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.
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.
“Unfortunately, in most parts of the country, effective antivenom is either unavailable or is too expensive for the communities most affected by snakebite.”
Sudden snakebite needs immediate treatment
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.”
Migrant harvest workers among most vulnerable
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.”
Lack of access to effective care and antivenoms
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.