When an Antonov 12 airlift took off Marseilles earlier this month, heading for one of the famished regions of Niger, it carried several tonnes of oil and sugar, things you’d expect would be used to help starving people. But it also carried tonnes of a 92 gram, 500 calorie foil sachet that is a household name in hungry countries and virtually unknown in well-fed ones. The sachets contain Plumpy’nut - known to millions of hungry and formerly hungry children as Plumpy – a peanut butter food for the acutely malnourished which may have transformed the way hungry people are treated. Some say this “magic potion,” as French newspaper Libération called it recently, might even herald the end of hunger. That’s excessive, says Isabelle Sauguet, sales and development manager at Nutriset, the French humanitarian foods company that invented Plumpy’nut. “I don’t think magic potions exist outside of Astérix. But Plumpy’nut has been revolutionary.”
The ingredients of this revolution are simple: Peanut paste, vegetable oil, milk powder, vitamins and minerals, combined in a foil pouch with red lettering and an apostrophe shaped like a peanut. Cut the corner of the pouch, feed to a severely malnourished child two to three times a day for about 40 days, and the child will usually be cured. Usually, a quarter of severely malnourished children don’t survive, even in clinical conditions. With Plumpy’nut, death rates can be cut by half. “This isn’t a small step,” says Dr. Mark Manary, an American paediatrician who uses peanut paste to feed malnourished children in Malawi. “It’s a quantum leap.”
And it’s needed. Every five seconds, a child dies because he or she was hungry. Hunger kills more people than AIDS, TB and malaria combined. Severe malnourishment – starvation complicated by disease – is a condition that’s as easy to get as it’s tricky to treat. The World Food Programme usually treats malnourished adults with one and a half cups of rice or flour, a tablespoon of beans or lentils, a spoonful of oil and a pinch of salt. But the more vulnerable severely malnourished – women and children – have to be given high-energy milk formulas called F100 and F75 that took years of research to develop. Ideally, a malnourished child stays in a Therapeutic Feeding Centre, or TFC, for up to four weeks, being fed at two or three-hourly intervals, with milk formulas that have been carefully diluted and measured out according to the child’s weight. If all goes well, the child should recover in about a month.
The treatment is labour-intensive, requiring strict protocols, careful dilution and clinical supervision, but there’s no doubt it works. That wasn’t the problem. “We were already asking ourselves questions about TFCs,” says Caroline Wilkinson, nutritionist with Action Against Hunger. “We were asking ourselves questions about whether mothers could and should stay for such a long time in a TFC, as it has consequences on life at home.” Every child in a TFC must be accompanied by a carer, usually the mother. This takes the mother away from any other children she might have, and from her fields. “You don’t have to go to Africa to find a mother who’d find that difficult, “ says Sauguet. “In fact,” says Dr. Steve Collins of the NGO Valid International, feeding a child in a treatment centre actually “has negative impact on food security. It’s a nasty cycle.” Malnutrition damages the immune system, too, so putting sick children amongst sick children is perfect breeding grounds for infection. And the coverage wasn’t good enough: In risky situations such as Darfur, mothers risked their lives to travel for days to the clinics, but many other mothers didn’t. Something had to change.
“The impetus really came in 1998 in southern Sudan,” says Collins. “There were tens of thousands of kids crowding centres that only had space for hundreds. It was obvious we had to find another way.” The solution, some people had come to think, was to treat the child at home, but with what? The milks had to be carefully diluted with clean water: When the mother is illiterate, and the water is dirty, it’s not going to work. Even leaving the milk standing around can contaminate it, because bacteria grows in water. Any alternative had to be non-water based, easy to store, easy to feed and easy to eat. It had to be a Ready-to-use-Therapeutic Food, or RUTF, that didn’t require clinical supervision.
The theory was there, but not the product, not until child nutrition expert Andre Briend caught sight of a jar of Nutella one morning. For a while, he’d been looking for a viable alternative to high-energy milk. Paste was it, he realised, and contacted Michel Lascanne, CEO of Nutriset, and someone on a similar quest. Lascanne had developed a chocolate bar during his time at a French dairy company, but the taste was bad, and in high temperatures, the chocolate melted. A paste made of peanut butter would store easily, Lascanne and Briend realised, and it was rich in protein and energy. By 1999, the recipe was ready.
It just needed a name. “We didn’t want a scientific name,” says Sauguet. “And we wanted an English name because so many people in the field work in English. We started with pump, then plump, then Plumpy’nut. We wanted something that encapsulated joie de vivre. A little bit of happiness.” And a lot of business. Now, the 40-strong staff of Nutriset, in their factory near Rouen in northern France, make a product that saves the lives of hundreds of thousands of children. “We’re not replacing NGOs,” says Sauguet. “We just hope we’ve taken on the cooking that they were having to do to prepare the milk. If the humanitarian network is a restaurant, we’re in the kitchen, out of sight.” Since January this year, Nutriset’s 24-hour production line has produced 1300 tonnes of Plumpy’nut, which sells for 27 centimes per sachet. It’s not much cheaper than the milks, but the sachets take up less transport space than the powdered milk, and NGOs save on the cost of hospital treatment. So far, it seems to be all pros and no cons. “Plumpy’nut is complete and it’s clean,” says Sauguet. “A child can feed himself, but he will self-regulate. “It’s hard to overfeed with Plumpy’nut,” says Saskia ven der Kam, a nutritionist with Médecins Sans Frontieres Holland. “It’s easy to gulp down milk but it takes hours to eat a jar of peanut butter.” And it even tastes good, thanks to the 28% sugar content.
But why did something so simple take so long to be invented? After all, the nutritional properties of peanut butter have been known since the freed-slave agronomist George Carver Washington invented a way to use surplus peanuts in the 19th century. “Partly, it’s because the milks were so good,” says Steve Collins. “But also, it’s because the treatment of severe malnutrition has been overmedicalised. Doctors see a severely malnourished child and they say, “there are metabolic complications, you have to put them in hospital.” That’s not always true.” Collins is the best-known advocate of CTC, or Community-based Therapeutic Care, which means children – after an initial triage and treatment phase – are treated at home. It needs ready-to-use foods to work, but Collins says the revolution isn’t about one brand. “Plumpy’nut has a good name. But writing about it is like writing about dental hygiene and only talking about Maclean’s toothpaste. From our point of view it’s not just about the product, it’s about the delivery. If every time someone is malnourished you put them in hospital, you’re giving the message that the family can’t deal with it.” In fact, mothers can treat even a severely malnourished child, with the right food.
In Malawi, Dr. Mark Manary came to the same conclusion about home-based treatment. “I was working in the hospital in 1994, and they told me, ‘don’t go to the malnutrition ward’. So I went. And it was an icky, awful place. I realised that the kids weren’t recovering. It was 15% recovery, 20% relapse and 40% malnourished and the rest died. Obviously that was unsatisfactory.” Manary read up on RUTFs, and started using them. With a mixture of traditional foods and RUTFs, 75% of kids recovered. On an entirely-RUTF diet, recovery was at 95%. “Usually something that works on a small scale doesn’t work on a big scale. But this did.” In 2003, Manary began thinking about how to deliver the food cheaply and appropriately, and Project Peanut Butter began. They used local food – peanut butter, chickpeas or soya – and added the milk, oil and vitamins. After plodding through recipes in the kitchen, and testing them on the two children of the local MSF director, they found a solution that worked. “Why does it work so well? It has everything it needs in it. Nobody has to cook it, which was one of the barriers. The kid just has to stick his finger in the jar. There’s no water, so bacteria can’t grow. And thirdly, it’s not like any other food that people eat - we tell them it’s “special medicine food” - so there’s less problem with sharing [with siblings].”
Nutriset, meanwhile, had no objections. “They heard about what we were doing and they were like, ‘that’s neat!’ They’ve been an ally and a friend.” A Nutriset food scientist came down to help set up the Project Peanut Butter factory, and a Malawian production manager recently did a two-week internship in France. “Our philosophy is to feed children,” says Sauguet. “As long as it’s for a specifically humanitarian aim, and the quality control is acceptable, that’s fine.”
It’s less fine, though, if the rival is a commercial company. Nutriset’s CEO Michel Lascanne swears that profits – which have doubled since 2001 - are put back into research and development, and the company has so far refused to countenance using its technology to sell purely commercial products like high-energy bars for athletes. But when German company MSI – like Nutriset, a for-profit manufacturer of humanitarian food products – tried to develop its own version of Plumpy’nut “we ran into big problems,” says CEO Dietmar Kneer. “We didn’t know there was a patent on the product and we got into trouble with Nutriset. They’ve built up a monopoly.” Isn’t that reasonable, for a commercial company? “It seems to me very aggressive, for a humanitarian product. A monopoly makes it more expensive for humanitarian organisations.” For now, Plumpy’nut’s only real competition is BP100, an RUTF in biscuit form produced by Norwegian company Compact. “But it’s not an either or situation,” says Wilkinson. It’s whatever’s available and whatever works, says van der Kem of MSF. “Our aim is to treat people and hope they never have to use it again.”
Patent issues aren’t of concern to children like Milika, either. When she arrived in Manary’s malnutrition ward, she was 18 months old and weighed 5 kg. Her grandmother lived on the streets and her mother was a schoolgirl who’d gone back to school. The typical response in a case like that would be, ‘this is a waste of time.” But Milika’s grandmother fed her the peanut butter, and came back for more when she was supposed to. The child thrived and survived. Other “lost causes” like HIV positive children show similar results. Project Peanut Butter is now running a pilot for HIV-positive adults in Malawi. Meanwhile, the World Health Organisation, the highly conservative arbiter of the world’s health standards, will have a meeting in November to consider recommending CTC and ready-to-use therapeutic foods.
If it’s not a revolution, then it’s a highly satisfactory evolution. “The successful treatment of severe malnutrition was possible before,” says Caroline Wilkinson of Action Against Hunger, “and it will continue to be so without RUTF. But it is a revolution in that it offers a chance to do treatment at home that is safe. It opens a lot of doors that weren’t open before.” For Milika and her like, that’s not peanuts.
Published in the Independent