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...for discovering and campaigning relentlessly for an affordable preventative against bilharzia.
Aklilu Lemma was a young Ethiopian doctor, when he discovered a natural treatment against bilharzia, also known as schistosomiasis, a debilitating and eventually fatal illness. He relentlessly studied and systematically improved his research, developing an affordable preventative, i.e. cheap, locally-controllable means of eradicating a disease that, after malaria, is the second greatest scourge in the Third World.
Bilharzia, or schistosomiasis, is a debilitating and eventually fatal illness, which afflicts more than 200 million people in 74 countries of Africa, Asia and Latin America. Present therapies for bilharzia, and molluscicides to kill the snail-carriers of the disease, are far too expensive for the communities that need them.
In 1964 a young Ethiopian doctor, Aklilu Lemma, discovered that suds from the fruit of a common African plant, the endod or soapberry, which African women have used as soap for centuries, act as a potent molluscicide. To follow up this discovery, Lemma in 1966 established the Institute of Pathobiology in Addis Ababa University, and for the next 10 years he directed a team to carry out systematic research on endod. He was joined in this work in 1974 by Legesse Wolde-Yohannes.
The discovery seemed to offer no less than cheap, locally-controllable means of eradicating a disease that is the second greatest scourge (after malaria) in the Third World. And Lemma's early research confirmed this potential. Yet progress in making this endod product available to the people who need it has been extremely slow, for reasons that expose some of the biases and failings of the international medical community.
However, Lemma's and Wolde-Yohannes' persistence and the support of key scientists and donors in the West have opened the door to the necessary laboratory and field trials. An endod research and application network has also been established, linking five African countries, and the plant is being grown and used for experimental control of schistosomiasis.
Before his death in 1997, Lemma and colleagues established the Endod Foundation to serve as an umbrella for all endod-related work. Following collaboration with Lemma, the University of Toledo, USA, was granted a US patent on an endod-based molluscicide intended to control the zebra mussels which have recently invaded American lakes and caused extensive damage to water supplies. This has opened a major new hope for marketing and exporting endod as a cash crop.
Aklilu Lemma took a doctorate in pathobiology from Johns Hopkins University, Baltimore, USA. In Ethiopia he held many senior academic and advisory positions. From 1976 he worked in the UN system and became Deputy Director of UNICEF's International Child Development Centre in Florence, Italy, before taking up a Visiting Professorship in the Department of International Health, Johns Hopkins University.
December 9th, 1989
SCIENCE FROM THE THIRD WORLD
The Example of Endod in overcoming Obstacles
New Approach to Community Health
This year marks the 25th anniversary since I first came across the potential values of Endod, the Ethiopian berry plant, scientifically called Phytolacca dodecandra. This encounter was made in the town of Adwa, in the northern part of Ethiopia, during an ecological investigation of the distribution of particular freshwater snails that serve as the critical link in the transmission of schiatosomiasis, a serious and rapidly spreading tropical disease that afflicts some 200-300 million people in Africa, parts of the Caribbean and South America, and Asia.
I observed that in areas downstream from where people were washing clothes with Endod, there were more dead snails than anywhere else. Observing this phenomenon repeatedly, I collected some live snails from upstream and asked one of the women to put a bit of the Endod suds from her washbasin into the snail container. Shortly after, the snails shrank, passed a few bubbles of gas, bled and died. It was this original observation that led to the discovery and to many subsequent years of scientific study, hard work, frustration, hope, and at times, despair, which climaxed by the honour of the 1989 Right Livelihood Award, for which I and all my colleagues are most grateful.
Back in our laboratory in Addis Ababa the first questions we eagerly wanted to answer were: What were the level and diversity of activities of the Endod berries? Are the different species of snails that transmit schistosomiasis affected by it? What also does it kill? We found that the sun-dried and crushed berries, when suspended and serially diluted in distilled water killed all the different species of snails in minute amounts (10 to 25 parts per million) within 24 hours. This was done using standardized test procedures so that others could easily repeat our work, as indeed they did, and our findings were shortly reconfirmed.
There are alternative molluscicides to Endod, BUT they come at a high price. We do have safe and effective chemotherapeutic agents for the treatment of schistosomiasis, BUT people who have been treated in endemic areas become re-infected rapidly. Health education and latrine building could help, BUT, this is a long-range prospect tied to a rise in the socio-economic standard of the society as a whole. THEREFORE, the use of molluscicides to control the snails seems to be the major alternative.
Chemical compounds, such as copper sulphate, have been used as molluscicides for many decades in Egypt and Sudan as an effective means of controlling schistosomiasis. In the recent past, however, another more effective compound, the nicolsamid ethnolmina salt called Bayluscide produced in West Germany, has been found to be more effective and is currently the only molluscicide recommended by WHO for wide use. BUT, this compound is very expensive, US$ 25,000 - 30,000 per ton in hard currency. Partly as a result of this prohibitively high cost, most developing countries, especially those in Africa, are not doing anything about controlling this disease. In the meantime, the many well-intentioned agricultural development and water conservation schemes are serving as new reservoir sites for the snails to bread and the disease is spreading rapidly, but silently.
The implications of this phenomenon, as can be readily realized, are very serious. The role of Endod here is to replace the expansive chemical molluscicides. Through the development and use of simole appropriate naronomic techniques and extraction and application procedures, people could easily grow, process locally, and use Endod or similar other natural products to control schistosomiasis on a community self-help basis.
The first ten years, from 1964-74, were the period of our greatest scientific challenges, leading to major discoveries and exciting prospects for multiple uses of Endod. Most of the scientific studies on the molluecicidal and other properties of Endod were undertaken during these exciting 10 years. Findings were published in major international publications and presented at a number of international conferences.
The results of our early pioneering laboratory studies and field evaluations showed the very high potency and specificity of Endod to snails and its safety to mammals and other non-target animals and the ecology. These studies were published in various journals, including the Bulletin of the World Health Organization in 1970 (volume 42, pages 597-612).
During a two-year sabbatical leave I spent in the United States (1970-1972), important chemical and toxicological investigations were undertaken. At the Stanford Research Institute (SRI) in Menlo Park, California, the following studies were conducted. Chemical isolation and identification of the active principle, named "lemmatoxin' by Robert Parkhurst, the chemist who did the work; tests that established the nonmutagenic nature of the product with additional studies on the safety of the butanol extract to non-target animals. Other potential uses of Endod were also investigated: its fungicidal properties, its potential as an additive to detergent formulations, as a foaming agent in lightweight concrete preparations, and as a spermicide for possible use in birth control (for which SRI obtained a patent). I also spent some productive time at the University of California Medical Center in San Francisco, where, in collaboration with Professor Donald Heyneman, we did additional toxicological and molluscicidal tests. At the Harvard University School of Public Health, working with Professor Andrew Spielman, we studied the larvicidal effects of Endod against mosquito larvae, as well as its snail ovicidal (egg-killing) properties. At the US Public Health Service in Puerto Rico, in collaboration with Dr. Barnett Cline we conducted a limited-scale field evaluation of the butanol extracts in natural bodies of water.
During the period of 1969-1974, a major five-year project was undertaken in the town of Adwa, to control schistosomiasis, primarily by use of locally collected Endod as a molluscicide, involving active community participation -- a critically important factor. The results showed that transmission of the disease was significantly reduced from 63% to 33% in the population of 17,000 people. Among 3,500 children from the ages of 1-6 years, the infection rate fell from 50% to 7% (85% reduction). These results were presented at the International Conference on Schistosomasis held in Cairo, Egypt, in 1975 and published in the proceedings of that conference.
Another milestone was achieved during 1976-81, when the Netherlands Government supported some important agrobotanjcal studies on Endod. The studies were conducted by a Dutch scientist, Dr. Charles Lugt, and his Ethiopian counterpart, Dr. Legesse Wolde-Yohannes, my colleague and co-winner of this Award. Out of over 500 varieties of Endod collected from all over Ethiopia, they cultivated 65 different strains and selected three varieties with especially high molluscicidal potency and high yield of berries. One of these strains, E-44, has been introduced and successfully cultivated in at least five African countries (Kenya, Tanzania, Zambia, and Swaziland) and Brazil. It has also been chosen to serve as the standard "reference" strain of Endod for all toxicological and field evaluation.
The period between 1981-86 was a transition period, a struggle to get international acceptance and increased support for our studies, often marked by frustration, delay, and disappointment. We planned and expected that this period would see the expansion of our earlier studies, increasing the agricultural production and promoting the large-scale application and field evaluation of Endod as a molluscicide in integrated control of schistosomiasis on a community self-help basis.
For such activities the Ethiopian government needed foreign starter assistance withleadership from international health bodies like the World Health Organization (WHO). Surprisingly, with complete disregard to our twenty years of research and the centuries of traditional use of Endod as laundry soap, WHO required further studies to confirm the safety of Endod to humans and the environment before they would give clearance for its wide use.They insisted that the scientific work we did in Ethiopia and elsewhere must be repeated under standardized conditions following "Good Laboratory Practices" (GLP) in internationally recognized institutions -- meaning in developed countries. As a precondition for field evaluation, they required that this biodegradable natural product be subjected to the same rigorous toxicological tests required before any unknown synthetic chemical product can be registered as a pesticide. This, of course, meant the need for substantial financial resources to support such studies in countries with "GLP'. But, the WHO was neither providing any resources, nor even supporting our efforts to raise funds for the confirmatory studies which they required. I have no explanation for this bias.
The only reason given for not allowing field testing of Endod was its toxicity to fish. It is a well known fact, however, that the same fish-killing property is shared by other molluscicides, including the only molluscicide approved by WHO for global use, the petrochemical byproduct Bayluscide. But, the important point here is that edible fish and disease transmitting snails do not normally live in the same habitat. Edible fish normally reside in larger bodies of water whereas the snails require slow flowing streams and canals or shallow shores of larger water bodies. As molluscicides are applied to these bodies of water, the fish become irritated and swim rapidly into safer waters. The snails, without such mobility, are the principle targets of the molluscicides. Small fish in shallow waters may be killed by molluscicides, but the fish repopulate from untreated bodies of water upstream, as well as from the eggmasses of the fish, which are not affected by Endod. And, as was pointed out, since Endod is biodegradable, its active principle rapidly decomposes, breaking down into inert and non-harmful material within a few days.
From a traditional acceptability point of view, Endod is a typical example of a natural product that has been selected by society through centuries of its safe use for washing clothes. People in the Ethiopian highlands have in the past, continuing into the present, adopted and cultivated the Endod plant (synonymous with "soap") near their homes, using the berries as a laundering agent for the glistening white cotton shawls, the shama, which is characteristic of our culture. The fish killing property of Endod is also well known and traditionally accepted. In fact, people in rural communities use it as an intoxicant to collect edible fish.
The last few years have seen important breakthroughs that have countered many of the biases and obstacles raised against Endod that for so long have gone through a vicious circle: no funds were made available for the rigorous toxicological tests required before Endod could be officially field tested - and no field tests could be sanctioned until these tests were completed.
As part of the continued fight to gain recognition for the study of Endod, in 1983 I organized the First International Workshop on Endod, held in Lusaka, Zambia. A large number of concerned scientists and interested Africans attended, with the meeting formally opened by the Prime Minister. It was both a scientifically and personally rewarding meeting for my colleagues and me, for those who have been engaged in Endod studies for many years. It gave us strong moral support, encouragement and a real sense of collegial solidarity. The proceedings of that meeting, published in 1984 in book form by Tycooly International Ltd. continue to serve as a consolidated source of useful information on Endod.
A Second International Workshop was held in Swaziland in 1986, the proceedings of which were also published in book form with the financial support of UNICEF. By the time of the Swaziland meeting, the Ethiopian Strain E-44 of Endod had been introduced and experimentally studied in a number of countries including Swaziland, Zambia, Zimbabwe,Kenya, and Brazil.
The Third International Workshop is now planned and will take place in Ethiopia in May 1990.
Following the workshops in Zambia and Swaziland, the UN Development Programme (UNDP)/UN Fund for Science and Technology for Development, in cooperation with the International Development Research Centre (IDRC) in Canada, convened an Endod Toxicology Expert Group meeting in New York in February 1986. The objective of that meeting was to identify and remove the main obstacles against the trials and eventual application of Endod. A second meeting of the same group was held at the WHO in Geneva in December of the same year. This Expert Group developed a standard procedure for preparing water extracts of Endod for testing in different laboratories and delineated selected basic toxicological tests to be performed under "GLP", as required by WHO.
IDRC has since commissioned some of the acute mammalian and eco-toxicity studies that are now being performed in Canada, basically repeating what we did several years before, but this time under "Good Laboratory Practices".
In a parallel, independent initiative, the Finnish International Development Assistance Agency (FINNIDA) is presently considering to fund the remaining toxicological studies required for the international registration of Endod as a pesticide, following the WHO procedures used for registering any chemical product. A coordinating committee has been established to oversee this process. FINNIDA is also providing support for agrobotanical and community-based studies in Zambia on a bilateral assistance basis.
In other developments, scientists in 10 African countries and Brazil have established an Endod Technical Cooperation Among Developing Countries (TCDC) Network and are planning to have a newsletter to exchange their research findings and coordinate their work. In the Netherlands, a group of concerned and interested scientists have formed a "Support Endod Group" that is doing extraction and toxicological evaluation work. In Florence, Italy, an Italian "Technical Working Group on Endod" has put together a major project for collaborative agro-botanical studies in Ethiopia and Zimbabwe. They are now trying to obtain some funds for this important effort. Most of these initiatives require basic financial support.
Lessons for the Future
Thinking beyond Endod, some useful lessons can be drawn from these 25 years of struggle to help promote the future of science and technology in Africa.
We have learned the hard way that the root problems of scientific research in Africa are not only the lack of adequate facilities and funds, but also the biases of individuals andorganizations in industrialized countries who occupy key position to advise and influence the decisions of donor groups. Even our own government officials who rely on foreign assistance and the scientific support of such international organizations may be unduly pressured.
Sadly, there are still some biases and doubts in some western establishments that such a positive experience could come out of Africa. Except for occasional lip service, little credit is given to the wisdom of traditional societies in their ability to select, over long periods of time, such natural products as Endod for their continual and demonstrably safe use. To modify and redirect this traditionally accepted product for the control of schistosomiasis (whose spread owes much to well-intentioned but epidemiologically disastrous projects designs) is a major challenge.
Thorough toxicological evaluation should indeed be required of any product before it is used in field conditions. But such evaluation should also include the traditional knowledge of the people about such products. The logic of requiring the same toxicological tests from both, a known biodegradable natural product and an unknown synthetic chemical product should also be questioned. In any case, such toxicological tests at least on natural products, should be undertaken in collaboration between industrialized and Third World countries, with the objective of helping the later build its own capacity for such studies.
After three decades of post-colonial struggle, hopes and disappointments, I believe that the best future course for Africa is to invest in efforts to build on the endogenous capabilities ofits own people. This can be done through raising self-esteem and self-confidence by creating a sense of respect for the wisdom and experience of its own traditional societies, perhaps through the integrated application of modern and traditional technologies. Future actions should also recognize and strengthen existing African scientists and research and training institutions. Africa's scientific and technological manpower must be increased by many fold.
It is only through this type of major efforts that we can promote sustainable and self-reliant development in Africa.
International collaborative and development aid should be more geared towards helping us help ourselves, however slow and frustrating the process may appear, rather than creating increased dependence, as has been the case so often in the past. Put very simply, development assistance should focus more on teaching us how to fish rather than giving us fish when we are hungry and then only when our cries are heard throughout the world through the mass-media.
In conclusion, I would like to thank the so many friends and organizations in both developed and Third World countries who have been our genuine partners in this venture. I would particularly like to recognize the support and encouragement of the Addis Ababa University and the Ethiopian government, various donor groups in the United States, the Netherlands government, IRC of Canada, and the United Nations, UNFSSTD and UNICEF. I would also like to thank my wife, who for 25 years has given her unfailing support in my struggles for the international recognition of Endod.
Finally, I want to thank the Right Livelihood Society for giving us this opportunity to speak our minds frankly and openly to an audience that can make a difference. May this occasion serve as a major encouragement to the many able Third World scientists, in whose name we would like to accept this Award.