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01/10/2014 | 13 Questions for Dr. Zvi Bentwich, Israeli public health crusader, on Ebola and public health lessons from Ethiopia and the Occupied Territories

Martin Edwin Andersen

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 conversation …

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 Ethiopia?

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?”

Andersen:  And how did that get moved forward?

Bentwich:  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.

Andersen:  So you were ready to move to a whole new level …

Bentwich:  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 clear.

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, against them. 

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 … and this fits with what we are trying to do.

Andersen:  And the most important lesson in all of this?

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 re-infected.

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.

Andersen:  Given 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 with. 

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 doors.

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 schools.

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 the Palestinians?

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?  

Bentwich:  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.

Offnews.info (Argentina)

 



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