Mambas, medicine and one girl’s race to survive Kenya’s biting problem | Rebecca Ratcliffe

In a country where snakebite treatment is costly, hard to come by and often inadequate, Rashid Chiti feared the worst when his daughter was bitten

Rashid Chiti knew immediately it was serious. His daughters, Salome, seven, Esther, nine, and Grace, three, had been outside in the field, checking on the family’s animals and crops. When it started to rain, the two older sisters raced one another home, with Esther carrying the youngest on her back.

Salome, the lightest on her feet, was running ahead in the distance. She didn’t notice the long, grey shape lying in her path. It was a black mamba, one of the world’s most venomous snakes.

Salome
Salome, right, with her sister Sarah. Photograph: Rebecca Ratcliffe

When his daughters made it back to the house at about midday, all Chiti can remember is chaos. “I just grabbed her and looked at the bite,” he says through an interpreter. “When I saw that there was blood there, I realised: ‘Oh my God, it’s happening.’”

The number and variety of snakes in their home county, Kilifi, on the coast of Kenya, is among the highest in the country. Chiti had warned his children about snakes and knew others who had died from bites.

He called his brother and asked to borrow his bicycle. Meanwhile, Salome’s sister, Sarah, 23, tied tubing to her leg. They borrowed a motorbike from the local church and travelled 5km to a private clinic in Taru, a small town near Mombasa. They were advised to go immediately to Mariakani hospital, a further 50km away.

As sweating was followed by incontinence and then vomiting, Salome was becoming weaker and weaker. “She had dull eyes. It was like she couldn’t see you, even though she was looking through her own eyes,” says her father.

“It was like there wasn’t anybody in her body,” recalls Sarah. “It was like she had completely given up.”

When Salome’s family arrived at Mariakani hospital, they were told by doctors there was no anti-venom available. Instead, with her health rapidly deteriorating, she was sent to a second hospital, Mombasa Coast general. She was admitted at midnight and given one vial of anti-venom. But it had zero effect, says Dr Zaheer Bagha, who cared for her: the treatment she was given, like many in Kenyan hospitals, was appropriate only for Indian snakes.

A collapse in the anti-venom market means that, across sub-Saharan Africa, only a tiny proportion of need – 2.5% – is being met by effective treatments. While the need for anti-venom is high, production rates have instead fallen in recent decades. A lack of investment by governments, inefficient production, poor regulation and the inappropriate marketing of products have led to a treatment crisis.

“It is a poor man’s disease,” says Dr Eugene Erulu, at nearby Watamu hospital. “If they bite the rich or the most powerful people in the government then the attention would be different. But it’s the poorest of the poor – the guys who are tilling on their farm.”

An estimated 1 million people are bitten across sub-Saharan Africa, with as many as 20,000 killed by snakebite envenoming. Accurate figures for snakebites in Kenya aren’t known because hospitals are not required to record cases. Even if they did, many victims, especially those bitten in rural areas, do not make it to a hospital.

After decades of neglect, campaigners hope the issue is finally gaining the attention of governments. On Thursday, the World Health Assembly is expected to pass a resolution that could attract increased funding, lead to a more coordinated response from governments and boost research. Alongside the resolution, the World Health Organization (WHO) is developing a roadmap to minimise snakebite death and disability, particularly in low- and middle-income countries

Professor Abdulrazaq Habib, of Nigeria’s Bayero University, describes the resolution – driven forward by Costa Rica and Colombia, and co-sponsored by 25 other countries – as a major development. “The lack of recognition in the past means funding for control efforts was really not taken seriously. [The resolution] will be a stepping stone towards having snakebite on the radar,” he says.

The tools for tackling snakebite already exist, but they need to be made accessible, adds Royjan Taylor, director of Bio-Ken, a reptile research centre in Kenya that specialises in snakebites. “It’s all about anti-venom and training. If you get anti-venom – and someone knows how to give it, and you get it in time – then you’re not even talking about it any more,” says Taylor.

A
A black mamba at Bio-Ken Snake Farm in Kenya. Photograph: Bio-Ken Snake Farm

When Bagha saw that Salome was deteriorating, he called the James Ashe Antivenom Trust. Established by Bio-Ken, the trust provides anti-venoms free of charge to patients. After the swift administration of two vials of anti-venom, Salome woke up and made a full recovery.

The trust, a partner of Health Action International, takes as many as 10 calls a week in rainy season, the peak time for snakebites. The majority of incidents involve venomous species such as puff adders, black or green mambas, and spitting cobras. Many of the victims are children.

Recently, two brothers were bitten by a puff adder while sleeping. The eldest was bitten on the head, the youngest on the leg; both survived. In another recent case, a young girl was bitten by a red spitting cobra on the first floor of a stone building. Everyone in the local area knows someone who has been bitten.

Despite the constant need for snakebite treatment in the county’s hospitals, there is little training for medical staff and prevention work is limited. “Three-quarters of those tilling are bare footed. Many also have livestock chicken in the household and this attract rats and snakes,” says Erulu. “The biggest problem [for doctors] is knowing how to manage snake bites, because this something that is never taught in university.”

Community health workers, who tend to be the first point of access in remote, rural areas, also lack training.

Traditional healers, thought to be used by 70% of snakebite victims in Kenya, are another major concern. “They will have some herbs and get a razor blade and cut the patient to make [the bite] bleed,” says Michael K Katana, who was chief of Watamu for 20 years. “Some medicine is put there. It can be many different things: ash or some leaves and herbs.”

Boys
People in remote, rural areas of Kenya tend to run the greatest risk of dying from snake bite. Photograph: bio-ken.com

The cost of hospital care, which will include a fee for useless anti-venoms, is unaffordable for many, says Katana. To prevent the sale of such treatments, the WHO has started work assessing different anti-venoms, with the aim of recommending certain products for use in particular countries.

“It’s hoped that will [offer] support from a global level to give more guidance to countries as to how to strengthen the regulation, and also what is an anti-venom that is seen to be effective,” says Benjamin Waldmann, programme manager for snakebites at Health Action International.

David Warrell, emeritus professor of tropical medicine at Oxford University, believes too many unscrupulous producers are marketing products that don’t work. “In some cases, their specificity is inappropriate to the country in which they are being marketed,” says Warrell.

“For example, Indian manufacturers ruthlessly promote their products in countries in Africa where the English name may sound the same – like cobra – but the actual species being targeted is quite different.”

It is hoped that the addition of snakebites to the list of neglected tropical diseases, along with the forthcoming resolution, will increase the number of products being developed and bring down the price.

“Already, in the past six to 12 months, we’ve had a number of enquiries from potential new manufacturers,” says David Williams, head of the University of Melbourne’s Australian Venom Research Unit, and now chair of the WHO’s snakebite envenoming working group. “And there are a number that are likely to come into market in the next few years.”

“At the moment, anti-venom is working out at [the cost of] two goats,” says Taylor. “If you could bring it down to the price of a chicken it would make a big difference to who could afford it.”

The
The venom of a black mamba is milked at Bio-Ken Snake Farm in Kenya. Photograph: Bio-Ken Snake Farm

Back in Mombasa, Salome sits silently as the family discusses leaving the hospital. She is normally a chatterbox, her dad says. “Wait until we get home, everyone will get the long version,” he quips.

The hospital bill for Salome’s treatment was 97,194 Kenyan shillings (£721), a sum completely unaffordable for the family. Chiti was able to pay 25% of the fee, while the doctor and hospital agreed to waive the rest of the cost. The anti-venom was donated free of charge by the James Ashe Trust. Many others do not get the same support, and instead face crippling debt. Without settling the bill, Salome would not be permitted to leave the ward. Now she is about to return home.

“I’ve seen people who have died from snakebite,” reflects Chiti. “I thought I was going to lose her.”

Read more: www.theguardian.com

About the Author

Leave a Comment: