg to a twig or rusty nail.

This, after the party was made to wait nearly an hour—the ‘Golden Hour’ as doctors call it—for medical attention. And this, in a place where the country’s ‘Big Four’ venomous snakes—the Spectacled Cobra, Common Krait, Saw-Scaled Viper and Russell’s Viper—are known to be scarily common, according to snake expert Gerry Martin, who is also a local resident. It was a Russell’s Viper that bit Maria.

The government clinic was a tragedy in waiting, but where else would Maria have gone? Not to Sister Mary Thomas at the convent outside the village, certainly, Sister Mary Thomas with her prayers and belief in the healing powers of snake charms called Snake Stones. But she was taken next to Sister Thomas because there was no other option nearby. Surprisingly, Sister Thomas recommended taking the girl to Bangalore, nearly 40 km away, to an expensive hospital called St John’s, this being the nearest and among the best in the city.

Here, the doctors in the Emergency Room refused the girl admission. Speaking to Open later, a spokesperson at St John’s has this to offer: “There were no beds [available that day].” The spokesperson does not feel the need to refer to his medical records for that particular day. Doing so would breach patient-doctor confidentiality, it seems, which would violate medical ethics. Turning away a patient, though, didn’t strike anyone as unethical. “Anti-Snake Venom serum can be administered on a stretcher,” says Martin, a herpetologist who has been bitten in the past and seen many snakebite cases, “There is no need for a room. The doctors should have known that.”

Also, St John’s did not have a free dialysis machine at hand, which Maria was in urgent need of now. The venom had crippled her kidneys, which were no longer cleansing her body of waste products. In effect, Maria was facing two poisons—viper venom and her own unpurified blood. She was in a critical state, but could still be rescued, as the herpetologist vouches.

Refused admission at St John’s, the party went to Venkateshwara Hospital at Madiwala, a Bangalore suburb around 2 km away. It was evening by now, recount her parents, nearly three hours after the bite.

At this hospital, Dr N Vijay Kumar, its managing director and owner, does what St John’s ought to have: he admits Maria Benedict, who is still conscious but bleeding at the bite’s wound and in severe pain, and he injects her with ASV serum. For the next 48 hours, Maria will receive 22 vials of it (15 vials is the usual dose.) But Maria needs more to fight the venom, it is decided, because she has gone critical. An overdose might cause a reaction, a dangerous complication in an already critical patient. But the increased dose may just save her—an outcome that has been reduced to a probability, and a swiftly declining one at that.

“It was a matter of saving her life first,” says Dr Kumar.

Venkateshwara hospital has a dialysis machine available. By now, Maria’s bitten leg has swollen up. So her leg muscles are punctured to relieve the internal pressure in an operation known as fasciotomy. At last, sigh the parents, Maria is under medical care. But 48 hours later, Venkateshwara hospital estimates that the girl’s treatment and room rent have already run up a bill of Rs 80,000, which Sagairaj cannot afford. So, against medical advice, the party—Sagairaj, his wife Annie, Sister Mary Thomas and a few village residents—decides to transfer Maria to another hospital, a private but charitable one. There is no free or cheap government hospital in reachable range.

Her other organs failing now, perhaps a little girl would sense that she is dying. Like a bad penny, wading through Bangalore’s workday traffic, the party reaches St Martha’s Hospital, known for its charitable treatment of the poor. In a last-ditch attempt, St Martha’s injects Maria with 11 vials of ASV serum. But it is too late for treatment.

Maria Benedict’s final words to her mother are a request to see her siblings. “You get well and come home first,” Annie tells her.

It won’t happen. Maria is declared dead on the picturesque premises of St Martha’s. This hospital does have a dialysis machine suitable for children, and it did admit Maria, unlike St. John’s and the tetanus-shot-happy government doctor. At the end, none of it mattered.

Isn’t it common sense to keep life-saving equipment handy? Shouldn’t ASV serum be effective, especially 33 vials—that’s 3,300 mg—of it?

These are two questions that deserve to grow louder in a country that treats snakebites as less important than communicable diseases. Non-government doctors tell Open that the Union Ministry of Health has yet to publicise guidelines on the treatment of snakebite victims. ‘Guidelines’ is a fancy name for a checklist of time-bound dos for any doctor handling a snakebite patient. If India has such guidelines at all, it isn’t doing enough to educate its doctors. This leaves enterprising doctors to devise their own action plans to save their patients. One of them is Dr Nagaraj, who also does not use a second name and has documented over 6,000 cases of snakebite, venomous and non, at his hospital in Hoskote, Karnataka, over the past 20 years. “Since we get a snakebite case almost daily,” says Dr Nagaraj, “we keep a dialysis machine and respirator and pump in the emergency room.” This way, there is no scramble for such machines, and the case gets the urgency it deserves.

What would help is a clear set of standardised procedures, something doctors are demanding that the Health Ministry issue. Says Dr Dilip Punde, a maverick doctor in rural Nanded, Maharashtra, whose work on snakebite treatment was once chronicled by Discovery channel: “Doctors simply do not know of guidelines on handling snakebite cases here, not even the recommended dosage of ASV serum.”

Also sorely needed is a proper research effort to develop more effective ASV serums. But few at the Centre seem to care. Dr Punde relates an incident to illustrate the mindset of the Government vis-à-vis the menace. In 2005, he was publicly felicitated for his work by Agriculture Minister Sharad Pawar. At the ceremony, Dr Punde suggested that Pawar spearhead a nationwide campaign against snakebite fatalities, since farmers are most vulnerable to it. The doctor demanded that certain Public Health Centres across the country be made snakebite specialists and supplied with Anti-Snake and Anti-Scorpion Venom serums. He also raised the point about the need for better serums, and asked the Centre to develop venom detection kits (as Australia has), so that even inexperienced doctors can tell a venomous snakebite apart. Fourth, he demanded that snakebite deaths be made ‘notifiable’, which means that every such death would need to be reported to the state government by doctors handling such cases. And lastly, Dr Punde suggested that even urban medical colleges familiarise their students with snakebite cases; after all, rural patients often have to rush to urban hospitals for treatment.

Pawar went through the paces of the ceremony, and went away. Dr Punde kept at it, forwarding his demands to the Maharashtra state government; also, he convinced the area’s local MLA to raise the issue of snakebite neglect in the Maharashtra Legislative Assembly. Six years later, he is still awaiting a response.

Disappointed, last year Dr Punde and other snake experts and doctors across India set up the Toxinological Society of India, a conference forum and pressure group.

India’s government runs national-level campaigns against malaria, filaria, polio and other such diseases, but has no action plan for snakebite treatment. Could it be because it is mainly a killer of the rural poor?

The apathy is systemic. As recently as April 2011, the Government had no precise figure of the toll taken by unnatural causes such as snakebite. In any case, its official records feature not all deaths, only reported deaths, namely those that occurred in government hospitals. And even these numbers are suspect. Doubt has been cast on the Centre’s official figure of 1,359 deaths in 2007, for example, by a 2010 World Health Organization booklet published in India titled Guidelines for the Management of Snake Bites (author: David A Warrell).

For more reliable data, observers need to turn to the Million Deaths Survey (1998–2014), an ongoing sample survey that has covered 2.4 million households round the country and recorded 1.4 million deaths. The largest of its kind, the Survey has the help of government employees working under the Registrar General of India, and was launched by The Centre for Global Health Research, a Canadian NGO funded by the Canadian Institutes of Health Research, the US National Institutes of Health (USA), the Bill and Melinda Gates Foundation (USA), St Michael’s Hospital (Canada), and University of Toronto (Canada). In April 2011, by examining data on snakebite deaths over 2001–03, the Survey arrived at an estimate of 49,500 such deaths across the country in 2003 alone. According to the Survey’s authors, this figure is half that of AIDS deaths in India.

The typical ASV serum administered in India—the only one in common use—is formulated as a mixture of antibodies for the Big Four: the Spectacled Cobra, Common Krait, Russell’s Viper and Saw-Scaled Viper. The Government is content with a four-in-one serum because it is cheaper and more convenient to store than sets of individual serums, and because it works on a few other species related to the Big Four as well. But the problem is, being a four-in-one, it is also that much more dilute in tackling the venom of a particular bite.

Not just that, non-governmental experts are finding that the Big Four are not evenly common across India, that there are other venomous species specific to assorted regions. The Hump-Nosed Viper, for example, is common in Kerala (in addition to the Big Four). “The ASV does not work on the venom of the Hump-Nosed Viper,” says Dr Punde, going by his field experience.

What would work better, suggest doctors who have dealt with a wide range of cases, are a set of region-specific ASV serums. And to add to the complexity, says Martin, even the Big Four show significant differences in venom, depending on region. “The potency of a Russell’s Viper in a northern state is likely to differ from that of one from a southern state,” he says. The potency and chemical make-up of snake venom may depend on the snake’s diet, the local climate, or even other factors that await further research, he explains.

Thankfully, a group of researchers has taken it upon itself to make up for the Government’s neglect of this field. Led by Romulus Whitaker, a reptile expert, the team is busy collecting venom samples from around the country. “It will take us three years at least,” says Martin, who is part of the joint effort. The team will test the ‘Big Four’ ASV serum on each venom sample collected to pinpoint particular snake venoms that still have no antidote. They will also analyse samples of venom from within the same species across the country to spot potency variations by region. If all goes by plan, this should pave the way for region-specific treatment guidelines and ASV serums.

For now, African countries are ahead of India in their efforts to contain snakebite fatalities. The government of Nigeria, for instance, has not only put out snakebite dos and don’ts for its medical students and field doctors, it has also got its labs actively looking out for better serums. It’s a cue India had better take, and take promptly. That’s the least we owe Maria Benedict.

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