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A mother feeds her malnourished child at a Nutrition Rehabilitation Center (NCR) in Shivpuri, India. (zackary canepari/zackary canepari/THE GLOBE AND M)
A mother feeds her malnourished child at a Nutrition Rehabilitation Center (NCR) in Shivpuri, India. (zackary canepari/zackary canepari/THE GLOBE AND M)

Stephanie Nolen

India's poor suffer in official food fight Add to ...


Thousands of packets of emergency therapeutic food destined for severely malnourished children in India have instead been shipped from here to Afghanistan and Madagascar, after India ordered Unicef to stop using the internationally-recognized treatment because the government had not approved it.

Unicef was using Plumpy'nut, an acclaimed French-made product used to treat the life-threatening condition known as "severe acute malnutrition" in children, in the states of Madhya Pradesh and Bihar. Other aid agencies also use the product in India.

But the central government says it never approved Unicef's import of Plumpy'nut, is not convinced it works and that Unicef and others must use Indian-made products rather than imports in order to safeguard the country's food security.

The dispute with Unicef is the latest twist in a story of bureaucratic ineptitude and corruption that has kept a nation with a booming economy from making any progress in lowering malnutrition over the past 15 years. India is home to 40 per cent of the world's malnourished children.

The World Health Organization recommends Plumpy'nut as one of two forms of the most effective treatment for severe malnutrition. Unlike other therapies, parents can administer it at home and there is no need to hospitalize the child. In India, 43 per cent of children are malnourished, and the two states where Unicef is working are home to more than half of the cases. Eight million Indian children are so underfed they need emergency therapeutic intervention.

The government has forced the United Nations children's agency to stop giving Plumpy'nut to desperately sick children, to ship the packets of the medicinal food it already had in India back out of the country and to redirect $880,000 (U.S.) that would have been used to purchase more.

The Ministry of Women and Child Development, which oversees programs on child nutrition, refused to speak to The Globe and Mail about this issue. However, a senior ministry official, Dr. Shreeranjan, recently told other media that the central government had not approved use of Plumpy'nut, that Unicef's importation of the product came "as a surprise" to the ministry and violated protocols, and that nutrition programs have to use Indian-made products.

Sarah Crowe, regional spokesperson for Unicef, acknowledged that the agency did not have specific permission to use Plumpy'nut from India's central government, but noted that the two state governments which requested Unicef's help in their malnutrition emergencies were aware the therapeutic food was the internationally-recommended treatment and was being used - to great effect - in their states.

Those state governments have remained silent through this controversy.

People on all sides of the issue agree it would be preferable to use a locally-made therapy. Two Indian manufacturers are working on prototypes of products similar to Plumpy'nut, and Médecins sans frontières (MSF) is evaluating them for use in its India malnutrition programs.

"Ultimately our aim is to get it produced locally and to have governments have it as part of their protocols," Ms. Crowe said. "Local production is the only sustainable way." But the Indian government's move to force Plumpy'nut out of the country, and end its use for children starving now, has frustrated many working in the field of malnutrition.

"The tragedy is there seems to be no middle road: Can't we use a solution that exists while we work on a local solution? Because there are those eight million kids," said Purnima Menon, a researcher with the Asia office of the International Food Policy Research Institute.

Plumpy'nut, invented by French pediatric nutritionist André Briend in 1999, is a peanut-based paste that includes milk fortified with a range of vitamins and minerals - vital for stabilizing an acutely malnourished child. Unlike the other forms of therapeutic food, it is not mixed with water (so there is no risk of contamination from impure water sources, which were ubiquitous in Bihar, where Unicef introduced Plumpy'nut after massive floods) and does not need to be refrigerated. It is administered by parents at home, rather than requiring the hospitalization of the child (and the presence of a parent), which is expensive and often impractical.

Yet the hospitalization method is the one that the Indian government is now insisting be followed. Research from across Africa and South Asia has found that home-based care produces better results than inpatient centres. MSF has used Plumpy'nut, and a similar biscuit product to powerful effect in crises such as the famine in Niger and the mass displacement in the war zone of Darfur.

"India is two decades behind in treatment," said Leena Menghaney, of MSF's Access to Essential Medicines Campaign. "What we [Indians]are using here they used two decades ago in Malawi."

The issue of malnutrition in India is highly politicized. A vocal "right to food" campaign has pushed government into providing midday meals to millions of poor children through schools and neighbourhood centres, but the reach of the program has been impaired by gross corruption and bureaucracy. In any case it misses infants and toddlers, the most critically-affected group.

And it is a prevention program, not a treatment. While the government is accusing Unicef of "violating protocols," the fact is that the central government has no protocol for the treatment of severe acute malnutrition, which causes 3,000 infant deaths a day in India.

The government's demand that Unicef use a local product instead of Plumpy'nut has obscured the fact that it is a therapy, and that there is currently no Indian alternative. Supplying fortified grains, as is done in some parts of India, won't rescue a dying child. "Medical research has shown that using local foods typically found in South Asia, it is difficult to achieve the nutrient density" of Plumpy'nut or a similar biscuit-style product, MSF's Nutrition Team Leader Stéphane Doyon wrote recently.

Ms. Menghaney said she understood the government's concerns about building a sustainable nutrition intervention that relies on local industry. "But will the Indian government get past the politics to be able to treat?"



Plumpy'nut is a peanut butter paste fortified with milk, minerals and vitamins. Peanuts contain mono-unsaturated fats, which are easy to digest. They are also very high in calories, which means that a child will get a lot of energy from just small amounts (important because the stomachs of children suffering malnutrition will have shrunk). They are rich in zinc and protein - both good for the immune system. Protein is also needed for muscle development.

Peanuts are a good source of vitamin E, a powerful antioxidant that helps to convert food into energy.

Plumpy'nut was created by André Briend, who spent years working in humanitarian crises. He realized that a ready-to-eat supplement that needs no cooking or added water, and is cheap to produce, could help to save millions of lives in remote and under-developed areas. Plumpy'nut is now produced in Normandy by a company that specializes in food relief, in partnership with Unicef, the United Nation's children's organization.

Plumpy'nut was first used in 2004, during the crisis in Darfur in western Sudan, and then promptly was put to use in Niger, where a food crisis developed even though there was plenty of food in the markets - prices had sky-rocketed, though, because of a poor harvest after years of drought and the worst locust invasion for 40 years.

Previously, malnourished children were given milk and other vitamin-packed substances in hospital, by drip. It took several weeks for them to regain strength, and all the while they occupied precious space in hastily erected emergency centres. Once they were back home, their only hope of survival would be if their mothers, often weak and hungry themselves, could supplement their breast-feeding with special milk formulas. Those were costly and in areas of poor water supply prone to spreading other diseases, such as diarrhoea -- which can kill weak children.

Plumpy'nut is normally given for four weeks, at home, at a cost a little more than $20 (Canadian).

Source: The Times

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