PHA-Exch> a position on RUTF - for your support

[Claudio Schuftan]

---------- Forwarded message ----------
From: Vandana Prasad chaukhat at yahoo.com


Some of us have (hastily!!) drafted the position paper herebelow on the
hasty propogation of plumpy nut - an imported and expensive ready to use
therapeutic food (RUTF) in continuation of the on-going campaign for good
quality and sufficient food for children as the most important way to
prevent and manage malnutrition.
the paper is self explanatory though the issue is complex.
please have a look. we look forward to your comments and support.
there is a current urgent policy context heavily in favour of pre - packaged
RUTF and we would like to take this position to policy makers.
pls endorse with name and organisation. we want this to be a comprehensive
list rather than a representative one.
pls also discuss and disseminate in your relative states and campaign groups
for further action.
e mails to chaukhat at yahoo.com, radha at bpni.org, arun at ibfanasia.org


*How Should India Approach The Management Of SAM?*

*A Position Paper*


The numbers of children who are currently suffering from malnutrition in
India is an extremely serious matter of national shame and distress. Not
only has this situation persisted for far too long, it remains intractable
even during the recent phase of rapid economic growth. Of late, there has
been intense debate and discussion on how to best intervene to make a change
that is both substantial and rapid, and various groups of experts have
presented strategies to policy makers as to the steps that need to be taken
for both preventing malnutrition and treating its most severe forms.1

This position paper responds to a particular strategy that has been
introduced at state level without due process of discussion on its
repercussions and implications; namely, the use of imported Ready to Use
Therapeutic Foods (henceforth RUTF) for the management of Severe Acute
Malnutrition (henceforth SAM).

The current situation is this –

   1. A product called Plumpy Nut has been imported for distribution to
   children with SAM in several states, including Madhya Pradesh, Jharkhand,
   Orissa, Bihar and Maharashtra under the aegis of UNICEF and through the
   mechanism of Nutrition Rehabilitation Centres (NRCs). There is a proposal to
   make it the "prescribed treatment" for SAM.
   2. This product is imported from a company called Nutriset in France. If
   produced in India, it would cost approximately US $ 40 or approximately Rs.
   2000/- per child per treatment2
   3. Plumpy Nut efficacy has been demonstrated in other countries such as
   Malawi, Niger, Ethiopia, DR Congo and Mozambique in conditions of disaster
   and famine.
   4. The studies demonstrating the efficacy of Plumpy Nut have been
   primarily conducted in disaster situations, where other community-based
   treatments for SAM have not existed, eg. refugee camps, famines, etc. There
   are few studies comparing the impact of Plumpy Nut with other specific
   community-based treatments for SAM developed from local indigenous foods.



In juxtaposition of these facts –

   1. The guidelines for community and home-based treatment of SAM
   formulated by a large group of experts and supported by the Indian Academy
   of Pediatrics recommends the use of home-based food (modified from the
   family pot). It specifically warns that commercially available international
   RUTF may not be suitable, acceptable, cost effective and sustainable3.
   2. Many locally produced/producible foods that are culturally acceptable
   and relatively low cost have been used for SAM in India for many decades by
   reliable academic and medical institutions as well as by non governmental
   groups.







































































































N.B: Shelf life is not a necessary condition for these locally produced
ready to eat foods as they are prepared in quantities needed by local
women's groups under the supervision of the respective hospital or NGO.

   1. Several experiments are on using modified family foods to treat SAM.
   Jodhpur Medical College has been using a mix of energy dense khichri, milk,
   raar, dal, sugar, fruit, fruit juice and egg to treat SAM both in
   institutional and home settings. This is in the process of analysis and
   documentation. In Tamil Nadu, the Direct Nutrition Programme gives a mix of
   80g rice, 10g. dal, 2g. oil, 50 g. of vegetables and condiments at a total
   cost of Rs. 1.07 to each child between 2 and 4 years of age. This provides
   358.2 calories and 8.2g protein per child.6 The Sattu Maavu listed in the
   table above is given as complementary food for children between 6 and 36
   months of age and pregnant and lactating women, and costs approximately Rs.
   15 per kilo. Other experiments by NGOs such as Mobile Creches have used
   common foods including eggs, soya products and milk for demonstrable impact
   at a cost of Rs 8 per child per day for full day-care nutritional facilities
   7.



   1. These foods have been completely ignored in the haste to introduce
   Plumpy Nut, which, though an efficacious formula, seriously disturbs the
   concept of self reliance in food security and creates an unnecessary
   dependence upon a product upon which families and communities have little
   control.



   1. Alternate foods have many additional advantages –


   1. They promote local agricultural practices as they use millets and
   locally available foods


   1. They promote local livelihoods amongst the very families what may be
   harbouring children with SAM in a milieu of general poverty and food
   insecurity thus conferring more than food supplementation – an opportunity
   to raise economic status. They may use the agency of existing women's groups
   and SHGs as well as small scale industry
   2. By being much more decentralised a process, they allow greater
   community participation and control.




*Evidently, though there are few formal studies documenting their efficacy
there are some, along with plenty of anecdotal evidence of success. The very
fact that these pre existing attempts have not been properly studied,
analysed and documented by research and expert bodies on nutrition is a
matter of concern. It is hard to explain why it has been permitted for a
somewhat alien product to be introduced at such large scale without
investigating the relative merits and demerits of the ready to use foods
that we have been using in such prestigious institutes as mentioned above.
It would not have been either difficult or time consuming to study these
further for a few months before arriving at a suitable strategy for SAM that
includes supplementary food.*

Perhaps it leads us into our long standing recommendation and demand, that
the country needs to develop a well discussed and debated policy of child
nutrition rather than have to combat each contingency as it arises.

This policy necessarily needs to keep in mind that supplementary nutrition
is *one*, though important, part of the multi pronged strategy to bring
about overall food security for children and families, and the best SN would
be one that promotes self reliance, decentralisation, community
participation and is low cost and culturally acceptable. An imported or
centrally prepared very expensive food that displaces other locally
producible options can hardly hope to fulfil these criteria and should be
abandoned in favour of the 'right' product. Adequate thought, planning and
research should go into developing such policies rather than succumbing to
various pressures in haste and allowing unsustainable processes that may
prove difficult to reverse and will cause long term harm to the very
communities and families whose children we aim to 'treat'. We also need to
continuously remind ourselves of the comprehensive set of strategies that
will bring about the ultimate goal of child health, nutrition and well being
through services of general care, health and nutrition in an environment of
overall food, economic and social security.
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