For reference malaria killed 600.000 in 2020 according to WHO,  so it is pretty surprising to me that I've never heard of snakebites given that they kill about 1/6th of what malaria does (not to mention the handicapping). 

Super interesting writeup, I'm glad that my horizon is now a  little wider.

Summary: Good news!! If you read this post last year, about 50,000 fewer people are dying each year than you thought. 

I'm very sceptical of the WHO estimate of 81,000-138,000 annual fatalities. Following the citations:

• That WHO stat (citation 6 in the report linked in footnote 2, note that link automatically downloads a pdf) cites Gutierrez et al. 2017.
• Gutierrez et al. have a range of 81,410 to 137,880. This range is not a confidence interval, but "combined upper estimates of mortality" (page 2) — meaning these numbers are each upper bounds. Gutierrez et al. have two citations for the range, Kasturiratne et al. 2008 and Chippaux 1998.
• Kasturiratne et al.'s "high estimate" is 93,945 deaths per year. They come to this number by averaging rural and urban incident/fatality rates in a way which I don't agree with,^[1]  and applying regional fatality rates to areas without data.^[2]
• In Chippaux, the largest number I can find is 125,345. Despite the specificity, this paper relies heavily on round numbers.^[3] Also, the paper is 26 years old, and the number of people employed in agriculture (top risk for snakebites) has fallen by more than a third.
• I have no idea where the 137,880 number in Gutierrez et al. comes from, and therefore where the WHO got that figure, and therefore where the number in this post comes from. It's widely cited to the WHO report, but I lose track of it before Gutierrez et al. 

What numbers seem more reasonable? From the 16-year-old Kasturiratne et al. paper, I find their low estimate (19,886 annual deaths) too low, so I'd accept their range of 19,886 to 93,945 as a acceptable confidence interval (90% for the year 2007). The Chippaux numbers are much too high, and the higher Gutierrez et al. number is entirely unsourced. Further, as noted above, the decline in agricultural labor over the past two decades will have reduced exposure to snakes, and the rapid expansion of medical care in rural India will have further addressed the problem. 

Thankfully, the 2019 GBD report[^5] did a much better job (imo) of estimating this. Their value estimate for all deaths from venomous animals is 79,700, and venomous snakes is 63,400.^[4] This seems much more reasonable, though GBD figures do have a history of being too high, and I personally revise my median estimate down to 55,000. 

^[1] They assume that all rural areas have the highest incident and fatality rate, which seems obviously untrue. But to create an upper bound when dealing with lots of missing data, fine.

^[2] "Our approach minimised this effect [of ignoring regions with missing data], although in some regions, such as the Caribbean, lack of data still meant that we were forced to use very high rates in our calculations of the high estimate." (page 1601)

^[3] 80% of this high estimate relies on this paragraph:

"In Asia (population, ca. 3500 million) as a whole there may be up to 4 million snake-bites each year, of which almost 50% are envenomed. Approximately half of the victims reach hospital and the annual number of deaths resulting can be estimated at 100000." 

The 100,000 number is not justified any further.

^[5] I used the query tool here; you need to make a free account. 

^[4] This leads to the question, what other other venomous animals are killing 16,000 people per year? I couldn't find an easy answer; my guesses in order are scorpions, jellyfish, and spiders. I highly recommend Venomous by Christie Wilcox for a cultural and scientific history of venom.

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Does anyone know if there are any ways to direct funding to this? I'd be potentially interested in exploring it.

I'm a bit late to the party on this one, but I'd be interested to find out how differential treatment of indigenous groups in countries where snakebites are most prevalent impacts the tractability of any interventions. I don't have any strong opinions about how significant this issue is, but I would tentatively suggest that a basket of 'ethnic inequality issues' should be considered a third 'prong' in the analysis of why snakebites kill and maim so many people, and could substantially impact our cost-effectiveness estimates.

Explanation:

The WHO report linked by OP notes that, in many communities, over 3/4 of snakebite victims choose traditional medicine or spiritual healers instead of hospital treatment. I don't think this is a result of either of the two big issues that the OP identifies - it doesn't seem to stem from difficulty with diagnosis or cost of treatment, so much as being a thorny problem resulting from structural ethnic inequalities in developing countries.

I'm most familiar with the healthcare context of Amazonian nations, where deeply embedded beliefs around traditional medicine and general suspicion of mestizo-run governments can make it more difficult to administer healthcare to indigenous rainforest communities, low indigenous voter turnout reduces the incentives of elected officials to do anything about poor health outcomes, and discriminatory attitudes towards indigenous people can make health crises appear less salient to decisionmakers. Given that indigenous groups in developing countries almost universally receive worse healthcare treatment, and given that much indigenous land is in regions with high vulnerability to snake envenoming,^[1] I wouldn't be surprised if this issue generalised outside of Amazonia.

Depending on the size of the effect here, this could considerably impact assessments of tractability. For example, if developing country governments won't pay for the interventions, it might be difficult to fund long-term antivenom distribution networks. Alternatively, if indigenous groups don't trust radio communications, communicating health interventions could be particularly difficult. Also, given the fact that 'indigenous' is a poorly-defined term which refers to a host of totally unrelated peoples, it might be difficult to generalise or scale community interventions.

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   Study here (which I've not read).

Thanks for the post - this seems like a really important contribution! 

[Caveat: I am not at all an expert on this and just spent some time googling]. Snake antivenom actually requires that you milk venom from a snake to produce, and I wonder how much this is contributing to the high cost ($55–$640)  of snake venom [1]. I wonder if R&D would be a better investment, especially given the potentially high storage and transport costs for snake venom (see below). It would be interesting to see someone investigate this more thoroughly.

Storage costs are pretty low in that cost effectiveness estimate you cite [2], but it seems pretty plausible to me that storage and transportation costs would be much higher if you wanted to administer snake venom at smaller clinics that were closer to the victims of snake bites. The cost was based on this previous estimate,  in which they say“The cost of shipping from abroad where the antivenoms are manufactured, transportation within Nigeria and freezing of antivenom (including use of supplementary diesel power electric generators in addition to national power grid) is estimated at N3,000 ($18.75) from prior experience and expert opinion. But it was assumed that appropriate storage facilities already exist at the local level through immunization/drug services and that no additional capital investment would be required to adequately store the antivenom in the field” [3].
I'm not sure exactly what facilities are required and how expensive they would be, but this seems like it could be an important consideration.
 

[1] Brown NI (2012) Consequences of neglect: analysis of the sub-Saharan African snake antivenom market and the global context. PLoS Negl Trop Dis. 6: e1670.

[2] Hamza M, Idris MA, Maiyaki MB, Lamorde M, Chippaux JP, et al. (2016) Cost-Effectiveness of Antivenoms for Snakebite Envenoming in 16 Countries in West Africa. PLOS Neglected Tropical Diseases 10(3): e0004568. https://doi.org/10.1371/journal.pntd.0004568

[3] Habib AG, Lamorde M, Dalhat MM, Habib ZG, Kuznik A (2015) Cost-effectiveness of Antivenoms for Snakebite Envenoming in Nigeria. PLOS Neglected Tropical Diseases 9(1): e3381. https://doi.org/10.1371/journal.pntd.0003381

Quite educative! Thank you for this information. Are there any preventive measures used?

In Uganda (which is in the tropics), there is potential to see many snakes.  in order to prevent such occurrences, there is sensitization about removing bushes and trimming all grassy areas regularly.

Furthermore, there are some plants which are used to prevent snakes from getting into homesteads, farms, etc. These include what are called "snake plants", tobacco plants, etc., which are planted around farms and homes. That is the local way of keeping snakes away. 

Very nice post. Snappily written and information-dense. With a quick scroll, I feel like I learned a lot. I would really like more posts like this. Thank you!

Thanks for this writeup! I definitely never thought about snakebites as a major issue before, despite its similarity to "obvious" global health issues like malaria.

Really interesting summary, thanks for sharing. Whilst not an expert, I've done some work in past with diagnostics in developing countries in Africa.

It's common for manufacturers to make big claims about their technology, but what's crucial is having independent evaluation/certification from regulators.

In the case of snake bites, I would imagine its tricky to prove the test works. Not easy to find snakebite victims in time.

I had a look at the venomaid website and didn't see anything about whether they had approval for their tests. That can take a long time.

Happy to collaborate on this and ask around the diagnostics people I know if interested?

Fascinating. Have any public health departments tried snake extirpation in certain areas? (Or is that an obviously flawed approach?)

Oooh, I'm hopeful this technology could be used for identifying insect stings too! Insect antivenom faces some similar challenges.

What about something they can wear on their leg to prevent the snakebite? 

Thank you for sharing this! It's always so heartbreaking to learn of something new that causes so much pain and suffering, but identifying it is the first step to ameliorating it! Hoping some plucky and dedicated EAs take this on as a potential cause area, and the radio + testing combination seems like a great place to start!

99% Invisible had a podcast on this that I found really interesting. The scale of the problem must have gone completely over my head. Great write-up!

multiple steps to be taken at simultaneously

Typo

Thank you for this write-up! I want to flag that in addressing this problem and possible solutions, there are also significant implications for (wild) animal suffering—e.g. Rileyharris's note about antivenom requiring "milking" of captive snakes and Cienna's comment about predator-play interactions—and I would hope any solution would take this into account in a meaningful way.