The new snake oil: antivenoms that are as useless as water

Note: this piece contains videos and images of snakes

He was reaching for the lamp, the last moments Kamidikolo* had use of both of his arms.

He had been trying to see what had caused rats to come running into his home when he was bitten.

By the time Kamidikolo made it to hospital, snake venom had already started breaking down his skin and muscle. The flesh around the bite was necrotising – dying. The process gives off a smell like rotting meat.

The only treatment that could hold off the damage was snake antivenom. Kamidikolo, 60, a handyman from the south of Uganda, was given a vial of this treatment, but it couldn’t stop the trail of destruction the venom had begun to chart through his body.

In sub-Saharan Africa, the Bureau of Investigative Journalism (TBIJ) can reveal, patients face a “Wild West” of ineffective antivenoms that are badly made, badly marketed and badly regulated. Some are about as useful as injecting water, experts said.

TBIJ tested samples of antivenoms bought in three countries, and found some antivenoms could require more than 70 vials to effectively treat some bites. Antivenoms are often in very short supply; most facilities do not stock enough and patients could not afford – or receive – that many vials in time for it to work.

One antivenom company has been accused of fraudulent research. Another business exported an antivenom for Indian snakes to west Africa, where they knew it would not work – an act experts called unethical and potentially criminal.

Antivenoms are “antique” medicines that have been made the same way for more than a century: by injecting horses and sheep with snake venom and extracting antibodies from their blood. (Antibodies are produced by the immune system to fight off viruses, toxins and other dangers.)

This antique origin is one of the reasons antivenoms have avoided some of the regulations that now apply to many other drugs. Despite being a life or death medicine, they are not held to the same standards as something as commonplace as paracetamol. There are no requirements for antivenoms to go through clinical trials to prove they are safe and effective in humans.

“It’s a cowboy show out there,” said Thea Litschka-Koen, a leading snakebite expert in Eswatini, southern Africa. “Some of them are selling stuff that honestly, you may as well just pour down the drain.”

A hidden crisis

The damage a snake bite does depends on the snake. If it’s a venomous snake, it can cause life-changing injuries – or even death.

“You get horrific wounds,” said Litschka-Koen, who founded the Eswatini Antivenom Foundation, a charity that raises funds to treat snake bite victims. “And when I say horrific, I will send you pictures that make your eyes water.”

Some snakes, like the one that bit Kamidikolo, have “cytotoxic” venom, meaning it damages and eventually kills cells. People who’ve survived these bites say it feels like being injected with burning acid. A cytotoxic bite wound can cover an entire arm and chest, or a whole leg, and take almost a year to heal, Litschka-Koen said.

Other snakes, such as the West African carpet viper, stop blood from clotting and cause excessive bleeding. And then there are snakes like the infamous black mamba, whose neurotoxic venom strangles nerve signals from the brain. Victims feel their body shut down in paralysis.

Just how many people are affected by snake bites is a bit of a mystery. It’s a problem that often goes unrecorded. The World Health Organization (WHO) says 5.4 million people are bitten each year. Estimates on deaths around the world range from 80,000 to 140,000. But who is most affected is clear.

“It’s a poor man’s disease,” Litschka-Koen said. “That’s the cruel truth of snakebite.” Those who are bitten typically live in remote, often rural, areas, mostly concentrated in south Asia and Africa. Farmers and children are among those most commonly bitten.

Including Kamidikolo, TBIJ examined seven cases where snakebite victims were left badly injured despite getting treatment. Two didn’t survive. While death is the ultimate risk, three times as many people survive and are left with permanent disabilities.

Months on, Kamidikolo still doesn’t have full use of his arm and relies on painkillers and sleeping pills . It means the father of five children under the age of ten, who makes a living from odd jobs – fixing, building, digging – cannot work. He can no longer afford to send his young children to school.

This is a common story; Litschka-Koen has seen everyone from a respected elder to an 18-month-old girl robbed of limbs, cast off by communities, and consigned to poverty.

“Snakebite has devastating economic consequences on the individual, the family, as well as the entire country,” said Litschka-Koen.

The best way to prevent these consequences is quick treatment with antivenom. With an effective dose, properly administered, chances of survival can be six times higher. But for people like Kamidikolo, local herbalists are often much easier to reach than conventional medical care. Even those in major urban centres may face difficulties – snakebite has little to no place on the curriculum at many African medical schools.

In wealthy countries like Australia, where antivenom is high quality and free to patients, snakebite causes just one to two deaths per year. But in many African countries, effective treatment has been plagued by issues for years; in 2023, an estimated 20,000 people died from snakebites in sub-Saharan Africa.

“We need to get a handle on it,” said Litschka-Koen. “It's shocking that it's taking so long.”

“You can’t look away from the cruelty and pain and suffering.”

Like injecting water

In his third-floor office in a squat glass-panelled building in Valencia, Spain, Professor Juan Calvete examined a small vial with a blue lid. Calvete is respected around the world as an expert in snake antivenom. The walls and shelves around him were adorned with trinkets and keepsakes from collaborations with other experts. In the adjoining lab, machinery whirred and clicked as his colleagues analysed venoms and antivenoms.

Calvete rolled the vial in his hand, peering at the text on the label. It listed the venom of Indian snakes it could be used to treat, some of the label was written in Bengali, and gave the price of the vial in Indian rupees. It was, unmistakably, an antivenom made for India. But it was purchased by a TBIJ reporter in east Africa.

Snake venom and its effects vary a lot from species to species, and even within the same species based on where it lives, what it eats, and other genetic factors. An antivenom formulated to work in one region can be virtually useless against snake bites somewhere else.

Calvete put it more bluntly when he explained what would happen if you were bitten by a highly venomous African snake like a black mamba and then given the Indian antivenom he was holding.

“You can do two things," he said. “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 one flavour that you like, take it. Because it will be the last thing that you eat.”

Calvete’s words carry clout. His lab at the Instituto de Biomedicina de Valencia is trusted as the sole source of the WHO’s official assessments on antivenom quality. TBIJ saw him swarmed at a snakebite conference by people seeking his opinion.

Scientific research has long proven that Indian snake antivenoms won’t work against African snakes. Calvete tested two Indian antivenoms purchased in Uganda and Nigeria by TBIJ. Made by Bharat Serums and Vaccines (BSV) and Premium Serums and Vaccines – who also make different, African antivenoms – they showed desperately low capacity to work against sub-Saharan African snake venom.

“Giving a patient this antivenom will be almost as if you inject distilled water in the body,” he said.

Both companies denied exporting their products to Uganda and Nigeria respectively. Premium Serums told TBIJ: “We have never ever exported our [Indian antivenom] to Africa. It is unfortunate that regulatory authorities in … Africa are allowing imports of such non-suitable snake antivenoms.”

The BSV antivenom has been exported to Mali, Somalia and Tanzania in recent years, and a TBIJ reporter was able to buy a vial in Uganda last year.

Dr David Williams, one of the WHO’s leading experts on snake bites, said people who buy antivenoms for national health ministries don’t always understand how they work.

“Nobody tells them what species of snake they’re meant to be looking for,” he said. “They buy the cheapest product they can possibly find. And 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.”

But a manufacturer like BSV should know where its product will work. The company – which declares its mission is “to preserve, protect, and enhance quality of life” – has been making antivenoms for years. It doesn’t make an antivenom for Africa; when TBIJ called BSV, an employee confirmed that the one antivenom the company makes is for use against Indian snakes.

BSV’s actions have caused deaths before. One of its older antivenoms was made using a mix of venoms from African and Indian snakes. Crucially, it used an Indian species of viper instead of the common African species. When it was used in Ghana in 2004, research showed it led to a nearly seven-fold rise in mortality compared to patients treated with a different antivenom.

Manufacturers are not always involved in the distribution of antivenoms. But BSV has been – records show it made several shipments of its Indian antivenom to Mali, where it couldn’t work.

BSV denied exporting its product to Somalia, Tanzania and Uganda, but said its exports to Mali had been approved by the country’s health ministry. The Malian health ministry denied this.

Dr Williams called BSV’s exports to Mali “extremely inappropriate.”

At his lab in Valencia, Calvete was more scathing.

“There are no good words to describe this,” he said. “They have been in the field for many years so they should know what they are doing.”

“If this is the case, it should be investigated as a fraud because it would be criminal to sell a lifesaving product to a country where it will not work,” Calvete said, adding: “If I had one of these people in front of me, I would say, ‘You are a son of a bitch.’ ”

Investigating Inosan

Even antivenoms created specifically for Africa vary wildly in quality. Inoserp Pan-Africa, made by the Mexican and Spanish company Inosan Biopharma, claims to combat bites from 18 different species of snakes.

But TBIJ’s testing showed that per vial, Inoserp was far and away the worst of all the African antivenoms tested. In fact, in tests against sub-Saharan African snake venom, it performed worse than one of the antivenom products made for Indian snakes. The problem is not that it contains the wrong antivenom but that there’s not enough of it in the bottle. In the lab, Inoserp’s binding capacity against mamba venom was shown to be ten times less per vial than a rival’s product (PANAF Premium).

The implications for patients are severe. For instance, the test results suggest that medics could need more than 70 of these vials to treat the bites of some of the most dangerous snakes.

That many doses would introduce two problems: delay, and high costs.

In reality a medic is very unlikely to administer that many vials.

Firstly, a doctor will wait hours between each dose of antivenom to see how a patient responds. So it would in all probability take too long for the medicine to work. “Time is life,” said 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.”

The cost is also prohibitive. A single Inoserp dose, purchased in Tanzania where healthcare isn’t always free, cost TBIJ $66 (£50), roughly a month’s earnings on the country’s minimum wage.

The problem, as the testing reveals, is that compared to its competitors, Inosan puts a fraction of the active ingredient needed into a vial of Inoserp.

Inoserp’s poor performance is not surprising for Calvete. He believes that Inoserp doesn’t live up to the claims it makes on its packaging. Calvete said he has spoken to Inosan about this, “but they have not changed how they make their product”.

“You sell more vials, you get more money,” Calvete said.

Inosan has sold $3.2m worth of Inoserp to at least 13 sub-Saharan African countries over the past five years, according to shipping data analysed by TBIJ.

Inosan told TBIJ that Inoserp has undergone several clinical trials, and that “almost all” testing has shown “acceptable neutralization and meets specifications with respect to other similar products.” It added that even though its products contain a lower amount of active ingredient, “this does not indicate any reduction in neutralizing potency or dilution. We assess the neutralizing capacity irrespective of the protein content.”

The company defended its pricing, saying it had not yet made a profit on the antivenom and that intermediaries like wholesalers were responsible for some of the cost.

On the ground, doctors’ experiences vary. Dr Eugene Erulu, a medical practitioner from Kenya with more than 20 years’ experience in snakebite, refuses to use Inoserp.

But others disagree. Dr Nicklaus Brandehoff is emergency medicine physician and executive director of the Asclepius Snakebite Foundation, which runs clinics in Guinea and Sierra Leone. He said Inosan’s product “seems to do its job pretty well”. This was particularly true, he said, for neurotoxic snake venom – the type that damages the nervous system, causing muscle weakness and paralysis.

Red flags in regulation and research

The WHO has its own approval process as a safety net for countries without the means to check antivenoms. It threw out Inosan’s last application. It was unable to guarantee that the benefits of using Inoserp would outweigh the risks, based on the evidence presented. The company is currently in the process of being assessed again.

Dr Abdul-Subulr Yakubu leads the cardiology unit at Tamale teaching hospital, but he ends up regularly treating snake bites; northern Ghana is snake country.

He often finds himself having to give a patient several times the recommended dose of antivenoms, including one made by the Indian company Vins. The WHO terminated its assessment of Vins’ sub-Saharan African products, like it did Inosan’s, in 2017.

“We’re not sure if we have to give large volumes because it’s not very effective,” Dr Yakubu said. After all, there are many other factors that can complicate treating a snake bite. 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.

Vins applied to get a WHO recommendation for its antivenom in 2016. The process was cancelled when – among other issues – Vins submitted a paper on its medicine supposedly by two respected researchers, both of whom denied having any involvement in the study.

Professor Kate Jackson, one of the listed authors on the paper, confirmed: “I didn’t collect those snakes and they don’t exist in [the Republic of the] Congo.” She doesn’t recall Vins contacting her about the paper.

Vins claimed “a senior employee” presented the research under Jackson’s name and their contract was “immediately terminated” when the company found out. “Since then, we have further strengthened our protocols to ensure that this is never repeated … We agree that indulging in such acts calls for the validity of the data to be questioned.”

It’s another example of questionable practices and the scarcity of reliable research. Without it, health workers told TBIJ they try the available antivenom and hope for the best, without ever being sure if it was the medicine, or the patient’s luck, that had the most effect.

TBIJ tested a vial of Vins purchased in Uganda. It contained far more of the active ingredient than Inosan’s product does.

Having performed poorly in tests in the past, Vins was overall the best-performing antivenom in TBIJ’s testing and against three out of four snakes it outperformed one of the only antivenoms approved by the WHO for use against some snakes in sub-Saharan Africa – PANAF, the antivenom made by Premium Serums for use against snakes in the region. But Calvete said that even the best antivenoms available in sub-Saharan Africa “could be better and should be better”.

Vins has re-applied to the WHO and is currently going through their approval process again.

Falling short

While ineffective antivenom can have deadly consequences, it’s really the last of many hurdles between a snakebite patient and survival. First they have to get to a clinic at all, in time, and hope the clinic actually has a suitable antivenom.

Shortages are a huge problem across the continent, as Dr Nicholas Amani Hamman, medical director of Nigeria’s Kaltungo Snakebite Hospital and Research Centre, is only too aware. Just this autumn, he had to watch a four-year-old boy die while waiting for a second dose of antivenom.

Desire had been taken to the hospital after being bitten by a snake on his way home from helping on the farm and given one bottle of EchiTAb-Plus-ICP, an antivenom designed to treat Nigerian snakes. It wasn’t enough and his blood wasn’t clotting, but Dr Nicholas didn’t have any more to give. His hospital urgently appealed to officials and charities for the medicine, but it didn’t come in time to save the boy.

In other cases, shortages open the door to inappropriate, substandard or even fake antivenom flooding in.

A few hours’ drive north, Professor Abdulrazaq Habib heads up the Nigerian Snakebite Research Intervention Centre. When antivenom is out of stock in his hospital, he will write a prescription for patients to take to a pharmacy.

A patient may have to “go back to his village and then sell a goat or a sheep or a cow” in order to afford treatment. Even then, there’s no guarantee they’ll get the right one. Over the years, 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.

When TBIJ sent a reporter to a pharmacy in the northwest of Nigeria, we were offered antivenoms suitable for Indian snakes and a rabies vaccine. Neither would have helped against a snake bite.

Neglected by the world

Very little antivenom is manufactured in sub-Saharan Africa. It’s estimated the region receives as little as 2.5% of the antivenom it needs. It has come to depend on imports, creating what Thea Litschka-Koen and other experts call the “Wild West”. Sloppy practices and unscrupulous manufacturers have thrived.

“Listen, let’s not paint every manufacturer with the same brush. There’s some phenomenal manufacturers out there … We mustn’t think that everybody out there who’s making antivenom is doing it for a quick buck. That’s not true,” said Litschka-Koen. “The reason for this entire shitshow is that snakebite was totally ignored.”

Snakebite is known as the most neglected of the neglected tropical diseases. That’s a classification given to a group of preventable and treatable conditions. Despite its toll, snakebite only cemented its place on the WHO’s list of priority neglected tropical diseases in 2017, years after other illnesses.

Most countries in the world have agreed to a goal of halving global mortality and disability from snake bites by 2030. However, in the five years since that goal was set, snake bites have received just $83m in funding for research and development. By comparison, Ebola got $1.65bn in similar funding. Ebola killed 2,485 people in those five years; snake bites may have killed more than 150 times as many.

But there are promising developments. Eswatini, Litschka-Koen’s homeland, has managed to secure international funding to make an antivenom for local snakes. This, combined with a big picture approach to tackling snake bites, means that in the most recent snakebite season, Eswatini recorded zero deaths for the first time in its history.

Habib believes Africa has “enormous” potential if given the right support. Producing high quality local antivenoms, he said, should be the aim. National governments need to step up as much as the international community; he points to antivenom shortages in Nigeria at the peak of snakebite season, which he puts down to poor planning.

“I'm not saying it's easy, but doing nothing is not an option.”