At the age of 13, most children’s ‘miraculous’ stories revolve around surviving a knee scrape. In fact, at that age many children remember how they survived a bicycle fall or came out of a dog chase unscathed.
But for thirteen-year-old Menza Benjamin, the story he lived to tell is different. A normal day outside could not have gone more awry. He was happily picking up cashewnuts when he felt a hot burning sensation on his leg. Before he could fully grasp what had happened, he felt another hot bite. Moments later, he started to vomit and broke out in a cold sweat. And then he passed out.
That was three years ago and it was only later that he realised it was a snake bite. Today, Menza is lucky to be alive and sitting at the snakebite seminar held in Watamu, Kilifi County, early November.
What saved him was the speed with which his uncle acted. His uncle immediately put him on a motorcycle and took him to the Bio-Ken Snake Farm, 12 kilometres away. By the time they reached the farm, the boy was already showing rapidly advancing symptoms of black mamba bite. At the farm, it was decided that Menza had to be rushed by car, along with a supply of suitable antivenom, to a local private hospital.
Black mambas are among the fastest and deadliest snakes in the world, and their bite requires urgent attention.
In the neighbouring Taita-Taveta County, in May this year, a farmer was tilling his farm in Maungu near Voi, when he was bitten by a snake on the middle finger.
His family put him in a matatu and took him to Voi — a 30-minute drive. From the symptoms, the doctor pinned it down to a puff adder, one of Africa’s most venomous snakes.
The doctor administered an antivenom immediately. Despite this, the patient’s condition deteriorated, calling for doctors to give him another shot. On the fourth day, the patient died from severe internal bleeding. He had been put on the wrong antivenom.
Experts admit that Kenya has been experiencing cases of a mismatch in antivenom. In Menza’s case, the correct antivenom, which is produced by the James Ashe Anti-Venom Trust (Jaat) and is supplied to the Kilifi County Hospital, was used.
“In Kilifi County there has been no case of a child dying from a snake bite because of the antivenom,” says Dr Shebe Mohammed, a researcher at Kenya Medical Research Institute in Kilifi. “And this is despite the three to four children brought to the county hospital every month suffering snake bites.”
Almost every snake can bite but most attacks are by harmless, non-venomous species. Venomous snakes use the toxin as a feeding mechanism. The poison quickly knocks down prey so that it does not get away and breaks down the tissue to make it easier to digest. The venom is not for killing humans. And that is why, health experts say, it is important to understand the difference between venomous and non-venomous snakes.
For Kilifi, the difference seems well understood. From traditional healers to doctors, understanding this concept has become the thin line between life and death. The snake farm is known to everyone as a sanctuary for snakebite victims and the availability of good quality antivenom there.
Traditional healers ‘treat’ non-venomous bites with charms and chants, all for a chicken and a few hundred shillings. The patient, oblivious of the difference between the bites, happily pays the traditional healer, relieved to be ‘treated’. But these healers know venomous snakebites are not their speciality and require immediate attention, and so without hesitation they refer the victims to the mzungu at the snake farm. It has proved to be a working relationship.
The snake farm was founded by the reptile guru, the late James Ashe, and his wife Sanda in 1980. Years after retiring as curator of the snake park at the Nairobi Museum, the couple settled in Watamu as Kenya’s coastal strip is rich in reptilian wonders. Since then, the farm has expanded into research and public awareness run by Royjan Taylor. The bi-annual snake seminars started 21 years ago, but unfortunately the only people absent at most snake seminars are policy makers from government institutions.
“Taylor set up Jaat to meet the increasing need for good antivenom when the seminars and training of local doctors and nurses convinced people that they really can be saved from dangerous bites,” says Sanda.
“Snakebites are complicated,” explains Tom Menge, a toxicologist and chief pharmacist at Kenyatta National Hospital, Kenya’s largest referral facility. Venomous snakebites require the correct antivenom, followed by care.
“The antivenom registered in Kenya is by the Pharmacy and Poisons Board (PPB). As it is registered there, the assumption is that PPB has verified the antivenom,” he says.
And therein lies the crux of the problem. The antivenom available in the country is proving to be ineffective. One theory is that it was approved based on dubious data presented to PPB by the manufacturer. That raises questions about the board’s efficiency because, as experts say, venom varies from snake to snake — even within the same species — depending on the region it is from.
“Producing antivenom is challenging,” continues Menge, “because it requires venom from the snakes of all ages, different eco-zones and also during different seasons.”
In Kenya there is no facility to manufacture antivenom. Jaat purchases its supplies from South Africa for the safety of the farm’s snake handlers. It also provides the antivenom on a non-profit making basis, on request and in consultation with doctors treating dangerous snakebites. This is what saved Menza’s life. But it is expensive, as a 10cc vial costs about ShSh20,000, and a recommended dose varies between two and four vials.
“The challenge is that an unregistered product cannot be used in a public institution like KNH, whether it works or not, to avoid litigation. The World Health Organisation therefore has the responsibility to set higher standards of antivenom production from start to finish,” stresses Menge.
The situation in Kenya is frightening. The declining availability of high quality antivenom in sub-Saharan Africa is a real and unnecessary tragedy, and constitutes a major neglected global health concern. The amount of suitable antivenom marketed in these countries has fallen to crisis levels, representing only a fraction of the amount required, according to a research paper titled Consequences of Neglect: Analysis of the Sub-Saharan African Snake Antivenom Market and the Global Context, by Nicholas I Brown.
Snakebites are also labelled “neglected tropical diseases” by WHO and hence receive little funding or opportunities for research, innovation or business interest.
In addition, a snakebite in tropical developing countries in Africa, Asia, South America is an occupational hazard in the poorer segment of the society: women who walk barefoot for miles in search of water, peasants working in farms, herders on the move with their livestock, and children at play in rural homesteads.
“The highest risk group is the productive age of 15 to 30 years because they are more active,” states Dr David Williams, who is CEO of Global Snakebite Initiative, head of Australian Venom Research Unit at Melbourne University, and head of the toxicology centre at University of Papua New Guinea. He shows horrific images of snakebite victims in Africa, India and Papua New Guinea with rotting flesh and amputated or paralysed limbs.
“The cost to the community of looking after the person is enormous and collectively it’s billions of dollars in lost productivity,” he says. “We don’t know how big the problem is in Africa as there is no system in place to collect data.”
It is estimated that 85 per cent of snakebite victims opt for traditional healers because antivenom in hospitals is deemed ineffective.
“Yet good antivenom is extremely effective,” says Dr Williams. “But because the market is not regulated, the antivenom available is not for African snakes.” And the wrong antivenom kills the victim.
The harsh reality is that manufacturing high-quality antivenom makes little business sense, unless the government steps in with funding. Compared to other medical conditions such as Aids, malaria and tuberculosis in developing countries, snakebites are a drop in the ocean and hence government funding is allocated to diseases deemed more pressing.
It is an approach that needs to be changed, say experts. Until the late Princess Diana of Wales took up the cause of landmine victims, it was an issue largely ignored and unknown. Similarly, says Dr Williams, snakebite victims need a political voice to become a public issue and be dealt with at the grassroot level.
“Antivenom must be listed as essential medicine on the WHO list, which obligates member countries to stock them. At the same time, there is need for research into effective antivenom involving researchers from home countries.”
There are opportunities if countries worked regionally such as those in eastern Africa — Kenya, Rwanda, Ethiopia, Tanzania, and Uganda — because these require the same antivenom, he adds. It would then make business sense to have one procurement system to order a large quantity from a manufacturer.
“Seventy per cent of snakebites are preventable if people wore shoes,” states Diana Barr, Technical Support Officer of the Papua New Guinea Snakebite Project — University of Melbourne. “It’s cheaper than a snakebite. Teaching First Aid, producing posters of local snakes and training health care workers on how to physically handle snakebite victims and doing play backs minimises further injury.”
If the antivenom doesn’t work, one suggestion is to send it to the country office that supplied it and ask for something that works, because every life matters.
“It all boils down to awareness,” says Alex Mutiso, environmental manager at Tullow Oil in Turkana. The firm has a snake handler at the oil fields. “We catch up to two carpet vipers a day which are released away from the camp.”
Strict but simple guidelines at the camp, such as not leaving shoes outside, checking before you wear them, not walking in the dark. and so on, have helped minimise bites. The on-site medic has never had to treat a venomous snake bite.
But for Winnie Bore, a pharmacist at KNH, watching victims succumb to snakebites led her to become an activist and found Snakebite-Kenya a year ago to provide antivenom in rural areas, help rehabilitate victims disabled or visually impaired by such bites, and develop a research programme because there is very little information on the issue in Kenya.
Statistics of deaths by snakebite in Kenya, according to Sanda Ashe, are hard to acquire with the current lack of detailed data to use as an estimate. But there has been a surge in bites and deaths where large areas of virgin land are being cleared of bush and forest. People come into contact with snakes more than in long-established inhabited areas, she says.