A clinical immunologist and world-renowned expert on AIDS research, Dr. Zvi Bentwich has through his NALA Foundation (www.nalafoundation.org) recently launched the Better Future for Ethiopian Children pilot program. It is expected to treat hundreds of thousands of Ethiopian children during the current school year. Along with providing medicine (including 400,000 tabs of Praziquantel/PZQ donated by Medpharm, a generic U.S. pharmaceutical company), the children are to receive leadership training and education to become health ambassadors in their families and communities.
During the last six years
Bentwich initiated a large-scale eradication of Neglected
Tropical Diseases in Ethiopia that reached more than one million
people. The first physician to deal with AIDS in Israel and founder of the
first and largest AIDS center in that country, Bentwich is a professor emeritus
of medicine of the Hebrew University Hadassah Medical School and today a
professor of virology and immunology and head of the Center for Emerging
Tropical Diseases and AIDS at the Faculty of Health Sciences at the
Ben-Gurion University. Among other recognitions, Bentwich received in 2010 a
lifetime award from the Israeli Knesset for his contributions to Israel
Medicine and Medical Sciences.
Recently the pathbreaker in
clinical, educational and biomedical research visited Washington, D.C, and sat
down near the White House with veteran journalist Martin Edwin Andersen to talk
about the importance of the lessons learned in Ethiopian public health and what
that means in a world seemingly petrified by the Ebola virus outbreak.
Here is some of that
Andersen: Dr. Bentwich, tell us a little
bit about your NALA Foundation and its pilot program on a "Better Future
for Ethiopian Children" and what you hope to do with the program. First,
though, why is it called the NALA Foundation?
Bentwich: When I started it was basically an academic
outreach operation. But very soon we learned that our university did not have
any presence in Ethiopia, if you wanted to employ, or if you wanted to buy, or
you wanted to do things—it was financially cumbersome and very difficult. There
were independent entities registered in Ethiopia—associated with Johns Hopkins,
Columbia, and Washington University—each one of them being the implementing arm
of those academic institutions. Likewise we then decided that we had to
found an organization that would be independent of the university, and would
enable us to raise money and to do the work in Ethiopia.
While we started in Addis Ababa
with a target of 20,000 people we moved to Mek'ele, the capital of Tigray
state, so our operation expanded into Mek'ele and, indeed, we founded NALA,
which is called NALA because the guy who was our first CEO came with a long
experience in Tanzania and NALA in Swahili means “help” (or “gift”). For
legal purposes NALA Foundation Ltd. is registered in Israel as a “company for
social benefit”—the equivalent of a non-profit organization, but with the
structure of a company.
Andersen: And what brought you to
Bentwich: I came to the whole idea of eradication or
at least control of neglected tropical diseases through the fact that I have
been involved with AIDS for 30 years—I was the first physician to deal with
AIDS in Israel—and I established the first AIDS center in the country, which
was also the largest.
As a result I was exposed to
the immigration to Israel from Ethiopia which at that time—we are talking about
the early ‘90s—included quite a number of HIV-infected immigrants. Since I was
in charge of following these patients I became aware of the fact that they were
also co-infected with several parasites and, having seen that, I asked the
question if these infections could play a role in getting infected with HIV.
These were questions we all asked at that time.
That led to a series of
studies, the result of which was very clear in the sense that there was a
profound effect of these infections on the immune system. That made me come up
with the idea that these intestinal parasites affect the host immunity and
therefore must play a role in coping with HIV:
First, it makes the host more
susceptible to get infected with HIV.
Two, people become less able to
cope with the disease.
And three, it undermines the
response to vaccination.
Without going into the details,
it is good to get rid of these infections and eradicate them. It came out in a
very high-profile paper, asking “can eradication of these diseases change the
AIDS and tuberculosis epidemics?”
how did that get moved forward?
With that background, I said that the next steps should be taken in those
countries—of course implying Ethiopia, because these people came from Ethiopia.
We are talking about the early 2000s, when I was distracted because I had other
functions and roles to play. Essentially, I came back something like eight
years ago, changing my affiliation when I became Professor of immunology and
virology at the Ben-Gurion University (of the Negev) and also established a
center for tropical diseases and AIDS with the idea that that would give me the
opportunity to follow on those basic questions, or concepts.
Before 2006 I visited Ethiopia
something like eight times, and then I went on a few more trips there with the
idea of starting this operation of eradication or controlling of these
diseases. I struggled to make the bio-AIDS community accept this principle as a
standard of care, which did not happen. I therefore decided to pursue this
pathway not through the AIDS (effort), but to do it independently
and do it in any case—it not good to have these infections, and all
of us live better without them!!,.
In 2006-2007, I went to
Ethiopia to see how feasible this objective would be. We raised the seed money
to start such an operation and we made connections with a number of organizations
in the United States—among others, the American Jewish World Service, a few
others—and then the Earth Institute of Columbia University came as a partner to
an extent, so as to raise the money and also to develop the program.
you were ready to move to a whole new level
Developing the program is a very central part of the story. Why? At the
beginning I was looking around to see to what extent this was at all done and
what are the problems in reaching such objectives. And things became very
One, that the prevalence of
these diseases was very high in all of Ethiopia, with a population of between
70 and 80 million at that time. There were various estimates but probably the
average prevalence of these diseases was around 30-40 percent, so we are
talking about a problem affecting 30 or 40 million people !
Two, the country as a whole was
not doing anything seriously against it.
Three, it affected poor
people—one could say that these diseases affected the poorest of the poor—low
sanitation, low hygiene, unclean water, and of course, an abundance of the
parasites, whether in the water, or in the ground. So if one needs to control
these diseases it is not sufficient to treat people and get rid of the
infections, which by the way is relatively easy and even cheap. One also has to
deal with changing the environment, which is much too much expensive, or
changing the behavior.
Therefore, right from the
beginning we developed a plan that would try to address this huge problem by combining
mass drug administration to a large number of people with a program of
changing behavior, through health education.
If one looks now on this sort
of development, throughout those seven or eight years, one can say very clearly
that it took us time but, by now, we really developed an efficient and
successful plan due to the fact that with time we realized what are the
necessary components. We became more familiar with the culture, with the
structure of education and health systems to work with them and not, of course,
And last but not least, get the
right local community leadership that will cooperate with us in a very
intensive way and get the cooperation of the health and education systems,
reinforcing all of this with young student delegations that came with us from
Israel. So that overall we developed a system which facilitates help for the
local people, not depending on our presence and creating a situation
whereby we help them to help themselves.
Andersen: U.S. and other media focus has
been, of course, on West Africa and the Ebola scourge there. What, based
on the Ethiopian experience, do you think that is really important to focus on
in this new front against contagious diseases?
Bentwich: I will start with what we are doing
and then get back to that. I think that fortunately and even happily the
Ethiopian government has finally made the fight of containing and overcoming
these diseases—the neglected tropical diseases—a priority. If you talk
about numbers and impact, these neglected tropical diseases form the largest
public health problem faced by Ethiopia. They are not “killers” in the sense
that you die from fatal disease, but in terms of their impact and their
influence on growth, on morbidity rather than on mortality, this is a huge
problem. And as I said, the government—and for that matter the World Health
Organization, the WHO—has recognized now that this is a priority
fits with what we are trying to do.
Andersen: And the most important lesson in all
Bentwich: What we have learned from experience
and what has succeeded is a very worthwhile lesson with a much wider
implication. If you focus on the height of infection of schistosomiasis, which
is one of the diseases that cause more serious problems, and while it does not
kill people in large numbers can also be fatal. The average prevalence that we
met in Mekele in 2009—measured by a random sampling survey— was about 60
percent ( with some schools having a prevalence of 100 percent!) . In four
years, by 2012, we achieved a sustained reduction of the mean
prevalence to below five percent !!. Now, this is a very significant
achievement. Surveys done several months after the intervention reflect the
sustained impact of what we were doing, and therefore we can say that it
reflects the success of the education, that resulted in a change in behaviour so that the children did not get
It needs to be understood that
we are talking about a problem that affects a quarter of the world’s population
to varying degrees—1.5 billion people have these problems. That’s why WHO made
it a priority, because these are the diseases of the poorest of the poor, and
they perpetuate poverty because you are less able to work, you don’t grow, you
are sick, you aren’t efficient and you don’t learn as much—there’s a whole
complex. Aside from the very important element of HIV and TB to which it
contributes, looking at it from a wider perspective, the priority of working in
this direction is very clear. You are dealing with something huge.
Lastly, relatively speaking it
is the cheapest intervention in public health—if you treat AIDS, or malaria, it
costs more money. Here we have a model that can be copied, that is doable and
can be multiplied.
Now going back to your question,
Ebola is the typical example of insufficiency of the public health systems in
those countries where it happened. While it is true that it is a more serious
outbreak—because there was none before like this and maybe the nature of this
epidemic is singular, or different from the previous ones in its severity; that
still is an open question. But there is no argument that containing these
diseases is totally an issue of public health, and that it would not happen in
the developed world.
Andersen: Then why
such fear outside the zones of underdeveloped public health?
Bentwich: The fright, the concern, the message
conveyed by the media to an extent reminds me of the beginning of the AIDS
epidemic, when they said that it was Doom’s Day, that it was going to affect
the entire population—that’s not going to happen, neither in America, or in
Western Europe. I am not saying that there won’t be cases in America or in
Europe, but that is not an issue, not a problem, because the public health is
such that you can contain it. It is not a disease like AIDS at the time for
sure that you don’t know if somebody gets infected, the disease may develop for
eight years, and meanwhile you get all the other people infected. In
clear distinction Ebola is an acute, short, fatal disease and therefore
it is a different story.
the challenges, do you think foundations and other nonprofits are making the
right choices in supporting public health and in making a maximum impact?
Bentwich: This is a tough question to answer
because there is no doubt that there are very fine organizations that are doing
very important work. However, if I was to say what is the main criticism
vis-à-vis some of these organizations, maybe even the culture of some of these
organizations, is that they are too much outsiders. They do not cultivate and
develop sufficiently the work from bottom up; in other words, very often they
come as foreigners and outsiders that teach, or instruct, rather than work
We learned, to an extent the
hard way, that the process that we underwent taught us very, very clearly what
were the mistakes and what we see in other organizations. They also have a bad
element in the way the money is spent—salaries, facilities, the way some people
live that is very different; nobody is expecting that people from the U.S. or
Europe will necessarily live like Ethiopians, but that very much depends
on the degree. The standard of living, the way the money is spent, is not—let’s
put it this way—a good lesson. So this is a second kind of criticism. Don’t get
me wrong; I think there are extremely important contributions of some of these
NGOs, I have seen it very clearly in Ethiopia.
Andersen: A least
one generic pharmaceutical company (and a leader in this sort of effort), Medpharm has been participating in the
"Better Future for Ethiopian Children" pilot program. What
exactly has that meant to your efforts, and is it time to issue a friendly
challenge to other pharma to match efforts such as those, both in Ethiopia or
elsewhere where the need is great?
Bentwich: This is a very good and important
question—and the answer is not straightforward. What I would say, definitely
you see a company like MedPharm that is helping, and this is fantastic. There
is no question that the delivery, or the operation, depends on the medication.
It costs money, and you should have somebody take care of that part.
To the credit of the big Pharma
in recent years, there has been a movement towards generating or donating large
amounts of these medications for these diseases by several of the big Pharma.
Just to name them—Merck, GlaxoSmithKline, Sanofi, and J&J—each one of them
have donated large amounts of medications for various neglected tropical
diseases. Why did they do it? Probably because it didn’t cost them that much;
because they wanted to have a better public profile. So this trend is
commendable, it is a positive thing to happen in whatever way you choose
to look at it.
But this is not sufficient. In
other words, the needs are bigger than what they have. The bottom line—we need
more donations, and generic drugs are certainly one part of the answer, we need
more companies to donate, and we need the same companies to donate more.
Andersen: I understand that you are one
of only a handful of physicians from Israel who are able to work with
Palestinian colleagues to assist them and the local population help beat back
the threat of HIV/AIDS in the West Bank and Gaza medically. Obviously in
this, like in working in Ethiopia, language is important. This is something I
learned myself when I briefly taught at Addis Ababa University and found that
some of my students had to translate my lectures into a second, and sometimes
even third language, in order that all of the students would understand and be
able to participate appropriately.
Bentwich: I belong to Physicians for Human Rights,
where we go to the Israeli occupied territories and give medical care to
Palestinian Arabs. So I took special lessons in learning Arabic and I can tell
you that the fact that I can speak the language is a very clear personal
experience on the difference between having some interpreter or conversing or
at least communicating with patients in Arabic.
If you got to the more distant,
more different culture—and Ethiopian culture is clearly a more different
one—the more important it is to create bridges with that culture. And it
is more complicated in this case. Why? Because we are talking about changes in
behavior; you want to influence people to change their behavior and part of that
behavior is of course very deeply integrated into their culture, their habits,
their traditions, the whole structure of society.
In this regard, I think that
there are two kind of polar experiences. One is that you need to have people
with good standing in the society or in that community that have influence in
that micro environment. So we were learning the hard way when we started, when
we came we thought that just by communicating with the headmasters or the
directors of education that you will get your way. And we learned that
that doesn’t work, and then we had the local person who had had some public
health training, and he understood what we were trying to do—but again, his
personality and his leadership were deficient. We were not living there at that
time, and again it didn’t work the way that we wanted.
Then we found a true leader in
that community, a guy that everybody knew and who had their respect—he was part
of another NGO in that town—and so we recruited him. Once we recruited him we
got into the society and we could open doors that were not exactly open before.
So there is no doubt that addressing such an issue and wanting to reach
results, to succeed in that assignment, required knowledge, channels, and open
Now I have to confess that I
did not learn Ethiopian languages, but it is clear that language is very
important. So this is one part of the story.
Andersen: And the rest?
Bentwich: The second part, which I would
say is not less impressive, is the experience we had through our students. What
I described was a gradual building up of a system that allowed us to do what we
wanted to do. The other part was not planned ahead of time, but students in Ben
Gurion came to me—they heard about this operation—and they wanted to volunteer.
To make a long story short, we had a delegation of 10 very fine students, not
professionally into the health sciences—most of them were physical therapists
and lab technicians—most of them girls and they came with us to essentially
pass the message of health education, the change of behavior, to schools.
Now Mek'ele has roughly 70
schools., public and private and up to secondary schools. It is a township of
250,000 people. So we thought, all right, we will bring the students and
we will try to cover part of the schools—we did not expect them to cover 70
This was truly a success
story—because of two things that we did not expect, that we did not know would
happen. Young people, not knowing the language but very naïve and full of good
spirits and commitment, found a way to reach the children. They made such good
contact with the local children, who were extremely enthused, and with good
cooperation and collaboration with the teachers, in less than three months they
covered the whole 70 schools. They devised games, they devised all sorts
of interaction with the children. Just as an illustration: I came
to visit and the school children—some of them really small—gave lectures
in their own language to the classes, on what you should do, and so on and so
forth. So this was a very impressive kind of experience which essentially
showed us that you can get with young people and get sort of an entrance into
things that, with all our professional knowledge, we couldn’t succeed as much.
This led to the last development—once
(the Israeli) students were there and showed what they could really achieve, we
decided that that was really a good bridge to the local students. In other
words there was a local university, there are college students; why not recruit
them to help their own people? And this is where we stand now. They have a
students’ club and they partner with our students and they are now leading that
kind of movement. Looking ahead, I would say that a very important ingredient
is getting Ethiopian volunteer students to be part of the leadership of
this whole operation.
Andersen: Given the news over last few
months from the Occupied Territories, are you able to continue your work among
Bentwich: Generally speaking you can divide Israelis
into those that believe and those who are skeptical, who say that there is
nobody to talk to. Whether it is because I am optimistic, or whether because of
my own lessons from my experience, I firmly believe that there is no other way
but to reach a compromise to live in peace.
This could be a paradise if we
could overcome those things that are tragic, terrible, something that you
shouldn’t accept; but how do you reach that? Then, of course, the question is
much more difficult to answer. I even wrote a piece very shortly before I came,
that there is a very acute need of leadership and essentially this is on both
sides although I have to admit that nowadays it is even more the problem of the
Israelis than that of the other side. This needed leadership should
come from the right nationalist side and not from the left-liberal side,
and make that bold step that is needed to reach out. I think that is
essentially what is needed.
But on the lower level, every
time I come back from this experience—say a Saturday that I spend wherever I am
in the Occupied Territories—I come back and say ‘I wish I could take all the
Israelis in my pocket to see that it is not terrible, it is not frightening,
one meets only with a warm and pleasant reception and there are
sufficient people on the other side who really want to live in peace. So that’s
the answer. Do you need to take young people and have them spend time with
their colleagues? Yes. But that regretfully is not happening.
Andersen: Your visit to the United States
is part of a continuing effort that only someone like you, who has received
prestigious life-time awards for your many contributions to medicine and
medical sciences, can embark upon. For those who want to make a contribution
from other stations in life, what can they do to help?
In a way it sounds very simple: Support us, give us money.
The main message that I carry
is: 1) It is the most cost-effective public health intervention; 2) it is
probably the major public health problem in the world, and 3) I as an Israeli
want to do things, not just for our people, but for others.
If you ask what they can do, of
course they can volunteer, they can come and help us, but the bottom line is
material support, because though it is very cheap and cost-effective every intervention
costs and we need that support.