Snakebite and the Use of Traditional Healing in Myanmar

i
The Use of Traditional Healing for Snakebite in Myanmar
A thesis submitted in partial fulfilment of the
HONOURS DEGREE of BACHELOR OF HEALTH SCIENCES
in
The School of Public Health
Faculty of Health Sciences
The University of Adelaide
by
Eliza Schioldann
November 2016

ii
This work contains no material which has been accepted for the award of any other
degree or diploma in any other university or other tertiary institution and, to the best of
my knowledge and belief, contains no material previously published or written by another
person, except where due reference has been made in the text.
I give consent to this copy of my thesis, when deposited in the University of Adelaide
library, being available for loan and photocopying.

iii
Acknowledgements
Firstly, I would like to thank my supervisor Dr. Afzal Mahmood for allowing me to join
the Myanmar Snakebite Project, and for his help and guidance. It was a university
course of his that inspired me to pursue the field of public health in the first place,
and for that I am grateful.
I would also like to acknowledge my honours coordinator Adriana Milazzo, who
supported me in my ambitious decision to undertake honours research in an
overseas setting. On that note, the costs involved in undertaking research overseas
can be significant, and I wish to express my gratitude to the University of Adelaide
for their support in that respect.
To the Project staff in Myanmar, particularly to Mya Myint Zu Kyaw and Dale Halliday
who greatly contributed to the wonderful four weeks that I spent there earlier this
year; thank you.
Importantly, I wish to express my gratitude to the women, men and children in
Myanmar for welcoming us into their communities and sharing their valuable
experiences. My infatuation with South East Asia lives on.
Lastly, I wish to thank my family and friends for their encouragement throughout the
year.

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Table of Contents
Abstract......................................................................................................................................1
Introduction...............................................................................................................................2
Background................................................................................................................................4
Literature Review.....................................................................................................................4
Myanmar’s Demography..........................................................................................................4
Epidemiology of Snakebite .......................................................................................................4
Snakebite Treatment................................................................................................................5
Myanmar’s Healthcare System.................................................................................................6
Traditional Healing...................................................................................................................7
Traditional Healing For Snakebite.............................................................................................8
Cost of Treatment....................................................................................................................8
Education & Prevention............................................................................................................9
Dialogue between Traditional Healing & Biomedicine............................................................. 10
Method ....................................................................................................................................11
Aim/Research Question.......................................................................................................... 11
Research Design..................................................................................................................... 11
Data Collection....................................................................................................................... 12
PRA Meetings......................................................................................................................... 12
Focus Group Discussions......................................................................................................... 14
Research Participants & Selection Criteria............................................................................... 14
Data Analysis ......................................................................................................................... 15
Ethical Considerations............................................................................................................ 15
PRA results...............................................................................................................................17
Snakebite............................................................................................................................... 17
Cost....................................................................................................................................... 18
Transport............................................................................................................................... 18
Prevention............................................................................................................................. 19
Types of Traditional Healing................................................................................................... 19
Quality of Traditional Healing as Perceived by the Communities.............................................. 20
Other Reasons for the use of Traditional Healing for Snakebite ............................................... 21
FGD results...............................................................................................................................23
The Snakebite Problem........................................................................................................... 23
Traditional Beliefs.................................................................................................................. 23
Cost....................................................................................................................................... 23
Lack of Resources................................................................................................................... 24
Education............................................................................................................................... 24
Word of Mouth...................................................................................................................... 24
Discussion ................................................................................................................................26

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Traditional Beliefs& Beliefs about Effectiveness..................................................................... 26
Perceptions of Modern Medicine............................................................................................ 26
Transport............................................................................................................................... 27
Differing Views between Community Members and Healthcare Staff ...................................... 27
Incorporation of Traditional Healing into the Modern Healthcare System................................ 28
Improving Data ...................................................................................................................... 29
Limitations............................................................................................................................. 30
Conclusion................................................................................................................................32
Reference List..........................................................................................................................33
Appendices..............................................................................................................................38
Appendix I: Logic Grids& Search Terms................................................................................... 38
Appendix II: PRISMA Flow Chart............................................................................................. 39
Appendix III: Ethics Approval.................................................................................................. 40
Appendix IV: Participation Information Sheet ......................................................................... 42

1
Abstract
Snakebite is a public health problem disproportionately affecting populations in the developing
world. Farmers are particularly exposed to snakes, and due to their rural location, experi ence
lengthy delays in accessing primary healthcare. In areas that traditional healing for snakebite still
exists, certainchallenges arise becauseof the furtherdelaysof necessarybiomedical treatment that
occur.
A literature review has revealed gaps in community based qualitative data for snakebite in
Myanmar, and forthe traditional healthsystemandits effects on access to timely care. This data is
necessary to implement effective health services to reduce snakebite mortality and morbidity.
The aim of this study was to engage with communities in Myanmar in order to understand their
healthseekingbehaviours inrelationtosnakebite.Usingparticipatory research methods, this study
gathered and analysed data through engagement with three rural communities in the Mandalay
regionof Myanmar. The participatoryworkconsistedof three participatoryrural appraisal meetings,
and three focusgroupdiscussionsconsistingof healthcare staff responsible for these communities.
Communitiesreportedthatamajorityof snakebite victimsusedtraditionalhealingmethodsatsome
point after their snakebite, and contributory factors to the use of a traditional healer were
transportation,cost,poorqualityhealthcare (oraperceptionof such), andtraditional beliefs.Aswell
as administering traditional treatments, monks and healers often acted as a referral for hospital.
Healthcare staff identified cost and transport as the only restrictive barriers to biomedical care.
However, community members revealed that even with improved access to adequate healthcare,
they were likely to still visit a monk or traditional healer. The valuable findings from this study
suggest a need to work closely with traditional healers for improved patient outcomes.

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Introduction
Until now,the importance of snakebite asapublichealth problem has been underestimated, and it
was only in 2009 that snakebite was identified by the World Health Organization (WHO) as being a
neglectedtropical disease(NTD).(1, 2)
About50% of snakebites result in envenoming, with the other
50% of snakebite victims receiving ‘dry bites’, with no venom.(3)
Global annual estimates for
incidence of snakebite are as high as 600,000 cases. Global mortality estimate from snakebite is
20,000 deaths, and actual figures are expected to be much higher.(4, 5)
Due to insufficient data
collection that relies on hospital records, it is almost impossible to give a definitive figure for
snakebite incidence.(6-8)
Permanent effects of snakebite, depending on the snake, include chronic
hypopituitarism, chronic renal failure and paralysis.(3)
Both the incidence and disease burden of
snakebite are estimated to be highest in rural areas of the tropics and subtropics of South/
SoutheastAsiaandSub-SaharanAfrica.Thisismostlydue tothe numberof venomoussnake species,
populationdensity,prominence of agricultural activity and a lack of programmes equipped to deal
with snakebite.(5, 9)
Because of the rural location of most of these agricultural workers, lengthy delays in transporting
patientstohealthcentres cause majoraccessissues,particularlyif the bitesoccurwhen workers are
in the fields.(1, 10, 11)
Additionally, the use of alternative or complementary therapies such as
traditional healingmayfurtherdelayorcomplicate the necessarybiomedical treatmentof snakebite
envenomation.Aside fromthe initial effectsof snakebite,thesedelaysinreceiving snake antivenom
can result in further harm, such as the irreparable damage of vital organs and even death.
Snakebite inMyanmariscommon, as a large majority of the labourforce isemployed in agriculture;
the main demographic at risk of snakebite. Most bites are attributed to Russell’s viper (Daboia
russelii siamensis),envenomationbywhich cancause swelling, haemorrhaging,defibrination, shock,
and oliguricacute renal failure.(12-14)
Asaresult,bothsnakebiteandthe use of traditional healing for
snakebite manifest as significant public health problems for Myanmar.
In muchof the developingworld, snakebite is a disease of occupation, with farmers and plantation
workers particularly exposed to snakes, and the development of multiple cropping techniques
furtherincreasingthisexposure.(15, 16)
Bothmenandwomenare involvedinfarmingactivitiessuchas
soil preparation,plantingandharvesting.Children are alsoatriskof snakebite.(17)
Consequently, the
demand for antivenom has also increased, prompting higher prices and lower quality antivenom
production.(16)
Snakebitedisproportionatelyaffectsfarmersandplantationworkerscomparedtothe
restof the population.(18)
InMyanmar,duringharvestingandploughingseasons, plantation workers

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and farmersare highlysusceptible tosnakebite,particularlybykraits, cobras,andRussell’svipers.(17,
19, 20)
Withinthe currentcontextof Myanmar, factors such as poverty, governance issues, and traditional
farming practices can complicate snakebite management.(12)
For at least some snakebite patients,
the detrimental outcomes may be attributable to the delays or other harms caused by some
traditional health methods. Theoretically, and given suitable strategies, it should be possible to
reduce the mortality of snakebite to practically zero with appropriate public health interventions,
such as those implementedinNepal andother developing countries.(21, 22)
For both prevention and
treatment of snakebite, education is the key approach. However, to optimise the delivery of
educational programs,the extent,bothof snakebiteandof the use of traditional healing, must first
be understood.
Thisresearchoccurred as a part of an overarching project, the Myanmar Snakebite Project, headed
by honourssupervisorDr.Afzal Mahmoodand hiscolleagues. A collaborativeproject, it was created
in response to a request from Myanmar’s Ministry of Industry (MOI) and Ministry of Health (MOH)
and supported by the Australian Government’s Department of Foreign Affairs and Trade (DFAT),
with the aim of “improving the health outcomes for snakebite patients in Myanmar”.(23)
The
objectives of the overall research are to gather information on snakebite victim’s treatment,
community knowledge and health care practices, primarily through the use of a community based
survey. This will inform future community health education, first aid training, and the training of
primary health care staff.

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Background
Literature Review
As part of thisresearch,andto define the extentandscope of traditional healing,aliterature review
was conducted. This was to identify any gaps in the literature and inform future research. Several
mainthemeswere evident;education,prevention, and a dialogue between traditional healers and
biomedicine. The major debate within the literature appeared to be between those authors who
acknowledged the value of traditional healing, and those advocating for the eradication of the
practice. AppendixI illustratesthe logicgridsused to source the literature from databases PubMed
and Scopus,and AppendixII containsa PRISMA flow diagramto summarise how many articles were
included for review and synthesis. Before discussing concepts of traditional healing, I will outline
Myanmar’s demography,the epidemiologyof snakebite, and Myanmar’s health system/ the health
services available for snakebite victims.
Myanmar’s Demography
Myanmar is locatedinSoutheast Asiaandisthe largestcountryinthe region. A low density country,
as of 2015, the population was approximately 54 million.(24, 25)
Myanmar has an abundance of
natural resources but a lack of infrastructure, with only 26% of the population having access to
electricity in their homes.(26)
It is still ranked 150 out of 187 countries on the Human Development
Index.(26)
Furthermore, 70% of Myanmar’s population still reside in rural areas, where poverty is
mostprominent,particularly due toareliance onsubsistence agriculture andcasual employment.(25,
26)
Those livinginrural areasare susceptible toeconomicvolatility,astheylive ator nearthe poverty
line, and are subject to other vulnerabilities such as climate change and extreme weather
conditions.(25)
Lack of access to healthcare for these groups leads to poor health outcomes, such as
high prevalence of malaria, tuberculosis, HIV and malnutrition.(27)
Epidemiologyof Snakebite
Snakebite isthe eleventh largest cause of morbidity and mortality in Myanmar, and its incidence is
undernational surveillance.(17, 20)
Snakebite morbidity and mortality is almost entirely preventable,
but inSouthAsiais impactedby excessive traveltimestohealthcentres from rural areas, scarcity of
antivenom and inadequate health services.(1, 5, 7, 28)
The rural poor rely on traditional farming
techniquesforincome,butthese farmingtechniquesare partof whatmakes them so susceptible to
snakebite.(29)
Risky behavioursincludinglackof use of preventativefootwear, insufficient torches in
low light areas, storage of food near dwellings, and bundled crops of hay during harvest are still
practiced.(1, 20, 22, 29)
Effects of snakebite occur rapidly, and delays in access to treatment can be

5
detrimental.A studyof snakebite fatality in rural Nepal identified several contributory factors that
ledto snakebite mortality,including:visible signsof envenoming,use of atraditional healer,andlack
of available transport to an appropriate healthcare facility.(9)
The mean age of snakebite victims in Myanmar is 30 years old, making Myanmar’s workforce
particularlyvulnerable.(1, 20)
Asaconsequence,familiesmaysuffersignificantlyfromalossof income,
as well as the costs of transport, treatment and other factors when a family member is afflicted by
snakebite.(1, 17, 30) There canalsobe significantopportunity cost if families must forego economically
beneficial activitiesin ordertoseekhealthtreatment.(5)
However,alackof timelymedical treatment
that results in permanent sequelae, such as local tissue necrosis or neurological damage, can be
more costly.(5, 31)
For example, acute renal failure, which commonly results from envenomation by
Russell’sviper,isparticularlydifficult to manage in developing countries such as Myanmar because
of a lack of resources to allow for dialysis.(2, 29)
Critically, as Harrison et al. (29)
point out, incidences of NTDs appear to be directly correlated with
povertylevels,andthe same developingcountries that suffer most from snakebite also experience
the major burden of other NTDs such as cholera and Japanese encephalitis. The continued
prevalence of these diseases may have led to a lack of focus on snakebite as a major public health
problem. This lack of needed focus could be the reason for the shortage of quality antivenom
development and inadequate services.
Snakebite Treatment
The degree of snake envenomingdependsonseveral factors,including effectiveness of the snake’s
venom injection, and time between bite and treatment.(15)
Snake venom is a combination of
enzymes and toxins which can have deadly effects. The only specific treatment available for
snakebite envenomation is the administration of antivenom.(1, 2)
The recommended treatment for
snakebite victims usually consists of resuscitation of the patient (if required), followed by
identification of the snake species, administration of antivenom, ancillary treatment, and
rehabilitation.(3)
In developed countries, antivenom is generally affordable, effective, and safe.(32)
However, itremainsinaccessible tothe mostmarginalisedpeople indevelopingcountries who need
them most. The economic viability of antivenom production can be very poor, as production is
generally small scale and low yield. Theakston and Warrell (31)
point out that attempts to privatise
antivenom production in developing countries can threaten continued production due to a lack of
profitability. Shortagesof antivenom,particularlyinareas that lack local manufacturers, have led to
the creation of sub-quality, low potency versions that display limited or zero efficacy. There are
several polyvalent antivenom producers in India responsible for providing the South Asian region

6
with antivenom but studies have shown the potency of these Indian antivenoms to be low, and
geographical variation of snake venom may also impact on their effectiveness.(17)
Studies have
revealedthatantivenomwhich is prepared with local venom is more capable in neutralising snake
venomeffectsthanimportedalternatives.(16, 17)
A combination of poor quality imported antivenom
and a low supply of locally produced antivenom in Myanmar may create difficulties in accessing
modern treatment and prompt continued use of traditional methods for treatment of snakebite.
Myanmar’s Healthcare System
The majority of Myanmar’s rural areas are serviced by the township healthcare system (THS). The
THS is often the only government funded health service for these rural populations, with a typical
THS service having a catchment population of 150,000 to 200,000 individuals. These services are
managed by a township’s Health Department, and led by a Township Medical Officer (TMO).(33)
Each catchment area has a township hospital (e.g. Kyaukse Hospital), and a network consisting of
stationhospitals,rural healthcentres(RHCs) and sub rural health centres (sRHCs). RHCs are staffed
with a health assistant (HA), lady health visitor (LHV), a midwife and a public health supervisor.(33)
Myanmar people generally prefer to access the modern healthcare system rather than the
traditional system.(34)
However, as Skidmore points out, a combination of a lack of trained medical
professionalsandpovertymeanthattraditional remedies and practitioners may be the only option
for some.(34)
Critically, Skidmore finds that engagement with the healthcare system in Myanmar is
dependent on several factors, including; cost, previous experiences, fear of surgery, belief in
religious or spiritual healers, location of the patient, and the severity of the condition.(34)
A WHO policynote revealedthatin2011, 60% of Myanmar’shospitals,mainly station and township
hospitals,were performingpoorlyinall areas,includingsnakebite treatment. Factorscontributing to
the poor performance included financial barriers to patients accessing healthcare, insufficient
supplies of equipment and medicines, and inadequate staffing.(33)
In 2008, Myanmar experienced a surge in snakebite cases following Cyclone Nargis, resulting in a
shortage of antivenom,and ineffective dosesbeingadministeredtosnakebite victims.(32)
Combined
witha lack necessary coldchainstorage forliquid antivenomatsome RHCs, treatment for snakebite
in rural areas of Myanmar is problematic.(10, 35, 36)
As well as problems with the supply of antivenom, treatment for snakebite in Myanmar is also
impacted by staffing issues, particularly in rural areas. This is particularly an issue in rural areas, as
any health staff that are available to treat snakebite are often inadequately trained.(6)
Accuracy in
snake identification is critical in the treatment of snakebite, especially when treating with

7
monovalentantivenom.(6, 36)
A studyof snakebite inNorthwestIndiarevealedthatdoctorsinprimary
healthcare centreswere oftenunable torecognisethe signsof envenomation,andwere distributing
inadequate doses of antivenom.(1)
Similarly, in Myanmar, shortage of properly trained staff is
commonplace inrural areas, and as with antivenom shortage and quality issues, may contribute to
the ongoing use of traditional methods.
Traditional Healing
Traditional medicine and healing is defined by WHO as “the total combination of knowledge and
practice,whetherexplicable or not, used in diagnosing, preventing or eliminating physical, mental
and social diseases.Thispractice exclusivelyreliesonpastexperience andobservationhandeddown
fromgenerationtogenerationverballyorinwrittenform.”(37)
Bodeker and Kronenberg (38)
describe
traditional medicine as the “indigenous health traditions” of the world. Traditional practitioners
include bonesetters,herbalists andspiritualists.(39)
Some traditional healing is rooted in faith-based
healingpractices,butemphasisisalsoplaced on herbal medicine and natural remedies.(40)
The use
of medicinal plants has long been a cornerstone of culture in developing Asian nations, from the
ancient scriptures of Hinduism, to Ayurveda and the Unani medicine of South and West Asia.(41, 42)
Contemporarily,the scope andsignificance of traditional healingisnot entirely known, as it is often
practicedina clandestinemanner.(40)
The transitionfrom subsistence to market economies, as well
as cultural and environmental changes, have heavily impacted the use of traditional medicines, as
well as the availability of these herbal remedies in nature. However, it is thought that more than
80% of the world’s population still use traditional healing for healthcare, whether alone or
complementary to conventional or biomedicine.(41)
The South Asianregion hashadthe mostprogress intermsof traditional healingbeingacceptedinto
national healthpolicy,mostlydue to politicisation of the traditional medicine agenda, and the fact
that medicinal plants are generally perceived as safe and effective.(36)
WHO advocates the use of
traditional healingin the primaryhealthcare system, and Western pharmaceutical companies have
acknowledgedthe value of some potenttraditional herbs.(4, 34, 38, 40, 41, 43)
AsapredominantlyBuddhist
nation with over 100 ethnic groups, Myanmar has both a rich heritage and a continued prevalence
of traditional medicine andhealing,basedonherbs, minerals and animals.(42)
The literature reveals
extensive use of traditional healing for all manner of public health problems, informing that
traditional healing is also being used for the problem of snakebite.

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Traditional HealingForSnakebite
In developing countries, up to 80% of snakebite victims seek treatment from traditional healers
before turningtomodernmedicine,delayingcritical medical treatment.(7, 8)
Globally,traditional first
aid methods such as electric shock, suction, tattooing and herbal remedies are still used for
snakebite.(2, 3, 15, 43)
Infact, variousherbal remediesandethnobotanicalshave beenreported to show
venomneutralisingproperties.(28)
Currentliteratureaboutsnakebite indevelopingcountries informs
aboutseveral reasonsforthe prevalence of traditional medicine andhealing,includingaffordability,
availability, and cultural familiarity.(27, 37-39, 41)
Firstly,cultural beliefsmaydictate the use of traditional healing. Many South Asians attribute some
of theirillnessestospiritual problems forwhichatraditional healercantreat, andonlyif an illness is
believed to be ‘organically’ caused, are they likely to seek the help of a biomedical healthcare
provider. If this treatment proves to be unsuccessful, they may turn back to traditional healing,
suspecting a ‘non-organic’ source of illness after all.(44)
For snakebite, traditional remedies are often credited for their apparent healing properties.
However, it is suggested that many of these seemingly successful treatments are instances of dry
snakebite, or non-envenoming, where there has been nothing to heal. This may contribute to
harmful reverence of ineffective practices.(32)
Communityunderstandingsaboutthe actual andperceivedeffects/complicationsof antivenom may
also act as a deterrent to accessing biomedical healthcare. Indeed, antivenom can induce adverse
reactions in patients.(1)
Side effects of antivenom can include urticaria, pruritus, and anaphylactic
reaction.(2)
Traditional healers may eventually refer their patients to a hospital, but often after
severe complicationsdevelop.(8)
The resultingdelayintreatment,whichcanamountto several days,
may alsoresultinthe failure of biomedical healthcare anddeathof the patients.(8, 45)
Thismaycreate
a perceptionaboutthe ineffectivenessof modernmedicineanda distrusttowardWesternpractices,
in turn prompting people to seek traditional treatment in the future.(44)
Cost of Treatment
For many, the financial cost of treatment, whether traditional or biomedical, can be unaffordable.
Awale et al.’s (42)
study of traditional medicines in Myanmar, revealed one traditional practitioner
whospecialisedinremoving animal poisons with ‘thunder stones’, charging anywhere from 10,000
to 50,000 kyat ($10-50 AUD). Although traditional treatment costs may outweigh the price of the
actual antivenom, other costs involved in biomedical treatment may include confirmation of
envenomation, administration of antivenom, hospital admission, and routine care, and can easily

9
amountto more than a year’swage.(46)
Additionally,there isa willingness by healers in Myanmar to
accept paymentinlivestock,foodorotherin-kindmethods, increasing access to those most unable
to receive biomedical treatment.(42)
Consequently, the use of traditional healing and medicine for
manymay not be a choice,but a resultof the lack of affordabilityof allopathichealthcare.(37)
Among
some populations where traditional medicine has historically been used, conventional medicine is
actually preferred, but traditional healthcare is often used as a final resort.(27)
Many of these traditional methods, such as incision, herb ingestion and snake stones, have proven
to be ineffective, and in some cases, are harmful. (2, 3, 47)
Their use can cause infection, bleeding,
gangrene and other problems, which may further complicate any medical treatment that is
eventuallyreceived.(2, 8)
Whilstnotatraditional method,the continued use of tourniquets also risks
negative consequencessuchasnecrosis,gangrene andischemia.(1)
Use of suction,incisionand other
traditional methods can be associated with longer delays in hospital presentation, greater risk of
permanentdisabilityordeath,andhighermedical costs (e.g. more antivenom required, and longer
hospital stays).(45)
Traditional healing may be the only readily accessible form of treatment for many rural, poor
populations.(42)
Itisestimatedthatmostsnakebite victims in Myanmar take at least 2 hours, and up
to several daystoreach the nearesthealthcare facility,whereastraditional healers usually reside in
the local community andare more easily accessible.(18, 47)
The extent to which traditional healing is
still used to treat snakebite in Myanmar is unknown, but it is widely recognised that traditional
healing for snakebite is often used alongside, rather than instead of, conventional medical
treatment.
Education& Prevention
Victimshave abetterchance of receivingthe necessary antivenom if they can correctly identify the
snake theyhave been envenomed by, and correct identification can avoid the wastage of valuable
resources and the unnecessary exposure of patients to adverse reactions from antivenom.(48)
However, as Warrell (2)
points out, even specialists in herpetology can make mistakes in snake
identification,andthustoexpectvictims of snakebite to identify the type of snake they have been
envenomed by is unrealistic. The development of a rapid diagnostic test for venom of different
species is necessary, but may be made difficult by the lack of information available on the
distribution of venomous snakes in Myanmar.(1, 6, 22)
Primarypreventioniscrucial indecreasingthe mortalityandmorbidity of snakebite envenomation,
as are improvementsineducation.However,animportant challenge in Myanmar appears to be the

10
continuedprevalence of traditional healing,andthe associateddelaysinseeking medical treatment
for snakebite victims.
Dialogue betweenTraditional Healing&Biomedicine
Despite obviouscomplications with the use of traditional healing for snakebite, the solution is not
necessarily to disregard the use of traditional healthcare altogether, as some scholars have
suggested. (1, 15, 47, 49)
Anysuchsuggestion mayseemlogical froma clinical point of view. However, it
failstotake intoaccountcomplex societal factorssuch as a deep embedment of traditional beliefs.
More reasonably,some scholarspropose dialogue betweentraditional healers and modern medical
practitioners.(37, 39, 42)
Some scholars argue that this dialogue should not exist for the sake of it, but
rather that the scientific basis for these herbal treatments needs to be proved before any
partnershipbetweentraditionalhealingand modern medicine can be established.(4, 38, 43)
Radically,
Gupta and Peshin (36)
have recommendedthe use of traditional herbs instead of antivenom, due to
the difficultiesof antivenomadministrationinrural areas.However,evenwithtraditional medicines
that have proven efficacy, issues may include a lack of hygiene and knowledge of appropriate
dosage.(27, 38)
Another view is that traditional healers themselves could be incorporated into the
healthcare system, but that certain traditional methods such as suction and incision should be
activelydiscouraged.(15)
The spiritual aspectsof traditional healingmayalsobe incorporated.A study
of Myanmar refugees by Bodeker et al. (27)
revealed that on a psycho-social level, even when
conventional medicine provedtobe technicallymore effectiveforcertain conditions,the separation
of the Myanmar people fromthe traditional,spiritual practicesof theirancestors,had the potential
to exacerbate theirconditions. Thisexemplifies the fact that even though traditional practices may
not have a biomedical effect, the phenomenon of a meaning response, or “the psychological or
physiological effects of meaning”(38)
, could have a marked influence on treatment outcomes.

11
Method
Aim/ResearchQuestion
The aim of this research was to engage with rural communities in Myanmar in order to understand
theirhealthseekingbehavioursinrelationtosnakebite. This included determining when they seek
the helpof a traditional healer,andtheirreasonsfordoingso. Furthermore,thisresearch sought to
ascertain whether traditional healing is accessed concurrently with biomedicine, or whether it is
used as an alternative. Therefore, the question used to guide this research was:
What are the views of community members and healthcare workers relating to the use of
traditional healing for snakebite in Myanmar?
This research took place in rural communities of Myanmar, where snakebite is endemic and the
practice of traditional healing is known to be used.
ResearchDesign
This research has taken a phenomenological approach, whereby phenomena are understood
through the subjective experiences of individuals.(50)
Using participatory methods, snakebite was
studied through the lens of the people who experience snakebite, so can provide detailed
descriptions of their experiences. Gutiérrez et al. (51)
have observed that modern medicine based
health programmes in rural communities are often culturally biased and paternalistic, lacking
participation of the communityinquestion.Involving these communities in their own research can
solve some of these problems, and using the research as a process of empowerme nt makes it
culturally appropriate and suited to the local context of Myanmar.(52)
Both methodologies
acknowledge thatlocal communitieshave valuable stores of knowledge, in this instance, regarding
snakebite in Myanmar, and the research activities can help them to realise this.(52, 53)
Some researchmethods may oversimplify complex rural phenomena.(54)
Surveys make people the
objectof developmentratherthanactive participants, and generally, “the questions are framed by
outsidersbasedontheirperceptionsof the rural world”.(54)
Mukherjee observes that development
projects that do not use a participatory framework for rural projects are often ill-informed and do
not generate the positive benefits intended, and the opinions of the rural people in question are
oftensimplifiedandundervalued. (54)
PRA attemptstochange this,bytakinga bottomup rather than
top down approach. Evidently, the views and perceptions of the ‘top’ e.g. development
professionals, will differ significantly from those at the ‘bottom’, e.g. the rural poor.(54)
Chambers
referstoPRA as a group of approachesthat “enable local people toshare,enhance andanalyse their
knowledge of life and conditions, to plan and to act.”(55)
Goals of PRA include avoiding biases,

12
learningfromthe local people ratherthantryingtoteach them, and,critically,triangulation; the use
of several methodstoenhance the qualityof the data.(55, 56)
The specificpurpose of the participatory
work was to investigate the phenomena of snakebite and traditional healing and communities’
perspectives, involving in-depth discussion and experience sharing. This practice helped develop
comprehension, make generalisations about phenomena/aspects of the snakebite problem, and
create potential solutions.(52)
Data Collection
This study is based on the methodologies of participatory action research (PAR) and PRA, and the
qualitative research instruments used were focus group discussions (FGDs) and PRA meetings.(52)
PARinvolvedthe use of FGDswith primary healthcare workers, and PRA meetings with community
memberswere heldtogainunderstandingof people’sexperiences and knowledge about snakebite
and traditional healinginMyanmar.(52)
Bothreliedonvaluable interaction between the participants
with local knowledge, experiences and views relating to snakebite and traditional healing. This
yielded some thick, descriptive data that would be more difficult to obtain through structured
settings such as one-to-one interviews.
This qualitative study took place with the help of local Myanmar health care staff who are
conductingresearchforthe Myanmar Snakebite Projectinthese communities.Some of the sessions
were moderatedbyaMyanmar staff member,andothersbyan Australianstaff member,assistedby
a translator. Both of these approachesrequiredatranslatortoassistinfacilitatingthe discussionsby
translating either from the Myanmar language for note taking in English, or into the Myanmar
language for communicating with the community.
PRA Meetings
The PRA meetings took place in local community meeting places, ensuring an appropriate
environmentthatfostered maximum comfort and interaction between participants. The meetings
involvedseveral methodsdesigned to give voice to and empower some community members who
would normally find it difficult to participate, and this was achieved by using oral and visual
representation. These methods included the use of paper and pens for the community to create
‘problemwalls’,andstorytelling.Other possibilities could have included the use of physical objects
such as stones,groundorpaperto create maps/figures, anddrawingVenndiagrams.(57)
The problem
wall exercise required participants to visualise a wall, with each ‘brick’, or problem, symbolising a
part of the overall snakebite problem. Because of the participatory nature of these sessions, there

13
was nodefinedsetof questions,withaview of enhancingparticipationandallowinglocal people full
control of the participatory interaction process.
As moderators, we commenced these sessions by discussing the overall aim of the session, i.e.
workingtogethertolearnabout the extent and aspects of the snakebite issue, and then prompted
the participants with open topics of discussion.(58)
The community members were encouraged to
interactand share witheachother. Key probes were eventually used to ensure that the concept of
traditional healing was addressed during these meetings.(57)
Another staff member or intern was
presenttoassistinnote taking. Due to the interactive nature of the sessions,the note takerplayeda
critical role indata collection,andthe noteswill become amajorelementof the analysis. Any visual
data collected during the PRAs such as problem walls drawn by participants (as seen in figure 1
below) were filed as data.
Figure 1: Participants create a ‘problem wall’

14
FocusGroup Discussions
The FGDs alsotookplace inlocal communitymeetingplaces,andconsistedof healthcare staff who
were responsible forthe communities inwhichthe PRA meetingswere held. Inasimilarmannerto
PRAs,FGDs are a qualitative methodusedtounderstandphenomenafromthe perspectiveof the
participants, andcan act as an empoweringtool in PAR.(52)
Participantsusuallycome fromsimilar
cultural and social backgrounds,orshare commonexperiences/areasof concern;yieldingvaluable
interactionbetweenthe participants.(52)
Inthiscase,the focusgroupparticipantswereall local
Myanmar healthcare staff who,more oftenthannot,hadhad some experiencesof snakebite,either
personally,intheirlocal community,orthroughtheirwork.The FGDsconsistedof a total of 23 local
Myanmar healthcare workers,rangingfromhealthassistants,tomidwives andpublichealth
supervisors.
Of keysignificance duringanFGDis the interaction thatoccurs betweenparticipants,andthe role of
the researcheristo moderate,andtoencourage free,opendiscussion. The interactioncanbe
valuable forseveral reasons,including,asKitzingerarticulates,thatparticipants,particularlywhen
knownto eachother,will oftenchallenge eachotheronperceivedcontradictions,clarifyideas,and
helptoarticulate thoughtsthathave beenleftunspoken.(59)
ResearchParticipants&Selection Criteria
Myanmar is a vast anddiverse country,whichmakesit difficult to find sample villages to represent
the widerpopulation.Furthermore,snakebite incidence ishigherinsome areasthan others, and are
therefore of more interesttothe project. The sampling strategy for the Project’s community-based
surveywasbasedon WHO guidelineswhichrecommendedaprobabilitybased sample that adheres
to a stratified cluster design. This meant that owing to the use of Probability Proportional to Size
(PPS) sampling, larger villages had a bigger probability of being selected than smaller villages. In
selecting villages for the qualitative study to include, several factors were considered, including
snakebite incidence,political milieu, accesstohealthcare services, andease of access.As the project
isbased in Mandalay, villages needed to be within a reasonable driving distance of Mandalay. The
villageswere inMadayaandKyaukse townships, both in the Mandalay Division of Myanmar. These
were within the catchment areas of primary health care facilities (RHCs), where primary care for
snakebite is available. Some were closer to urban areas and hospitals, and others more rural, but
overall,tendedtoreflectatypical rural Myanmar village. Accordingtolocal governmentrecords,the
villages used for our PRA meetings have a combined population of 456 people. A total of
approximately135 villagersattendedthe 6meetings,butasthe sessions were held in public places,
people came and went, so it was difficult to obtain an exact number of attendees.

15
Recruiting individual participants was a combination of volunteer sampling and snowball/chain
sampling. The communities were approached through primary health care workers, who, after
permissionfromvillageleaders,invitedindividualstoparticipate;especially those with experiences
of snakebite. This project hoped to gain the participation of farmers and other groups who are
particularly exposed to snakebite. After the primary health care workers invited some community
members to participate using volunteer sampling, these initial respondents were asked to find
others willing to participate, i.e. snowball and chain sampling.(52)
Data Analysis
The PRAs andFGDs yieldedseveral pagesof raw dataeach, whichwasusuallycorroborated witha
secondnote taker.Thisdata was thenanalysed basedonBraunand Clarke’s six phasesof thematic
analysis,whichinclude familiarisationwiththe data,generatinginitialcodes,searchingforthemes,
reviewingthemes,anddefining/namingthemes.(60)
Ethical Considerations
The Myanmar Snakebite Project, andthisparticularresearchelement, had ethics approval from the
Human ResearchEthics Committee (HREC) at the University of Adelaide. This approval reflects the
compliance of the project with National Health and Medical Research Council (NHMRC) values and
ethics, i.e. respect, research merit and integrity, justice, and beneficence.(61)
A copy of the ethics
approval letter can be viewed as Appendix III. It was also approved by the Department of Medical
Research in Myanmar.
In order to gain informed consent, all participants were over 18 years old, and any potential
participantsprovidedwithaparticipantinformationsheetexplaining the full nature of the research
(translatedintotheirlocal language). Anexample of this participant information sheet can be seen
as Appendix IV.This informationwasalsosharedverbally,bearinginmindthe possibility that some
of the communitymembersmaynotbe literate enoughtoreadthe writteninformationsheet. Itwas
anticipatedthatthe topicof the research maycause emotional distress to participants, especially if
askedto relive painful memoriessuchasthe lossof a family member to snakebite. While this could
have beenmanagedthroughthe provisionof counsellingtoparticipantsif necessary,asLiamputtong
and Ezzy (52)
note,the needforcounsellingisavoided if research is conducted in a sensitive way. By
nature, participatorymethodologiestend to address the potential for unequal power dynamics, by
way of conducting research with participants rather than on them.(52)

16
Any data relating to the project were securely stored in a locked room in the Myanmar Snakebite
Project office in Mandalay, and staff who came into contact with the data were required to sign
confidentiality agreements, ensuring privacy and confidentiality of all participants.(52)
As the participatorysessions took place in communities, the identity of participants was known by
the other participants as well as health care workers. However, participants were assured that by
sharingtheirexperiencesandobservations,orbychoosingtowithdraw fromthe sessions,theywere
in no way compromising their future access to care. Overall, the benefit of participating in this
research (i.e. reducing snakebite mortality in Myanmar) outweighed any minor risks.
For cultural appropriateness,participatorysessionswere conducted in the presence of local Project
staff and translators.
Followingthe sessions, participants were provided with free information on first aid and effective
managementof snakebite. Furthermore, the Projectprovidedsnacks to share with the participants,
as a token of appreciation. Some researchers argue that payment or compensation for research
participantsisinappropriate,asitrisksskewingthe results.Others suggest that in fact, “researchers
should value the contribution, knowledge and skills of the informants”, and that compensation or
incentivesisaneffectivewayto convey thisappreciation.(52, 62)
Asthe ongoingprojectendeavours to
buildlastingrelationshipswith the participating communities, this was deemed to be appropriate.
We foundthatsharingfoodduringthe PRA meetings and FGDs to be an effective way of enhancing
friendship and improving the participatory processes, and sharing food is seen as a strong cultural
practice in Myanmar.

17
PRA results
The communitiesinKyaukse andMadayatownshipsinwhichwe conducted the PRAs were farming
communities. Each reported a reliance on agriculture for survival, growing various crops such as
onions, chillies, turmeric and rice. All acknowledged that snakebite was a problem in their
community.
Snakebite
During the rural appraisals, we encountered seven people who informed us that they had been
bittenbysnakesinthe past.Of those,fourreported farming on their plantations at the time. Three
had beenbitten whilst either walking in the village or being in their homes. A majority stated that
their bites occurred either early in the morning or in the evening time, which they believed to be
peak times for snake activity. We were informed that the villages’ harvest seasons run from June-
JulyandOctober-November,and thatmore snakebitesoccurduringthese times.One grouprecalled
twosnakebite casesperdayduringharvest.Of the seven, four reported being bitten on the foot or
lowerleg,one onthe finger. One reported having been bitten by snakes more than 20 times in her
lifetime. Three of the victims were female and the other four were male, with a median age of 26
years old. Only one snakebite victim reported taking any preventative measures. Figure 2
summarises these details.
Snakebite
victim
Age (at
time of
bite) Gender Bite site Location Time Snake Hospital
Traditional
healer Additional:
1. ~35y.o. M
Foot/low
er leg
Turmeric
plantation 7:00PM - Yes
After
hospital
Was not fullyhealedafter
hospital- onlyafter seeing
a healer
2. ~45y.o. M Foot
Banana
plantation 6:30 PM Viper Yes No
Had a torch but was not
looking down, was not
wearingshoes. Killed the
snake for identification
3. 18y.o. F Finger
Betel
plantation - Viper No Yes
4. 28y.o M - In the village - - Yes
After
hospital Bitten whilst getting water
5. 20y.o. M Foot In the village Evening - No Yes
6. 12y.o. F Leg In a house 4:00AM - Yes No Snake was under her bed
7.
Various F Various
Various
plantations -
Cobra(in 1
instance) No Yes
Victim reports being
bitten >20 times
Figure 2: Table of snakebite victims

18
Two participants reported being bitten by a viper, one was bitten by a cobra, and the rest did not
identifythe snake bywhichtheywere bitten.Twoof the snakebitevictimsinformedthattheyvisited
a traditional healer after presenting to a hospital, two said they had been to hospital and not to a
traditional healer, and three said that they had been to a traditional healer but not to a hospital or
rural healthcentre.Inotherwords,the majority of the snakebite victims had accessed the services
of a traditional healer or monk at some point during their treatment.
One womanreportedbeingbittenwhenshe was18 or 19 yearsold;she waspickingbetel leavesand
a viperbither onthe finger.She wentstraighttothe monk for traditional treatments in the form of
herbal medicine tattooing, and says she was entirely healed after a month of these treatments.
One man, working in his turmeric plantation at dusk, was bitten by a snake and fainted. He was
driven to Kyaukse Hospital where he was given some antivenom and was discharged after two
months, at which point he went to see the monk for further treatments. His first four vials of
antivenomwere providedfree of charge,andhe had to pay for the subsequent three. He estimates
that his hospital stay cost up to 370,000 kyat (370 AUD), whereas the treatments from the monk
were free.
Cost
Cost was frequently identified as the main factor that influenced health seeking behaviour. The
general consensuswasthatthe cost of hospital treatmentforsnakebite, including car hire, hospital
admissionand antivenom,isaround 300,000 kyat(334 AUD). In contrast,treatment from a monk or
traditional healer was more often than not free of charge, or for a voluntary donation. One person
informed us that they paid approximately 30,000 kyat (33 AUD) for their visit to the monk in their
village.The snakebite victimswhoreportedseeking treatment at a hospital all cited the prohibitive
costs involved,withone man’s treatments amounting to 2800 AUD. The family burden of caring for
patientswasalsoa commontheme,particularlyforthose whohadtocease workingwhilstarelative
was hospitalised for snakebite. Relating to the issue of cost is poverty. Participants described the
dilemma in which they work early in the morning and late at night, despite their knowledge that
snakesare most active duringthese times.Assubsistence farmers, they have no choice but to work
during these risky periods.
Transport
In each community, transport was a large concern. One village had no car at all, with participants
sayingthat if theyrequiredemergencytransportforanincidentsuchas snakebite, they would have
to renta car from anothervillage atgreatfinancial cost. The othervillagesdidhave communitycars,

19
but one of themhad brokendownandthe communitylackedthe fundstorepairit. A motorbike was
oftencitedasthe primarymode of transportation. Several family members sometimes crowd onto
one motorbike to transport somebody to hospital. The community that had a monk performing
traditional treatmentsforsnakebitepointedoutthatbecause the monklivesinthe village,transport
for traditional healing is not an issue.
Prevention
Prevention was discussed as something the communities lacked knowledge in. One community
informed usthattheyhad notbeentaughtanythingaboutthe preventionof snakebite. Participants
of another group pointed to a lack of preventative measures, such as torches and rubber boots in
their community as being a major contributory factor to high incidences of snakebite. Community
members were aware of the risk that snakes posed, but deemed some preventative measures as
impractical.The womanthatreportedbeingbittenmore than twenty times responded that “since I
have beenbittensomanytimes,Isometimeswear rubber boots in the fields. But they are very hot
to wear”.
Typesof Traditional Healing
Participantsdidnot distinguish between traditional healing as a practice and traditional healers as
the practitioners,butthere wasa distinction betweenmonksand non-religioushealersas being two
separate types of traditional healing providers.
Both monks and non-religious healers use a variety of techniques, both physical and spiritual. The
physical techniques reported included chewing on a root for diagnosis of type of snake, making
incisions with a razor blade, tattooing with either ink or herbal medicines, use of a syringe to suck
out venom,andthe heating of a glass bottle to draw the snake venom out. Participants of one PRA
meeting described the monk’s treatment in detail:
Using a razor blade, the monk makes 10 parallel surface cuts around the wound. He then takes a
20cc plastic syringeand cuts off the top, placing it on the bite site. Using a second syringe and a thin
tube, he draws out the poison, which can be seen being removed in thick clots. After the poison is
removed,blood startsto come outof the syringe.If the blood is not clotting,the monkknowsto refer
patients to hospital (about 5% of cases). The monk uses a bowl of bottled water to flush out the
syringe throughout the procedure, and has the patient consume some traditional medicine (an
unknown recipe) to increase urine output. If the patient urinates 3 times after, they are said to be
cured. (See figures 3a & b below)

20
Non-invasive techniques include the use of ‘holy water’, ingesting herbal concoctions, chants,
prayers and astrology. These are practiced by both monks and other traditional healers.
Qualityof Traditional HealingasPerceivedbythe Communities
Participants placed emphasis on the legitimacy of the traditional healing practices. Visiting a
traditional healer or monk was commonly reported, with most of the snakebite victims having
accessed these services at some point following their bite. Many participants revealed to us that
even if there was an adequately stocked clinic in a nearby village, they would still choose to see a
traditional healer. Theyplace ahigh degree of trust in the healers, partly due to their reputation of
havingsofewsnakebite fatalitiesattheirhands. Participantsreported successrates of up to 95% for
traditional treatmentof snakebitecases by healers or monks. Reasons given for the continued use
of a traditional healer or monk for snakebite treatment included the seemingly high success rates,
proximity of the care, low cost, word of mouth, and beliefs in efficacy.
One of the traditional healersresponsiblefortreatingcommunitymembersforsnakebiteattendeda
PRA meeting:
Figure 3a: Local community members
demonstrate syringe technique
Figure 3b: Local community members
demonstrate syringe technique

21
I am 58 years old and live in this village. When I was 33, I myself was bitten by a snake and went
straight to a monk for treatment. The monk tattooed my entire body with medicine and gave me
coconut juice infused with herbal medicines. I recovered after 3 days. After this, I was taught by the
monkand then decided… to learn more.The monkalso uses astrology.Forexample,thegeographical
location of a patient’s birth may determine the type of treatment they receive. He has now stopped
practicing, and so refers some snakebite victims to me. I have been practicing since 1997 and have
treated more than 50 people for snakebite, all of these have been successful. I use astrology and
some traditional remedies.
Overall,communitymembersspoke veryhighlyof the monksandtraditional healersresponsible for
treating snakebite victims.
OtherReasonsforthe use of Traditional HealingforSnakebite
Community members tended to speak unfavourably of visits to hospital, citing reasons such as
unkindtreatment,andbeingafraidof the staff, with statements such as “I am afraid of the hospital
because the care is not good”. Although, one snakebite victim liked the care that he received at
hospital, and did not seek any traditional treatments:
I wasbitten earlier this year when I wasworking on my banana plantation. My family were with me
butthe weatherbecamebad so I walked themhomeand then returned to the plantation alone.Ihad
a torch but wasn’t wearing shoes or looking where I was walking, so I stepped on a viper. I used
banana leaves to kill the snake and took it back to the small hut on my plantation. I managed to go
backto my homeand passed outin the car on the way to KyaukseHospital, a 45 minute drive, where
I spent 3 days. I was then referred to Mandalay General Hospital for dialysis. I liked the care that I
received at this hospital. While at Mandalay General my foot became very swollen and blistered.
Afterdialysis and a long stay in the orthopaedicunit,I asked if I could return to my village. I returned
to my village but thewound wasnothealing properly so I had to return to the hospital for 1 month. I
received a skin graft and now I have to travel to Mandalay every 10 days for treatment. I have not
used any traditional methods or been to see a traditional healer. The total cost of my snakebite
treatment has been about 2,500,000 kyat (2800 AUD). (See figure 4 below)

22
One issue that emerged during the participatory sessions was the misconception that snakebite
victimsmust bring the snake with them to hospital for identification. The individual who reported
having been bitten more than 20 times over her lifetime told us of her belief that “If I go to the
hospital I have to take the snake with me, so I go to the traditional healer instead”. Another spoke
about his efforts to kill the snake after having been bitten, because he wanted to bring the snake
with him to hospital.
Figure 4: Snakebite victim explains his injury to
project staff

23
FGD results
The Snakebite Problem
At one FGD, healthcare staff stated that the snakebite problem in their area is improving. Some of
the staff highlightedchangingtechnologyasamajor improvementtothe snakebite problem in rural
areas,with the use of tractors and other modern technologies reducing the number of encounters
between humans and snakes. Staff told that snakebites sustained are mostly from vipers, and to a
lesser extent, cobras. They also reported that in many cases, the type of snake is unknown.
In regards to snakebite treatment, health staff reported improvements. This is in part due to the
possessionof acommunitycar,withone PHS II sharing that “the situation is getting better because
nowwe have a communitycar.Before,carswere onlyprivatelyownedand not for emergency use”.
Despite reportingthatthe snakebite problemisimproving, some healthcare staff reported that the
use of traditional healing for snakebite is actually increasing. At each FGD, health staff identified
three contributory factors to the use of a traditional healer: easy transportation, low cost, and
strong traditional beliefs.
Traditional Beliefs
During the focus groups, participants spoke of the strong belief that community members have in
traditional healing. It was communicated that community members often go to hospital for other
ailments,butwill still seeatraditional healerinthe case of snakebite. Theyreported that in contrast
to theircommunitymembers, theydidnotpersonallybelieveintraditional healing practices, and as
healthcare professionals,theyhave nocontact with traditional healers or monks. On the one hand,
manyof themagreedthatif there was enough medicine available at the RHCs, most people would
reportstraightthere and notto a traditional practitioner.Onthe otherhand,some staff argued that
the main health seeking determinant was not cost, but a strongly established belief in the monk’s
abilitiestoheal. Staff were aware of varioustraditionaltreatmentsavailable fortreatment,including
tattooing, incision, and using a glass bottle to remove venom.
Cost
Staff identified financial cost as a significant issue; both the prohibitive costs of the biomedical
treatment of snakebite for their patients, as well as a lack of resources for health education and
healthstaff.Theycouldunderstandwhy patients would preference a traditional healer, being that
the traditional treatmentsworkedonthe basisof an optional donation, with one participant telling
us that “inthe past, we lost many lives to snakebite because anti-venom was unaffordable and we
had to go to the traditional healers.” Some staff believed that this was still the case, recounting an

24
instance of a snakebite case in hospital which cost the patient 1,000,000 kyat (1135 AUD). Others
countered that this was not so common anymore.
Lack of Resources
As well as financial issues, the staff cited other problems with the healthcare system that they
thought may influence the use of traditional healing, including a lack of staff and inadequate
supplies.“We have a problem with lack of staff. Staff get transferred and then are not replaced, so
we are overloaded with patients.” In one FGD, the participants informed that they believed the
monkonly treats people because he wants what is best for the community, and that he knows the
RHCs are not adequately stocked with antivenom. Health staff in one community were under
instruction that after administering 4 vials, they had to refer patients to hospital. “Antivenom is
limited in the RHCs, and we have been informed that after administering 4 vials, we must refer to
hospital. Today, we have 8 vials; 4 from India and 4 from the MPF”.
Education
The education,bothof communitymembersandtraditionalhealers/monks was discussed at length
by healthcare staff. On the notion of prevention, one participant observed that “some snakebite
victimsdon’tcare about the riskof snakebite astheydonotwant to modifytheirlifestyle; carrying a
torch isinconvenient.Peopleliketofinishtheirworkontime,andbootsslow themdown,especially
if they have to work in water and mud.”
A lack of knowledge dissemination regarding prevention was noted by the staff, adding that
snakebite educationshouldinclude bothpreventionandtreatment.Staff considered a need to help
communitiestorecognisepotentiallydangerous methodspracticedby the monk. They also pointed
out the need to educate the traditional healer, that their methods can be dangerous not only for
their patients, but also for themselves.
Word of Mouth
Word of mouth wascitedas an importantcontributoryfactorfor both the use of traditional healers
and hospital. Healthcare staff concluded that snakebite survivors who share their stories after a
positive experience in hospital could be a good influence on others, but also that those who share
theirnegative experiencescould be a bad influence on others, perhaps encouraging the continued
use of traditional healing.

25
Some staff mentioned that monks and traditional healers could possibly be incorporated into the
modern healthcare system, as monks in particular are very trusted members of society.
There is a belief that the monk in their community is simply doing the community a service, as he
knowsthat the local RHC isnot adequately stocked with antivenom, and that if there were enough
antivenom, he would happily refer patients to the RHC. The majority thought that given time,
preference for traditional healing will decrease.
In orderto ease thistransition, staff identifiedaneedtoimprove relationships between healthcare
staff and the community. At one particular FGD, a woman recounted an incident in which she was
late to see a patient, which created a misunderstanding between her and her community. In doing
so, she realised the importance of fostering mutual understanding between health staff and
community. The rest of the health staff stressed that in order to best serve their communities’
needs,theyshouldaimtobe well qualified,goodatcommunication,andavailable at all times. They
highlighted the importance of quality care, consisting largely of kind treatment and adequate
supplies.
Figure 5: Healthcare staff at a FGD converse with project staff

26
Discussion
Duringthe participatoryfieldwork,itbecame clearthatsnakebiteincidenceishighlycorrelated with
agricultural activity. The fact that communities reported higher incidence of snakebite during the
harvestseasoncoincideswithstudiesthatreveal highersnakebite incidence duringthe rainy season
and periods of agricultural activity.(1, 20)
Traditional beliefs, transportation and cost were the three
main factors identified as contributing to the continued use of traditional healers and monks.
Traditional Beliefs&BeliefsaboutEffectiveness
Religion and spirituality plays a key role in influencing decisions about snakebite treatment. That
90% of Burmese people are reportedtobe TheravadaBuddhistswouldexplainthe legitimacyplaced
on the monks’ treatment of snakebite.(63)
It is unlikely that this will change significantly any time
soon.Thus,predictionsof the healthcare staff thatgivenadequateclinics,community members will
no longer seek treatment from traditional practitioners for snakebite are probably unrealistic.
Traditional healerswere viewedwithahighdegree of legitimacybycommunitymembers,butnotso
much by the healthcare workers. Thisisinline withNewman et al.’s study of traditional healing for
snakebite inrural African communities.(64)
In discussing his treatment methods, it became evident
that the healerhada verymethodical wayof doingthings,includingobservingthe patientovertime,
and administeringdifferentremedies dependingonthe type of snake.He alsomentionedthat these
methodsare officiallyrecognisedbythe Departmentof Traditional Medicine inMyanmar.Itis highly
likelythatthese factorsleadtothe continuedlegitimacyof traditional healingpracticesin Myanmar.
There are several possibleexplanationsforthe citedsuccess rates (and therefore legitimacy) of the
traditional healers. As the traditional healer is the first point of contact, it is possible that they are
only treating the mild envenomations and dry bites.(65)
Participants informed us that traditional
healers do often refer to hospital if the case is too severe, meaning that permanent sequelae and
deaths may only occur when patients reach hospital.
Perceptionsof ModernMedicine
Poor care received in health facilities and hospitals was another motivating factor for the use of a
traditional healer. These perceptions seem to be based on the idea that antivenom is not available
and, if available, is low quality. This corresponds with what the healthcare staff told us during the
FGDs about having low stocks of antivenom, which was often imported from India.

27
That communitymembersbelievetheyneedtobringthe snake with them when seeking treatment
possibly reflects incomplete information given to the community by healthcare providers, as they
seemtothinkthat bringingthe snake to hospital for identification is essential. Although useful for
diagnosis and the administration of appropriate antivenom, this is not necessary. This
misinformationcouldbe harmful inseveral ways,includingindividualsputtingthemselves in further
danger by trying to catch the snake, delays in treatment time as a result of trying to do so, and an
individualpreferring a traditional healer to biomedicine because of an inability to bring the snake.
Thougha potentiallyharmfulactivity,asWilliamset al. recount, the snakes that have been brought
inby previoussnakebite victimshave contributed valuable knowledge to snakebite epidemiology,
and the identification of “medically important species” such as Naja siamensis.(32)
Transport
Roads travelled duringthe participatoryresearchtoreachthese villageswere often unsealed and in
poor condition, making the transport difficulties faced by these communities apparent. A lack of
transportation,combinedwith the physical distance to hospital, can mean that a traditional healer
becomesthe preferredandfirst option. Critically,once delayshave occurred,antivenal treatment is
not sufficient in treating a snakebite patient who could be suffering from renal, circulatory and
respiratory issues.(2)
DifferingViewsbetween Community Membersand Healthcare Staff
The research informed of differing perceptions of snakebite and traditional healing between
healthcare staff andcommunitymembers.Forexample,manyof the communitymembersinformed
that evenif costand transportationwere notissues,theywouldstill gotosee a traditional healer or
a monk because of either a genuine belief in their abilities, or a spiritual belief. Healthcare staff
responsible for these same communities stated that if the issues of cost and transportation were
overcome,theircommunitymemberswouldgostraight to hospital and no longer seek the services
of a traditional healer or monk.

28
Incorporationof Traditional Healingintothe Modern Healthcare System
When both community members and healthcare staff were asked about the possibility of
incorporatingtraditional healersintothe modern healthcare system, there were mixed responses.
Many felt that as the healers/monks do already refer severe snakebite cases, they are already
incorporated. Others felt that the traditional health practitioners simply want what is best for the
patients,andwould happily forego any future procedures if services were available. However, we
receivedthe impressionthatsome monksandtraditional healersreliedonsnakebite treatment as a
formof income.Thiswouldmeanthat foregoing snakebite treatment could affect their livelihood.
The participatoryworkrevealedthatphasingout traditional healing altogether isn’t an option, due
to a deepembedmentof traditionalbeliefs.Inasimilar study in Nepal, it was found that traditional
healerscouldbe successfullytrainedtoperformcritical rolesintheircommunities,suchas provision
of knowledge aboutprimarypreventionandhealthcare,identificationof critical cases, and referring
of patients to hospital.(39)
Anyplanto combat the snakebite probleminMyanmarshouldacknowledge traditionalhealersasan
existing and valuable health resource, as evidently, they remain integral to Myanmar’s healthcare
system.(27)
Theprevalenceof traditional medicine and healing is reflected in Myanmar’s healthcare
system at all levels, including training, education and research. Myanmar has fourteen traditional
medicine hospitalsaswell aspharmaceutical factoriesdealingspecificallywithtraditional medicine.
(34)
For future consideration of traditional healing and medicine in Myanmar, traditional healing
shouldbe contained withinthe context of a contemporary healthcare discourse. Treatment should
be culturallyaware,ashealthworkerswithsome knowledge of traditional healingare able to better
understand their patients and how to help them.(27)
Education/Prevention
The general consensusof the literature is that health seeking behaviours e.g. the use of traditional
healers, can be difficult to change. Literature on snakebite reveals that while improved access to
healthcare and treatment of envenoming are critical, preventative efforts such as education of
communities are paramount.(2, 6, 17)
Rural populations are often uninformed and use inappropriate
firstaid,expandingthe delaysintreatment.Educationforbothsnakebite prevention and treatment
is needed.(1)
A lackof preventativemeasuresfor snakebite was discussed during the participatory sessions, and
communitiesappearedkeentoadopt them.However, farmersare opting to not wear rubber boots,
for reasonssuchas perceivedinconvenience, reduced mobility, and for some, a cultural belief that

29
footwear should not be worn whilst working in the rice paddies.(2, 19)
In fact, the rubber boots that
had beenavailableuntil recentlyhadno demonstrated ability to withstand penetration with snake
fangs.(19)
The MPF has nowdeveloped protective,fang-proof rubber boots, which were tested with
farmers in an acceptability trial carried out by the Venom Research laboratory.(19)
Almost 100% of
those surveyedintendedtokeepusingthe boots afterthe trial evenif theywere expectedtopay for
them, because they found them comfortable, and appreciated the feeling of protection that they
provided.(19)
One of the womenreportedbeingbitteninthe middle of the nightwhilesleepingonthe floorof her
home,andsimilarnarrativeshave alsobeenseeninthe literature.This anecdotal evidence suggests
that perhaps,kraitsmaybe responsibleforahighernumberof the bitesthanpreviouslydiscussedin
the literature and in the FGDs with healthcare staff. Given that most antivenom in Myanmar is
manufactured for use against cobra and viper bites, further research into polyvalent antivenom
productionissuggested.Thatsnakebitesare being sustained at night while victims are sleeping on
the floor of their homes suggests a need for education about prevention. A study of snakebite in
Nepal revealed that communities have combated this through sleeping under mosquito nets, and
otherbehavioural modificationscouldincludesleepingonelevated surfaces, rather than traditional
practices of “open-style habitation” and sleeping on the floor.(1, 2, 21)
Some healthcare staff didnotsee snakebiteasbeingaproblemintheirareas. To put this in context,
whilst a community may experience three deaths from snakebite in one year, they might also
experience many more deaths from dengue fever, diarrhoeal disease and HIV/AIDS, for example.
One staff member suggested combining snakebite education with talks about other issues such as
dengue fever which may present more of an issue for the majority of the community. Non-
government organisations, religious groups and health staff are potentially capable of knowledge
disseminationincommunities. (17)
As well respected members of communities, traditional healers
could also be trained to propagate public health messages.
ImprovingData
In order to improve services such as antivenom distribution, more accurate statistics are needed.
Given that the PRA meetings revealed that many potential snakebite victims would only seek
treatmentfromtraditional healers,the problemwithhospital providedstatisticsforepidemiological
data isevident. (18)
State governmentsinIndiaoperate healthinsuranceschemeswhichcompensate
farmers for accidents such as snakebite. This incentivises the reporting of snakebite, enabling the
state governmenttoobtaina snakebite incidence estimate more reliable than that based solely on
hospital data.(5)
Considering that some snakebite victims only access the traditional healthcare

30
system, perhaps traditional practitioners should also be considered as a source of data.(5, 65)
Lam et
al.propose that while the recordsof traditional practitioners alone may not be accurate, they could
complement hospital and other forms of data.(65)
Limitations
Generally speaking, according to saturation theory, qualitative research should continue until any
additional dataacquireddoesnotcontribute to further understanding.(52)
However, in undertaking
research such as this honours project, budget, time and other limitations must also be taken into
account. So,whilstfurthersessionsmaywell haveenrichedourunderstanding(andfurther sessions
are indeedtakingplace aspartof the overall MyanmarSnakebite Project), the data acquired within
the four weektimeframe werestill sufficientinmakingsome valuable preliminaryfindings. Thoughit
may not necessarily be possible to make wider generalisations about snakebite in Myanmar from
these findings alone, the narratives inform how and why traditional healing is still used for
snakebite. It may also inform Myanmar’s healthcare system on how to positively interact with
communities.Thisresearchhighlightedthe phenomenaof traditional healingasexperiencedin rural
communities of Myanmar. While the situation may be somewhat different in other communities,
this understanding will help inform the health system on how to positively interact with
communities.
The need for a translator in both the FGDs and PRA meetings presented some issues. Firstly, we
noticed that it significantly affected the flow of the discussions and the ability to actively engage
withparticipants.Additionally,some of the nuancesof expressionwere almostcertainlylostthrough
the translation process. Ideally, to help mitigate this effect, translators would have been project
staff,well acquainted to the aims of the Project. However, practical reasons, such as the preferred
translator having another job, made this impossible.
The demography of the PRA meetings was varied, but often primarily older females. Whilst these
sessionsstill provided us with some valuable information, this is problematic as the main group at
risk of snakebite are male farmers aged between 18 and 36.
The sessions,whichusuallyoccurredinthe middle of the day,wentforseveral hours.We found that
as time wenton,we lostparticipantswho likely needed to return to work. For future research, this
issue wouldneedtobe tackled,eitherthroughmaking the meetingsatamore appropriate time that
suits the farmers, or by incentivising their participation so that they are not confronted with an
opportunity cost by attending the meetings. This is best put by Chambers, who writes that

31
development projects are often marred by biases such as project bias, which have a tendency to
direct the attention away from the poorest people.(57)
Similarly,one of the PRA meetings consisted predominantly of mothers and their newborn babies,
because of a free immunisation session that was to be held afterwards. While this may have
incentivisedattendance forademographicthatwe mightotherwise have missedouton, the session
was consequently shorter and did not yield as much data.
The FGDs presented some unique limitations. Firstly, that some of the healthcare staff who were
participating were also involved in the Myanmar Snakebite Project’s overall survey. Thus, when
asking questions such as the extent of the snakebite problem in Myanmar, staff may have been
basingtheiranswersonsurveyresponsesratherthantheirownperceptions.Furthermore, the FGDs
took place in open areas of the communities, where there were almost always other community
memberspresent.Thismayhave resultedinstaff notfeelingthattheycouldspeakfreelyabouttheir
opinions without judgement.
In spite of these limitations, the research was still able to yield some valuable data, particularly in
the form of rich narrative, and this can be used to inform further research.

32
Conclusion
Evidently,the practice of traditionalhealingisquite prevalentinrural communitiesof Myanmar,and
well respected and utilised by the communities in question.
In 2016, the continued use of traditional healing appears to be driven mainly by factors of cost,
accessibility of modern medicine, and prevalence of traditional beliefs.
The research indicates that with community education, medical training and the improved
distributionof anti-venom, the burdenof snakebiteinMyanmarwill ease,and the use of traditional
healing for snakebite could continue to decrease. However, attempts to phase out traditional
healingaltogetherare unlikelytowork. Thisstudytherefore recommendsthattraditional healers be
used as a culturally appropriate partner of the biomedical health system, for provision of first aid,
accurate information sharing, and referrals.

33
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38
Appendices
Appendix I:LogicGrids & Search Terms
PubMed
Search: (((Snake Bites[mh]ORSnake Venoms[mh]ORElapidVenoms[mh]ORViperVenoms[mh] OR
Snake Envenomation[tiab] ORSnake Bit*[tiab] OREnvenom*[tiab])))AND((Plants,Medicinal[mh]
OR Medicine,Traditional[mh] OREthnopharmacology[mh] ORTraditionalHeal*[tiab] OR
Shamanism[mh] ORShaman*[tiab] ORTraditional Heal*[tiab]ORIndigenousMedicin*[tiab] OR
ComplementaryTherapies[mh] ORMedicine,EastAsianTraditional[mh] ORTraditional
Practitioner*[tiab]))
=273 Results
Scopus
Search: ( TITLE-ABS-KEY( "Medicinal Plant*" OR "Traditional
Medicin*" OR ethnopharmacology OR "Traditional Heal*" OR shaman* OR "Indigenous
Medicin*" OR "ComplementaryTherap*" ) AND TITLE-ABS-KEY( "Snake Bites" OR "Snake
Venoms" OR "ElapidVenoms" OR "Viper
Venoms" OR snake envenomat* OR envenom*) ) AND ( LIMIT-TO ( LANGUAGE , "English") )
=105 Results
Traditional Healing Snakebite
Plants, Medicinal[mh] OR Medicine,
Traditional[mh] OR
Ethnopharmacology[mh] OR
Traditional Heal*[tiab] OR
Shamanism[mh] OR Shaman*[tiab]
OR Traditional Heal*[tiab] OR
Indigenous Medicin*[tiab] OR
Complementary Therapies[mh] OR
Medicine, East Asian Traditional[mh]
OR Traditional Practitioner*[tiab]
Snake Bites[mh] OR Snake
Venoms[mh] OR Elapid
Venoms[mh] OR Viper
Venoms[mh] OR Snake
Envenomation[tiab] OR Snake
Bit*[tiab] OR Envenom*[tiab]
Traditional Healing Snakebite
“Medicinal Plant*” OR “Traditional
Medicin*” OR Ethnopharmacology
OR “Traditional Heal*” OR Shaman*
OR “Indigenous Medicin*” OR
“Complementary Therap*”
“Snake Bites” OR “Snake
Venoms” OR “Elapid
Venoms” OR “Viper Venoms”
OR Snake Envenomat* OR
Envenom*

39
Appendix II:PRISMA FlowChart
Articles identified through PubMed
and Scopus database searching
n=378
Records recommended by
supervisor
n= 28
Records after
duplicates removed
n=422
Records screened (title &
abstract)
n=422
Records
excluded
n=327
Full-text articles
assessed for eligibility
n=95
Full text articles
excluded (with
reasons)
n=62
Studies included in
qualitative synthesis
n=33
Records identified through
forwards/backward searching
n=36

40
Appendix III:EthicsApproval

42
Appendix IV:ParticipationInformationSheet

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