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3 AM. The phone falls to the floor as I grope around in the dark.

"We have another one for you, boss", the voice says, with the schadenfreude that the night doctors feel when summoning the on-call staff.

"What, another snakebite ?" I wonder what the poor man was doing getting bitten at that hour.

It has been a tough night for the emergency doctors. Patients look up hopefully at the first sign of a doctor, while others complain to triage. There is some blood on the floor in the main room; the smell of sweat hangs thick in the air.

The interns gesture tiredly in the direction of the resuscitation room. "There is a transfer letter somewhere," they tell me. It is a pithy statement of fact, even for Papua New Guinea. "Thank you for taking K, who is 12 years old. He was bitten by a snake at 6 PM. We have no tet tox or penicillin. We have no antivenom. Yours truly." I'm not sure if they mean to tell me that they have thought of these things, or they are hoping we will provide some for them.

The child is not well. Held up by his tired parents, his eyes are heavy from fatigue and from the neurotoxin that is taking over. He is still breathing, with some effort. He does not care that saliva spills from his chin onto his T-shirt. He will need to be ventilated soon, but not yet. His blood does not clot. I have learned not to ask the lab to tell me how long it takes; once I called for missing results only to be told that they couldn't give me a clotting time, as they were still waiting. It has been a steep learning curve for me.

The refrigerator in the emergency department has contained two ampoules of sea snake antivenom for a few years now. No-one at the hospital has ever heard of anyone being bitten by a sea snake. The paediatric ward staff tell me they do not have any polyvalent antivenom, but I run across to make sure. It would not be the first time they have tried to save some antivenom. Pharmacy is locked, but I checked there earlier in the day. The nurses in intensive care eye me suspiciously. "We are full, boss."

Unfortunately, little has changed regarding antivenom availability for snakebite victims in this region during the past century. The global burden of this eminently treatable condition is estimated at approximately 100 000 deaths each year,⁹ about a tenth the mortality attributable to malaria. Most of these deaths are concentrated in the Indo-Pacific region,¹⁰ where the poor (or absent) access to antivenom for most people results in snakebite mortality orders of magnitude greater than that in Australia (see Box 3). Indeed, tragically, although the burden of snakebite on the local people stimulated Calmette's original studies at the Vaccine Institute in Saigon (now Ho Chi Minh City),¹¹ no snake antivenom was made in Vietnam for the next 100 years.

There were five snakebites today and two yesterday — unusual even here. There are over 100 snakebite victims seen each year at Port Moresby General Hospital and we had received 20 ampoules of antivenom in the year 2000. There are seven ventilators. I try again to wrest an ampoule of antivenom from the intensive care ward by telling the staff that this patient might not need to come up to their ward if he had some. They honestly do not have any.

I try all the tricks. Neostigmine sometimes helps if the snake was a death adder. I know that over 90% of bites are from taipans, but it is worth a try. I wonder if the scientists who theorised about cholinergic neurotoxins ever thought that it would come to this. It has been said that as the horses used to produce antivenoms for other snake venoms were the same ones used for the taipan antivenom, the antivenoms might have some activity against other snakes. Perhaps the sea snake antivenom might yet be useful. . .

Fortunately for childhood vaccination, the establishment of the Global Fund for Childhood Vaccines by the William H Gates Foundation represents an unprecedented opportunity for infectious disease control by a systematic change in vaccine procurement methods.¹⁸ This change recognises that while "responsibility for health is national . . . the determinants of health and the means to fulfil that responsibility are increasingly global".^18,19 A similarly coordinated international strategy is required to tackle the neglected issue of snakebite.

We propose a comprehensive program that builds on the resources and relationships acquired by the Children's Vaccine Initiative²⁰ and on World Health Organization (WHO) policy initiatives towards securing global access to essential drugs.²¹ It would employ strategies such as that adopted by the Pan American Health Organization's revolving fund, which emphasises sustainability by long-term government commitment before donor-supported expansion.²² This International Snakebite Initiative (ISI) would recognise that antivenoms are, like vaccines, international public commodities usually manufactured by the same companies facing the same pressures of economics.¹⁸ This is already recognised implicitly by the inclusion of antivenoms in the WHO's essential drug list.²³ The ISI would require an interdisciplinary and multisectoral partnership maintaining national responsibility and aiming, where possible, for antivenom self-sufficiency. In addition to procurement, it would facilitate the development of new antivenom technology and adjuvant therapies. It would also encourage sustained primary-prevention programs, sponsor research and implement appropriate first-aid methods, ongoing snakebite injury surveillance and improved clinical education tools such as regional snakebite management guidelines.

I intubate the boy, leave the intern with the bag, and go back to intensive care and give the staff the bad news. They tell me again that there are no ventilators. I ask which patients' wantoks (relatives) are staying with them. I tell them that we need the ventilator for a child and that they will have to help.

I disconnect a patient's ventilator and attach the bag to his tube, explaining to his relatives,"This is how you breathe for him. If you stop, he does not breathe." The lesson is easily understood. We transfer the boy from emergency to intensive care and the other patients' relatives look at us impassively.

Locally, efforts to enhance antivenom availability in PNG through calls for direct or indirect price subsidies^16,25 have been ineffective.^12,16,25,26 This reflects the general difficulty of facilitating access to essential drugs by appeals to charity or corporate social responsibility.²¹ Commercial disinterest in this class of pharmaceuticals is clearly evident in the apparent recent withdrawal of the incumbent snake antivenom manufacturer from the United States market.²⁷ This has handed a monopoly to the new producer, which is now selling the most expensive antivenom in the world.¹⁴ We therefore argue that a new and more sustainable approach to antivenom procurement is required. Our proposal places antivenoms within global initiatives to secure access to essential drugs, particularly immunotherapeutics, in partnership with donors, the public sector and the pharmaceutical industry.²¹

Despite these challenges there is room for optimism. The chosen theme of PNG's 25th anniversary of Independence last September was "Walking together", or Raka hebou in Motu and Wokabaut wantaim in Tok Pigin. This theme resonates strongly with our aspirations for regional and global partnerships for snakebite control. Australia, with its distinguished record in antivenom research and development as well as in the Children's Vaccine Initiative, has the potential to play a leading role in the ISI. Countries with a high burden of snakebite, such as PNG and Vietnam, have well-organised national health systems effectively participating in global vaccination programs and disease eradication.²⁸ Australian medical staff assist with snakebite management in regular regional toxinology teaching workshops and courses,²⁹ and by international hospital-based, exchanges, sponsored by Australian institutions.³⁰ Indeed, in the very week of PNG's Silver Jubilee celebrations, two such snakebite workshops were held at PMGH by one of us (K D W).

Nevertheless, the need for global snakebite control is urgent and "action plans express no outrage".³¹ Unless affluent nations like Australia rise to this challenge, variations on our tragic scene will be replayed daily throughout the Asia-Pacific region for want of a 19th-century therapy.

Acknowledgements

Competing interests

References

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Department of Pharmacology, University of Melbourne, VIC.
Kenneth D Winkel, MB BS, PhD, Director, Australian Venom Research Unit.

Reprints: Dr K D Winkel, AVRU, Department of Pharmacology, University of Melbourne, VIC 3010.
kdwATunimelb.edu.au

©MJA 2001
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