Why Antivenom Is Not the Solution: An analysis of causes of mortality among Myanmar’s snakebite victims and the implications for public health policy

1. I N T R O D U C T I O N

Myanmar is home to some 44 species of venomous snakes whose bites are potentially fatal to humans (Leviton 2003). The Russell’s Pit Viper is the most prolific actor, accounting for about 80% of all officially documented bites in the country annually (Warrell 1991). Following Russell’s (in order of fatalities) are the Monocellate Cobra, the Green Pit Viper, and the Malayan Krait. These four account for some 96% of all fatalities (Aye 2018).

Importantly, all these same species of snakes thrive in Thailand also, especially in agricultural areas (Patikorn 2022(4)) (Goldstein 2023). So far, nothing unexpected, as Myanmar and Thailand share a common border of about 2,416 kilometres (Seekins 2006).

What should set healthcare policy alarms ringing, however, is the staggering difference in the rates of death between the two neighbouring countries (WHO 2022).

A comparison of mortality rates due to snakebites in the most recent years reported documents that Myanmar citizens suffer about 4,000 snakebites per year of which 1,000 perish—thus achieving about a 25% mortality rate (White 2019).²

Thailand, by way of contrast, records some 9,100 snakebites per year leading to only about 100 deaths—a paltry 1% mortality (TNHCO 2022) in stark contrast.

Why the vast disparity in mortality rates? This research uncovers clues to answer that precise question.

2. L I T E R A T U R E R E V I E W

Myanmar currently has a population of about 53.8 million people, while Thailand has a population of about 71.6 million people (UN 2022). Given the relative sizes of each country, the geographically larger Myanmar (about 676,578 square kilometres in all) has a lower population density of about 80.08 persons per kilometre, while the somewhat smaller Thailand (513,120 square kilometres) has a higher population density of about 140.54 persons per kilometre (Statista 2023).

Thus, both as a measure of population, and of population density, it would be reasonable to assume a roughly similar pro rata incidence of snakebite, particularly because both nations devote vast amounts of land to agriculture.

To the contrary, however, although the incidence of snakebites is as would be predicted, the mortality rate in Myanmar far exceeds that of its neighbour, Thailand (Ralph 2022).

Nevertheless, most literature focuses on how to manage snakebites in the region using similar protocols. Indeed, the epidemiology is well known, and antivenom is routinely produced in both countries in adequate quantities (Hofer 2018).

But although the existing literature about snakebites in Myanmar lays out clearly how to reduce exposure and what to do in case of envenomation (Win 2002) (WHO 2016), it nevertheless largely fails to account for the lived experiences of clinicians and patients in remote areas of Myanmar who stand at high risk of venomous bites, and whose practical problems may well differ from other nearby ASEAN countries.

To understand potentially unique problem sets, we turned next to live interviews.

3. C O N C E P T U A L F R A M E W O R K

This study is grounded in the view that leadership is a social construction (Cascant 2022), and that in certain decolonising nations including Myanmar leadership is a construction that transmogrified during the violent period of British colonisation (Visone 2017), and has therefore remained in a partially catatonic undeveloped state due to the traumatic legacy effects of the colonial era (Xiaojing 2022).

For this precise reason, a great many remedies that work reliably in societies unencumbered with the debilitating development challenges of decolonisation fail to work in nations bearing up under those stressors (Gordon 2023). Case in point: the highly time sensitive treatment for snakebites in Myanmar.

4. M E T H O D O L O G Y

The author initially gathered data quantifying incidences of snakebites and snakebite induced deaths in Myanmar and Thailand from recent available sources published by the Myanmar Ministry of Health, the Thailand National Health Commission Office, the World Bank, and the World Health Organisation.

Then, having established a meaningful contrast in patient outcomes between the two nations, the author undertook a Literature Review of some 56 original peer-reviewed research sources and data banks. The average age of the research considered for this study ranged from 1997 to 2023, with a median publication date of 2021 and a mode publication date of 2022.

To verify or falsify the secondary findings against primary research, the author next conducted a series of long-form semi-structured interviews over a period of 90 days during the monsoon season in 2022 with first-responder medical personnel from 21 medium and small sized hospitals and clinics located across Myanmar. The interviews were conducted in person, beginning in the author’s home village then moving outward toward the periphery.

Hospitals and clinics in remote areas participated in the interviews with the author online via Zoom using both English and Myanmar languages. In cases where strong dialects presented a risk of misunderstanding, the author employed third-party local interpreters to join the interviews to enhance clarity.

Then, as patterns of potentially intermediating contributory factors driving snakebite mortality in Myanmar began to emerge, the author turned attention back to quantitative data to see whether the problems teased out in the interviews might also be supported in quantitative data as well—if, for example, such factors as differing investment commitments, infrastructure limitations, or education rates both correlated with the interview findings, and also matched the contrasting outcomes in mortality between the two countries.

Finally, utilising a qualitative narrative approach, the author detailed the aggregate research findings (in Section 5, below) to unpack both the contributing factors attendant to increased snakebite mortality, as well as to connect those problem sets to a larger context of decolonial leadership development and legacy challenges faced in Myanmar by the present generation.

5. F I N D I N G S A N D D I S C U S S I O N

Clinicians explained in interviews that possible contributing factors to snakebite mortality in Myanmar include:

(1) The hospital or clinic cannot afford to purchase the antivenom due to lack of funds. Hence, the patient’s death is a budgeting or poverty problem (Habib 2018) (Myint 2019).

(World Bank 2020)

(2) The antivenom was duly purchased by the hospital or clinic, but it is now regrettably out of stock due to use by others. Thus, the snakebite patient falls victim to an everyday purchasing problem (McCaughan 2022).

(3) The antivenom was purchased and remains in stock. However, the current stock has expired due to lengthy storage at the hospital or clinic. Therefore, the patient dies due to an inventory management problem, easily solvable in the commercial world outside healthcare (Kingori 2022).

(4) The antivenom was purchased properly, remains in stock, and is up to date having not yet reached its expiry. However, the liquid antivenom was not refrigerated properly due of intermittent electricity outages in the hospital’s or clinic’s region. So in such a case, the patient passes due to an infrastructure problem (Palmer 2021).

(IEA 2020)

(5) The antivenom is available at the hospital or clinic, and is in excellent condition. But unfortunately, the medicine itself is counterfeit (fake) or has poorly prepared ingredients, due to having been purchased from disreputable suppliers, possibly allowed into Myanmar due to a bribe at some level. Here the patient faces the life-threatening consequences of a corruption problem (Debie 2022) (Naher 2020).

(6) The antivenom is in stock, has been properly refrigerated, and is of high quality. However, the nearest hospital or clinic is simply located too far away for the snakebite victim to reach in time to receive effective care. Thus, mortality ensues due to Myanmar’s geographic problem (Paul 2019) (Tang 2017).

(Paul 2019)

(7) The clinic or hospital is near enough for the victim to reach in time, and the antivenom is in order. But doctors no longer work at the facility full time, either because they are stretched too thin across the territory, or because they have chosen to be absent to undertake civil-disobedience activities: thus (for the patient at least), a labour problem (Kingori 2022) (Saw 2019).

(8) Even though a doctor is not available on site, a nurse or other medical assistant is present. However, unfortunately the assisting party was not trained to properly diagnose the snakebite and administer the antivenom correctly. Here we encounter a training problem. In cases like this discovered in interviews, an attempted resolution often involved sending the snakebite victim’s family or neighbours back to the victim’s home village in an ill-conceived attempt to find and photograph the offending snake with a mobile phone, during which delay the patient expired (Mahmood 2019).

(9) The patient or his or her family is noncompliant and so refuses or fails to follow through with their treatment protocols as instructed by medical personnel, dramatically increasing the chances of extended morbidity or even mortality due to Myanmar’s ongoing education problem (Parandeh 2022) (Raza 2004) (Schioldann 2018).

The nine factors which emerged during the interview phase of this research suggest a tentative conclusion that (1) it is safer to be bitten by a snake in Thailand than in Myanmar (WHO 2022).

And (2) the ultimate cause of death in Myanmar will likely not be due to lack of efficacy in epidemiology, pharmacology, or biostatistics (Cook 2021).

But rather, death will arrive as the result of poor management practices—practices which have not yet been properly vetted to Myanmar's own indigenous ways of developing (Barrero 2022, Steinhorst 2022).

Fortunately, these are matters which can—and must—be ameliorated by an ongoing programme of robust national development, both in and outside the domain of healthcare itself (Ratner 2022) (Talukder 2023).

A C K N O W L E D G M E N T S

This research was funded by International Leadership University (ILU) in Myanmar. The author is grateful to ILU’s researchers, staff, and graduate students for their cooperation in making this work possible. The author also acknowledges the invaluable cooperation of the Ministry of Health who provided generous access to relevant statistical data required for this research.

N O C O N F L I C T O F I N T E R E S T

The author declares he has no known competing financial interests or personal relationships that could have influenced the work reported in this paper.

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T O C I T E T H I S A R T I C L E

Dare, Richard (2023). Why Antivenom Is Not the Solution: An analysis of causes of mortality among Myanmar’s snakebite victims and the implications for public health policy. International Journal of Decolonial Leadership: 23 (2), 167-173.

Copyright © 2023 the author. Published by International Leadership University Press