Ethics of use of ready-to-use-therapeutic foods

Dear Editor,

I have been following the debate on the ethics surrounding the research on Community Therapeutic Care (CTC) and Ready to Use Therapeutic Foods (RUTFs), and was wondering whether the issue of ethics in the current use of RUTF's in the field is also being discussed, as this also could have effects on the quality of the research and effectiveness of future CTC programmes.

I have just returned from a 5 week mission throughout three regions of Afghanistan, as part of the Quality Project implemented by Groupe URD. During my visit, I was struck to find a large number of NGOs distributing RUTFs to severely malnourished children in Supplementary Feeding Programmes (SFPs), sometimes with fortnightly distributions (mothers receiving 30 to 60 Plumpy nut packets at a time), and most often with very little if any specific medical supervision of severely malnourished patients (sometimes including pregnant or lactating women, admitted according to MUAC).

Have the following issues been raised?

• Is it ethical to distribute a (very expensive) product for which the protocol is not yet fully tested and approved, and the efficiency of which is not proven outside the Therapeutic Feeding Centre (TFC)?
• How can we deal with the commercial interests lying behind the distribution of RUTFs? Is Afghanistan a potential new market for such foods, and what is the role of aid agencies in these strategies?
• How is this product being used within households (sold? shared?) and how may these practices hinder the future proper use of RUTFs in research programmes or actual CTC programmes, once the protocol is developed? Is RUTF a food or a medical treatment, and if it is the latter, can it be freely distributed without careful monitoring and supervision?

I was concerned because many SFPs where RUTFs are distributed are implemented by agencies or field personnel who do not necessarily have nutritional training, are not familiar with the specificities of severe malnutrition nor are aware of the issues surrounding CTC. Furthermore, the monitoring, when it is done, tends to show poor results with very high rates of defaulters (up to 70% in some centres) which probably include mortality cases. Weight gains (when they are calculated) average around 2 to 4g/kg/day, with potentially wide differences in results between programmes.

Many staff who were asked about the pertinence of distributing RUTFs say "it's that or we do nothing". The Afghan context indeed makes it very difficult to implement TFCs. Factors such as distance for beneficiaries, difficult access to remote areas for agencies, difficulty for women in leave their homes, the lack of staff (expat and Afghan) trained in nutrition, and the lack of NGO capacity to implement TFCs are all severe constraints. But is the distribution of RUTF (in SFPs) better or worse than nothing?

I feel concerned about this issue, as I have seen a similar example of RUTF distributions in SFPs or even blanket distributions in Ethiopia, and imagine that other examples must be widespread, given the current 'publicity' around CTC & RUTFs.

In some quarters it is argued that now that we have RUTF, CTC programmes are feasible but we must go sufficiently slowly to learn the lessons. It will surely take time to do the research on the appropriate use of RUTFs, but with the products already on the market, is the practice not going too fast? And if so, what can be done to ensure these new products are 'properly' used until the research yields more results?

Yours sincerely
Charlotte Dufour

Nutritionist, Groupe URD (Urgence Rèhabilitation Dèvelopement). Email: cdufour@urd.org.Web: http://www.urd.org