An impoverished African nation was making promising strides in medicine —
before the government clamped down on its foreign partnerships.
Early this year, Eritrea severed a scientific lifeline almost as old as
the African nation itself. The Eritrean National Health Laboratory in
Asmara cut long-standing ties with Washington University School of
Medicine in St Louis, Missouri, potentially setting back many gains that
the country had made in public health. “St Louis supplied everything:
American doctors, expertise, chemicals, materials,” says Assefaw
Ghebrekidan, an Eritrean ex-freedom fighter who now heads the
public-health programme at Touro University in Mare Island, California.
“And now it's all over.”
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| Isaias Afwerki (centre) in 1992, a year before he became Eritrea's first
president. He has recently halted the country's collaborations with US
medical schools. |
Eritrea, an impoverished country of 5 million people on the Horn of
Africa (see 'A troubled corner'), is not known for its science. It ranks
177th out of 187 countries on the United Nations Human Development
Index. It comes in last in terms of press freedom and is the eighth most
militarized country in the world. The World Health Organization
estimated that there were just 5 medical doctors per 100,000 people in
the country in 2004.
But against this depressing backdrop, the country's medical-research
partnerships have been a source of promise and pride. Eritrea built its
first medical school in 2003, aided by scientists from the Central
University of Las Villas in Santa Clara, Cuba. After US universities
helped to establish postgraduate training and research programmes in
paediatrics, surgery, and obstetrics and gynaecology at the institution,
Eritrean medical scientists published their first papers in
international, peer-reviewed journals. Public health has benefitted. In
1991, Eritrea was cursed with the highest maternal mortality rate in the
world — 14 deaths per 1,000 births. In 2010, it was on track to meet
the Millennium Development Goal of cutting that rate by 75% by 2015.
But progress in Eritrean science has now gone into
reverse, say a number of scientists and doctors in exile. In response to
mounting criticism from the United Nations and the United States over
the country's human-rights record, Eritrean President Isaias Afwerki is
severing partnerships with all US universities, says Ghebrekidan.
“Everything that Eritrea has worked so hard to achieve is at stake.”
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| Add caption |
Jon Abbink, an anthropologist at the Free University of Amsterdam,
says that these actions will have widespread negative effects, “in the
education system, in the constant 'brain drain' of educated people to
greener and freer pastures, and in the inhibition of international
scientific cooperation”. Eritrea, he says, is one of the few remaining
countries in Africa that have failed to embrace scientific freedom.
“It's out of sync with global trends,” says Abbink.
Eritrea was once a colony of Italy, but the United Nations
handed it over to Ethiopia after the Second World War. In 1961, Eritrea
started to fight for its independence in a war that would last three
decades: the United States supplied Ethiopia with guns and money, but
the rebels, led by Afwerki and the Eritrean People's Liberation Front
(EPLF), persevered.
The liberation movement had remarkable credentials. “It
was led by 29 doctors of medicine,” says Ghebrekidan, who was head of
the EPLF's medical services. “No other rebel movement has ever had so
many intellectuals.” Even Afwerki had abandoned a degree in engineering
to lead the fight.
Another academic, Melles Seyoum, was working as a
pharmacist at an Ethiopian hospital when the war broke out. He coolly
stole US$140,000 worth of antibiotics, microscopes, surgical blades and
stethoscopes and delivered them to Eritrean freedom fighters, wrote
journalist Michela Wrong in her book
I Didn't Do It For You
(HarperCollins, 2005). Seyoum became an integral member of the EPLF,
teaching soldiers how to test blood and prepare Petri dishes in a
hospital 5 kilometres long and dug into the side of a rocky valley — a
clinic known as 'the longest hospital in the world'. After a visit in
1987, a British doctor wrote
1
about the impressive standards of care at the hospital: a 1-tonne
machine manufactured antibiotics every day; a doctor performed facial
reconstructions; and amputees played basketball.
Power struggle
In 1993, after the war ended and Eritrea gained
independence, Afwerki was elected president by a national assembly
largely composed of former members of his rebel army. He promised that
within four years, Eritrea would have parliamentary and presidential
elections, press laws and a new constitution. Seyoum enthusiastically
backed Afwerki and was, in return, appointed director of the prestigious
National Health Laboratory, which performed most of the country's
clinical testing and worked on developing treatments for disease.
But following a failed assassination attempt in 1996, the
president postponed elections indefinitely and refused to implement the
constitution that had been drafted. In 1998, he invaded Ethiopia,
triggering a humiliating two-year war that caused the deaths of more
than 60,000 Eritreans and a temporary loss of one-quarter of Eritrean
territory. Afwerki's popularity plummeted, and many of the academics who
had helped to rebuild the country moved abroad.
On 3 October 2000, some of them decided to use their
friendship with Afwerki to persuade him to hold elections or step down.
From a conference hotel in Berlin, Ghebrekidan and 12 other scientists
and professionals, many of whom had been involved in drafting the
constitution, composed a letter to the president
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| High-quality pharmaceuticals and intravenous fluids were prepared and
surgeries performed in Eritrea's 'longest hospital in the world' during
the country's fight for independence.ANGESOM TEKLEHAIMANOT BOKRU | |
“Much of the world community, including our fellow Africans, perceive
the Eritrean government and its leadership as aggressive and
irresponsible,” wrote the group, urging Afwerki to implement the
constitution, hold democratic elections and set free the growing number
of people his regime had jailed. “We urge you most sincerely to seize
this moment of crisis and turn it into an opportunity to reclaim your
hard-earned reputation as a leader.” Four days later, after it had
reached Afwerki, the letter was leaked to the press, igniting Eritrea's
first-ever public debate about leadership.
To its members' surprise, the group — which became known
as the G-13 — was invited to Eritrea for discussions with Afwerki. One
member, Mohammed Kheir, later wrote that he was nervous that it might be
a trap. But they accepted the invitation and flew to Eritrea. After
waiting for several days, the president agreed to see them. Soldiers
escorted the academics to his office, where Afwerki berated them for
leaking the letter to the media — something that they denied — and cast
them as traitors. The group was escorted back to the airport. Since
then, no members have returned to Eritrea; most now hold prestigious
positions at US universities. “It is very fortunate that we escaped,”
says Haile Debas, now head of the University of California Global Health
Institute in San Francisco.
Although the plea failed to sway the president, it
encouraged others to criticize him openly for the first time. In July
2001, Semere Kesete, leader of the student union at the University of
Asmara — Eritrea's only institute of higher learning — criticized the
government for reducing academic freedom. He was arrested and thrown
into solitary confinement, causing riots at the university. When the
government demanded that the students do extra national service — on top
of the 18 months required of all men and women — they didn't turn up.
In retaliation, the government bussed all of the students to the Danakil
Depression in southern Eritrea, one of the hottest places on Earth, to
build roads. Two students died from the heat.
Crackdown
A month later, Afwerki launched his biggest crackdown yet.
He shut down all private media, threw 10 journalists in jail and
imprisoned 11 politicians who had demanded elections — many of whom were
old comrades in arms. He also began to dismantle the University of
Asmara.
“What could be the justification for killing the only
university we had capable of producing students that could be accepted
by universities abroad?” asks an Eritrean scientist who lives out of the
country and wishes to remain anonymous because of concerns about the
safety of family members still in Eritrea. “The aim was simply to
prevent the students from all being in one place, where they had the
power to rise up,” says Debas. In place of the university, the
government built a number of small colleges, arguing that these would be
more accessible to students.
Even as Eritrea lost its only university, it continued to
make progress in medicine. In 1997, the country had gained a proactive
health minister, Saleh Meki, who helped to develop crucial partnerships
with US universities including George Washington University in
Washington DC; Washington University in St Louis; Columbia University in
New York City; Stony Brook University in New York; and the University
of California, Berkeley. By bringing experts into Eritrea, these
partnerships helped the country to pass scientific and public-health
milestones. A polio-immunization campaign extended coverage to 95% of
all one-year-olds and eradicated the disease. An anti-malaria drive from
2000 to 2004 reduced morbidity and case fatality by 84% and 40%,
respectively.
In 2003, Haile Mezgebe, then a surgeon at George
Washington University, was part of the group of medics who helped to set
up the Orotta School of Medicine in Eritrea. Mezgebe moved to the
country to run the collaboration; he was joined by Mary Polan, who
travelled regularly from the department of obstetrics and gynaecology at
Columbia University, and other US doctors and surgeons who worked to
treat and train Eritreans. In 2009, Orotta graduated its first class of
39 doctors. “It was quite extraordinary,” says Jack Ladenson, a doctor
based at Washington University. “Suddenly, in one day, there was a 30%
increase in the number of doctors in Eritrea.”
Success story
Meanwhile, clinical testing and research was taking off at
the National Health Laboratory. In 1998, the only blood tests available
in Eritrea had been done on a single machine. Scientists from
Washington University installed new equipment at the lab and trained
technicians to perform a range of chemical tests, including the
haemoglobin A
1C test for diabetes and a test for thyroid
malfunction. They also launched a national diabetes-management programme
and a long-term research project to gauge its progress; in 2007, the
project leaders found
2 that the programme had significantly improved Eritrean diabetes management. Ladenson, Seyoum and others co-authored a paper
3
showing that the overall quality of chemical tests for disease at the
national lab was on a par with that at Washington University. “A simple
but sustainable national laboratory system has been established in the
developing nation of Eritrea,” the paper said.
But outside the medical arena, the situation was less
rosy. Richard Reid, a historian at the School of Oriental and African
Studies in London, visited the Eritrea Institute of Technology in Mai
Nefhi, one of the unaccredited colleges set up after the University of
Asmara was shut down. He was told that students who cheated on exams or
skipped classes were jailed on site. Military training was mandatory
between 4 and 7 a.m., and students wryly referred to digging trenches as
'digology', adds Reid.
And any success in science and medicine was short lived.
In 2008, without explanation, Meki was removed as health minister, along
with the coordinator for US–Eritrean scientific partnerships. The chair
of the paediatrics department at Orotta was arrested because of his
religious views. And in 2011, Afwerki ordered all scientists from George
Washington University — including Mezgebe — to leave the country.
At the start of 2012, Afwerki cut off the partnership
between the National Laboratory and Washington University in St Louis.
Several sources, who wish to remain anonymous for fear of retaliation
against friends and relatives, report that Seyoum, the lab's director,
was “frozen”, an Eritrean term for the practice of stripping government
employees of their titles and duties while restricting them from travel
and other jobs to silence them.
Nature contacted officials in the
Eritrean government and its US and UK embassies repeatedly by phone and
e-mail for a response to these allegations, but had received none at
the time of going to press.
The severing of ties may be a backlash against the United States and
the United Nations over their criticism of Afwerki's human-rights
record, says Ghebrekidan. In 2009, the United States imposed sanctions
on Eritrea for supporting Islamist insurgents in Somalia. A highly
publicized cable from US ambassador Ronald McMullen, later released by
Wikileaks, said that “Eritrea's prisons are overflowing, and the
country's unhinged dictator remains cruel and defiant”. In July, the UN
Human Rights Council established a special rapporteur to investigate
reports of rights violations by Eritrean authorities, amid stories that
Afwerki keeps his critics in solitary confinement in shipping
containers.
Berhane Ghebrehiwet, an Eritrean immunologist at Stony
Brook University, says that Afwerki's distrust of foreign involvement
and aid in Eritrea is understandable. The United States did, after all,
support Ethiopia during the fight for independence. “You cannot cripple a
man and then accuse him of having limped,” he says. “All the president
dreams of is to make Eritrea a prosperous and self-reliant nation at
peace with itself, its neighbours and the rest of the world.”
Others are less sympathetic. “Afwerki is getting more and
more paranoid,” says Ghebrekidan. “He thinks that the American doctors
who come to save Eritrean lives are actually CIA agents.”
Afwerki has effectively destroyed intellectual freedom in
Eritrea, says Abbink. “No independent academic research in any field is
possible.” Fundamental research “or what is left of it” is now under
pressure to pursue “practical” issues with immediate applications to
development, he concludes.
Yet some scientists are still proud of the progress
Eritrea has made. Andemariam Gebremichael, dean of the Orotta School of
Medicine, wrote in an e-mail that he aims to create “an environment
where individuals develop their intellectual potential”, adding that he
hopes to produce another 150 doctors to bring the country up to
international standards. It will be a significant challenge, writes
Gebremichael. Only seven foreign teaching doctors — all Cuban — remain
at the institution.
After a year in solitary confinement, student-union leader
Kesete escaped with his guard to Ethiopia, and from there to the United
States. “We walked for six days and nights, surviving on nothing more
than biscuits,” he says.
Kesete sees little prospect of change, and despairs of his
country's future. “The government has persecuted not only scientists,
but also the science itself,” he says. He calls international
collaborations a “waste of resources and energy”, because Afwerki will
not hesitate to eject foreign scientists, no matter how crucial they are
to Eritrea's development. Rumours that the University of Asmara may
reopen this year are preposterous, he adds. “It is safe to say that
academia is dead.”
1.MERON Amanuel of team UCI CONTINENTAL CENTER won the second phase of the tour and was awarded the EWSA red jersey.
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