Disappointed I missed the competition—but have a couple of comments anyway ;)
On snake bites I can comment from a Ugandan public health perspective, with high likelihood of generalisability to other sub-saharan African countries at least.
This intervention makes little sense to me, because the major barriers to reaching antivenom are not knowledge and complacency, but financial and practical. Those barriers need to be overcome before a campaign like this could have potential to be useful.
People are terrified of snakes and would generally love to get antivenom if they had any chance. We have had 3 people die in our OneDay Health centers of snake bites. They flat refused to go to hospital even after all our advice and pushing because they didn’t have the money and didn’t believe they would make it. Their decisions may not have been entirely irrational.
Financial—Antivenom is EXTREMELY expensive, we’re talking upwards of $100 a vial and VERY RARELY freely available within life-saving distance of a snake bite. Gathering this amount of money straight away in a rural setting within an hour of the bite is far more often impossible for rural subsistence farmers. Raising the money to potentially save a life could well be possible, but not that quickly
Practical—Often antivenom just isn’t available at all within lifesaving distance, even if the finances are there. At a guess In Uganda there might be 10-15 towns/cities with antivenom, with perhaps 70-80% of people living over an hour practical travel distance away from said antivenom. Even if somehow someone bitten managed to… (within an hour or so)
a) Raise the money b) Find transport means quickly enough
More often than not it will be futile because the antivenom is simply too far away.
Cheaper antivenom and Closer antivenom is needed before raising awareness will make cost-effective sense. I’m surprised this scored so highly on the prediction market.
That is really upsetting to hear. Do you have any idea how a BOTEC for an antivenom availability / accessibility program in your service areas might look? Based on three deaths in a few years, the # of clusters of ODH centers, and Wikipedia suggesting a five-year shelf life for antivenom, it doesn’t seem implausible.
Obviously, this would have to be an inject now, ask for partial payment later kind of operation (and you might well not get payment).
Thanks so much I always love your ideas and bent towards action its amazing. Now that think about it and after your comment, snakebite might be a bigger problem than we give it credit for. We do have 36 ODH health centers and average maybe 1 snakebite death a year, so its still very spread out.
Unfortnately I don’t think it makes financial sense to have antivenom in remote places yet, this is for a few reasons
It needs a fridge! That’s not cost-effective at the last mile. Cost of fridge and powering fridge >>>>> even expensive cost of antivenom
The next step which makes sense I think would be to get antivenom into every Ugandan town, rather than at the last mile. That massively reduces travel time and cost even for people coming from remote areas
A lot of staff training needs to take place for any antivenom program- perhaps 4 in 5 (or less) snakebites here are from non-venomous snakes, so its actually not great medical practise to evacuate everyone who is bitten for antivenom. We get loads of snakebites that from the description seem like a non-venomous snake, which we observe as per our clinical guidelines and send home. Yes this is a big risk as we could get it wrong, but until antvenom is 10% of the cost its a risk we will continur to take
R&D for antivenom that s a)cheaper and b) doesn’t need a fridge for me might be the cost-effective ticket right nw (great uncertainy). The London school of tropical medicine and others are trying at this which is great.
I wonder if heavily subsidizing the cost of transport and antivenom for selected victims where it would be available in time might be part of the solution. That has a lot of contingencies—you need a high enough index of suspicion, nearby-enough antivenom, early enough recognition, and a source of transporting either the victim or the antivenom (preferably both). But it seems like subsidizing access to antivenom that is available could be highly cost-effective when those criteria are met.
(One of the things I like about ideas centered around saving rural patient populations money is that there is an implied lower bound of ~ 1.0X cash transfers as long as the patient would have been as well off if they were given the $100ish as they were having been given the antivenom.)
Yep I really agree that a well targeted fund to transport patients with dangerous conditons that urgently need higher level care (obviously not only snakebite) could be a HIGHLY cost-effective intervention, if difficult to pull off at scale.
Love a bit of Fermi napkin stuff so...
Imagine on average transport costs paidwere $50 per severe patient, and this saved conservatively an extra 1 life every 50 patients referred (entirely plausible). That’s 2500 for a life, and there would be additional benefits on top of only life saved, including quicker recoveries and probably uncovering some underlying diseases as well.
Its the kind of thing we could probably manage as OneDay Health as our nurses would be great gatekeepers, but trying to do it on a larger statewide or countrywide scale would be very difficult with misuse and corruption likely to seriously reduce cost efficiency.
Disappointed I missed the competition—but have a couple of comments anyway ;)
On snake bites I can comment from a Ugandan public health perspective, with high likelihood of generalisability to other sub-saharan African countries at least.
This intervention makes little sense to me, because the major barriers to reaching antivenom are not knowledge and complacency, but financial and practical. Those barriers need to be overcome before a campaign like this could have potential to be useful.
People are terrified of snakes and would generally love to get antivenom if they had any chance. We have had 3 people die in our OneDay Health centers of snake bites. They flat refused to go to hospital even after all our advice and pushing because they didn’t have the money and didn’t believe they would make it. Their decisions may not have been entirely irrational.
Financial—Antivenom is EXTREMELY expensive, we’re talking upwards of $100 a vial and VERY RARELY freely available within life-saving distance of a snake bite. Gathering this amount of money straight away in a rural setting within an hour of the bite is far more often impossible for rural subsistence farmers. Raising the money to potentially save a life could well be possible, but not that quickly
Practical—Often antivenom just isn’t available at all within lifesaving distance, even if the finances are there. At a guess In Uganda there might be 10-15 towns/cities with antivenom, with perhaps 70-80% of people living over an hour practical travel distance away from said antivenom. Even if somehow someone bitten managed to… (within an hour or so)
a) Raise the money
b) Find transport means quickly enough
More often than not it will be futile because the antivenom is simply too far away.
Cheaper antivenom and Closer antivenom is needed before raising awareness will make cost-effective sense. I’m surprised this scored so highly on the prediction market.
That is really upsetting to hear. Do you have any idea how a BOTEC for an antivenom availability / accessibility program in your service areas might look? Based on three deaths in a few years, the # of clusters of ODH centers, and Wikipedia suggesting a five-year shelf life for antivenom, it doesn’t seem implausible.
Obviously, this would have to be an inject now, ask for partial payment later kind of operation (and you might well not get payment).
Hey Jason
Thanks so much I always love your ideas and bent towards action its amazing. Now that think about it and after your comment, snakebite might be a bigger problem than we give it credit for. We do have 36 ODH health centers and average maybe 1 snakebite death a year, so its still very spread out.
Unfortnately I don’t think it makes financial sense to have antivenom in remote places yet, this is for a few reasons
It needs a fridge! That’s not cost-effective at the last mile. Cost of fridge and powering fridge >>>>> even expensive cost of antivenom
The next step which makes sense I think would be to get antivenom into every Ugandan town, rather than at the last mile. That massively reduces travel time and cost even for people coming from remote areas
A lot of staff training needs to take place for any antivenom program- perhaps 4 in 5 (or less) snakebites here are from non-venomous snakes, so its actually not great medical practise to evacuate everyone who is bitten for antivenom. We get loads of snakebites that from the description seem like a non-venomous snake, which we observe as per our clinical guidelines and send home. Yes this is a big risk as we could get it wrong, but until antvenom is 10% of the cost its a risk we will continur to take
R&D for antivenom that s a)cheaper and b) doesn’t need a fridge for me might be the cost-effective ticket right nw (great uncertainy). The London school of tropical medicine and others are trying at this which is great.
I was afraid of some of that. :(
I wonder if heavily subsidizing the cost of transport and antivenom for selected victims where it would be available in time might be part of the solution. That has a lot of contingencies—you need a high enough index of suspicion, nearby-enough antivenom, early enough recognition, and a source of transporting either the victim or the antivenom (preferably both). But it seems like subsidizing access to antivenom that is available could be highly cost-effective when those criteria are met.
(One of the things I like about ideas centered around saving rural patient populations money is that there is an implied lower bound of ~ 1.0X cash transfers as long as the patient would have been as well off if they were given the $100ish as they were having been given the antivenom.)
Yep I really agree that a well targeted fund to transport patients with dangerous conditons that urgently need higher level care (obviously not only snakebite) could be a HIGHLY cost-effective intervention, if difficult to pull off at scale.
Love a bit of Fermi napkin stuff so...
Imagine on average transport costs paidwere $50 per severe patient, and this saved conservatively an extra 1 life every 50 patients referred (entirely plausible). That’s 2500 for a life, and there would be additional benefits on top of only life saved, including quicker recoveries and probably uncovering some underlying diseases as well.
Its the kind of thing we could probably manage as OneDay Health as our nurses would be great gatekeepers, but trying to do it on a larger statewide or countrywide scale would be very difficult with misuse and corruption likely to seriously reduce cost efficiency.
Love the thinking.