Venomous snakebite is "the biggest public health crisis you've never heard of," said former U.N. Secretary General Kofi Annan as he was working to get the issue onto the global health agenda in 2015.
Each year, roughly 140,000 people die from snakebite 'envenoming' (basically, when a venomous snake delivers venom into the body through a bite or spray). Another 2 to 3 million are bitten each year and survive but can face serious injury or long-term disability as a result.
In 2017, the World Health Organization recognized snakebite envenoming as a neglected tropical disease. "Since then, only limited progress has been made," said David Lalloo, vice chancellor of the Liverpool School of Tropical Medicine.
That's where the snake statues come in.
As part of an effort to put the dangers of snakebite back on the agenda, Lalloo and a group of global health experts launched Strike Out Snakebite at the World Health Forum that wrapped up this week in Geneva. To garner attention, the initiative erected eight large snake statues around the city.
NPR spoke with Lalloo, who has worked on snakebite for about 30 years, about the statues, the hidden burden of snakebites and what the initiative aims to achieve.
This interview has been edited for length and clarity.
So I've got to start with the snake statues. What's the deal there?
They were pretty spectacularly colored and colorful and pretty large. I actually saw them before I knew they were part of the initiative. I thought, this is really weird. There was no label at that point, so you just saw this snake in the middle of the park.
But they certainly attracted lots of attention throughout the week. People generally are fascinated by snakes, they either love them or hate them but are fascinated. So these are a very effective way of capturing their attention, to get the general public behind this as an issue.
I think a lot of people don't think of snakebite as a major global health problem. Why does it deserve more attention?
Snakebite is a problem that's very much hidden to the broader populations living in cities and to health planners because it does affect the poorest of the communities in the poorest areas of relatively poor countries. The challenge is that almost all of those individuals live in rural areas, often going about their daily work in the fields.
Because it occurs in such remote areas, we don't have very good statistics. And so it's very much under-recognized as a big problem.
What can happen when someone gets bitten by a venomous snake?
There's a wide variety of effects.
Some venomous snakes will cause a lot of local swelling, occasionally you can get quite significant tissue damage. If you get tissue breakdown, you may get ulcers, you may lose the skin. Those will not always heal well, particularly if you haven't got very good surgical facilities, so people can lose function of an arm or a leg because of snakebite. That can have a huge impact on their life, and their family's life, if they're the breadwinner.
And then you can have severe neurotoxicity [damage to the nervous system] that stops breathing or causes blood clotting problems. People will die from severe neurotoxicity and sometimes from bleeding or shock.
There's some really interesting evidence on psychological morbidity as well, that people after snakebite have depression or post-traumatic stress disorders.
What was the goal of the Strike Out Snakebite initiative at the World Health Assembly this week?
The ultimate goal is that every adult and child that needs an antivenom gets a high quality antivenom delivered to them rapidly. The steps on the way to that are to, first of all, have a choice of different antivenoms we know are both effective and safe, and to have supply chain systems that will get those to the patients that need them.
Alongside that, you'll have a workforce that is well-trained, that is familiar with how you manage snakebite. And then I think we'll have clear education campaigns for the population about how they avoid snakebite and what they do if they get snakebite.
In 2019, WHO developed a roadmap for snakebite envenoming. It was estimated that about $140 million would be necessary to achieve that. In reality, only between 10% to 15% of that funding has been achieved. This initiative is very much an attempt to ultimately just put snakebite back on the map and highlight where we need investment to make a big difference to this disease.
What's the current state of treatment?
Antivenoms are the mainstay of treatment, and they're made by putting snake venom into an animal, usually a horse or sheep. Then you take the blood from the animal, you process that and make it into an antivenom.
But the venom of different species is very, very different indeed. The venom of Asian snakes is completely different to that of African snakes. And even across the African continent, the venom of different species will vary quite considerably. So that has to be taken into account when you're making antivenoms and when you're distributing antivenoms.
Another challenge with antivenoms, particularly in Africa, is that they have not always been very well regulated. So there've been poor quality or ineffective antivenoms around. So the number of people, particularly in Africa, that have access to effective, high quality antivenoms is very low indeed. Even when there are good antivenoms available, they tend to be very expensive and way beyond the affordability for many health systems.
Are there efforts to develop newer vaccines?
There's a lot of work trying to specifically target antibody molecules against the toxins, rather than being pretty crude and sticking venom into a horse.
There are also efforts to develop drugs that will neutralize some of these toxins. The advantage of a drug is that they could potentially be given by mouth in very remote settings, whereas antivenom needs to be given into the vein. And you can only do that in bigger health clinics or hospitals. And so a drug that you could give in a very remote area would potentially be life-saving. Because most people are bitten in rural areas, it takes a long time to reach full health facilities.
What about delivering care, what can be improved there?
I think there's some very simple stuff that could be done on training of both medical personnel and the population.
There's also this element of educating populations about prevention — how do you prevent snakes biting you? When is the most dangerous time for snakes to bite? Are there things you can do to protect, seal your hut or your house to stop snakes [from] coming inside?
There's also a need to educate the population so that they know that if they have a severe snakebite, they need to go to the nearest health facility as soon as possible. Antivenom is more effective if it's given as soon after the bite as possible.
I think the health system challenges are going to be considerable in terms of getting antivenoms to the right place, with appropriately trained staff at smaller centers closer to rural areas. The reality is that countries find the antivenom bills quite substantial.
All these efforts will cost money. Are you concerned about funding this lesser-known problem in the current climate of shrinking funds for global health?
Well, the short answer is yes. It's probably the most difficult time for global health funding in the last 20 years. We need to look for different sources of funding and also need to look at how we can integrate this [snakebite initiative] with the other initiatives, like efforts to have community health workers deliver more primary care.
With a little bit of initiative and a bit of funding, we can make a big difference.
Postscript: The snake sculptures were taken down after the World Health Assembly ended this week. They're currently on their way to London, where they'll stay until they can find a permanent home.
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