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Therapeutic itineraries of snakebite victims and antivenom access in southern Mexico [1]
['Chloe Vasquez', 'Macalester College', 'Saint Paul', 'Minnesota United States Of America', 'Edgar Neri Castro', 'Facultad De Ciencias Biológicas', 'Universidad Juárez Del Estado De Durango', 'Durango', 'Eric D. Carter']
Date: 2024-08
Most interviewees were working-age males who had been bitten on farms, as well as in and around the house. All respondents described themselves as either mestizo, Tseltal, or Tzotzil (in Chiapas) or Chinantec (in Oaxaca). We documented 54 snakebite incidents, which took place between 1977 and 2023, among the 47 interviewees ( Table 1 ). The most common anatomical site of the bite was the hand, followed by the leg ( Fig 2 ). In 61% (n = 33) of incidents, traditional medicine was used, including use of herbal remedies (54%, n = 29), consulting with curanderos (28%, n = 15), consuming alcohol (37%, n = 20), and cutting and/or sucking the wound (24%, n = 13) ( Fig 3 ). We did not consider tourniquet use as a traditional medicine method, as this used to be widely recommended by medical professionals until recently; tourniquets were used in 30% (n = 16) of incidents. In 21% (n = 11) of incidents, respondents reported following a special diet after the snakebite, composed mostly of broth, tostadas and black coffee, while excluding meat, fat, oil and other “hot” foods.
Therapeutic itineraries
Therapeutic itineraries varied significantly as snakebite victims sought healing following their accident. The most common self-reported symptoms were pain, swelling of the wound site, dizziness, vomiting, and bleeding from the bite wound, eyes, teeth, and ears. Snakebite victims received help from family members, medical professionals, curanderos, neighbors and strangers. Assistance from family members, coworkers, neighbors and strangers included preparing and administering homeopathic remedies, carrying victims from the mountain or farm to town, transporting the victim to the hospital, and searching for antivenom (Fig 4).
The therapeutic itinerary begins with the snakebite incident. Based on our analysis of case history interviews, most interviewees experienced envenoming, and thus risk of sickness, permanent injury or death. Yet, there is potential for confusion in self-diagnosis at the time of the bite, given reports of mild or asymptomatic snakebites. For one, some venomous and non-venomous snakes look similar. The cotorrera (Bothriechis bicolor) was the most reported species involved in snakebite incidents, as this snake makes its home in high-elevation coffee trees in Chiapas. This snake has a bright green color with teal spots and mild venom, causing mostly symptoms of pain and local swelling [29]. In the Sierra Madre region, there is also a similar-looking snake that is entirely non-venomous. The harmless bejuquilla, or Oxybelis fulgidus, shares the cotorrera’s habitat and bright green color. The similarity of these two species is a potential cause of confusion, and respondents mentioned changes in health-seeking behavior as a result of perceived asymptomatic cotorrera bites, which may have been caused by the bejuquilla.
"There are two types of these green snakes, there is one that is green green, and another that has light blue spots. They say that this one with spots is more dangerous, many have been bitten. You don’t die, but it causes a lot of pain. But Jose resisted, I don’t know if he is stronger."—Jose’s father (Jose bitten 2021).
Two victims mentioned that a bite could be less severe if only one fang penetrated the wound. Others mentioned luck or personal "strength" when comparing their asymptomatic experiences with those of peers, who reacted to envenoming from what they thought was the same species.
"Another friend was bitten [by the same snake], and I didn’t pay attention to him because [that snake] had already bitten me in the past. But he swelled up, he was resting for about 5, 6 days… There are people with stronger blood, like me, who are not affected by the snake." Luis, bitten 3 times in 1978, 1987, and 1993.
To treat snakebite, interview participants tended to prefer allopathic medicine; however, traditional medicine was generally more accessible for economic, geographic, and social reasons. Hospitals were far from the site of most snakebites, so that victims had to travel hours to reach a medical facility. Distance seemed to be the most pressing obstacle to antivenom access (Fig 5). For those who remembered their travel itinerary (n = 24), respondents reported an average travel time of 2.76 hours just to reach the first medical facility.
"Another guy here died. He grew ginger and was bitten by a viper. He didn’t make it down [the mountain]. He was 32 years old, and left 3 kids and his wife. He died horribly." Daniela, bitten in 2013. "I cured it with a vine called curarina. I took it crushed, with alcohol. At this time there was no clinic, there was no hospital, there was nothing… If a snake bit me now, I would go to the municipality to the hospital, where they have medicine. Now there are doctors. Before, how? There was just monte [mountain and/or bush]. Those herbs are not enough." Arturo, bitten 1983. "I could barely bear the journey back to the town. It’s two hours walking, and I came quickly. I was shaky. I said, ’I’m going to die here‴ Martin, bitten 2022 (Fig 6).
Even for those who reached the medical facility successfully, antivenom was rarely in stock. Those who reached a clinic or hospital (n = 22) received antivenom 23% of the time. Of the 22 victims who reached antivenom (either at the hospital, or independently), 16 reported receiving less than a minimum dose (5 vials for Antivipmyn), or reported that the hospital ran out of antivenom during treatment.
"It’s not easy to buy the antidote. It’s hard to find. There is none." Lorenzo, bitten 2005. "When we got to the hospital, they had the dose but it wasn’t a complete one. It wasn’t enough" Marco, bitten 2015. "They got to the hospital 30 minutes later, but the hospital didn’t have any antivenom. Silvester’s family went to look for the antivenom and they bought two from a private doctor for 3,500 pesos [$200] each. They wanted to buy more, but the doctor only had two." Field Notes on Silvestre, bitten 2021.
Cost was another obstacle to receiving antivenom. Of the 22 patients who received antivenom, 12 had to pay out of pocket for at least one vial. When discussing their therapeutic itineraries, many respondents mentioned the costs of transportation and accessing antivenom. In the case of Federico, bitten 2008, hospital authorities expected payment for the ambulance trip. Federico’s brother had to seek funds from a campaigning politician, who helped them if they promised not to consult a curandero. This caused a delay in transportation to the next medical facility, where Federico could be treated.
"I was cleaning [weeding] coffee [plants] when it [the snake] bit me. My son-in-law did me the favor of bringing me to the hospital. When we got to Mapastepec, there was no medicine, nothing. That’s when my breathing stopped. They transferred me to Tapachula. When we got there, there was no medicine there either. They told me that they had one in San Cristobal [the state capital], but the doctor said, ’by the time the medicine gets here, you’ll be dead.’ Well, we had to check around there [in Tapachula]. My family went to the veterinary for animals. They found a vial there. But they’re expensive. 3,500 pesos [$200] per vial. They injected me with around 5." Eduardo, bitten 2019. "We took him immediately to the nurse here, and she injected him with a small vial. But it’s expensive… We injected one vial here so he would survive until La Revolución, and from La Revolución to Villa Flores because they didn’t accept him in La Revolución." Interview with Emilio’s wife, Emilio bitten 2016. "I think that they should have the antivenom in all the clinics. As the health center here is very small, we don’t have doctors. When things are serious, we go to Valle or Tuxtepec. And at the very least you have to have money, because if not, they won’t treat you. The snake antivenom is expensive." Daniela, bitten 2013.
Consulting clinics or hospitals did not exclude the possibility of a later visit to a curandero, or vice versa. Many victims who chose to seek medical help reported using traditional medicine or visiting a curandero to survive the long journey to medical facilities. Upon arrival at the hospital, most victims reported that antivenoms were out of stock. At this point, the victim could risk the journey to the next hospital (usually 2–4 hours by car or ambulance). Alternatively, the victim’s friends or family could go search for antivenoms in pharmacies or through individual health practitioners. On these occasions, families had to pay out of pocket for the antivenom, reporting a price around 3,500 pesos (US$200) per vial, with a recommended dose starting at 5 vials.
There are other extraneous reasons why a victim would have a negative perception of biomedicine. Victims mentioned the secondary effects of Western medicine (n = 1), a fear of amputation (n = 1), and a fear of fasciotomy, an operation where surgeons slice the limb in order to relieve excessive pressure caused by swelling from a snakebite (n = 1).
There were two other common paths. One was a purely homeopathic solution, which was most common among victims who reported few severe symptoms (e.g., did not experience bleeding from eyes, ears, or gums), or in cases where medical facilities were perceived as out of reach or nonexistent. Another important therapeutic itinerary involved the independent search for antivenoms. Victims or families purchased antivenoms from local nurses or medical professionals, pharmacies, or even, in one case, from vector-control brigades. On one occasion, a nurse claimed the hospital had no antivenom. After the victim’s family searched fruitlessly for the antivenom and returned empty-handed, a doctor scolded the nurse and affirmed that the hospital had antivenom. Multiple accounts reported nurses and doctors selling the antivenom privately.
Of the 22 victims who reached antivenom, 72.7% (n = 16) reported receiving a dose less than 5 vials (the minimum recommended dose of Antivipmyn), or reported that the doctors wanted to inject more vials but ran out of antivenom. We counted these as underdosages. These included victims who purchased antivenom from outside of hospitals. Estimated time to reach hospitals and antivenom are based on victims’ estimations. These estimates do not consider those who could not recall the amount of time spent in transit.
Many victims who were bitten over two decades ago mentioned that new local clinics and hospitals make healthcare more accessible than before. To analyze change over time and mitigate the problem of recall bias, we compared treatment-seeking behaviors in two time periods, 1977–2010 and 2011–2023 (Fig 7). More recent victims were somewhat more likely to reach hospitals and to receive antivenom, and less likely to have used traditional medicine. Despite victims’ reports of improved hospital access, recent victims reported longer travel times to hospitals and to reach antivenom, as compared to pre-2011 victims (Table 2). However, we note that many of the people we interviewed could not recall the time-related information at all, especially in the pre-2011 group.
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