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Bench Maji, a small area in the southwest of Ethiopia, is home to approximately one million people. The area is considered one of the toughest disease hotspots in Ethiopia, where according to a survey by the Federal Ministry of Health (MoH) in 2014, 82% of children in the capital city were infected with bilharzia. Caused by parasitic worms, bilharzia has devastating physical and cognitive impacts on the daily lives of infected individuals. In just three years a community intervention program, spearheaded by NALA and pharmaceutical company Merck, caused a reduction in the prevalence of bilharzia in children to 12.9%. Throughout the past decade NALA has successfully implemented programs throughout Ethiopia that reduce the prevalence of disease in school aged children. A community intervention in the city of Mekelle, situated in the north of Ethiopia, caused the prevalence of bilharzia to drop from 40% to less than 2% in 6 years. However, what NALA is most proud of is the low prevalence of disease that is maintained in communities over half a decade later.
Eradicating neglected tropical diseases (NTDs)
NALA, a small organisation with a yearly budget of less than 1 million dollars, owes its founding principles and ability to cause such significant impact to the work of Professor Zvi Bentwich from Ben Gurion University. The first Israeli doctor to work with AIDS patients, including the Ethiopian community in Israel, Professor Bentwich observed that in addition to HIV infection, many individuals were also suffering from intestinal worms, causing immune system depletion. Professor Bentwich hypothesised that neglected tropical diseases (NTDs), including intestinal worms and bilharzia, were increasing the vulnerability of populations to HIV/AIDS. Therefore, according to Professor Bentwich’s work, to efficiently combat the HIV pandemic, NTDs had to first be eliminated. Due to the gravity of significance that the research held work had to be done and in 2011 NALA was established as an independent NGO, dedicated to eradicating NTDs.
The initial years of Prof. Bentwich’s activities revealed several important points:
1. NTDs perpetuate poverty through impacting the physical and cognitive development of individuals in areas where they are endemic.
2. In relation to deadly epidemics of Africa (HIV/AIDS, TB, and Malaria), NTDs were not considered a priority by the Ethiopian Ministry of Health. Reinforced by most of the population being infected by at least one NTD, an impression was formed that NTD infection was inevitable.
3. Mass Drug Administration (MDA) campaigns are the main vehicle for treating disease, however these approaches inevitably failed. "Living in crowded environments with polluted water sources" explains Professor. Bentwich, "means that once drug distributions stop, children suffer from reinfections, it is comparative to placing a plaster on a deep wound."
Community Ownership
Professor Bentwich and NALA CEO Michal Bruck, introduced to NALA a holistic approach for intervention. This approach places focus on partnerships with the community, government, and local employees, who share in the planning and implementation of activities and innovations.
"Our goal" explains Michal "is to break the cycle of poverty through eradicating treatable yet neglected diseases. The holistic approach that includes consultations with local leadership and professional community, enables NALA to understand the underlying reasons for high rates of morbidity. In addition, NALA constantly procures advice from experts in fields of health, education, and water to create innovate approaches and solutions to fighting disease. However, ultimately it is the community that holds the key to change, and only through them understanding the benefit of such activities can programs have impact"
The intersectoral approach that NALA endorses together with the local governments, enables sectors not to examine the field from their point of view, but improve the overall lives of individuals and communities. "So far, sectors have been working separately and only looking through the narrow lens of their field" admits Semein Kubela Wadla Woreda Health Office Head, "but we have now all come together and have a more holistic view of the community’s needs. Therefore, we are better able to improve peoples’ living conditions and overall well-being".
Michal, through her vast experience attributes the elimination of NTDs to several factors:
- Community involvement and health education engagement using technological aids and interactive games that lead to behaviour change and the adoption of healthy habits.
- Research and development, including the testing of new methods and approaches to disease control.
- Program support from all stakeholders to encourage and promote behavioural change including a healthier and safer environment, such as improvements to water and sanitation in communities, with the support of NALA.
Innovation
Michal explains that the mission of NALA is to implement a global model of disease prevention, reducing drug dependence through the achievement of long-term solutions. In 2019 NALA, together with the Ethiopian Ministry of Health and World Health Organisation, created the national policy for NTD prevention. NALA also created an online course for health workers and instructed in trainings for Ministries of Health all over East Africa. NALA continues to form platforms for collaborations across sectors in the field of health, education, economics, and water in Ethiopia, both at the district and national level through a process that includes mapping, prioritisation, decision making and resource transfer.
NALA’s innovative research and development has bought new insights and presented significant achievements. In the case of trachoma, focus was previously placed on older children despite the majority of morbidity occurring in children aged 1 to 9 years old. This discovery led to the creation of a program, in collaboration with health and education experts, to prevent early childhood morbidity. Similarly, in the field of WASH infrastructure, NALA’s experts discovered that in 80% of school water infrastructure was inoperative, with the investment for repairing this infrastructure significantly smaller than the construction of new infrastructure. This discovery led to the creation of WASH on Wheels, a mobile WASH repair unit with the goal of providing school children with safe and free access to water.
NALA owes its success to its partners both in Ethiopia and from around the world. "The partnership with Merck, the pharmaceutical company that produces bilharzia medication, is a collaboration we are incredibly proud of. Not only does it allow us to prevent disease in Bench Maji, but it has also enabled us access to experts in the field of bilharzia and given us tremendous freedom of action for implementation of new models." Michal continues to emphasise that NALA is "thirsty for collaborations with Israeli companies and organisations who will present us with new approaches and innovations.
Sustainable Impact
"NALA, as a small organisation with limited resources has the great ability of being able to think outside the box and move things along at a greater pace" adds accountant Amir Sabhat, a board member of NALA since 2019. "NALA has great ambitions. Through the recruitment of investments, NALA aims to expand its activities and achieve greater impact. Furthermore, the cost of intervention is negligible compared to the results, where for every dollar of investment there is 25 times return on socioeconomic benefits. The viability is clear." Amir concludes that NALA "is not looking to simply extinguish fires, but rather to stop the fire relighting altogether."
To highlight this, Amir admires the organisation’s management and board of directors, which is made up of Israelis, Israeli Ethiopians, and local Ethiopians; perfectly deducing NALA’s approach. This makeup enables NALA to interact with communities, not in a colonialist fashion, but rather in a sensitive and appropriate manner. If the COVID-19 pandemic has highlighted anything over the past two years, it is that we are far more connected than once thought, and no society can thrive whilst another is lacking.
Bench Maji Project
Goal: Eradication of NTDs with an emphasis on bilharzia
Length of Project: 5 years (2013-2018)
Yearly investment: Merck invests 113,000 Euros per year, on average
Midline Outcomes: Reduction of 61% in the prevalence of bilharzia in endemic areas
The key to success: Community mapping; establishment of a intersectoral government system for the treatment of morbidity in the area; intense campaign through local health and education systems with the assistance of local volunteers; construction of WASH infrastructure in schools; encouragement of sanitation condition improvements in the community; support for drug distribution in the community.