It was a
cool December afternoon, in a field outside Mawlamyine, Mon State.
Fourteen-year-old Ko Aung (not his real name) stood sentry over his family’s
herd, watching the cows as they munched on knee-high weeds.
When he
looked down, the snake was already poised at his feet. Brown with black spots
and 4 feet long, it was a Russell’s viper, one of Asia’s deadliest and most
aggressive snakes. Ko Aung froze.
Without
warning the triangular head snapped forward, and the serpent sunk its teeth
into his foot, releasing about 70 milligrams of venom into his bloodstream.
The
strike started an anatomical stopwatch. From the moment he was bitten, Ko Aung
had about three hours to get the proper dosage of anti-venom before his body
entered a fatal stage of kidney failure.
Bites
like Ko Aung’s happen every day in Myanmar. The Ministry of Health logged 18.3
cases of poisonous snakebites – and 1.4 deaths – per 100,000 people in 2012,
its most recent report. That amounts to about 28 known poisonous bites per day,
with more likely unreported.
But in
Mandalay and Sagaing regions, known instances go up nearly 80 percent from the
average. In Magwe Region, mortality more than doubles. The entire Myanmar
heartland – a fertile, primarily agrarian stretch where snakes lurk throughout
hundreds of thousands of acres of rice paddy – is one of the most dangerous
places in the world to get bitten by a snake.
The
Myanmar Snakebite Project (MSBP), or more formally “Improving the outcomes for
snakebite patients in Myanmar”, an Australian/Myanmar effort between the two
governments, is working to address the snakebite threat. Begun in 2014, the
A$2.3 million grant (US$1.66 million, or K1.96 billion) from the Australian
government has transformed the way Myanmar produces, distributes and uses
anti-venom.
“There’s
never enough,” said David Bacon, the project manager based in Mandalay.
The MSBC
began after Daw Aung San Suu Kyi drew attention to Myanmar’s snakebite problems
during a 2013 speech in Sydney. Cyclone Nargis had ravaged the country in 2008,
and anti-venom stores never recovered from the spike in snakebites during the
crisis. Myanmar was producing just 15,000 vials per year – well below the
international standard of 80,000.
Clinical
Associate Professor Chen Au Peh from Adelaide University worked with Myanmar
colleagues to develop a project with Myanmar’s Ministry of Health, which
administers and distributes anti-venom, and the Ministry of Industry, which
produces it.
Australian
and international experts advise Myanmar staff on best practice across the
anti-venom supply chain, from producing vials to distributing them more widely.
Myanmar provides the anti-venom for free, as well as dialysis treatment if
necessary, but travel costs are a heavy burden on poor rural families like Ko
Aung’s.
Shortening
the distance to treatment is another aim of the MSBP. After Ko Aung was bitten,
his family rushed him to the nearest township health centre in Paung township,
where he received four vials of anti-snake venom before transferring to the Mon
State hospital several hours away.
The
venom, which causes blood clotting as well as a host of other life-threatening
conditions, created a hemorrhagic blister that ruptured his foot. Even though
he received anti-venom within the three-hour time window, he still suffered a
severe loss of kidney function. Doctors in Mon State transferred him to
Yangon’s Specialty Hospital, where six sessions of dialysis probably saved him
from organ failure.
Sitting
in a hospital bed, he surveys the mangled mess of bandages around his foot. The
dressings hide a gaping wound where his flesh once was, but Ko Aung is one of
the lucky ones.
Health education
According
to Dr Khin Thida Thwin, the renal physician at Yangon Specialty Hospital and
head of the Snakebite Unit who treated Ko Aung, many victims end up turning to
traditional healers, who often treat snakebites with tourniquets, cutting or
tattooing – all of which are more harm than help.
“This
traditional medicine has been around a long time,” she said. “Some people still
believe in it. That’s why we have to provide health education.”
That’s
the primary thrust of the MSBP’s public health work in Mandalay Region. Using
Myanmar’s education resources, the team is supporting community prevention and
education programs across Kyaukse and Madaya township areas in Mandalay Region.
Bacon
said the project team was helping local health professionals create a pilot
model for early treatment and improved referral of snakebite victims. Ko Aung’s
case was a model in that the township health centre communicated with the
regional hospital, which then managed a rapid transfer to Yangon. Most cases
don’t flow so smoothly.
By
organising training for more than 700 healthcare workers, the project hopes to
streamline the treatment process while at the same time building the capacity
of an educated professional workforce that knows exactly what to do when the
next farm worker gets bitten.
In early
May, the Ministry of Health ordered the Mandalay Region Rural Health Centres to
stock a minimum of four vials. “The doctors and health workers in the townships
and RHCs can now demand that [snake anti-venom] be provided and make sure that
it arrives,” said Mr Bacon.
Production
A visit
to the Ministry of Industry’s new anti-venom production facility, which
Industry Minister U Khin Maung Cho opened on May 20, reveals a shiny
world-class laboratory filled with state-of-the-art equipment. Deputy general
manager Dr Aung Zaw said K5 billion (US$4 million) went into the structure,
which contains a large freeze-drying machine that will allow the anti-venom to
be stored as powder.
Australian
experts advised the ministry on what equipment to buy and partly funded the
freeze dryer. As for the horses used to generate the anti-venom, veterinarians
helped Myanmar staff make key changes.
Because
the horses are so large, they can develop more anti-venom antibodies. These
antibodies are extracted, purified and concentrated for human use.
But horse
mortality reached 20pc, an expensive loss of investment and time. Part of the
problem was treatment; They were keeping nearly 300 horses on a 9-acre pasture,
repeatedly injecting them with the venom.
“There
was a shortage of anti-venom because there was a scarcity of healthy horses,”
Dr Aung Zaw said. “At the time we could only produce 15,000 vials a year.”
Now,
after consulting with Australian veterinarians, horse mortality has been
improved by half. And with the new facility, freeze-dried anti-venom will soon
be available to rural townships that lack electricity for refrigeration.
The
Australian government has donated 30 solar-powered refrigerators to selected
rural health centres in Madaya and Kyaukse. The refrigerators will serve until
the new, German-engineered freeze-drying equipment begins producing the
powdered versions that do not require refrigeration.
It’s a
turning point for one of Myanmar’s deadliest problems. After years of producing
well below the national requirement of 80,000 vials per year, Dr Aung Zaw said
2016 would be the first year that Myanmar met international standards.
The MSBP
will run its course by the end of 2018, and Dr Afzal Mahmood, an expert on
healthcare in developing nations, says the goal is to leave behind a sustainable
blueprint for the Myanmar government.
“International
aid is not sufficient for improving the healthcare of a country. It’s local
government that must do it,” he said. “Our role is to create, and assist the
local government in creating, a model.”
RJ Vogt
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