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He had heard rats scuttling around and was reaching to turn on his bedside lamp when Kamidikolo Badilu was bitten. By the time he reached hospital, snake venom had already started breaking down his skin and muscle. The flesh around the bite was necrotising, or dying.
The only treatment to stop the damage was antivenom and a vial was given to Badilu, 60, a handyman from Lwanga, southern Uganda. But it was too late to stop the damage to the finger and arm where he was bitten.
In sub-Saharan Africa, patients face a “wild west” of antivenoms, with many badly made and poorly regulated in an area where there is a shortage of reliable medicine, experts say. Some antivenoms are about as useful as injecting water.
The Bureau of Investigative Journalism (TBIJ) bought samples of antivenoms in three countries and had them tested, and found that more than 70 vials of some of the antivenoms would be needed to treat some bites effectively.
One antivenom company has been accused of fraudulent research. Some antivenoms made to treat Indian snakebites end up in African where they do not work – a trade that experts called unethical..
A major issue for doctors, researchers and patients is that antivenom is not held to the same regulations that apply to many other drugs.
The first snakebite antivenom was made in the mid-1890s and the method has changed little since: snakes are “milked” for their venom, which is injected into horses or sheep and the antibodies that their immune systems then produce are extracted via the animals’ blood.
There are no requirements in sub-Saharan Africa for antivenoms to be tested in clinical human trials to prove they are safe or effective.
“It’s a cowboy show out there,” says Thea Litscha-Koen, who founded the Eswatini Antivenom Foundation, which raises funds to treat victims. “Some of them are selling stuff that, honestly, you may as well just pour down the drain.”
A bite from a venomous snake can kill or cause life-changing injuries. “It can be horrific,” says Litscha-Koen, “I will send you pictures that make your eyes water.”
Some snakes have “cytotoxic” venom, which damages and kills cells. Victims say it feels as if you are being injected with acid. A cytotoxic wound can cover the chest and arm, or an entire leg, and take months to heal, Litscha-Koen says.
Other species, such as west Africa’s carpet viper, stop blood from clotting. Then there is the black mamba, whose neurotoxic venom strangles nerve signals from the brain and shuts down a human body.
The World Health Organization (WHO) estimates that 5.4 million people are bitten by snakes each year, causing between 80,000 and 140,000 deaths.
In 2023, an estimated 20,000 people died from snakebites in sub-Saharan Africa. In the same year in Australia, where antivenom is of a high quality and free, two people died.
“It’s a poor man’s disease,” Litscha-Koen says. “That’s the cruel truth.” Victims typically live in remote, often rural areas, in south Asia and Africa. Farmers and children are most at risk and a snakebite usually has devastating economic consequences for entire families.
Six months on, Badilu, who had a skin graft on the arm where he was bitten, still relies on painkillers and sleeping pills. The father of five children under 10, who made his living from fixing, building and digging, can no longer work and so his children no longer go to school.
With an effective dose of antivenom, properly administered, the chances of survival and recovery are very high. But for people like Badilu, the odds are against them.
On the third floor of a glass-panelled office block in Valencia, Spain, Prof Juan Calvete runs a laboratory analysing venoms and antivenoms. He holds a vial in his hand, peering at the label. The antivenom was bought in east Africa for the TBIJ’s investigation, and lists the venom of Indian snakes it could be used to treat. The label is partly written in Bengali with the price in Indian rupees.
Venom’s effects vary from species to species, and even within the same species depending on where the serpent lives and what it eats. An antivenom formulated to work in one region won’t necessarily be effective somewhere else.
Calvete explains what would happen if you were bitten by a highly venomous African snake such as a black mamba and given an antivenom for Indian snakebites, such as the one he is holding.
“You can do two things,” he says. “One, is to take the phone and say goodbye to your mother. And the other, if you have an ice-cream shop nearby and you find the flavour that you like, take it. Because it will be the last thing that you eat.”
Calvete’s lab at the Valencia Institute of Biomedicine is the sole provider of official assessments on antivenom quality for the WHO.
For the TBIJ’s investigation, Calvete tested two more Indian antivenoms bought in Uganda and Nigeria – both had low capacity to work against sub-Saharan African snake venom.
“Giving a patient this antivenom will be almost like injecting distilled water in the body,” he says.
Calvete’s team tested five antivenoms bought in Nigeria, Tanzania and Uganda. Each came as a fine powder, which was weighed and diluted to examine ingredients. The team tested how well each product would bind to the venoms of widely found African snakes: the puff adder, black-necked spitting cobra, black mamba and the west African carpet viper. The binding capacity of an antivenom shows how much of the venom it will “stick” to per unit. The first step in neutralising the toxins in the venom is for the antivenom to bind to them. If it does not stick, it won’t work.
Two of the antivenoms were manufactured for use in India not Africa, and showed a low capacity to work against the venom of sub-Saharan African snakes. Meanwhile, another antivenom was found to contain a tenth of the active ingredient of its competitors. The two other antivenoms made for sub-Saharan Africa performed better, although Calvete noted that even the best antivenoms available in the region “could and should be better”.
Dr David Williams, a snakebite expert at the WHO, said even those ordering in antivenoms for national health ministries don’t always understand how they work.
“Nobody tells them what species of snake they are meant to be looking for,” he says. “They buy the cheapest product they can possibly find. It’s not until it ends up in the doctor’s hands that somebody works out that it is not for the snakes that come from our country.”
Antivenoms don’t have to be labelled specifying how much key ingredient is in each vial. There are no legal grounds on which to challenge manufacturers’ claims about the bites they can treat and dosage required.
Calvete described the current regulations as a tragedy: “You need to change the rules.”
The implications for patients are severe. “Time is life,” says Calvete. “The probability that you get out of the hospital with all your limbs is much higher if you don’t have to be treated with vial after vial.”
Dr Abdul-Subulr Yakubu leads the cardiology unit at Ghana’s Tamale teaching hospital, but regularly treats snakebites. He often finds himself having to give a patient several times the recommended dose of antivenoms.
“We are not sure if we have to give large volumes because it’s not very effective,” Yakubu says. After all, there are many other factors that can complicate treating a snakebite. Many snakebite patients who go to hospital have been to local healers first, delaying their treatment and sometimes introducing infections. Some come in too late for antivenom to work. Others don’t know what kind of snake has bitten them, making it harder to give the best treatment.
There are other issues too – shortages of medication increases the death toll from snakebites across Africa. Dr Nicholas Amani Hamman, medical director of Nigeria’s Snakebite hospital and research centre recalls watching a four-year-old boy die last year, while waiting for a second dose of antivenom that didn’t arrive in time.
A few hours’ drive north, Prof Abdulrazaq Habib at the Nigerian Snakebite Research and Intervention Centre, knows that when antivenom is out of stock and he writes a prescription for patients to take to a pharmacy, it is a gamble.
He says a patient might have to “go back to his village and then sell a goat, or a sheep” to afford treatment. Even then, there is no guarantee they’ll get the right one. Habib has seen everything from genuine medicines that don’t work for the snakes in the region, to fake products, to asthma medication sold as antivenom because the bottles look similar.
A reporter sent to a pharmacy in north-western Nigeria was offered antivenoms suitable for Indian snakes and a rabies vaccine. Neither would have helped against a snakebite. Very little antivenom is manufactured in Africa. It’s estimated the continent receives as little as 2.5% of the antivenom it needs. It depends on imports, and lax practices have thrived.
Among tropical diseases, snakebites are the most neglected. Most countries in the world have agreed to a UN goal of halving global mortality and disability from snakebites by 2030. However, in the past five years snakebites have received $83m in funding for research and development, compared with $1.65bn in similar funding for Ebola, which has killed far fewer people.
But there are promising developments. Eswatini has managed to secure funding to produce an antivenom for local snakes. During the most recent snakebite season from September 2023 to May 2024, Eswatini recorded no deaths for the first time in its history.
Habib believes there is enormous potential to make antivenom in Africa. Producing high-quality local antivenoms, he says, should be the aim. Governments need to step up, he says, pointing to poor planning that led to antivenom shortages in Nigeria at the peak of snakebite season.
“I’m not saying it’s easy, but doing nothing is not an option.”
