13 Questions for Dr.

Zvi Bentwich, Israeli public health crusader, on Ebola

and public health lessons from Ethiopia and the Occupied erritories
A clinical immunologist and world-renowned expert on AIDS research, Dr. Zvi
Bentwich has through his NALA oundation !www.nala"oundation.org# recentl$
launched the %Better uture "or &thiopian 'hildren( pilot program. It is expected to
treat hundreds o" thousands o" &thiopian children during the current school $ear.
Along with providing medicine !including )**,*** ta+s o" ,ra-i.uantel/,Z0 donated
+$ 1edpharm, a generic 2.S. pharmaceutical compan$#, the children are to receive
leadership training and education to +ecome health am+assadors in their "amilies
and communities.
During the last six $ears Bentwich initiated a large-scale eradication o" Neglected
3ropical Diseases in &thiopia that reached more than one million people. 3he "irst
ph$sician to deal with AIDS in Israel and "ounder o" the "irst and largest AIDS center
in that countr$, Bentwich is a pro"essor emeritus o" medicine o" the 4e+rew
2niversit$ 4adassah 1edical School and toda$ a pro"essor o" virolog$ and
immunolog$ and head o" the 'enter "or &merging 3ropical Diseases and AIDS at
the acult$ o" 4ealth Sciences at the Ben-5urion 2niversit$. Among other
recognitions, Bentwich received in 6*7* a li"etime award "rom the Israeli 8nesset
"or his contri+utions to Israel 1edicine and 1edical Sciences.
9ecentl$ the path+rea:er in clinical, educational and +iomedical research visited
;ashington, D.', and sat down near the ;hite 4ouse with veteran <ournalist 1artin
&dwin Andersen to tal: a+out the importance o" the lessons learned in &thiopian
pu+lic health and what that means in a world seemingl$ petri"ied +$ the &+ola virus
out+rea:.
Here is some of that conversation
Andersen: Dr. Bentwich, tell us a little +it a+out $our NALA oundation and its pilot
program on a =Better uture "or &thiopian 'hildren= and what $ou hope to do with
the program. irst, though, wh$ is it called the NALA oundation>
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 thingsit was
financially cumbersome and very difficult. here were independent entities
registered in Ethiopiaassociated with !ohns Hop"ins, #olumbia, and Washington
$niversityeach one of them being the implementing arm of those academic
institutions. %i"ewise we then decided that we had to found an organi&ation that
would be independent of the university, and would enable us to raise money and to
do the wor" in Ethiopia.
While we started in 'ddis 'baba with a target of (),))) people we moved
to *e"+ele, the capital of igray state, so our operation e,panded into *e"+ele and,
indeed, we founded -'%', which is called -'%' because the guy who was our first
#E. came with a long e,perience in an&ania and -'%' in /wahili means 0help1
2or 0gift13. 4or legal purposes -'%' 4oundation %td. is registered in Israel as a
0company for social benefit1the e5uivalent of a non6profit organi&ation, but with
the structure of a company.
Andersen: And what +rought $ou to &thiopia>
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 'I7/ for 8) years
I was the first physician to deal with 'I7/ in Israeland I established the first
'I7/ center in the country, which was also the largest.
's a result I was e,posed to the immigration to Israel from Ethiopia which at that
timewe are tal"ing about the early 9:)sincluded 5uite a number of HI;6infected
immigrants. /ince I was in charge of following these patients I became aware of the
fact that they were also co6infected with several parasites and, having seen that, I
as"ed the 5uestion if these infections could play a role in getting infected with HI;.
hese were 5uestions we all as"ed at that time.
hat 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. hat made
me come up with the idea that these intestinal parasites affect the host immunity
and therefore must play a role in coping with HI;<
4irst, it ma"es the host more susceptible to get infected with HI;.
wo, people become less able to cope with the disease.
'nd 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 high6profile paper, as"ing 0can eradication of these
diseases change the 'I7/ and tuberculosis epidemics=1
Andersen: And how did that get moved "orward>
Bentwich: With that bac"ground, I said that the ne,t steps should be ta"en in
those countriesof course implying Ethiopia, because these people came from
Ethiopia. We are tal"ing about the early ()))s, when I was distracted because I had
other functions and roles to play. Essentially, I came bac" something li"e eight years
ago, changing my affiliation when I became >rofessor of immunology and virology
at the Ben6?urion $niversity 2of the -egev3 and also established a center for
tropical diseases and 'I7/ with the idea that that would give me the opportunity to
follow on those basic 5uestions, or concepts.
Before ())@ I visited Ethiopia something li"e 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 ma"e the bio6'I7/ community accept this principle
as a standard of care, which did not happen. I therefore decided to pursue this
pathway not through the 'I7/ 2effort3, but to do it independently and do it in any
caseit not good to have these infections, and all of us live better without themAA,.
In ())@6())B, I went to Ethiopia to see how feasible this obCective would be. We
raised the seed money to start such an operation and we made connections with a
number of organi&ations in the $nited /tatesamong others, the 'merican !ewish
World /ervice, a few othersand then the Earth Institute of #olumbia $niversity
came as a partner to an e,tent, so as to raise the money and also to develop the
program.
Andersen: So $ou were read$ to move to a whole new level ?
Bentwich: 7eveloping the program is a very central part of the story. Why= 't the
beginning I was loo"ing around to see to what e,tent this was at all done and what
are the problems in reaching such obCectives. 'nd things became very clear.
.ne, that the prevalence of these diseases was very high in all of Ethiopia, with a
population of between B) and D) million at that time. here were various estimates
but probably the average prevalence of these diseases was around 8)6E) percent,
so we are tal"ing about a problem affecting 8) or E) million people A
wo, the country as a whole was not doing anything seriously against it.
hree, it affected poor peopleone could say that these diseases affected the
poorest of the poorlow sanitation, low hygiene, unclean water, and of course, an
abundance of the parasites, whether in the water, or in the ground. /o 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. .ne also has to deal
with changing the environment, which is much too much e,pensive, or changing the
behavior.
herefore, 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 loo"s now on this sort of development, throughout those seven or eight years,
one can say very clearly that it too" us time but, by now, we really developed an
efficient and successful plan due to the fact that with time we reali&ed what are the
necessary components. We became more familiar with the culture, with the
structure of education and health systems to wor" with them and not, of course,
against them.
'nd 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. /o 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: 2.S. and other media "ocus has +een, o" course, on ;est A"rica and the
&+ola scourge there. ;hat, +ased on the &thiopian experience, do $ou thin: that is
reall$ important to "ocus on in this new "ront against contagious diseases>
Bentwich: I will start with what we are doing and then get bac" to that. I thin" that
fortunately and even happily the Ethiopian government has finally made the fight of
containing and overcoming these diseasesthe neglected tropical diseasesa
priority. If you tal" about numbers and impact, these neglected tropical diseases
form the largest public health problem faced by Ethiopia. hey are not 0"illers1 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.
'nd as I said, the governmentand for that matter the World Health .rgani&ation,
the WH.has recogni&ed now that this is a priority and this fits with what we
are trying to do.
Andersen: And the most important lesson in all o" this>
Bentwich: What we have learned from e,perience 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 "ill people in large numbers can also be fatal. he
average prevalence that we met in *e"ele in ()):measured by a random
sampling survey was about @) percent 2 with some schools having a prevalence
of F)) percentA3 . In four years, by ()F(, we achieved a sustained reduction of the
mean prevalence to below five percent AA. -ow, this is a very significant
achievement. /urveys 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 re6infected.
It needs to be understood that we are tal"ing about a problem that affects a 5uarter
of the worldGs population to varying degreesF.H billion people have these
problems. hatGs why WH. 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 wor",
you donGt grow, you are sic", you arenGt efficient and you donGt learn as much
thereGs a whole comple,. 'side from the very important element of HI; and B to
which it contributes, loo"ing at it from a wider perspective, the priority of wor"ing in
this direction is very clear. Iou are dealing with something huge.
%astly, relatively spea"ing it is the cheapest intervention in public healthif you treat
'I7/, or malaria, it costs more money. Here we have a model that can be copied,
that is doable and can be multiplied.
-ow going bac" to your 5uestion, Ebola is the typical e,ample of insufficiency of the
public health systems in those countries where it happened. While it is true that it is
a more serious outbrea"because there was none before li"e this and maybe the
nature of this epidemic is singular, or different from the previous ones in its severityJ
that still is an open 5uestion. 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: 3hen wh$ such "ear outside the -ones o" underdeveloped pu+lic
health>
Bentwich: he fright, the concern, the message conveyed by the media to an
e,tent reminds me of the beginning of the 'I7/ epidemic, when they said that it
was 7oomGs 7ay, that it was going to affect the entire populationthatGs not going
to happen, neither in 'merica, or in Western Europe. I am not saying that there
wonGt be cases in 'merica 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 li"e
'I7/ at the time for sure that you donGt "now 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: 5iven the challenges, do $ou thin: "oundations and other nonpro"its
are ma:ing the right choices in supporting pu+lic health and in ma:ing a maximum
impact>
Bentwich: his is a tough 5uestion to answer because there is no doubt that there
are very fine organi&ations that are doing very important wor". However, if I was to
say what is the main criticism vis6K6vis some of these organi&ations, maybe even
the culture of some of these organi&ations, is that they are too much outsiders. hey
do not cultivate and develop sufficiently the wor" from bottom upJ in other words,
very often they come as foreigners and outsiders that teach, or instruct, rather than
wor" with.
We learned, to an e,tent the hard way, that the process that we underwent taught
us very, very clearly what were the mista"es and what we see in other
organi&ations. hey also have a bad element in the way the money is spent
salaries, facilities, the way some people live that is very differentJ nobody is
e,pecting that people from the $./. or Europe will necessarily live li"e Ethiopians,
but that very much depends on the degree. he standard of living, the way the
money is spent, is notletGs put it this waya good lesson. /o this is a second "ind
of criticism. 7onGt get me wrongJ I thin" there are e,tremely important contributions
of some of these -?.s, I have seen it very clearly in Ethiopia.
Andersen: A least one generic pharmaceutical compan$ !and a leader in this sort
o" e""ort#, 1edpharm has +een participating in the =Better uture "or &thiopian
'hildren= pilot program. ;hat exactl$ has that meant to $our e""orts, and is it time
to issue a "riendl$ challenge to other pharma to match e""orts such as those, +oth in
&thiopia or elsewhere where the need is great>
Bentwich: his is a very good and important 5uestionand the answer is not
straightforward. What I would say, definitely you see a company li"e *ed>harm that
is helping, and this is fantastic. here is no 5uestion that the delivery, or the
operation, depends on the medication. It costs money, and you should have
somebody ta"e care of that part.
o the credit of the big >harma 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 >harma. !ust to name them*erc",
?la,o/mithLline, /anofi, and !M!each one of them have donated large amounts
of medications for various neglected tropical diseases. Why did they do it= >robably
because it didnGt cost them that muchJ because they wanted to have a better public
profile. /o this trend is commendable, it is a positive thing to happen in whatever
way you choose to loo" at it.
But this is not sufficient. In other words, the needs are bigger than what they have.
he bottom linewe 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 $ou are one o" onl$ a hand"ul o" ph$sicians "rom Israel
who are a+le to wor: with ,alestinian colleagues to assist them and the local
population help +eat +ac: the threat o" 4I@/AIDS in the ;est Ban: and 5a-a
medicall$. A+viousl$ in this, li:e in wor:ing in &thiopia, language is important. 3his
is something I learned m$sel" when I +rie"l$ taught at Addis A+a+a 2niversit$ and
"ound that some o" m$ students had to translate m$ lectures into a second, and
sometimes even third language, in order that all o" the students would understand
and +e a+le to participate appropriatel$.
Bentwich: I belong to >hysicians for Human Nights, where we go to the Israeli
occupied territories and give medical care to >alestinian 'rabs. /o I too" special
lessons in learning 'rabic and I can tell you that the fact that I can spea" the
language is a very clear personal e,perience on the difference between having
some interpreter or conversing or at least communicating with patients in 'rabic.
If you got to the more distant, more different cultureand Ethiopian culture is
clearly a more different onethe more important it is to create bridges with that
culture. 'nd it is more complicated in this case. Why= Because we are tal"ing
about changes in behaviorJ 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 thin" that there are two "ind of polar e,periences. .ne is that you
need to have people with good standing in the society or in that community that
have influence in that micro environment. /o we were learning the hard way when
we started, when we came we thought that Cust by communicating with the
headmasters or the directors of education that you will get your way. 'nd we
learned that that doesnGt wor", and then we had the local person who had had some
public health training, and he understood what we were trying to dobut again, his
personality and his leadership were deficient. We were not living there at that time,
and again it didnGt wor" the way that we wanted.
hen we found a true leader in that community, a guy that everybody "new and who
had their respecthe was part of another -?. in that townand so we recruited
him. .nce we recruited him we got into the society and we could open doors that
were not e,actly open before. /o there is no doubt that addressing such an issue
and wanting to reach results, to succeed in that assignment, re5uired "nowledge,
channels, and open doors.
-ow I have to confess that I did not learn Ethiopian languages, but it is clear that
language is very important. /o this is one part of the story.
Andersen: And the rest>
Bentwich: he second part, which I would say is not less impressive, is the
e,perience 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. he other part was not
planned ahead of time, but students in Ben ?urion came to methey heard about
this operationand they wanted to volunteer. o ma"e a long story short, we had a
delegation of F) very fine students, not professionally into the health sciences
most of them were physical therapists and lab techniciansmost of them girls and
they came with us to essentially pass the message of health education, the change
of behavior, to schools.
-ow *e"+ele has roughly B) schools., public and private and up to secondary
schools. It is a township of (H),))) people. /o we thought, all right, we will bring
the students and we will try to cover part of the schoolswe did not e,pect them to
cover B) schools.
his was truly a success storybecause of two things that we did not e,pect, that
we did not "now would happen. Ioung people, not "nowing the language but very
naOve and full of good spirits and commitment, found a way to reach the children.
hey made such good contact with the local children, who were e,tremely
enthused, and with good cooperation and collaboration with the teachers, in less
than three months they covered the whole B) schools. hey devised games, they
devised all sorts of interaction with the children. !ust as an illustration< I came to
visit and the school childrensome of them really smallgave lectures in their own
language to the classes, on what you should do, and so on and so forth. /o this
was a very impressive "ind of e,perience which essentially showed us that you can
get with young people and get sort of an entrance into things that, with all our
professional "nowledge, we couldnGt succeed as much.
his led to the last developmentonce 2the Israeli3 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 studentsJ why not recruit them to help their own people= 'nd this is where
we stand now. hey have a studentsG club and they partner with our students and
they are now leading that "ind of movement. %oo"ing 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: 5iven the news over last "ew months "rom the Accupied 3erritories, are
$ou a+le to continue $our wor: among the ,alestinians>
Bentwich: ?enerally spea"ing you can divide Israelis into those that believe and
those who are s"eptical, who say that there is nobody to tal" to. Whether it is
because I am optimistic, or whether because of my own lessons from my
e,perience, I firmly believe that there is no other way but to reach a compromise to
live in peace.
his could be a paradise if we could overcome those things that are tragic, terrible,
something that you shouldnGt acceptJ but how do you reach that= hen, of course,
the 5uestion is much more difficult to answer. I even wrote a piece very shortly
before I came, that there is a very acute need of leadership and essentially this is
on both sides although I have to admit that nowadays it is even more the problem of
the Israelis than that of the other side. his needed leadership should come from
the right nationalist side and not from the left6liberal side, and ma"e that bold step
that is needed to reach out. I thin" that is essentially what is needed.
But on the lower level, every time I come bac" from this e,periencesay a
/aturday that I spend wherever I am in the .ccupied erritoriesI come bac" and
say 9I wish I could ta"e all the Israelis in my poc"et to see that it is not terrible, it is
not frightening, one meets only with a warm and pleasant reception and there are
sufficient people on the other side who really want to live in peace. /o thatGs the
answer. 7o you need to ta"e young people and have them spend time with their
colleagues= Ies. But that regretfully is not happening.
Andersen: Bour visit to the 2nited States is part o" a continuing e""ort that onl$
someone li:e $ou, who has received prestigious li"e-time awards "or $our man$
contri+utions to medicine and medical sciences, can em+ar: upon. or those who
want to ma:e a contri+ution "rom other stations in li"e, what can the$ do to help>
Bentwich: In a way it sounds very simple< /upport us, give us money.
he main message that I carry is< F3 It is the most cost6effective public health
interventionJ (3 it is probably the maCor public health problem in the world, and 83 I
as an Israeli want to do things, not Cust for our people, but for others.
If you as" 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
cost6effective every intervention costs and we need that support.