Snakebite envenoming is overwhelmingly an affliction of the rural poor in agricultural and herding communities and kills more people than any other disease on the neglected tropical diseases (NTDs) list of the World Health Organization (WHO). An estimated 2.7 million people are bitten by venomous snakes worldwide every year, resulting in death for more than 100,000 people and life-long disfigurement and disability for 400,000 more.
Snakebites hit the poorest of the poor, who often turn to traditional healers for treatment. One of various reasons for this is that they cannot access – let alone afford – conventional medical treatment.
In 2017, MSF treated 609 patients in different projects in Ethiopia, 322 of them from Abdurafi. In 2018, the number has increased, by the end of 2018 MSF treated 647 patients only in Abdurafi. These include so-called dry bites (warning bites) and bites with mild, moderate and severe poisoning.
With almost no funding currently coming from donors for snakebite prevention and treatment, the bottleneck remains the availability of effective and low-cost antivenoms.
The WHO has started helping countries select safe antivenoms, which are effective against local snake species, but a number of manufacturers have stopped producing some antivenom products, further limiting access for the victims of snakebite.
While MSF provides treatment free of charge in its facilities, elsewhere treatment can cost upwards of US$100, making it unaffordable in rural areas, such as northern Ethiopia, where most people at risk live.
Quality antivenoms that are effective against local snake species and safe when administered need to be made available, free of charge or at a price that everyone can afford. At the same time, more healthcare workers in remote farming areas need to be trained in how to treat snakebite.
MSF hopes that donors and governments will support the implementation of the WHO’s snakebite roadmap, an ambitious plan which includes a range of activities to help overcome the barriers people face in accessing treatment.
MSF is cautiously optimistic that the WHO roadmap could be a turning point in tackling snakebite. In the coming months, we will be working with governments, treatment providers, donors and communities affected by snakebite to make world leaders accountable for ensuring that the roadmap is implemented and leads to real change for snakebite victims everywhere.
The remote region of Amhara in northern Ethiopia is known for its fertile land and its vast commercial farms cultivating sesame, sorghum, cotton and other crops. It is also a region inhabited by some 20 different venomous snakes endemic to this part of Africa. During the peak of the harvest season, farm workers come across snakes almost every day.
In search of work, almost half a million daily labourers migrate every year from the highlands of Ethiopia to the lowland farms surrounding the town of Abdurafi. They usually arrive around August for the start of the harvest season. Most leave in October, but others stay on until early January for the sorghum harvest.
A young female migrant worker
A young woman with a swollen face sits on a bed in MSF’s close monitoring room, awaiting the result of her blood test for snakebite envenoming. Workey Mekonen was bitten on her forehead by a small snake while sleeping on the ground in a farm shed.
It is not only men who come looking for work; women, such as Workey, come too. Since her husband died four years ago, Workey has earned a meagre living for herself and her four children by cooking for farm labourers in the fields. She leaves her children with her sister in Tigray, half a day’s journey from Abdurafi, while she works as a cook.
The previous night Workey awoke with a sudden piercing pain to her forehead. When she caught sight of something slithering away across the floor, she realised she had been bitten by a snake. She had been sleeping on the ground of an open shed where crops and other farming materials were stored. Relieved at first that it was only a small snake, the pain and swelling soon made her fear for her life. Fellow farm workers took her to her uncle, who lives nearby. He had heard about MSF’s clinic in Abdurafi town, which treats people for snakebite free of charge, and took her there. By that time, Workey’s face was so swollen that she was unable to see. She was immediately admitted to the clinic for close monitoring.
Ten minutes later, Workey’s blood test result is ready. It shows no blood clotting, a clear indicator that the snake has injected its venom and that she needs to be treated with antivenom. MSF clinical officer Degifew Dires prepares the infusion, and spends the next 140 minutes slowly dripping it into the veins in her arm. “The first ten minutes are critical and need closest monitoring to ensure that she has no harmful reactions to the antivenom,” says Degifew. “Over the coming hours we will regularly check her physical condition and vital signs.”
“Workey soon felt better and, after five days in our clinic, she could be discharged fully recovered,” says MSF’s Dr Ernest Nshimiyimana. “She was lucky that she was brought to us in good time and treated with effective antivenom.”
Not everyone bitten by a snake in Ethiopia is so fortunate, as the antivenom to treat snakebites is out of many people’s reach. “Unfortunately, in most parts of the country, effective antivenom is either unavailable or is too expensive for the communities most affected by snakebite,” says Dr Ernest.
Migrant workers are particularly vulnerable to snakebite. They often work barefoot in the fields at night, using their bare hands to harvest crops. The sesame fields are particularly hazardous. Sesame does not grow very high but it does grow thickly, making it an ideal hideout for snakes. To harvest the crop, workers must crouch down, making both their hands and feet vulnerable to snakes.
“In the peak months we often have up to 20 patients with snakebite in our close monitoring room,” says Dr Ernest. “Having been bitten, many have to travel for hours, especially those working in the remote fields, to reach medical facilities. Timely treatment of snakebite is crucial.”
Antivenom is just one of a range of treatments, depending on the type and severity of the envenoming. “In October, for example, we treated 115 patients for snakebite,” says Dr Ernest. “Only 22 of these patients required antivenom administration, while 93 could be treated clinically. We can manage many bites conservatively with IV fluids, pain management, blood transfusion and leg or limb elevation. We also treat associated infections and give wound care if needed.”
As he speaks, Dr Ernest is doing the morning ward round in the close monitoring room. He stops to talk to a young man who was bitten by a snake on his foot while working on the family farm the previous night. The young man did not require antivenom administration, and the doctor is satisfied that the development of the swelling is being monitored and documented and that he will make a good recovery.
Many more lives could be saved if all snakebite victims in Ethiopia had access to such timely and effective care. For patients like Workey, the envenoming could have been life-threatening if she had not been able to access a clinic providing free and effective antivenom treatment.
Early morning in the sorghum fields
It is early in the morning in late November and still almost dark in the sorghum fields, a 30-minute drive from Abdurafi town. Daytime temperatures can reach 40 degrees so the harvesting takes place before dawn. Four migrant workers have started cutting the crops. Two of them have open-toed shoes, and all four work, cook, eat and sleep in the fields, either under trees or out in the open.
The fifth worker in the sorghum field, 35-year-old Afework Meseret, prepares a simple breakfast for his workmates under a tree at the field’s edge. They will eat dried dark fermented injera bread and shiro, a stew made of powdered broad beans and minced onions.
As he prepares the meal, Afework describes his life as a migrant worker. “Many of us come for the first time at the age of 19 or 20, and then we come every year,” he says. “We live in the fields for many months at a time. Where we are from, there are no jobs. The sorghum season ends in January, so we still have some weeks of work and income. Before the sorghum harvest, I worked on the sesame farms. I prefer to work in the sorghum fields – the crops are easier to harvest. We can do it standing up and walking around – that way we are less exposed to snakes. We know that snakes hide in the sesame fields. It is hotter during the sesame harvest and we work at night. We usually move from harvest to harvest. We work hard to earn enough money to bring back home; this is why we are here.”
Around Abdurafi town, more and more migrant workers are attending health education sessions run by MSF. They are aware of the risks of snakebite and of kala azar, a common but neglected disease transmitted by sandflies, which breed under the trees that edge these fields. Kala azar is endemic in the north of Ethiopia and is deadly without treatment. Afework and his four workmates in the sorghum field know they face an impossible choice: either they can sleep under a tree and risk being bitten by sandflies, or they can sleep in the open fields and risk being bitten by snakes.
Thirty-year-old Mandefro Mehirt is wary of snakes and makes efforts to protect himself. “I am afraid of snakes,” he says, cutting sorghum. “That is why I wear closed shoes – to protect my feet. A friend and colleague of mine was bitten this year. He went to a clinic for treatment and returned to work after five days. He was very lucky because he went straight for help.”
His colleague, 28-year-old Tetina Dagu, joins in: “I have not been bitten by a snake myself, but I have seen snakes in the fields. I have even killed one with a stick. This is why I have the stick. It is my only protection.”
Health education for migrant workers in Abdurafi town
On a busy junction that serves as meeting point for daily labourers and farm contractors in Abdurafi town, MSF’s community and health education supervisor, Yeshiwas Tesema, is speaking to around 200 men about the risks of snakebites.
Throughout November and December, hundreds of migrant workers gather here every morning and evening in search of work, before the sorghum harvest ends in early January and the Ethiopian Christmas holidays begin. It is a good opportunity for MSF to reach large numbers of people who at other times are scattered across the region’s farmlands.
“Traditional healers tie up the affected limb or give herbal infusions to drink,” says Yeshiwas. “Cutting around the bite to drain the venom is a common practice and often leads to complications or infections. We have seen many such cases here in our clinic and witnessed how delayed and inadequate treatment of snakebites can be lethal or end with amputation.”
Yeshiwas and his colleagues regularly run health education sessions in central locations where migrant workers gather. They hand out leaflets and explain how to protect oneself from snakebites and what to do if bitten. They share tips such as using flashlights when out at night, wearing boots and closed shoes, and seeking medical treatment as soon as possible instead of going to traditional healers.
Many people ask questions and one man shares his own experience of being bitten by a snake. “One night I went to collect the sesame that I had tied together, and a snake hiding in the sesame bit me on my right hand,” says 31-year-old Shambre Nigusa, from North Wollo Raykobo, a two-day journey away, who has come to work on the farms around Abdurafi every year for the past 11 years. “Soon my hand and the whole side of my body felt paralysed. I walked for hours from the field to the town of Abdurafi. I asked people for directions to the MSF clinic. I had previously attended a health education session and knew about their services. When I received the antivenom infusion, I soon felt the feelings in my hand and body returning. I am now completely recovered and have returned to work. I can do all the different farm activities.”
When the health education session has finished, Shambre continues his story, surrounded by fellow migrant workers who nod their heads in agreement. “The work we do is difficult and irregular,” he says. “There’s a lot of pressure on us and we keep working day and night to get paid. We do not have professional shoes or gear. I protect myself now by wearing sneakers, and I carefully choose the area in the field where I rest. I only earn enough to survive, but there are no better jobs where I am from.”