It’s a vicious cycle.

People find that they cannot get effective snakebite treatment – because cost or distribution problems make antivenom unavailable, or because they’ve been given a less effective antivenom, or because their treatment has been given to them the wrong way or too long after they’ve been bitten.

This leads people to stop seeking out treatment, and governments to stop their funding for it, reducing demand and forcing manufacturers to raise their prices. This in turn leads to cheaper, less safe, less effective products flooding the market, which the manufacturers of good-quality treatments then have to compete with – or get out of the market altogether.

This happened infamously with Fav-Afrique, one of Africa’s best polyspecific antivenoms. Its manufacturer, Sanofi Pasteur, decided to stop making it because it couldn’t compete with the cost of rival products. Sanofi released its last batch in 2014, which was usable up until its expiry date in June 2016; from that point on, a new manufacturer would be needed. Only in January 2018, 18 months after that final batch had expired, did MicroPharm announce it was taking over production.

At the root of this lies the biggest – and arguably hardest – problem that needs solving: the overall lack of trust in antivenom therapy.

“When nurses and health centres don’t have the right antivenom – or any at all – each time a snakebite happens, it stigmatises a little more this incompetence. People end up considering that the doctors can’t do anything,” says Achille Massougbodji. “There is a lack of trust, which translates into people massively delaying going to consult health services.”

Many patients reluctantly arrive at hospital days after a bite, when they are too sick to be treated properly. When doctors are then unable to help them, this reinforces the idea that they should seek traditional healers first. But the longer people wait to get antivenom, the less benefit they get from it.

However, cutting out traditional healers from a patient’s therapeutic journey may not be the solution.

Despite its small size, the West African carpet viper (Echis ocellatus) likely causes more snakebite deaths in Africa than any other species. Nick Ballón © Wellcome Trust

In the city of Atakpamé, in south-central Togo, a traditional healer sits by the side of the road, minutes away from the local hospital. On a large white sheet tied around two wooden poles, little painted icons show the different ailments he offers to cure. An eye-catching green snake sits in the top left-hand corner.

Sitting on a bench hidden behind the sheet, the old man refuses to give his name. But he is keen to show the plants and the dried-up snake heads and skins that he keeps in boxes, which are part of his therapeutic tools. Gradually, a little crowd forms around him, eager to hear him speak.

The relationship between traditional healers and their communities is deeply based on trust, and this is crucial in the context of snakebite. In many African cultures, being bitten by a snake is seen as something not entirely natural. People sometimes believe it’s a curse.

“There is this whole perception around snakes that means people tend to first go see the person who will not only treat the physical symptoms, but also address the spiritual aspects linked to snakebite,” Massougbodji explains.

So it’s unlikely that people would suddenly bypass their traditional healer to go straight to hospital. Massougbodji believes that working with healers is key – at least by training them to avoid doing things that could make the bite worse, and by getting them to redirect patients to health centres earlier.

However, rebuilding trust between patients and doctors, and getting people to seek antivenom in hospital, will only be possible if health professionals themselves have the right ideas on antivenom.

Jean-Philippe Chippaux, a research director at the Institute of Research for Development in France, knows this all too well. He has been working for decades in Africa on snakebite. He’s come to the northern Togolese city of Kara to speak to health professionals about his experiences, and to share his recommendations on how best to treat snakebite.

Much of Togo is rural, and many of the attendees see snakebite victims on a regular basis, but they never know quite how to react.

Charles Salou*, a paediatric doctor from the south of the country, is one of them. He is quite shaken up by the death of a 15-year-old boy under his watch the week before.

The boy was brought in by a nun, who paid for his treatment. Fearful of possible side-effects, Salou did as he had been taught, giving only one unit of antivenom, even when the boy’s symptoms persisted. It wasn’t enough to have an effect. The boy’s condition worsened, and he died.

Chippaux encounters misperceptions about antivenom’s safety a lot among health professionals. “They either believe it is a dangerous product that is difficult to administer, or that it’s a miracle product that can solve everything,” he says. “But that’s not the case. Antivenom is here to eliminate the venom out of the organism – not to treat the complications that arise.”

Not only do snakebite victims have to receive adequate antivenom, but they may also need to be given other medicines to help with any persisting symptoms. The problem is that little is known about the long-term complications of snakebite envenoming. Internal bleeding, for example, can still occur days after antivenom has been given.

But even if some outcomes can’t be predicted, or even treated, basic training like Chippaux’s is crucial.

“Had I received this training before the arrival of this patient, I could have saved him,” says Salou. “It pains me when I tell myself that.”

Back in Sokodé, Mamadou is getting weaker by the minute. He is suffering from severe anaemia, but the hospital doesn’t have any of the blood products that he needs. A week after his bite, it’s unlikely that more antivenom will help. Doctors are not even sure whether he is still bleeding internally, or if other problems could suddenly appear, making his condition worse.