<br><br>
<div class="gmail_quote">---------- Forwarded message ----------<br>From: <b class="gmail_sendername">Vandana Prasad</b> <span dir="ltr"><a href="mailto:chaukhat@yahoo.com">chaukhat@yahoo.com</a></span><br><br><br>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.<br>
the paper is self explanatory though the issue is complex.<br>please have a look. we look forward to your comments and support.<br>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.<br>
pls endorse with name and organisation. we want this to be a comprehensive list rather than a representative one.<br>pls also discuss and disseminate in your relative states and campaign groups for further action.<br>e mails to <a href="mailto:chaukhat@yahoo.com">chaukhat@yahoo.com</a>, <a href="mailto:radha@bpni.org">radha@bpni.org</a>, <a href="mailto:arun@ibfanasia.org">arun@ibfanasia.org</a></div>
<div class="gmail_quote"> </div>
<div class="gmail_quote">
<p style="TEXT-ALIGN: center" align="center"><font face="Times New Roman"><b><span style="FONT-SIZE: 13.5pt">How Should India Approach The Management Of SAM?</span></b></font></p>
<p style="TEXT-ALIGN: center" align="center"><b><span style="FONT-SIZE: 13.5pt"><font face="Times New Roman">A Position Paper</font></span></b><font size="3"><font face="Times New Roman"> <br> </font></font></p>
<p><font size="3"><font face="Times New Roman">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.<sup>1</sup> </font></font></p>
<p><font size="3"><font face="Times New Roman">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). </font></font></p>
<p><font size="3"><font face="Times New Roman">The current situation is this – </font></font></p>
<ol type="1">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l6 level1 lfo1; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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. </font></font></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l6 level1 lfo1; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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 treatment<sup>2</sup> </font></font></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l6 level1 lfo1; tab-stops: list .5in"><font size="3"><font face="Times New Roman">Plumpy Nut efficacy has been demonstrated in other countries such as Malawi, Niger, Ethiopia, DR Congo and Mozambique in conditions of disaster and famine. </font></font></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l6 level1 lfo1; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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. </font></font></li>
</ol>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font size="3"><font face="Times New Roman"> </font></font></p>
<p><font size="3"><font face="Times New Roman">In juxtaposition of these facts – </font></font></p>
<ol type="1">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l3 level1 lfo2; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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 sustainable<sup>3</sup>. </font></font></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l3 level1 lfo2; tab-stops: list .5in"><font face="Times New Roman" size="3">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. </font><a name="0.1_table01"></a></li>
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<p style="MARGIN-LEFT: 0.5in"><font face="Times New Roman"><span style="FONT-SIZE: 10pt">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.</span><font size="3"> </font></font></p>
<ol type="1" start="3">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l4 level1 lfo3; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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.<sup>6</sup> 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 <sup>7</sup>. </font></font></li>
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<ol type="1" start="4">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l5 level1 lfo4; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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. </font></font></li>
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<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l1 level1 lfo5; tab-stops: list .5in"><font size="3"><font face="Times New Roman">Alternate foods have many additional advantages – </font></font></li>
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<ol type="a">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l2 level1 lfo6; tab-stops: list .5in"><font size="3"><font face="Times New Roman">They promote local agricultural practices as they use millets and locally available foods </font></font></li>
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<ol type="a" start="2">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l0 level1 lfo7; tab-stops: list .5in"><font size="3"><font face="Times New Roman">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 </font></font></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-margin-top-alt: auto; mso-margin-bottom-alt: auto; mso-list: l0 level1 lfo7; tab-stops: list .5in"><font size="3"><font face="Times New Roman">By being much more decentralised a process, they allow greater community participation and control. </font></font></li>
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<p><font size="3"><font face="Times New Roman"><b>Evidently, though there are few formal studies documenting their efficacy there <i>are</i> 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.</b> </font></font></p>
<p><font size="3"><font face="Times New Roman">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. </font></font></p>
<p><font size="3"><font face="Times New Roman">This policy necessarily needs to keep in mind that supplementary nutrition is <i>one</i>, 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.</font></font></p>
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