Wednesday I wrote about how Jhabua's NRC is 15 patients beyond capacity and Thandla's is 10 above. Today I visited the third NRC in Jhabua, Petlwad NRC which is a 10 bedded facility and one that will only accomodate 10 patients. Not one over. While the other NRCs in Jhabua make room for the extra patients, Petlwad's NRC is turning them away with promises for admission the next admission cycle.
Now, Petlwad NRC staff are not heartless and have their own constraints. The staff are following the directions from their superiors (not everyone is as headstrong as my friend Heena at the Jhabua NRC). They were convinced they would get in trouble for admitting a child over capacity or off cycle. This block level hospital is not as well equipped and does not have as much extra space as Jhabua's district hospital. The NRC is a small building tucked in the back of the hospital campus. Theres no room for spillover patients in the hospital's pediatric ward or other wards. There doesn't seem to be strong committment from hospital in-charges (whom I've interacted with before).
I understand all these limitations, but regardless, this is not right. This NRC "waiting list" has disasterous consquences. A patient should never be turned away from treatment.
I have experienced multiple times the incredible challenge that all health workers face in the field of trying to convince a mother to take her child to an NRC. These centers are sometimes hours away in a non-familiar setting, often a district hospital where tribals are often treated poorly. They have to spend 14 days at this center while missing out on key responsibilities at home. While they receive 65 inr a day in wage compensation, this often does not make up for the farming work they are missing, or tending to their livestock, or feeding their other children or their demanding husband. "What, I'll go to the NRC with this child and the other children will become malnourished," one mother told me.
I've failed many times to convince a mother to go to the NRC. And I don't blaim those mothers. I wouldn't want to spend 14 days at an NRC, even the best ones I've seen.
So despite all odds and challenges, if we finally get a mother to agree to bring her child to an NRC and they gets turned away from treatment. We've lost her and quite possibly her child.
This is why we need village based treatment for uncomplicated cases of severe acute malnutrition. While I didn't see the children turned away, I'm sure they weren't extremely complicated cases on the verge of death (I really hope not, the Petlwad staff assured me a complicated case would be referred to Indore). These children who were turned away would be perfect candidates for Ready to Use Therapeutic Food (RUTF) - a supplement medically and nutritionally equivelant to the one given at NRCs, but without the risks of contamination associated with milk/water based products (see September 16th post for a detailed explanation of RUTF). This take-home treatment, however, is not approved for use in India because of politics.
What do we do?
While we're sorting out the RUTF issue, we have to make NRCs work and add more since even when RUTF is introduced, we'll still need functioning NRCs for complicated SAM cases. To start with in the Petlwad case, they do have 4 staff members for 10 patients. There must be a way for them to accomodate more patients. With a little pressure from the community, maybe the in-charge will sacrifice his big office? Maybe the hospital staff could sacrifice their breakroom? I'm no expert in hospital administration, but surely they could find away. I'll be raising this in Bhopal.
Thursday, September 17, 2009
The Science of Hunger
http://www.livescience.com/health/090916-hunger-defined.html
This article is a great intro to malnutrition and what it does to the body. Highlights:
"Every six seconds a child dies because of hunger and related causes"
"Under-nourishment occurs when people don't take in enough calories to provide them with the energy just to meet their minimum physiological needs. Malnutrition is more of a measure of what people eat, versus how much. Malnourishment occurs when people don't get the levels of protein, micronutrients (such as vitamins) or other critical components in their food, according to the WFP.
Malnutrition can have serious effects on the body:
This article is a great intro to malnutrition and what it does to the body. Highlights:
"Every six seconds a child dies because of hunger and related causes"
"Under-nourishment occurs when people don't take in enough calories to provide them with the energy just to meet their minimum physiological needs. Malnutrition is more of a measure of what people eat, versus how much. Malnourishment occurs when people don't get the levels of protein, micronutrients (such as vitamins) or other critical components in their food, according to the WFP.
Malnutrition can have serious effects on the body:
- Chronic malnutrition can stunt the growth of children.
- It can also cause children to be underweight for their age.
- An acute case can cause wasting, or severe weight loss.
- It can cause deficiency in key vitamins and minerals, such as anemia, or iron deficiency.
- The weight problems and deficiencies can increase susceptibility to disease.
- Malnutrition can become a secondary issue when the body can't take up the nutrients in food because of diarrhea or other illnesses.
Deficiencies in vitamins and minerals exact their own toll on the human body:
Iron deficiency, the most common form of malnutrition, affects billions worldwide. It can impede brain development.
- Vitamin A deficiency affects 140 million pre-school children in 118 countries. It is the leading cause of child blindness and can make people more susceptible to diseases. It kills one million infants a year, according to UNICEF.
- Iodine deficiency affects 780 million people worldwide. Babies born to iodine-deficient mothers can have mental impairments.
- Zinc deficiency results in about 800,000 child deaths a year. It weakens the immune systems of young children. "
Wednesday, September 16, 2009
RUTF and its absence
Today was an eventful day for treatment....and lack thereof
Today MSF announced the quality assurance certification of Compact's Ready to Use Therapeutic Food (RUTF) in India. This means that after months of quality and safety tests and inspections Compact's eeZeePaste can be safely used for the treatment of uncomplicated severe acute malnutrition (together with UNICEF, MSF is the recognized world authority on RUTF QA Certification). No word yet from the government on whether or not this life saving treatment for severe acute malnutrition will be allowed for use domestically.
I also visited the Nutrition Rehabilitation Center in Jhabua where they are treating 35 children with severe acute malnutrition (SAM) - 15 patients over their capacity of 20 beds. Patients are flowing into the pediatric ward of the hospital which is also over capacity with plenty more children hospitalized for severe diarrhea and cases of typhoid with 2-3 children per bed. Neighboring Thandla's NRC is also over capacity with 25 patients in their 10 beds.
As I sat down to catch up with Heena, the amazing nutritionist at the NRC who works above and beyond the call of duty, a batch of 5 children came into the NRC from just one block. She had been told the previous week not to accept more children than the NRC's capacity, but put her foot down saying that she would not send a child with complicated malnutrition home to die in the village. And she hasn't. As I shadowed her and the attending pediatrician through the process of screening and admitting these children, one child, a one year old with a shriveled up face and the leathery, wrinkly, hands of an old person started having trouble breathing. As the doctors rushed this child into the critical care unit with oxygen and started to insert a nasal gastric tube, I had to look away and sat with the other patients. Four children sat in worried mothers' arms, their dull-eyes almost waiting to be next. It's heartbreaking to see a child without that spark in their eye. As a one or two year old, what is exciting about the world if you don't even have the energy to lift your head?
The children I saw today desperately needed inpatient care for their severe severe severe acute and complicated malnutrition. But they didn't have to get to this point. They could have, should have had access to clean, safe, medically sound treatment for their severe acute malnutrition before they developed complications and began to slip. Also there should have been an intervention with these children when they had moderate acute malnutrition so that they wouldn't have become severe and needing treatment. Families should have been counseled and should have had access to prevention services so that these children wouldn't have become malnourished in the first place.
But the biggest tragedy today is the fact that these children desperetely required treatment at the village level to prevent the state they presented with at the NRC. And that treatment is available. But because of politics, field level workers are not allowed to use this treatment.
I'm opening up a can of worms for arguing on behalf of RUTF, but this is life or death. Politicians do not stare into the dull eyes of a malnourished child.
There has been a lot of debate about RUTF in this country since the Department of Women and Child Development (not the Department of Health) asked UNICEF to stop using RUTF in their emergency treatment efforts for severely malnourished children in the flood zones of Bihar and in Kalwa Block of Khandwa, MP (where over 60 children died of malnutrition in just 3 months). UNICEF was severely reprimanded for using an RUTF imported from France without explicit national government permission. For more press coverage of this debate, see the following articles:
http://in.reuters.com/article/domesticNews/idINDEL49936320090804?pageNumber=1&virtualBrandChannel=0
http://www.timesonline.co.uk/tol/news/world/asia/article6739362.ece
Opponents of RUTF cite the high cost of RUTF and question its sustainability. They fear that RUTF will be used as a supplement and will slowly begin to replace breast milk and rice and dal in the family pot. They do not understand that RUTF is a medical treatment advised for 14 days and cannot be replaced with local concoctions. Opponents of RUTF do not understand RUTF.
Let me clear up some facts about RUTF.
As I've described before, there are currently an estimated 8 million children under five years of age across India with severe acute malnutrition (SAM) a condition defined by extremely low weight-for-height or mid-upper arm circumference and carrying the risk of death for 10-20% of those afflicted. All these children require urgent treatment to bring them back to normal growth, but not all of them require hospitalization. Approximately 80% of these children, or 6.4 million, will have uncomplicated SAM, which means that while they are dangerously malnourished, they do not present with any complications such as pneumonia, hypothermia, edema, diarrhea etc. These uncomplicated cases require urgent care not necessarily in a facility but can receive RUTF administered in a community-based therapeutic care model. There will never be enough facilities in MP to treat the 1.3 million children who require SAM treatment right now.
There is currently no treatment option available for out-patient care for severe acute malnutrition in India. While there are many local recipes available for community based treatment of moderate acute malnutrition, these “home remedies” cannot be used for severe acute malnutrition because of the SAM child’s delicate state. A child with SAM needs specialized treatment that properly balances carbohydrates, lipids, proteins, and micronutrients in an energy-dense formula. Because of their fragile state of malnutrition, potential contaminants in this treatment, whether from unclean water or any other toxins that can be found in many village kitchens, may put the life of a child at risk. RUTF provides the right dose of nutrients to help a child with SAM recover quickly, without chance of contamination
RUTF is a medicine, not a supplement: RUTF is a formulation that should be treated like a medicine. It’s the equivalent to the F-100 formula (milk-based) used at hospitals across India but is instead made in a paste that can be safely given to a child to take home. RUTF is not a supplementary food or a method to prevent malnutrition, but is a treatment for a fixed amount of time to get a child back on a normal growth pattern and prevent death. RUTF has had astounding success in malnutrition treatment programs around the world.
The advantages of RUTF are:
a) if the child passes an appetite test, uncomplicated cases of acute malnutrition can be managed without going to the hospital
b) no risk of contamination since the product does not require water
c) no special training is needed to use RUTF
d) highly cost-effective compared to in-patient based approaches
e) weight gain from RUTF is higher than weight gain from F100 (5 times) and from fortified flours and other fortified foods used in supplementary feeding programs because the energy-density of RUTF is higher than in other formulations.
RUTF gives the mothers/families, assisted by trained local health workers, the primary role in treating malnutrition in their children. In this way, thousands of malnourished children can be managed in the community without caregivers having to spend days in hospitals and away from their families and work. It takes much of the burden off of government nutrition rehabilitation centers, allowing doctors to focus on only the most serious, complicated cases of SAM.
RUTF should be administered weekly under the supervision of trained health workers in conjunction with the child’s family over a 6-8 week period.
RUTF will be administered until the child has gained adequate weight. The child will then transition to a nutritious diet prepared by their family using locally available products along with micronutrient supplements.
RUTF is equal to F100/F75 not to local supplements: The WHO recommendations state that F100/F75 should ideally be used for inpatient treatment of complicated SAM cases. While the Government of India, with the recommendation of the Indian Academy of Pediatrics, recommends the use of F100/F75 - the same recipe, with equivalent nutrient content and higher caloric density used as a take-home formulation has raised an incredible controversy, despite being more effective in terms of weight gain, less expensive overall, and able to reach more children.
This is not to say that local products and remedies can't be effective in treating SAM. These should be considered as alternatives when RUTF isn't available and are up to the choice and tradition of every family. But on a whole, they're not working because we still see astronomical SAM rates.
As a policy, the government should look at what is the most effective treatment for SAM and should rely on domestic and international medical research. The recipes used by many groups in the field to treat SAM have not been clinically tested or even evaluated for their nutrition content. A critical element for the care of a SAM child is knowing their caloric and micronutrient intake. These local recipes should undergo clinical trials and evaluations if they are to be used as medical therapy.
SAM treatment is different than Moderate Acute Malnutrition (MAM) treatment: Children with SAM are at a high risk of dying and require a specifically therapeutic formulation for optimum weight gain, children with MAM do not. Local production of the foods recommended by DWCD would be perfectly targeted for MAM treatment. Treating the larger MAM population with local foods serves as a preventative measure and could also employ self help groups, community groups, use local produce and stimulate the local markets. These two feeding methods should be complementary, not exclusive. Local supplements are also ideal for ensuring that a child who has recovered from SAM does not slip back into malnutrition.
RUTF requires a high standard of quality control that villages cannot guarentee: RUTF should be produced in a facility that has been certified as meeting international food quality standards (Codex & HAACP regulations). RUTF production is tricky. Micronutrients and other ingredients need to be weighed precisely. There are many potential contaminantes from the aflatoxins in the peanuts to bacteria in milk power and oil that could make the product more harmful rather than beneficial. With their weak immune systems, even a small contamination could kill a SAM child. A village level nutrition supplement for SAM cannot effectively provide the high standard of quality assurance that is required for SAM supplements. RUTF production sites need sophisticated laboratory equipment on site and dedicated food scientists to check for toxin levels, bacteria, and other contaminents daily, in addition to food quality testing such as making sure that nutrition levels are as specified, that moisture is not present in the product and a whole number of other checks. These in-house labs also should undergo regular external quality assurance tests.
International success: RUTF has done wonders in reducing the malnutrition load and in responding to nutritional crisises across Africa and Latin America, especially in Malawi and Ethiopia. There are many studies that have compared RUTF's effectiveness vis a vi local alternatives and F100,F75: Each time RUTF comes out on top. Ethiopia, Malawi, Niger, South Africa, Cambodia, Mozambique, Haiti, Dominican Republic, and shortly, Nepal, all have or will have national level production of RUTF. MSF, UNICEF, WFP, Clinton Foundation, WHO - and the list goes on - all recommend using RUTF to treat SAM. I've included references to a few key international studies on RUTF below.
The way forward - RUTF domestic production: Before Compact started to make RUTF in India, the best of the few options for RUTF procurement in India was the industry leader Nutriset, who makes the original RUTF called Plumpy-nut. While this product is the international gold standard, it is expensive and has to be imported. For India to employ a long-term community based therapeutic care strategy for treatment of severe acute malnutrition, local, non-commercialized production of RUTF is ideal. This will take some time to institute, however. In the meantime there are two manufacturers, Cipla and Compact, who are making RUTF in India (Mumbai and Manesar, respectively). These low cost, high quality products can help us treat the millions of children who have SAM and would be ideal to procure for the national program until local production can be scaled up.
And as I started this posting off, Compact just got their quality certification. I've been to the plant, I've tasted their RUTF, I've met with their CEO, a man with morals who is out to save children's lives and not make a profit. This is the best option we've got. RUTF will allow millions of more children to be treated for SAM at the village level, freeing up NRC space so that Heena and her team can concentrate on just the most severe cases.
RUTF is only a temporary measure and a small part of the long fight against malnutrition. However is it a cost effective and safe means of treating acute malnutrition in children in a public health setting. RUTF is treatment which, if accompanied with proper community-based counseling and support mechanisms, should only be administered to a child once for up to one month. The goal is that by promoting local production of food supplements to treat MAM and through grassroots effort to prevent malnutrition, that RUTF will be used less and less over time.
For further reading, check out:
WHO/WFP/UNICEF Consensus document on "Community Based Treatment of Severe Acute Malnutrition" 2007: http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html
Compact's product: http://www.compactforlife.com/eezeepaste-rutf/
and a whole list of studies to back this up:
Today MSF announced the quality assurance certification of Compact's Ready to Use Therapeutic Food (RUTF) in India. This means that after months of quality and safety tests and inspections Compact's eeZeePaste can be safely used for the treatment of uncomplicated severe acute malnutrition (together with UNICEF, MSF is the recognized world authority on RUTF QA Certification). No word yet from the government on whether or not this life saving treatment for severe acute malnutrition will be allowed for use domestically.
I also visited the Nutrition Rehabilitation Center in Jhabua where they are treating 35 children with severe acute malnutrition (SAM) - 15 patients over their capacity of 20 beds. Patients are flowing into the pediatric ward of the hospital which is also over capacity with plenty more children hospitalized for severe diarrhea and cases of typhoid with 2-3 children per bed. Neighboring Thandla's NRC is also over capacity with 25 patients in their 10 beds.
As I sat down to catch up with Heena, the amazing nutritionist at the NRC who works above and beyond the call of duty, a batch of 5 children came into the NRC from just one block. She had been told the previous week not to accept more children than the NRC's capacity, but put her foot down saying that she would not send a child with complicated malnutrition home to die in the village. And she hasn't. As I shadowed her and the attending pediatrician through the process of screening and admitting these children, one child, a one year old with a shriveled up face and the leathery, wrinkly, hands of an old person started having trouble breathing. As the doctors rushed this child into the critical care unit with oxygen and started to insert a nasal gastric tube, I had to look away and sat with the other patients. Four children sat in worried mothers' arms, their dull-eyes almost waiting to be next. It's heartbreaking to see a child without that spark in their eye. As a one or two year old, what is exciting about the world if you don't even have the energy to lift your head?
The children I saw today desperately needed inpatient care for their severe severe severe acute and complicated malnutrition. But they didn't have to get to this point. They could have, should have had access to clean, safe, medically sound treatment for their severe acute malnutrition before they developed complications and began to slip. Also there should have been an intervention with these children when they had moderate acute malnutrition so that they wouldn't have become severe and needing treatment. Families should have been counseled and should have had access to prevention services so that these children wouldn't have become malnourished in the first place.
But the biggest tragedy today is the fact that these children desperetely required treatment at the village level to prevent the state they presented with at the NRC. And that treatment is available. But because of politics, field level workers are not allowed to use this treatment.
I'm opening up a can of worms for arguing on behalf of RUTF, but this is life or death. Politicians do not stare into the dull eyes of a malnourished child.
There has been a lot of debate about RUTF in this country since the Department of Women and Child Development (not the Department of Health) asked UNICEF to stop using RUTF in their emergency treatment efforts for severely malnourished children in the flood zones of Bihar and in Kalwa Block of Khandwa, MP (where over 60 children died of malnutrition in just 3 months). UNICEF was severely reprimanded for using an RUTF imported from France without explicit national government permission. For more press coverage of this debate, see the following articles:
http://in.reuters.com/article/domesticNews/idINDEL49936320090804?pageNumber=1&virtualBrandChannel=0
http://www.timesonline.co.uk/tol/news/world/asia/article6739362.ece
Opponents of RUTF cite the high cost of RUTF and question its sustainability. They fear that RUTF will be used as a supplement and will slowly begin to replace breast milk and rice and dal in the family pot. They do not understand that RUTF is a medical treatment advised for 14 days and cannot be replaced with local concoctions. Opponents of RUTF do not understand RUTF.
Let me clear up some facts about RUTF.
As I've described before, there are currently an estimated 8 million children under five years of age across India with severe acute malnutrition (SAM) a condition defined by extremely low weight-for-height or mid-upper arm circumference and carrying the risk of death for 10-20% of those afflicted. All these children require urgent treatment to bring them back to normal growth, but not all of them require hospitalization. Approximately 80% of these children, or 6.4 million, will have uncomplicated SAM, which means that while they are dangerously malnourished, they do not present with any complications such as pneumonia, hypothermia, edema, diarrhea etc. These uncomplicated cases require urgent care not necessarily in a facility but can receive RUTF administered in a community-based therapeutic care model. There will never be enough facilities in MP to treat the 1.3 million children who require SAM treatment right now.
There is currently no treatment option available for out-patient care for severe acute malnutrition in India. While there are many local recipes available for community based treatment of moderate acute malnutrition, these “home remedies” cannot be used for severe acute malnutrition because of the SAM child’s delicate state. A child with SAM needs specialized treatment that properly balances carbohydrates, lipids, proteins, and micronutrients in an energy-dense formula. Because of their fragile state of malnutrition, potential contaminants in this treatment, whether from unclean water or any other toxins that can be found in many village kitchens, may put the life of a child at risk. RUTF provides the right dose of nutrients to help a child with SAM recover quickly, without chance of contamination
RUTF is a medicine, not a supplement: RUTF is a formulation that should be treated like a medicine. It’s the equivalent to the F-100 formula (milk-based) used at hospitals across India but is instead made in a paste that can be safely given to a child to take home. RUTF is not a supplementary food or a method to prevent malnutrition, but is a treatment for a fixed amount of time to get a child back on a normal growth pattern and prevent death. RUTF has had astounding success in malnutrition treatment programs around the world.
The advantages of RUTF are:
a) if the child passes an appetite test, uncomplicated cases of acute malnutrition can be managed without going to the hospital
b) no risk of contamination since the product does not require water
c) no special training is needed to use RUTF
d) highly cost-effective compared to in-patient based approaches
e) weight gain from RUTF is higher than weight gain from F100 (5 times) and from fortified flours and other fortified foods used in supplementary feeding programs because the energy-density of RUTF is higher than in other formulations.
RUTF gives the mothers/families, assisted by trained local health workers, the primary role in treating malnutrition in their children. In this way, thousands of malnourished children can be managed in the community without caregivers having to spend days in hospitals and away from their families and work. It takes much of the burden off of government nutrition rehabilitation centers, allowing doctors to focus on only the most serious, complicated cases of SAM.
RUTF should be administered weekly under the supervision of trained health workers in conjunction with the child’s family over a 6-8 week period.
RUTF will be administered until the child has gained adequate weight. The child will then transition to a nutritious diet prepared by their family using locally available products along with micronutrient supplements.
RUTF is equal to F100/F75 not to local supplements: The WHO recommendations state that F100/F75 should ideally be used for inpatient treatment of complicated SAM cases. While the Government of India, with the recommendation of the Indian Academy of Pediatrics, recommends the use of F100/F75 - the same recipe, with equivalent nutrient content and higher caloric density used as a take-home formulation has raised an incredible controversy, despite being more effective in terms of weight gain, less expensive overall, and able to reach more children.
This is not to say that local products and remedies can't be effective in treating SAM. These should be considered as alternatives when RUTF isn't available and are up to the choice and tradition of every family. But on a whole, they're not working because we still see astronomical SAM rates.
As a policy, the government should look at what is the most effective treatment for SAM and should rely on domestic and international medical research. The recipes used by many groups in the field to treat SAM have not been clinically tested or even evaluated for their nutrition content. A critical element for the care of a SAM child is knowing their caloric and micronutrient intake. These local recipes should undergo clinical trials and evaluations if they are to be used as medical therapy.
SAM treatment is different than Moderate Acute Malnutrition (MAM) treatment: Children with SAM are at a high risk of dying and require a specifically therapeutic formulation for optimum weight gain, children with MAM do not. Local production of the foods recommended by DWCD would be perfectly targeted for MAM treatment. Treating the larger MAM population with local foods serves as a preventative measure and could also employ self help groups, community groups, use local produce and stimulate the local markets. These two feeding methods should be complementary, not exclusive. Local supplements are also ideal for ensuring that a child who has recovered from SAM does not slip back into malnutrition.
RUTF requires a high standard of quality control that villages cannot guarentee: RUTF should be produced in a facility that has been certified as meeting international food quality standards (Codex & HAACP regulations). RUTF production is tricky. Micronutrients and other ingredients need to be weighed precisely. There are many potential contaminantes from the aflatoxins in the peanuts to bacteria in milk power and oil that could make the product more harmful rather than beneficial. With their weak immune systems, even a small contamination could kill a SAM child. A village level nutrition supplement for SAM cannot effectively provide the high standard of quality assurance that is required for SAM supplements. RUTF production sites need sophisticated laboratory equipment on site and dedicated food scientists to check for toxin levels, bacteria, and other contaminents daily, in addition to food quality testing such as making sure that nutrition levels are as specified, that moisture is not present in the product and a whole number of other checks. These in-house labs also should undergo regular external quality assurance tests.
International success: RUTF has done wonders in reducing the malnutrition load and in responding to nutritional crisises across Africa and Latin America, especially in Malawi and Ethiopia. There are many studies that have compared RUTF's effectiveness vis a vi local alternatives and F100,F75: Each time RUTF comes out on top. Ethiopia, Malawi, Niger, South Africa, Cambodia, Mozambique, Haiti, Dominican Republic, and shortly, Nepal, all have or will have national level production of RUTF. MSF, UNICEF, WFP, Clinton Foundation, WHO - and the list goes on - all recommend using RUTF to treat SAM. I've included references to a few key international studies on RUTF below.
The way forward - RUTF domestic production: Before Compact started to make RUTF in India, the best of the few options for RUTF procurement in India was the industry leader Nutriset, who makes the original RUTF called Plumpy-nut. While this product is the international gold standard, it is expensive and has to be imported. For India to employ a long-term community based therapeutic care strategy for treatment of severe acute malnutrition, local, non-commercialized production of RUTF is ideal. This will take some time to institute, however. In the meantime there are two manufacturers, Cipla and Compact, who are making RUTF in India (Mumbai and Manesar, respectively). These low cost, high quality products can help us treat the millions of children who have SAM and would be ideal to procure for the national program until local production can be scaled up.
And as I started this posting off, Compact just got their quality certification. I've been to the plant, I've tasted their RUTF, I've met with their CEO, a man with morals who is out to save children's lives and not make a profit. This is the best option we've got. RUTF will allow millions of more children to be treated for SAM at the village level, freeing up NRC space so that Heena and her team can concentrate on just the most severe cases.
RUTF is only a temporary measure and a small part of the long fight against malnutrition. However is it a cost effective and safe means of treating acute malnutrition in children in a public health setting. RUTF is treatment which, if accompanied with proper community-based counseling and support mechanisms, should only be administered to a child once for up to one month. The goal is that by promoting local production of food supplements to treat MAM and through grassroots effort to prevent malnutrition, that RUTF will be used less and less over time.
For further reading, check out:
WHO/WFP/UNICEF Consensus document on "Community Based Treatment of Severe Acute Malnutrition" 2007: http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html
Compact's product: http://www.compactforlife.com/eezeepaste-rutf/
and a whole list of studies to back this up:
- Ciliberto, Michael A., et al., ‘Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: A controlled,
clinical effectiveness trial’, The American Journal of Clinical Nutrition, vol. 81, no. 4, 2005, pp. 864–870. - Collins, Steve, ‘Changing the way we address severe malnutrition during famine’, The Lancet, vol. 358, 11 August 2001, pp. 498–501.
- Collins, Steve, and Kate Sadler, ‘Outpatient care for severely malnourished children in emergency relief programmes: A retrospective cohort study’, The Lancet, vol. 360, 7 December
2002, pp. 1824–1830. - Collins, Steve, et al., ‘Management of severe acute malnutrition in children’, The Lancet, vol. 368, no. 9551, 2 December 2006, pp. 1992–2000.
- Diop, El Hadji Issakha, et al., ‘Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: A randomized
trial’, The American Journal of Clinical Nutrition, vol. 78, no. 2, August 2003, pp. 302–307. - Gross, Rainer, and Patrick Webb, ‘Wasting time for wasted children: Severe child undernutrition must be resolved in nonemergency settings’, The Lancet, vol. 367, no. 9517, 8 April 2006, pp. 1209–1211.
- Manary, Mark J., et al., ‘Home based therapy for severe malnutrition with ready-to-use food’, Archives of Disease in Childhood, vol. 89, June 2004, pp. 557–561.
- Navarro-Colorado, Carlos, and Stéphanie Laquière, ‘Clinical trial of BP100 vs F100 milk for rehabilitation of severe malnutrition’, Field Exchange, vol. 24, March 2005, pp. 22–24,
- Prudhon, Claudine, et al., 'WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children', SCN Nutrition Policy Paper No. 21, Food and Nutrition Bulletin, vol. 27, no. 3 (supplement), 2006,
- Sandige, H., et al., ‘Home-based treatment of malnourished Malawian children with locally produced or imported ready-touse food’, Journal of Paediatric Gastroenterology and Nutrition, vol. 39, no. 2, August 2004, pp. 141–146.
- World Health Organization and UNICEF, Global Strategy for Infant and Young Child Feeding, WHO, Geneva, 2003
- http://www.ahrchk.net/statements/mainfile.php/2009statements/2083/
- and theres many more where that came from
- Thank you to Rebecca and Fabian for helping me understand RUTF and providing countless references
Tuesday, September 15, 2009
Child Friendly Anganwadis and your chance to help
Goonj (http://www.goonj.com/) an wonderful Delhi-based NGO is sponsoring the Vastrasamman event during Joy of Giving Week across India. In Bhopal two friend-NGOs, Spaandan and Aham Bhumika, are organizing the efforts in MP. Its a drive to encourage and stimulate giving amongst Indians - not neccessarily monetarily, but mostly in used clothes, games, toys, furniture, etc. These goods will be redistributed by volunteers and NGOs across the state to people who would really value these items.
Relating to malnutrition, the many toys discarded by many urban kids that are still in almost new condition can make a huge difference in improving the nutritional status of children in rural areas. Let me explain:
Children who attend anganwadi centers regularly and spend the maximum amount of time there often have better nutrition outcomes than children who never come at all. This is in part because they obtain a supplementary meal there but also because if they spend enough time at the center, the anganwadi worker will eventually have enough time to notice a malnourished child, take his height and weight, and talk to his mother (in theory). If the child is in and out of the center in minutes along with dozens of other kids, this doesn't give the worker enough time to do her job (let alone start with preschool education). You can't blaim mothers for not sending her children the the anganwadi center for longer. They're often a plain room with no windows, stuffy, with nothing to keep a child under 6 entertained. I wouldn't want to hang out there or send my kids there.
who wants to hang out here?
But imagine if the anganwadi center was bright and colorful and full of stimulating posters, toys for kids to play with, educating games, and a cheer that would entice mothers to bring their kids and for kids to ask their mothers to go. In these "child-friendly" anganwadi centers, mothers are more likely to bring their kids, who are more likely going to want to stay, where they will be more likely to learn, and the anganwadi worker will be more likely to assess their height and weight.
I've seen examples of child-friendly anganwadi centers set up by the Spandan Organization in Khandwa, Madhya Pradesh. They started with donated toys, stuffed animals, posters, and games and then got the people from the village to donate paints and building materials from their homes. The whole village got involved in making the anganwadi center cheerful and child friendly, adding a covered area outside the main room where kids could sit outdoors and painting the place with colorful decorations. The anganwadi center was transformed into a place only the poorest people go to when they're sick (and often didn't get care) to a community location centered around maternal and child health. At Spandan's three child friendly anganwadis nutrition outcomes are noticably better than the neighboring centers.
I would encourage everyone in Bhopal to support this effort! Clean out the clutter from your homes and transform an anganwadi center! I also recommend that everyone check out Joy of Giving's website for a lot of volunteer opportunities around India: http://joyofgivingweek.org/
Here are details on the week long drive in Bhopal below:
"Vastra Samman" ( Dignifying Clothing ) Joy of Giving Week from 27th Sept. to 03rd Oct.'09
"Vastra Samman" ( Dignifying Clothing ) Joy of Giving Week from 27th Sept. to 03rd Oct.'09
Joy of Giving Week is a Nation wide campaign aimed at reinforcing giving as a festival. It is an effort to pool in resources that can be channeled to the marginalized. It is being simultaneously organized at 25 cities across the Country from 27th September – 3rd October’09. Give India and GOONJ are prime- moving this campaign.
At Bhopal level "Aham Bhumika" & "Spandan" have taken responsibility to facilitate it. But we certainly can't do it alone and are seeking wider civil society participation in this anecdote event.
AhamBhumika is facilitating "Goonj" in Bhopal for the Event "VastraSamman" during the Joy of Giving Week. Click on for more information at Joy of Giving Week official website.
Vastra Samman ( Dignifying Clothing )
During this campaign we will be collecting clothes, utensils, school material, toys, books, dry ration etc. The material will be distributed to the rural areas as an incentive under cloth for work programme.
You can support us:
(i) By launching collection drive in your colony, office, school, bank, college etc. ( Posters for this will be provided by us)
(ii) By approaching schools, colleges, organizations, corporate, kitty parties, residential societies, clubs, Satsang mandal etc.
(iii) Volunteering us in sorting, packing and transportation of the material.
(iv) By transporting material to our collection centres.
Collection centers in Bhopal where you can submit the material :-
1. Saraswati Collections, Geet Bunglow, Phase II , Ayodhya Nagar, Bhopal.
Contact person - Mr. Ranjan Singh (M) 9993365612
2. Matratva Medical Store, B Sector, Sarvadharam Colony, Kolar Road, Bhopal.
Contact Person - Mr. Subrat Goswami (M) 9826472718
3. Mona Resturant, 9-A, Saket Nagar, Bhopal.
Contact person - Mr. Yogesh Vaidya (M) 9826492924
4. HRLN, 10-B, Aman Complex, 2nd Floor, Above Noble Electronics, Govind Garden, Near Apsara Talkies , Bhopal.
Contact Person - Mrs. Shubhra Pachouri (M) 9993928903
At Bhopal level "Aham Bhumika" & "Spandan" have taken responsibility to facilitate it. But we certainly can't do it alone and are seeking wider civil society participation in this anecdote event.
AhamBhumika is facilitating "Goonj" in Bhopal for the Event "VastraSamman" during the Joy of Giving Week. Click on for more information at Joy of Giving Week official website.
Vastra Samman ( Dignifying Clothing )
During this campaign we will be collecting clothes, utensils, school material, toys, books, dry ration etc. The material will be distributed to the rural areas as an incentive under cloth for work programme.
You can support us:
(i) By launching collection drive in your colony, office, school, bank, college etc. ( Posters for this will be provided by us)
(ii) By approaching schools, colleges, organizations, corporate, kitty parties, residential societies, clubs, Satsang mandal etc.
(iii) Volunteering us in sorting, packing and transportation of the material.
(iv) By transporting material to our collection centres.
Collection centers in Bhopal where you can submit the material :-
1. Saraswati Collections, Geet Bunglow, Phase II , Ayodhya Nagar, Bhopal.
Contact person - Mr. Ranjan Singh (M) 9993365612
2. Matratva Medical Store, B Sector, Sarvadharam Colony, Kolar Road, Bhopal.
Contact Person - Mr. Subrat Goswami (M) 9826472718
3. Mona Resturant, 9-A, Saket Nagar, Bhopal.
Contact person - Mr. Yogesh Vaidya (M) 9826492924
4. HRLN, 10-B, Aman Complex, 2nd Floor, Above Noble Electronics, Govind Garden, Near Apsara Talkies , Bhopal.
Contact Person - Mrs. Shubhra Pachouri (M) 9993928903
I think some more sites will be added to this list next week when I'm in Bhopal, if so I'll update this post.
For any query please e-mail us at ahambhumika@yahoo.co.in or call Mr. Subrat - 9826472718 or Mr.Yogesh - 9826492924
For any query please e-mail us at ahambhumika@yahoo.co.in or call Mr. Subrat - 9826472718 or Mr.Yogesh - 9826492924
Friday, September 4, 2009
When things work
Today I witnessed democracy...
I had a meeting scheduled with the Jhabua district director of the Department of Women and Child Development (DWCD) - the department in charge of anganwadi workers, the village health workers who are the government's first line of defense against malnutrition. We're working with DWCD in Jhabua to train all anganwadi workers, anganwadi helpers (who right now don't do anything more than cook, but who have enormous potential), and village leaders in various aspects of malnutrition identification, treatment, and prevention. We were supposed to meet to finalize the training schedule.
Just as I sat down for my meeting with Mr. Jaura, a man donning a dhoti and the longest ear-hair I've ever seen barged in and sat down right next to me with a sheet of paper. He said he came from a remote village outside of Meghnagar, where there was no anganwadi worker. He handed Mr. Jaura a handwritten list with the names of 310 children he counted in his village (there should be 1 anganwadi worker for roughly every 100 children) and also listed out the various ailments children had - diarrhea, malnutrition (who knows how he measured), fevers, etc. He demanded that DWCD place an anganwadi center in his village.
Mr. Jaura immediately ordered an inspection of the village and got his staff started on the neccessary paperwork to create an anganwadi center in this village.
I was happy to wait my turn sipping chai while this whole process went on. About 20 minutes and DWCD was on their way to increasing access to anganwadi health and education services to one more village.
Of course this was just the first step in a long process to establish a new anganwadi center. And given the fact that the list of anganwadi centers the government says it opperates does not actually match up to the ground reality - we'll wait until we see children sitting on the floor eating and learning until we call this episode a complete success, but this is a step in the right direction and proves that in order for things to work we need the dedication from people like my long-ear-haired friend.
The rural poor are afforded numerous benefits and services from the government, but unfortunately many people are not aware of these rights and therefore do not receive the benefits. The times I've seen the system work the best are times like this when rural people take it upon themselves to demand these services from the government.
I'm going to try to make it out to this village soon to see where this man is coming from and what prompted him to come to the DWCD with this request. Will update!
I had a meeting scheduled with the Jhabua district director of the Department of Women and Child Development (DWCD) - the department in charge of anganwadi workers, the village health workers who are the government's first line of defense against malnutrition. We're working with DWCD in Jhabua to train all anganwadi workers, anganwadi helpers (who right now don't do anything more than cook, but who have enormous potential), and village leaders in various aspects of malnutrition identification, treatment, and prevention. We were supposed to meet to finalize the training schedule.
Just as I sat down for my meeting with Mr. Jaura, a man donning a dhoti and the longest ear-hair I've ever seen barged in and sat down right next to me with a sheet of paper. He said he came from a remote village outside of Meghnagar, where there was no anganwadi worker. He handed Mr. Jaura a handwritten list with the names of 310 children he counted in his village (there should be 1 anganwadi worker for roughly every 100 children) and also listed out the various ailments children had - diarrhea, malnutrition (who knows how he measured), fevers, etc. He demanded that DWCD place an anganwadi center in his village.
Mr. Jaura immediately ordered an inspection of the village and got his staff started on the neccessary paperwork to create an anganwadi center in this village.
I was happy to wait my turn sipping chai while this whole process went on. About 20 minutes and DWCD was on their way to increasing access to anganwadi health and education services to one more village.
Of course this was just the first step in a long process to establish a new anganwadi center. And given the fact that the list of anganwadi centers the government says it opperates does not actually match up to the ground reality - we'll wait until we see children sitting on the floor eating and learning until we call this episode a complete success, but this is a step in the right direction and proves that in order for things to work we need the dedication from people like my long-ear-haired friend.
The rural poor are afforded numerous benefits and services from the government, but unfortunately many people are not aware of these rights and therefore do not receive the benefits. The times I've seen the system work the best are times like this when rural people take it upon themselves to demand these services from the government.
I'm going to try to make it out to this village soon to see where this man is coming from and what prompted him to come to the DWCD with this request. Will update!
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