Health
The recently-concluded 71st World Assembly passed a resolution to address the burden of snakebites. What is India’s role?

Snakebite is a major public health problem in rural communities in several countries in South Asia, South-East Asia, Africa and Latin America. Globally, there are up to 2.7 million envenoming and 138,000 deaths annually due to snakebite. India has the most number of deaths due to snakebite with 45,000 deaths annually . Apart from deaths, snakebite also cause deep and long-lasting physical and psychological outcomes. Data on the non-death impact of snakebite is scarce, although some estimates from West Africa are available.

Numbers, however, do not paint the complete picture. Cultural beliefs on traditional folk medicines (like the Ojhas and "snake-stone" healers) in many parts of the world mean many individuals bitten by snakes never reach the health systems. Weak primary health care systems in these tropical countries also means that data on snakebite is ill captured. There is widespread consensus in the scientific community that the current burden of snakebite is a gross underestimation.

In spite of this large-scale burden, snakebite is a forgotten problem. Snakebite affects financially impoverished rural and indigenous communities, with failing healthcare systems—particularly agricultural workers, and children.  Snakebite-affected communities do not have a political voice of their own neither do they have social capital to build public opinion around their problems . However, the enormity of the problem and the neglect over the years has meant that many national governments can no longer ignore the plight of these communities.  Recently, the 71st World Health Assembly (WHA), adopted a resolution to address the burden of snakebite. The WHA is the apex body World Health Organisation (WHO), the latter being the world’s key policy setter on health issues and present in all countries.  Snakebite advocacy groups have largely welcomed the resolution.

WHO and snakebites: A crescendo-decrescendo relationship

The WHO had included snakebite in its neglected tropical disease (NTD) list back in 2009. There was no provision for funding attached to it and in 2013, the WHO removed it from the NTD list, without providing any explanation. In 2015, the WHO in a letter to The Lancet hasd acknowledged that it had “failed to attract the attention of the donor community”. Sustained advocacy and diplomatic parleys by 18 countries led by Costa Rica led to a recommendation on the re-addition of snakebite to the NTD list in January 2017, a move confirmed in the later part of the year. The current resolution reflects a crescendo for snakebite advocacy in the way that it provides a mandate to the WHO Director General (DG) to launch and implement a "roadmap" for action and foster international support from Member States. An MSF briefing mentions that the cost for this will be 16 million US$ by end of 2019. As such financing for addressing the burden of snakebite will not be easy.

Financing to address the snakebite burden

Flexibility for spending money has always been a major challenge for the WHO. Currently around 80% of funding is tied to projects specified by the donors. The WHO’s DG is trying to reform the financing system by increasing the assessed contributions of member states (which is not tied to any projects), but there is a lot of resistance to it. Success of resolutions depends on mobilisation of financial support from Member States and donors.

Raising donor money for neglected tropical disease has always been a steep  climb, and many commentators feel that, “it would be naïve to expect external donors to treat snakebite differently.”  For example, The Bil and Melinda Gates Foundation has previously been reported as rejecting funding to treat snakebite because it is “not infectious and therefore cannot be eradicated by vaccination.”

It is thus imperative for governments from snakebite-affected countries to support WHO. National and local level resourcing will also be crucial for actual implementation of the ‘roadmap’. During the discussion around the WHA resolution, many snakebite afflicted countries requested support from the WHO. Apparently, with the exception of Netherlands, none of the western countries is interested.

Snakebite and India: An opportunity for India?

With the highest number of deaths globally, an increasing role in global health, and the fact that it has substantial commercial interests (several major global anti-venom manufacturers are from India) it would have been only normal for India to take the lead in shaping the agenda around snakebite.  However, this was not the case. India was not one of the countries, which made the initial recommendation to re-add snakebite to the WHO NTD list in January 2017. The WHA resolution to address snakebite was sponsored by Colombia and Costa Rica, with India being one of the 25 other co-sponsor member states (sponsoring implies proposers of a resolution). The enormity of the burden of snakebite in India also means that the global programmme to address its burden can succeed without support and robust implementation in India.

It is time for India to take address this issue head on and fund snakebite issues nationally also assist other countries facing this problem. South Asian, South-East Asian and African countries are of immense diplomatic interest to India. Since 2009, India has committed at least US$100 million to bilateral health projects in 20 countries in these regions.  Supporting action on snakebite in these countries, through the WHO, will also be in alignment with the larger foreign policy ethos of south-south co-operation in comparison to the western concept of donor-aid relationship. Moreover, learnings from other countries can only help India address the issue of snakebite within our country too. The Africa-India partnership for access to medicines can also benefit immensely from such an initiative.  Continued diplomatic support from African countries is essential and access to snake anti-venom is a key issue that can cement this. Indian venom manufacturers would need significant investment in clinical trials in Africa as well as R&D for better redesigning. This is already happening in bits and pieces. For example, the Department of Science & Technology has recently funded a comprehensive study on snakebite in India, Malaysia and Vietnam as a part of the ASEAN-India collaborative work. What is needed is a more co-ordinated action and in alignment with the WHO roadmap that will be created.

It is time for India to take a more pro-active approach towards global health diplomacy and support collective action to address the burden of snakebite and ensure, “Health for All”.

Views expressed are author's own

Soumyadeep Bhaumik is a medical doctor and international public health specialist. He is a Research Fellow at The George Institute for Global Health, India and Associate Editor, Evidence Syntheses at the BMJ Global Health. He tweets at @DrSoumyadeepB