Issue 31 Editorial

A mother attending a MSF programme in Niger

One of the longest raging debates in nutrition continues in the letters section of this issue of Field Exchange. Put simply, does the nutrition community invest too much in magic bullets and not enough in home grown and more sustainable solutions? In the 1970s/80s, micronutrients supplementation became the 'magic bullet' to address malnutrition. Massive investments in Vitamin A, iron and iodine programmes were made while, according to critics, problems of chronic malnutrition and stunting were largely ignored. More recently, the roll out of community therapeutic care using ready to use therapeutic foods (RUTF) has drawn 'flak' from those who feel the approach is too dependent upon commercially produced, ready-made products and therefore not sustainable - see letters section in Field Exchange issue 19 (p23). The discourse on this subject is particularly apposite given the nature of so many field articles currently being submitted to the ENN, and in particular two of the articles published in this issue.

Our lead article describes MSF's experience of extending the use of new therapeutic products and operational strategies to the treatment of moderate acute malnutrition in Niger. During 2006, MSF operated 11 outpatient feeding centres attached to integrated health centres along with two inpatient referral feeding units, in two districts of Maradi region with an estimated population of 900,000 people.

Moderately malnourished children were admitted to these units and treated with the same medical and dietary protocols used for severe acutely malnourished patients (with the exception of no systematic antibiotic treatment at admission). Plumpy'nut® (1,000 kcal/day) was used as the RUTF offered to all outpatients.

A total of 64,733 children were admitted for acute malnutrition in 2006 and of these, 92.5% (59,880) were children with moderate malnutrition. Analysis of results for 59,698 moderate malnourished children showed a cure rate of 95.5%, death rate of 0.4%, and default rate of 3.4%. Average length of stay was 31.4 days and average daily weight gain was 5.28g/kg body weight/day.

As the authors of the article argue, these results are far superior to many emergency Supplementary Feeding Programmes (SFPs) implemented with blended flours. Indeed, the study just completed by SC UK and ENN of data sets from 82 programmes conducted by 16 agencies in 22 countries reflects a worrying situation with this 'standard' method of treating mild and moderate malnutrition in emergencies¹. Only 41% of the programmes met all SPHERE standards with regard to impact at individual level and low levels of coverage meant that impact at population level was minimal and not significant. The main reason for poor performance appeared to be high default rates, although management and quality of foods also appeared to have a role. Failure of SFPs is problematic because, although severe malnutrition has a higher relative risk of mortality, the much larger numbers of those with moderate malnutrition means that the population-attributable risk of malnutrition to mortality is much higher in this group.

A second field article in this issue by Erin Tansey and Dr. Ibrahim Bani is also based upon the experience of using a 'ready made' (albeit low cost) commercial product to address a long-standing micronutrient problem in Darfur. The Christian Blind Mission International, Canada (CBMI) and the Micronutrient Initiative (MI), together with the Sudanese Red Crescent Society (SRCS) and the Sudan Ministry of Health National Nutrition Directorate (MOH-NDD), set out to implement a pilot project to test the acceptability to the internally displaced population of low cost micronutrient premixes and the feasibility of using it to improve micronutrient status in a camp in Darfur. Micronutrient deficiency is considered a major problem in Darfur. As well as contributing to infant mortality, over 50% of all children 6-59 months are estimated to suffer from anaemia, while vitamin A deficiency is estimated at 36%. Although food rations provide some micronutrients, they are reportedly not enough to meet the needs of the most vulnerable populations - pregnant and lactating women and children under 5 years of age.

Both these articles show how 'high or higher tech' solutions still appear attractive to many agencies. The exchange of views on this in the letter section in this issue of Field Exchange centre around the use of ready made therapeutic products and can be summarised as follows.

On the one hand it is argued that the use of readymade products risks creating a large-scale dependency on expensive externally imported items. What happens when the emergency is over and funding dries up? There are also concerns about monopolies on production and therefore 'price fixing'. Protagonists of this view would prefer the use of locally made mixes with imported low cost vitamin and mineral mix (e.g. CMV therapeutic). They also argue that there are many experiences of ready-made F75 and F100 being used and supplies being erratic or drying up, so that health centre staff have to revert to home-grown solutions with inevitable adverse consequences for patients. There are also many experiences of home-based products being used at lower cost and working, so why change to a regime that is more expensive and may be precarious.

Arguments against this are largely nutritional, e.g. home-made products may have a higher than desirable osmolarity and can induce diarrhoea in a few children, quality control may be difficult to achieve using modular feeds, vegetable oils easily become rancid generating high peroxide levels that place at risk children who have very little in the way of anti-oxidants while locally sourced dried skimmed milk may not meet the low sodium and iron specification that commercial manufacturers source to make therapeutic milk. The bottom line for those who support the use of 'commercial' products is that "although we know we can 'get away' with using local ingredients we are falling short of the recovery we know we can achieve". Furthermore, it is argued, issues of sustainability are more a question of commitment and whether products are perceived as foods or medicines. If viewed as the latter, then there is less likely to be questions about sustainability in developing countries. Finally, there is no reason why therapeutic products, such as F75, Resomal and F100, could not be produced locally with quality control - similar to the way in which local RUTF manufacturing is currently being rolled out.

No doubt such arguments will continue and to some extent one cannot help feeling that the views of each camp are to some degree politically (with a 'small p') informed. However, as the ever pragmatic editor, one has to ask whether generalisations here are necessary or even desirable. Surely, each context needs to be examined and assessed individually. For each context, questions should be asked regarding whether ready made products can be locally manufactured, whether MoH policies and strategies exist or can be modified so that budgets are assured for commercial products, and whether existing home-grown modular feeding leads to adequate outcomes within existing health services and whether these can be improved upon. Then it simply becomes a judgement call.

As always, there are a whole array of other articles and research summaries in this issue of Field Exchange. A field article from the agency Self-Help Development International discusses the experience of establishing a seed development programme in Ethiopia, while Saul Guererro from VALID discusses a study showing the impact of previous non-admittance on Community Therapeutic Care (CTC) programmes in terms of subsequent rejection of the approach. Research summaries include a review of cash and voucher programming in a number of countries and experiences of more rapid nutrition survey implementation using the Lot Quality Assurance Sampling (LQAS) approach.

Enjoy and finally please don't forget to fill out your evaluation forms (included on your mailing insert and also online). Your feedback lets us know whether we are hitting the mark or whether you want change.

Jeremy Shoham

Any contributions, ideas or topics for future issues of Field Exchange? Contact the editorial team on email: office@ennonline.net

¹A Retrospective Study of Emergency Supplementary Feeding Programmes. Dr Carlos Navarro-Colarado. June 2007. ENN and SC UK. Available at http://www.ennonline.net/research/