The Peanut Solution

By Bryan Schaaf on Thursday, September 2, 2010.

Plumpynut, a peanut based paste, has revolutionalized the way in which severely malnourished children around the world are treated.  Many young lives have been saved as a result.  There is now increasing attention on how Plumpynut variants can prevent children from becoming malnourished in the first place.  In Haiti, both Meds and Food for Kids (MFK) and Partners in Health (PIH) produce products similar to Plumpynut.  In the below New York Times article, Andrew Rice describes the promise, politics, and profitability of Plumpynut.  Considering the negative impact that malnutrition has on the health and cognitive development of children in Haiti, it is well worth a read. 

 

9/2/2010

New York Times

The Peanut Solution

By Andrew Rice

 

Like most tales of great invention, the story of Plumpy’nut begins with a eureka moment, in this case involving a French doctor and a jar of Nutella, and proceeds through the stages of rejection, acceptance, evangelization and mass production. The product may not look like much — a little foil packet filled with a soft, sticky substance — but its advocates are prone to use the language of magic and wonders. What is Plumpy’nut? Sound it out, and you get the idea: it’s an edible paste made of peanuts, packed with calories and vitamins,that is specially formulated to renourish starving children. Since its widespread introduction five years ago, it has been credited with significantly lowering mortality rates during famines in Africa. Children on a Plumpy’nut regimen add pounds rapidly, often going from a near-death state to relative health in a month. In the world of humanitarian aid, where progress is usually measured in subtle increments of misery, the new product offers a rare satisfaction: swift, visible, fantastic efficacy.

 

Plumpy’nut is also a brand name, however, the registered trademark of Nutriset, a private French company that first manufactured and marketed the paste. It was not the intention of Plumpy’nut’s inventor, a crusading pediatrician named André Briend, to create an industry around Plumpy’nut. Briend, his friends say, was always personally indifferent to money. (Also, apparently, to publicity — he declined repeated requests to be interviewed for this article.) One element of genius in Briend’s recipe was precisely its easy replicability: it could be made by poor people, for poor people, to the benefit of patients and farmers alike. Most of the world’s peanuts are grown in developing countries, where allergies to them are relatively uncommon, and the rest of the concoction is simple to prepare. On a visit to Malawi, Briend whipped up a batch in a blender to prove that Plumpy’nut could be made just about anywhere.  Others, however, quickly realized that the miracle product had more than just moral value. Nutriset has aggressively protected its intellectual property, and the bulk of Plumpy’nut production continues to take place at Nutriset facilities in France. (Unicef, the world’s primary buyer, purchases 90 percent of its supply from that factory, according to a 2009 report prepared for the agency.)

 

Internationally, there has been a vituperative debate over who should control the means of production, with India going so far as to impose sharp restrictions on Plumpy’nut, calling it an unproven colonialist import. Elsewhere, local producers are simply ignoring the patent. In Haiti, two manufacturers are making products similar to Plumpy’nut independently of Nutriset: one is Partners in Health, the charity co-founded by the prominent global-health activist Paul Farmer. Partners in Health harvests peanuts from a 30-acre farm or buys them from a cooperative of 200 smallholders. It’s planning to build a larger factory, but for now the nuts are taken to the main hospital in Cange, where women sort them in straw baskets, roast them over an outside gas burner, run them through a hand grinder and mix all the ingredients into a paste that is poured into reusable plastic canisters. Peanuts in Haiti and throughout the developing world have a high incidence of aflatoxin, a fungus that can sicken children, especially fragile ones. But Partners in Health says the product, which it calls Nourimanba, is safe.

 

When I visited one of the charity’s outpatient clinics in July, 1-year-old Elorky Decena was silent and listless as a nurse hooked a scale over the clinic’s doorway and put him in an attached harness. A month before, he was found to have severe acute malnutrition, a condition characterized by extreme stunting and wasting that afflicts an estimated 20 million children worldwide. The nurse announced that he had gained more than four pounds on a diet of Nourimanba.  Patents are meant to offer incentives to innovators by giving them a time-limited right to exclusively exploit their ideas for profit. But many say that lifesaving products should be treated by a different set of rules. There has been a long and bitter argument, for instance, over the affordability of patented AIDS drugs in Africa. Critics have made a similar case against Plumpy’nut, which is fairly expensive, costing about $60 per child for a full two-month treatment. “We were concerned because of the way Nutriset was managing their intellectual property,” said Stéphane Doyon, a nutrition specialist with Doctors Without Borders, a medical charity. “We felt that there was the possibility for the creation of a monopoly.”

 

“Poverty is a business,” Patricia Wolff, a St. Louis pediatrician, said. She founded Meds and Food for Kids, the other local producer of fortified nut paste in Haiti. When I first spoke with her in May, Meds and Food for Kids was struggling to raise money to expand its operations, and Wolff complained mightily about the difficulties she faced because of Nutriset’s market dominance. “There’s money to be made,” she said, “and there are people who have that kind of way of thinking.” Two months later, Wolff made a tentative deal for Meds and Food for Kids to become a Nutriset franchisee. In the end, she said, she couldn’t afford to battle hunger on her own.  In the United States, Plumpy’nut’s sole manufacturer and chief promoter is a 38-year-old mother of four from Barrington, R.I. Navyn Salem doesn’t have a background in medicine or aid work. She first glimpsed the potential of Plumpy’nut three years ago on “60 Minutes.” Since then, Salem has devoted herself to making the product for export to needy nations like Haiti. Though her Providence factory, a joint venture with Nutriset, has all the trappings of a business, selling its wares to relief agencies under the name Edesia Global Nutrition Solutions, the operation is registered as a nonprofit foundation and was established with seed money from Salem and her husband, Paul, a private-equity financier. Dancing along the nebulous line between capitalism and charity, Salem casts herself as a marketer, offering a neatly packaged solution to a tragic and no longer intractable malady. On a Tuesday in May, she brought her message of good news to a Mother’s Day benefit in Midtown Manhattan.

 

This is not my ZIP code,” Salem said as she stood in the East Side Social Club, a wood-paneled restaurant, amid a jostling crowd of bejeweled women pinching noontime flutes of Champagne. She met one of the party’s hosts, Lauren Bush, the former model and niece of the most recent ex-president, a couple of years ago at a conference of the Clinton Global Initiative. Now Bush and her mother, Sharon, were selling a specially designed line of teddy bears — a big one called Plumpy and a small one called Nut — to raise money to purchase the product for children in Africa. When it came time to eat their own meal, a three-course luncheon, the party guests found seats at tables set with elaborate centerpieces, made up of stuffed bears and Plumpy’nut packets. As volunteers sold raffle tickets for a Dior handbag, Salem delivered a practiced speech. Earnest and attractive, with wide brown eyes, she told the audience that her father, a member of an Indian merchant family, grew up in Tanzania. “There are over a billion people in our world that are malnourished,” Salem said. “It’s a shocking statistic. The good news is there’s a very simple solution.” And that, she said, was Plumpy’nut. “It’s really revolutionary, because it doesn’t need to be mixed with water or refrigerated,” Salem continued. “And the most miraculous part is, it will transform a child from literally skin and bones to certain survival in just four to six weeks.”

 

This transformation, seen in before-and-after photos — on one side a sick and wasted child, on the other, a chubby, smiling one — was the promise that captured imaginations far beyond the technocratic community of specialists that originally developed Plumpy’nut. “People love a silver bullet,” says the prominent nutritionist Steve Collins. Salem’s decision to devote a portion of her family’s fortune to the cause was impressive, but she is hardly the only person who was touched by the substance’s potential. At the benefit, many of the attendees said they had seen the same inspiring “60 Minutes” segment, in which Anderson Cooper compared the paste to penicillin, concluding that it “may just be the most important advance ever” in the realm of childhood malnutrition. After Salem spoke, she began squeezing dabs of Plumpy’nut onto plates and passing them around, assuring the partygoers that the brownish goo was surprisingly tasty, with the consistency and sweetness of a cookie filling. Everyone ate it right up.

 

Plumpy’nut proved so palatable and so valuable that it was only natural that other interests were now trying to take a bite. “You want to hear about the bad stuff?” Salem whispered. There was a lot to talk about. Outside the restaurant, beyond the protective cordon of appreciation, rival factions were fighting over a less innocent — though perhaps no less important — issue: who should profit? Plaintiffs were suing, accusing her partners at Nutriset of anticompetitive practices to protect their position atop a $200 million marketplace. Doctors, foreign-aid organizations and agribusinesses were staking competing claims, each invoking the interests of the world’s most fragile children. “Forget all the politics,” Salem pleads. “I’d like to erase them all.” But try as she might, she can’t wish away the questions of property and law.  Everyone, it seemed, wanted to own a bit of Plumpy’nut.  

 

At the beginning, the problem was devilishly simple: malnutrition was killing millions in poor countries — it’s thought to be responsible for a third of all deaths of children under 5.  And yet the global medical community was expending little effort to develop improved treatments. In the early 1990s, the accepted regimen for severe acute malnutrition — a watery mixture fed through a tube — was 30 years old and was unable to prevent the deaths of 20 to 60 percent of patients in hospitals. Frustrated, a small group of doctors began searching for a better way to get nutrients into starving children. One of them was André Briend.  According to legend, Briend hit upon the inspiration for Plumpy’nut one morning at the breakfast table, when, after years of vainly mixing nutrients into cookies, pancakes and yogurt, he opened a jar of Nutella, and the idea came to him: a paste! Like most such stories, this one is not completely true — or rather, it elides many years of false starts, research, scientific collaboration and infighting. The first advance came in the form of F100, a dried high-energy milk that was fortified with a mix of vitamins and minerals that were designed to counter the specific biochemical effects of malnutrition in children. F100 had to be mixed with water, though, which in poor countries was apt to be rife with bacteria. It also tasted unpleasant. As a childhood-nutrition expert attached to a French government institute, Briend came up with the idea of mixing F100 together with peanuts, milk, sugar and oil. The concoction was full of protein and fat, which insulated its nutrients from oxygen and humidity and masked their unappetizing flavor.

 

The true advance lay not in the formulation, however, but in the way the paste could be put to work. Earlier treatments had to be administered in a hospital setting, which meant a long, expensive stay away from home for both mother and patient, so children were rarely brought in for treatment until they were already extremely weak and susceptible to all the pathogens that lurk in third-world health facilities. What Briend and a few other specialists envisioned was a treatment that could be administered at home, by families instead of doctors. For medical professionals, this required a radical shift in mind-set. Briend searched the world for someone willing to conduct field tests, cautioning that collaborators in his experiments, as he put it in a 2000 message to a malnutrition Listserv, “should be ready to accept a road with trial and errors.”  One doctor who decided to take a risk was Mark Manary, a pediatrician and professor, who was working at a hospital in Malawi. His malnutrition ward was crammed full of dozens of children lying on mats. “It was really an incredible burden,” Manary recalled. “These kids are deathly ill, you’re doing whatever you can for them, and you think you’re on the right track, and then you come in the next morning and four of them have died.” Manary emptied out the ward, sending his patients home with Plumpy’nut. Many malnutrition experts were horrified. “It seemed dangerous to them, and it made them afraid,” said Manary, who recalled that one eminent figure stood up at a conference and said, “You’re killing children.” In fact, when the results were analyzed, it was found that 95 percent of the subjects who received Plumpy’nut at home made a full recovery, a rate far better than that achieved with inpatient treatment.

 

The Malawi test emboldened Doctors Without Borders, which recognized that treating children outside clinical settings would allow a vastly scaled-up response to humanitarian emergencies. In 2005, it distributed Plumpy’nut to 60,000 children with severe acute malnutrition during a famine in Niger. Ninety percent completely recovered, and only 3 percent died. Within two years, the United Nations endorsed home care with Plumpy’nut as the preferred treatment for severe acute malnutrition. “This is an enormous breakthrough,” said Werner Schultink, chief of nutrition for Unicef. “It has created the opportunity to reach many more children with relatively limited resources.” Nonetheless, Schultink estimates that the product reaches only 10 to 15 percent of those who need it, because of logistical and budgetary constraints. Briend’s invention may satisfy a need, the hungrr of children, but that doesn’t directly correspond to economic demand, which is set by buyers — the donor nations and international agencies that spend billions of dollars on food aid and famine relief. This is the gap Navyn Salem is hoping to fill. Her mission is threefold. First, her plant manufactures Plumpy’nut for sale. Second, she is trying to use publicity and humanitarian appeals to persuade the customer base — the foreign-aid donors — to allocate more money to purchase and distribute the product.

 

Finally, and most ambitiously, she is advocating the use of Plumpy’nut and a number of spinoff products to address a wider array of challenges, including malnutrition prevention. The broadened market, in theory, could be enormous: The World Bank, in a recent report, recommended that aid agencies scale up their spending on such programs, which currently stands at $300 million annually, to $6 billion a year. The U.S. Agency for International Development, which administers the $2.2 billion Food for Peace program, has been examining the usefulness of Plumpy’nut and products similar to it. American food aid must comply with stringent regulations meant to encourage domestic procurement, a requirement Navyn Salem is perfectly placed to meet.  Salem’s interest in philanthropy was intensified after reading a biography of Farmer, the crusading physician, with whom she subsequently traveled to Rwanda, but it took Plumpy’nut to galvanize her thoughts. “We talk about AIDS, tuberculosis and malaria and how detrimental they are, these terrible epidemics, but then I realized that malnutrition was killing more than all of them combined,” Salem said. “And we know how to fix it.” She didn’t know much about famine relief or the insular community of nutritionists who deal with it, but she had a professional background in advertising and marketing, and she wanted to do something that drew on what she saw as her natural entrepreneurial strengths. “I thought, Let’s figure out if we can run a business that saves thousands and thousands of lives,” she said. Salem’s factory, located in an industrial area of Providence just off Interstate 95, cost $2 million to start. In March, right around the time she opened for business, she gave me a tour. The front lobby was decorated with large photos of grinning African children that Salem took on her trips to Rwanda and Tanzania. We donned blue smocks, hairnets and booties and entered the sanitized factory floor, where two workers, a Burundian and a Liberian, were using scoops to weigh out portions of sugar. “Most of our production staff are refugees who were recently resettled in Rhode Island,” Salem said. After the Plumpy’nut was mixed, it was run through overhead pipes into a contraption that squirted it into foil packets, which were sealed and ejected onto a conveyor belt, where workers packed them for shipping. In an adjacent warehouse, there were pallets of boxes labeled for delivery to Haiti, Yemen and Nicaragua.

 

Salem led me to a gleaming stainless-steel tank, which was about as tall as she was and hot to the touch. She opened a door on top, and a fragrant peanut smell wafted out as we craned to look in. “Here it is,” Salem said. “The magic stuff.”  That magic is the property of Nutriset. To trace how a family-run company based in a small town in the Normandy countryside ended up owning the patent to one of the world’s most promising humanitarian interventions, you have to go back to André Briend. He never knew anything about manufacturing food, so at the time he was trying to demonstrate the worth of Plumpy’nut, he signed a consulting agreement with Nutriset, which specialized in making therapeutic milk products. He and the company’s founder, a food scientist named Michel Lescanne, were listed as inventors on the 1997 French patent. The patent has since been registered in 38 countries, including much of Africa “Michel is a guy who probably holds hundreds of patents, he thinks up things all the time, but he didn’t have a viable business” before Plumpy’nut, said Mark Manary, who now runs a nonprofit group that manufactures the product under license in Malawi. “So André and I were all about this as a therapeutic opportunity, and Michel was like, ‘This is an entrepreneurial opportunity.’ ” Lescanne’s expertise was invaluable when it came to engineering the taste, texture and shelf life of Plumpy’nut.

 

For its contribution, Nutriset has been richly rewarded. Last year, the company produced around 14,000 metric tons of Plumpy’nut and related products, more than a tenfold increase over the amount it made in 2004, registering $66 million in sales. The family-owned company has paid out millions in dividends, according to an internal document, although the company claims the money has largely been reinvested in expanding the business. The state institute where Briend did his research receives 1 percent of sale proceeds, Nutriset says, while the inventor himself has renounced any ownership interest. A few years ago, after some pressure from buyers, Nutriset announced that it would take a more liberal stance on licensing the product — but only in the developing world. Its affiliate network has since expanded to 11 countries, most of them in Africa. But when it comes to Europe and North America, the company has been aggressive about protecting its interests. When Salem first approached Nutriset about obtaining a license to make Plumpy’nut, she says she received a frosty reception, even though her original idea was to build a factory in Tanzania, her father’s birthplace. After meeting with Salem and her husband, the company relented, although the plan changed a bit in the process. The locus of their new joint venture, Edesia, was shifted to Rhode Island, so that it could satisfy domestic-sourcing requirements for U.S. government aid.  “Our idea with Edesia is for it to really be an incubator,” said Adeline Lescanne, Michel’s daughter and the deputy general manager of the company. She said the company was investing its profits in research into a new generation of ready-to-use therapeutic foods, or R.U.T.F., as they are called in the jargon of the foreign-aid community. The new lines would be designed to prevent malnutrition, not just cure it. “It’s a kind of pity that there is not a lot of research on new R.U.T.F.,” Lescanne said. “There are only people fighting to produce this product.”

 

Nutriset’s critics say that line of argument is disingenuous, because the Plumpy’nut patent is so broad as to encompass just about any kind of nut-based nutritional paste. “There are other people that would like to enter into the business,” Ben Tabatchnick, who runs a New Jersey-based kosher soup company, said. “But everybody is afraid of being sued.” Last year, Tabatchnick went to France to talk to Nutriset about his plans to develop ready-to-use therapeutic foods on a for-profit basis. “I had a meeting with them that lasted about 10 minutes, and they threw me out of the room,” he told me. Afterward, Nutriset sent him a pair of ominous letters, indicating that it had found “some similarities” between Plumpy’nut and his product, Nutty Butta.  Nutriset has sent similar saber-rattling correspondence to a number of other potential competitors. Lescanne told me that Nutriset’s vigilance over its intellectual property has a benevolent purpose. Between now and the time the patent is scheduled to expire, in 2017, the company wants to focus on building its network of affiliates in countries like Congo, Mozambique and Niger. (Salem’s plant in Tanzania is supposed to open later this year.) “We have to protect this network,” Lescanne said. “We are a bit afraid that big industrial companies will come.” In recent months, to take one example, PepsiCo Inc. has talked publicly about playing “a more decisive role” in bringing ready-to-use foods to needy populations. This has raised hackles: in a recent journal article titled “The Snack Attack,” three nutritionists warned that Pepsi-branded therapies would potentially be “potent ambassadors for equivalently branded baby foods, cola drinks and snack foods.”

 

What we don’t want,” Salem told me, “is for General Mills to take over and put our Ethiopian producer out of business.” Opponents of the patent, however, say that Nutriset is just trying to avoid competition that would cut into its bottom line. Recently, a handful of companies have set up shop in countries where, because of the vagaries of various treaties, the Plumpy’nut patent is not in force. In the United States, two would-be competitors have taken a more confrontational route. They filed a lawsuit with the federal district court in Washington, D.C., seeking to have the patent invalidated.  The plaintiffs are a Texas-based manufacturer called Breedlove Foods and the Mama Cares Foundation, the charitable arm of a snack-food manufacturer based in Carlsbad, Calif. Both are small nonprofit organizations with strong ties to Christian aid organizations. But Nutriset’s defenders suspect that larger corporate interests are lurking in the background. In the French press, the patent dispute has been portrayed as a case of a plucky Gallic company besieged, as Le Monde put it, by “ ‘légions’ Américaines.”

 

In fact, there is a not-so-hidden instigator behind the case: the American peanut lobby. A few years ago, a Unicef official gave a presentation to an industry trade group, forecasting dramatically increasing demand for peanut pastes. That got the growers excited. They looked at Nutriset’s patent and came to the conclusion that, as a technical matter, Plumpy’nut was really nothing more than fortified peanut butter. “People have been making this stuff for centuries,” Jeff Johnson, a board member of the Peanut Institute, said. “It’s nothing new.” Johnson is the president of Birdsong Peanuts, one of the country’s largest shelling operations. Through a friend, he heard about Breedlove Foods, which was based in Lubbock, close to one of his processing plants. Johnson met with the company and proposed a challenge to Nutriset.  “It's a cotton-pickin’ shame that they decided to take the stance that they have with the intellectual-property issue,” said David Fish, Breedlove’s chief executive, whose lawsuit contends that the patent is hurting starving children. But even some Nutriset critics have questioned the motives behind the lawsuit, pointing out that America has a long and controversial history of dumping its agricultural surpluses on poor countries through food aid. “If you want to develop countries out of third-world status,” Fish replies, “they’ve got to come out and compete on the open market.” Plumpy! Plumpy!” With the shouted order from Rosemond Avril, an agent of a charity group, workers began unloading cardboard boxes full of foil packets from the back of a rusty blue truck. It was a sweltering Haitian morning, and next to a hive of canvas tents, the women of Bineau-Lestere were lined up beneath the branches of a gnarled quenepa tree. They were a handful of the millions displaced by last January’s earthquake, which had turned the nearby city of Léogâne into a jagged pile of concrete. Their camp, thrown up amid fields of sugar cane, was surviving on aid. On this morning, the U.N.’s World Food Program was distributing Supplementary’Plumpy, a slightly weaker formulation of the original product, to mothers with children between 6 months and 35 months.

 

Haiti wasn’t starving, but experts were still concerned about the perilous condition of its children. Even before the earthquake, an estimated quarter of them were chronically malnourished, and now many breadwinners were dead, livelihoods disrupted and much of the country’s commercial infrastructure destroyed. By administering Supplementary’Plumpy to children in the age group most vulnerable to severe malnutrition, the World Food Program was trying to keep a bad situation from turning into a crisis. Across Haiti, the agency was distributing such aid to 500,000 people, and the results of a survey suggested that malnutrition levels had remained stable. “This is all new,” said Myrta Kaulard, country director for the World Food Program in Haiti. “It’s preventative action.”  Darting around the scrum of women and toddlers, as a relief worker announced instructions in Creole through a bullhorn, Navyn Salem snapped pictures with her Nikon. She looked on with satisfaction as one jug-eared little boy ripped open a packet and squeezed the light brown paste into his mouth. She clicked the photo, and before long it was on its way to the Facebook page of Edesia Global Nutrition Solutions.

 

Salem had flown to Haiti a few days earlier aboard a private jet, lent by her husband, on a characteristically blurry mission: part sales call, part fact-finding tour. Edesia was sending its products to agencies in Haiti, the World Food Program among them, but what interested Salem most was the prospect of using ready-to-use foods to address conditions beyond severe malnutrition. She and Maria Kasparian, her second-in-command at Edesia, were shuttling from one charity to another in a loaned van, carrying boxes of free samples and brochures promoting three products designed to be taken as daily supplements. “Everyone knows Plumpy’nut,” Salem said before the trip, “but what we’re really trying to do is push these others, to address malnutrition sooner.”

 

Scientists have shown that there is, in the words of The Lancet, “a golden interval” for childhood nutrition that occurs before the age of 2. “This is the period when brain growth is very extensive and babies are developing their immune systems,” said Kathryn Dewey, a professor in the department of nutrition at the University of California, Davis. Stunting that persists after age 2 is generally irreversible, while improved nutrition in early childhood correlates to greater educational success. One study, in Guatemala, showed that boys given a nutritional supplement as babies made 46 percent higher wages as men. Dewey has been testing whether Nutributter, one of Nutriset’s new (and patent-protected) products, might achieve similar results. “There has to be a way to break the cycle of poverty and malnutrition that has plagued these populations for hundreds and hundreds of years,” she said. “That’s the more grandiose vision of where this is headed.”

 

In Haiti’s Artibonite Valley, Ian Rawson, the managing director of the Hôpital Albert Schweitzer, took Salem to see malnutrition inpatients — “our failures,” he called them — in a dimly lighted ward where they lay beneath a mural of parrots. Many of the children were unnaturally small and had patchy, orange-tinted hair, a classic sign of protein deficiency. “This,” Rawson said, waving a packet of Plumpy’nut, “is our immunization.” He was applying for a U.S. government grant to distribute Nutributter in the surrounding mountains, where poverty is dire, 9 out of 10 adults can’t read and acute malnutrition rates can top 35 percent. “It seems simple to me,” he said. “What’s the downside to me giving every child who’s over 4 months old a tube of Nutributter per day?”

 

Advocates of the preventive approach foresee a future in which children around the world consume a daily packet of nutrient-filled paste. “It’s not just for poverty-stricken people,” Salem said. “It’s just like I give my children a multi¬vitamin.” Of course, this changes the nature of the intervention from an emergency treatment to a habitual routine and also dramatically escalates its prospective cost to donors. As a practical matter, Salem says, supplements will probably have to reach children through consumer markets, perhaps with subsidies. Edesia is conducting testing in Tanzania to see whether Nutributter could be sold in stores.  Some experts, however, warn that enthusiasm may be running ahead of the science. “In their rush to be innovators, I think a lot of agencies are using ready-to-use supplementary foods without evidence,” said Steve Collins, who was a pioneering advocate of home-based care for severe malnutrition. “I wouldn’t want to see a new world order where poor people are dependent on packaged supplementary foods that are manufactured in Europe or the United States.”  His wariness reflects a larger ideological divide over the proper distribution of profit. Nutriset says it is committed to opening more developing-world franchises, a strategy that brings down shipping costs and hence prices, but the majority of its network’s inventory still comes from France, and now, with the entry of Edesia, Nutriset is going to be expanding exports from the United States. Collins asks, “How are they addressing the need for poor people in Haiti not to be dependent on outside intervention in the first place?"

 

This question hung, unanswerable, over Salem’s journey through Haiti. Salem went there with a promise to donate a shipping container filled with $60,000 worth of Nutriset-patented products to Partners in Health, the charity run by her friend Paul Farmer. While grateful, the organization still preferred to manufacture its own product, Nourimanba, with the profits accruing to local farmers. But even this program was more a principled exercise than a development strategy. Haiti’s endemic problem of malnutrition wasn’t something you could solve with peanuts. Partners in Health also took Salem on a couple of home visits. At a one-room shack in Cange, a mother presented her 3-year-old daughter, saying she had gained 11 pounds on a regimen of Nourimanba. But the mother complained that there was no help for other serious problems she faced, like the fact that she had no job and the tin roof of her shack leaked.  Out in the hills, down a muddy path shaded by coconut palms, the health workers checked in on a small wooden farmhouse. Two children living there were on a regimen of ready-to-use food — and six were receiving nothing. The older ones watched as their little sister wolfed down an entire cup of peanut paste for the benefit of the visitors. The children’s grandmother, who was looking after them, was asked why malnutrition had been diagnosed in these two and the others not. She said she couldn’t really say, except that there simply wasn’t enough food to go around. There was no foil-wrapped answer to the maddening persistence of poverty. All that existed was a determination to meet the challenge with all the fallible tools of human ingenuity. “We’re trying to put ourselves out of business,” said Salem, still brimming with optimism, after the trip. “That would be the best-case scenario.”

Making Nutrition a Sustainable Business in Haiti (11/1/2011)

New York Times
By Duff Wilson
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PHARMACEUTICAL companies around the globe are donating billions of dollars in free drugs to third world countries grappling with poverty and disease. The Illinois-based company is donating the time of dozens of workers with expertise in food sciences and engineering, in addition to $6.5 million cash, to build a charitable, self-sustaining nutrition enterprise in Haiti, the poorest country of the Western Hemisphere. On the central plateau of Haiti one day recently, 18 women sat in the shade hand-sorting peanuts in wide, flat baskets. “You know the misery we live in,” said one of them, Francilia Joseph. “I have six children at home. With this money, I’m able to send three of them to school.” Other workers roast the peanuts on gas stovetops, blend them in food processors with oil, powdered milk and vitamins, and spoon the sticky mix into plastic jars. The uniquely Haitian product, called Nourimanba, is an essential medicine for about 10,000 severely malnourished children a year. It is distributed to clinics by Partners in Health, a Boston-based nonprofit organization that is the largest provider of health care services in rural Haiti. A few hundred yards away lies a roadway of rocks leading to an empty lot. Rising soon: an 18,000-square-foot manufacturing plant to produce the vitamin-enriched peanut butter on a much larger scale. In addition, some regular peanut butter may also be exported for sale to sustain the business. If Abbott can build an oasis of locally grown, nutritious food manufacturing in Haiti, it will be a little bit of green in a notoriously dark place, where it is difficult to make any real difference in people’s lives. “If you’re going to see a transformational change in a place like Haiti, it’s going to take a strategy beyond philanthropy,” said Katherine F. Pickus, Abbott’s divisional vice president for global citizenship and policy. “We saw this as an opportunity for Abbott to not only give its products, but its expertise as a nutrition business.” Even before the 2010 earthquake heaped more misery atop the poverty in Haiti, one in four children had stunted growth. An estimated 2.2 percent of Haitian children under the age of 5 had severe acute malnutrition, according to the United Nations Children’s Fund. Now it is worse. The quake killed 316,000, according to the government, and forced hundreds of thousands of people to leave the devastated capital city, Port-au-Prince, for the deeply impoverished plateau. Nourimanba is a high-calorie, high-protein, peanut-based paste that does not require mixing with water or refrigeration. It is a Unicef-approved ready-to-use therapeutic food for severe malnutrition.
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“We’ve been producing locally grown therapeutic food since 2007,” said Joan VanWassenhove, associate coordinator for nutrition in Haiti for Partners in Health. “But Abbott’s involvement will help with quantity, as well as quality, and help with higher levels of food safety and sanitation standards. In our eyes, it’s going to be an astounding success.” As one small part of its work there, the health organization runs the Nourimanba operation near Corporant, about 30 miles north of Port-au-Prince. The group, affiliated with Harvard Medical School and Brigham and Women’s Hospital in Boston, was founded in 1987 to help Haiti. It has about 15,000 employees around the world. While the rudimentary production plant makes about 70 tons of Nourimanba for 10,000 children a year, the new one will push capacity to more than 350 tons and 50,000 children, the health group’s spokesman, Andrew Marx, said. Children receive it daily for six to eight weeks. The new operation will also expand on the 300 or so farmers who have a guaranteed market for their peanut crops. “An alternative to poverty and disease is to have a virtuous cycle of health, well-being and opportunity,” Mr. Marx said. “I’ve seen some children who are malnourished in my community receive Nourimanba,” one of the peanut farmers, Wesley Louis-Jean, said. “They regain their strength quickly with it. I’m happy to see that.” Abbott and its foundation previously worked with the health group in Malawi, Africa, to pay for a new clinic. “But this is a departure,” Ms. VanWassenhove said. “It’s not Abbott coming in and saying we have an idea we can do. It’s more like saying we want to take your vision and make it the best possible.” The charity is also a point of pride for a drug company that has been involved with some dark chapters in pharmaceutical history. Just last month, Abbott set aside $1.5 billion in anticipation of settling criminal and civil investigations that it had illegally marketed the epilepsy drug, Depakote, to elderly patients with dementia, for whom it was unsafe. Abbott, which had a $4.5 billion profit on $38.4 billion in sales in the 12 months ended Sept. 30, has been listed by The Chronicle of Philanthropy as one of the most generous companies in the United States. In 2010, The Chronicle found, 91 percent of Abbott’s giving, or $572 million, was in the form of products, the fourth-highest ratio among major companies. The view from Abbott is one of being thankful to work on such a meaningful project as the nutrition factory, according to Daniel Schmitz, a scientist and laboratory director of Abbott Nutrition in Columbus, Ohio, who is leading the nutritional team on the project. Abbott is donating the time of food scientists, chemists, microbiologists, formulation developers and process engineers, he said. Their work starts with the recipe. Nourimanba is made of peanuts, milk powder, vegetable oil, sugar and a specially formulated vitamin mix. It’s “a very good recipe, and it provides everything we need for malnutrition,” Mr. Schmitz said. But Abbott is looking at alternatives to the milk powder because it is imported and expensive. “We’re going to look at things that are a viable crop in Haiti,” Mr. Schmitz said. That may include soybeans, beans or other legumes — locally sourced ingredients that could cut that cost in half. “I’m excited about that part of it because that’s really a true R.& D. effort, and it just offers the potential to build in something that is truly Haitian,” he said. Then there is the factory. Groundbreaking was delayed this year by an outbreak of cholera that caused 6,000 deaths in Haiti. Now groundbreaking is planned for January and production before the end of 2012. “We’re building it to be a very robust, simple operation,” Mr. Schmitz said. For instance, the women picking out bad peanuts will be inspecting them on a table with a vibrating conveyer belt that aligns the nuts and bounces them so workers can see the tops and bottoms. “They’re still manually picking, but it’s much more efficient because you’re not rolling peanuts around a basket,” Mr. Schmitz said. The pickers said they appreciate this job, any job. “I didn’t have any work at all before this,” said one, Marie-Jo Louis-Beatrice. Half the number of pickers will be needed in the new place, but the others will be trained for other jobs, Mr. Schmitz said. Total employment is expected to rise to about 60 workers from 40 as the plant capacity expands fivefold. And that’s running just one shift. Mr. Schmitz said the plant could run many more hours if it finds more supplies and children to help. Ben Depp contributed reporting from Haiti. A version of this article appeared in print on November 2, 2011, on page F8 of the New York edition with the headline: Making Nutrition a Sustainable Business in Haiti.

Helping Haiti's Malnourished Children (CNN-10/11/2011)

Ready-to-use therapeutic foods are changing the way that severe malnutrition is treated Packed with nutrients, they have proved to be more beneficial than regular food In Haiti, the foods are saving children's lives and benefiting local farmers, too
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With his ribs showing and his skin practically hanging off him, Pierre Wisny is painfully thin. The 11-month-old Haitian weighs just 11 pounds, and it's no surprise that he is severely malnourished. The same applies for 3-year-old Alcincord Guerviscon, although it's clear -- even without measurements -- to see that his growth has been stunted by the same condition. He weighs only 15 pounds. In most of these cases, the children got this way because of poverty and a lack of access to good food. If they're not given emergency treatment, they could die or suffer more effects of malnutrition, including reduced brain development. For staff members at one clinic in northern Haiti, intervention comes in bright green packets: Medika Mamba, which means "peanut butter medicine" in Creole. It's a ready-to-eat paste packed with nutritious ingredients that -- over a period of weeks -- gives a jolt to the system and puts children back on track. Made by a U.S.-based nonprofit called Meds and Food for Kids, it's one of several brands of ready-to-use therapeutic foods. A Haitian child is given Nutributter, a supplementary food rich in nutrients."You can't rehabilitate a child who has severe malnutrition with a plate of beans and rice. There's just no way," said Thomas Stehl, the nonprofit's director of operations. "Their stomachs are too small and their nutritional requirements are too great to ever be satisfied in that way. So the quality and the density of food is really important. And that is why ready-to-use therapeutic food and Medika Mamba is such a great answer." At another clinic, where children have been on therapeutic food for several weeks, the difference is striking. When Guerline d'Haiti arrived at the clinic, she weighed 10 pounds. Three weeks later, she had gained 2 pounds and become much more active. Elcie Thoby, the head nurse of Limbe Hospital, says therapeutic food is a lifesaver. "If you have children that can't eat, really eat, that child won't survive," she said. "But with the Mamba medication specially made for little children -- if that child starts taking the Mamba normally and regularly, the child will recuperate and start eating again." Haiti has long been one of the poorest countries in the world, with many of its people living on less than $2 a day.
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Haiti Facts
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One in 10 children is acutely malnourished; nearly one in five is underweight.
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One in 14 children will die before reaching the age of 5.
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40% of all 5-year-olds have stunted growth and brain development.
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76% of Haitians are living on less than $2 a day.
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Haiti's average household income is about $400 a year.
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Sources: Meds and Food for Kids, World Bank But the poverty got even worse in 2010, when a massive earthquake struck in January, killing 316,000 people and displacing more than 2 million. As of July 2011, nearly 600,000 Haitians were still displaced, according to the International Organization of Migration. "When the earthquake came ... it became harder for the kids," said Patrice Millet, one of the top 10 CNN Heroes of 2011. "Now, most of them live in tents. ... They have to fight for everything." Through his nonprofit program, Millet has helped hundreds of children from Haiti's poorest slums, teaching them soccer and valuable life skills. But about once a week, he also gives them food to take home to their families. Even with Medika Mamba and other emergency foods out there, Millet and many others know that the best course of action is to prevent malnutrition in the first place. At Fort St. Michel Health Center in Cap-Haitien, Haiti, 350 at-risk children are enrolled in a study of a supplementary food known as Nutributter. Nutributter contains fewer calories than Medika Mamba and is designed to be taken with regular food, essentially "topping up" nutrients that are lacking in the child's diet. But there are critics of this type of intervention. Marcos Arana-Cedeno, a consultant who studied malnutrition in Chiapas, Mexico, says fortified foods can do more harm than good. "They are promoting dependence," he said. Arana-Cedeno is concerned that countries will simply distribute therapeutic foods instead of educating the public about malnutrition, something that "requires more energy and more effort." But Meds and Food for Kids says its program does take the long-term interests of the community into account. Rather than simply importing Medika Mamba, the organization makes the product in Haiti and works with local farmers, buying their peanuts and teaching them how to improve their yields.
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CNN Hero: Patrice Millet "The evolution of their thinking about business, about expanding their peanut production, about how that translates to other things, is really striking," said Jamie Rhoads, the group's agricultural development specialist. "They're organizing around the prospect of being able to sell us peanuts." They've also been learning better techniques. "We can say, 'Yes, we've improved,' " said Plovert Petit-Frere, president of a farmers cooperative in Haiti. "Especially in weighing the crop, because we've been able to conserve more of it that will last longer." Meds and Food for Kids says it plans to buy many more peanuts in the coming years to produce a new version of its product: Plumpy'nut Medika Mamba. It follows a deal with Nutriset, the world's leading producer of ready-to-eat therapeutic food. The new paste will use Nutriset's recipe, which meets the requirements of major agencies such as the World Food Programme and UNICEF. Each serving must come in an individual 500-calorie pack and have a shelf life of two years. Meds and Food for Kids also is planning a new factory in Haiti that it says will create at least 50 jobs. And once aid agencies approve local crops to be used as the food's main ingredient, the group says, it will use nearly 1,000 peanut farmers as suppliers. "It is about children, of course," Stehl said. "But it is more than that. (This) has the opportunity to actually catalyze economic and agricultural development in a country where it's needed." This story was produced by Global Health Frontline News. For more stories like this, go to www.ghfn.org.

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