Over the past few weeks, there has been a vigorous debate about Ready-to-Use Therapeutic Food (RUTF) in the media. Reportedly, certain Indian states are trying to experiment with the use of it - mostly by drawing on already successful pilots that have happened in states like Rajasthan, Gujarat and others, and perhaps more importantly, by drawing on the fact that internationally over 2 million Severe Acute Malnutrition (SAM) children are treated across the globe using the RUTF commodity.
Sadly, however, such debate has often been accompanied by inaccurate and sometimes false reporting of the nature of the product and the treatment model within which it is used. A good example of this is the letter from the All India Co-convenor of the Swadeshi Jagaran Manch, sent to the Union Minister for Women and Child Development, which misrepresents RUTF on multiple counts. I would like to take this opportunity to clear such misunderstandings. They are present not only in the letter but also in various sections of the media coverage.
Firstly, RUTF is a medical food and not a supplement designed to replace any supplementary, locally -based feeding practices - nor does it discourage in any form natural practices such as breast-feeding. Indeed, international regulations mandate that each RUTF packet be contained with the advisory that breastfeeding is essential for the health of the child for the first two years of his or her life.
What RUTF does is provide a curative solution to the problem of SAM. It, unlike normal malnutrition, is a case-scenario of visible and mortal wasting of a child, where the fatality rate may go as high as 30 per cent. A child in such a state is often unable to have regular meals, mostly because the digestive system is protruding and his throat muscles are too weak to swallow normal food.
In such a critical condition, the SAM child urgently requires medical support. RUTF, by the virtue of its ready-to-eat nature, paste form and high quality, allows this medical treatment to take place at the community level - through a treatment protocol commonly referred to as Community-based Management of Acute Malnutrition. Unlike claims to the contrary, this therapeutic feeding does not last for more than 12 to 16 weeks - long enough to get the child out of the danger zone of Severe Acute Malnutrition. All of these feeding practices are based on published World Health Organisation protocols, and are being deployed by a great range of international aid organisation and Asian and African nations with high malnutrition count.
The letter from SJM calls RUTF an "approach" that is harmful to the "local, bio-diverse and sustainable food cultures", none of which is true. RUTF, as a tool in Community based Management of Acute Malnutrition (CMAM) also requires the community to be educated on preventive measures against malnutrition including sustainable food culture, complimentary feeding practices, sanitation and gender disparity. It is solely a temporary curative measure - designed to push the child out of the danger zone of Severe Acute Malnutrition, so that they child may eventually adapt to normal dietary habits.
Secondly, there is substantial evidence on the efficacy of Community-based Management of Acute Malnutrition (with the use of RUTF) at both national and international levels. Internationally, the consensus amongst nutritionists and experts is quite clear. The biggest evidence for this lies behind the fact that over 2 million Severe Acute Malnutrition children all over the world receive treatment with RUTF (in the context of CMAM). The agencies leading and endorsing the treatment include World Health Organisation, UNICEF, Medicines Sans Frontier (MSF) amongst others. A simple google search for "CMAM" or "CMAM WHO" would lead countless examples across the world of the efficacy of RUTF within the CMAM context.
With respect to India, the biggest success for CMAM with RUTF has been the Rajasthan Poshan Project, whose overwhelmingly positive results were not referred to by SJM letter. Project POSHAN, implemented by National Health Mission in 2015-16, Rajasthan, treated 9,640 children with over 80% recovering from the state of Severe Acute Malnutrition, and more than 95% of children gaining weight. This CMAM pilot was facilitated by the use of RUTF manufactured in India.
The randomised trial comparing RUTF with nutrient-dense home-prepared foods, which the SJM letter refers to, has been profoundly misunderstood. The trial actually confirms the efficacy of RUTF in the treatment of children with uncomplicated SAM. This is evident from the correspondence of study's Lead Investigator, Dr Neeta Bhandari, over the article. After carefully rejecting the allegations of low recovery from SAM in groups fed with RUTF, she clearly notes that "by the end of the treatment phase 84.5% of the children in the RUTF-L group were no longer SAM".
Thirdly, since Severe Acute Malnutrition children are amongst the most medically sensitive sections of the society, the nutrition administered to them must be manufactured as per pharmaceutical standards of quality. The regulation of such quality is usually done by trained quality assurance staff from the UNICEF Supply Division and other large procurement organisations. And these standards and audits are equivalent to US FDA quality standards. Our own company undergoes stringent audits by UNICEF Supply Division inspectors at least once a year.
In line with the aims of the Make in India initiative which propagates the use of swadeshi local production, today the leading Indian RUTF manufacturers are at par with the international quality standards specified by UNICEF and WHO.
With the exception of facility-based treatment, there currently exists no public health solution for the treatment of approximately 94 lakhs SAM children in India. RUTF essentially represents a nutrition innovation that allows SAM to be treated outside the hospitals and medical facilities. In the process, it is relatively cost-effective, allows for larger coverage and has a large body of experience and evidence behind it - especially in the international context.
No doubt, a few civil society leaders may disagree with much of I have noted here. They may also support alternative pathways to our mutually shared objective of eradicating malnutrition in general and Severe Acute Malnutrition in particular. My intention in writing this article is ensure that the debate happens with all facts and viewpoints present. My hope is that decision making within the health and nutrition authorities occur through dispassionate analysis of data and best practices within India and across the world.
The writer is the CEO of Nuflower Foods and Nutrition.