Also In This Issue

When Words Fail

The Decade of Vaccines Collaboration

The Art of Making Vaccines More Affordable

Fighting Syphilis and HIV in Women and Children: Lessons from Uganda and Zambia

Vaccines: A Top Priority for Global Health

Vaccination Week in the Americas Goes Global

On the Brink of a Watershed Moment for HIV Vaccine R&D

Reflections of a Lifetime Dedicated to Public Health Advocacy - In Memory of Beth Waters

Sustained Fixes for Nutrition?

Bobbi Nodell

Plumpy'nut, a fortified peanut butter with milk and vitamins, has been hailed as a lifesaver for starving people. But for nutritionists like Dr. Susan Shepherd, who works in nutritional emergencies for Médecins sans Frontières (Doctors Without Borders), Plumpy'nut is far from a magic bullet. Not only is it expensive, but there is simply not enough of it. She estimates just 5 percent of the acutely malnourished people, who desperately need therapeutic foods like Plumpy'nut, are getting it.

And while such nutrition-dense foods are lifesavers, they are not a long-term solution. "If you really want to focus on under-nutrition, you need to work in prevention, targeting the golden window of opportunity – conception through the first 24 months," said Katharine Kreis, a senior program officer with the Bill & Melinda Gates Foundation.

According to the Lancet nutrition series (January 2008), 178 million children under 5 suffer from nutritional deficiencies – 55 million acute and 19.3 million severely acute (wasting). Unlike many diseases, malnutrition has a cure – a balanced diet, regular consumption of fortified foods, supplements when local foods don’t have the nutrients needed, and animal-based products like milk, fish, eggs and cheese.

As Shepherd notes, "Plumpy'nut is the equivalent of a glass of milk and a multivitamin." But for millions of people, essential vitamins and minerals are a luxury they simply cannot afford.

One solution is to dramatically increase spending on nutrition. According to the Lancet nutrition series, $300 million a year is spent on nutrition while $6 billion is spent on HIV/AIDS. But increasing public funding is not sustainable, say nutritionists. Making nutrition available and affordable requires a partnership with businesses, governments and non-governmental organizations to increase both the supply and demand for affordable products.

“Nutrition can only be sustainable if people ultimately pay for it,” said Dr. Alfred Sommer, dean emeritus of the Johns Hopkins Bloomberg School of Public Health. “Nutrition could stop being a program when governments change priorities."

Today, unlike any time before however, several partnerships are galvanizing efforts to solve the nutritional crisis with sustainable solutions.

Mass Food Fortification

One of the biggest drivers in forging public-private partnerships is the Global Alliance for Improved Nutrition or GAIN, an alliance of key institutions founded in a United Nations session in 2002. GAIN now has partnerships in 18 countries as well as a project with UNICEF on iodization of salt in 13 countries. GAIN’s current main effort is in mass food fortification – the addition of micronutrients to commercially processed staple foods such as maize, rice and wheat flour, condiments like salt, sugar, fish sauce and soy sauce, and milk and oil.

“GAIN uses different program implementation approaches according to the country’s specific circumstances,” said Regina Moench-Pfanner, senior manager of the Food Fortification Program. For example, in Egypt, GAIN is working with the United Nation’s World Food Programme (WFP) in partnership with the government to fortify the wheat flour used in baladi bread, the staple food consumed by low-income populations throughout the country and subsidized by the government.

GAIN is providing $3 million to the WFP to assist the government in strengthening and upgrading the quality system of the fortification of flour and in implementing a social marketing campaign to raise awareness of the health benefits of fortification, while the Egyptian government is investing $20 million for premix, equipment, manpower and quality control over five years.

In Pakistan, where food products are not subsidized, GAIN is working with the government and millers to support fortification activities, including buying the premix.

For long-term sustainability, GAIN and its partners advocate for mandatory food fortification laws, said Moench-Pfanner.

"I really think that organizations like GAIN are making a huge difference in this field," said Dr. Martin Bloem, chief of nutrition and HIV/AIDS policy for WFP and a board member of GAIN. "Ten years ago, I would be talking only about the public sector and I would say we need more money. But that's only part of the solution."

Sprinkles

Meanwhile, in rural Tanzania, the Boston-based NGO Global Action is fighting malnutrition with Sprinkles, a micronutrient powder of essential vitamins and minerals, such as vitamin A, the B vitamins, iron, iodine and zinc. These are essential to boosting the immune system and preventing millions of childhood deaths a year.

Global Action is launching a program in Tanzania in two regions where iron anemia is 88 percent and 79 percent respectively. The packets will be distributed at community health centers when children receive their free immunizations and through community health workers to reach a larger number of children in rural villages, said Michelle Lyden, the CEO.

Dr. Stanley Zlotkin, a senior scientist with the Hospital for Sick Children in Toronto, invented Sprinkles just 10 years ago and now it’s being used in 15 countries, according to the Sprinkles Global Health Initiative.

The H.J. Heinz Co. and DSM are the biggest producers of micronutrient powders like Sprinkles, which they provide to NGOs for low-cost or through donations. Heinz now has manufacturing plants for Sprinkles in India and Indonesia and could open more if there was demand, said Tammy Aupperle, the director of the H.J. Heinz Company Foundation, the philanthropic arm of Pittsburgh-based Heinz. “We are completely dedicated to this project,” she said.

Demand is created in many ways. Lyden said one way is for governments to take ownership and adopt Sprinkles in the national agenda similar to vitamin A and immunization. Another model being evaluated in Kenya and India is selling Sprinkles to women so they can sell it for a small profit (a penny or two). “Mothers want to have healthy children,” said Lyden, and many can afford to pay 20 cents to 30 cents a month.

In Guyana, the government received a loan from the Inter-Development Bank to improve its micronutrient status and now is paying a local manufacturer to produce Sprinkles, said Zlotkin. He said the packets are distributed through public health clinics, which reach many of the poor but not everyone who wants it.

“One has to be creative in distribution,” Zlotkin said. “You need multiple models of distribution – public sector, government sector, NGO sector and social marketing.” Population Service International in Washington, D.C, for example, has sold Sprinkles in Bostwana , Haiti, Bangladesh and Pakistan as part of its social marketing efforts.

Other Products

Many other solutions to the world's nutritional needs are under way, such as efforts to create a lower cost version of nutrient-dense ready-to-eat products like Plumpy'nut. Valid Nutrition, an Irish-based charity for example, is active in developing local production capacities in a number of countries – Kenya, Ethiopia, Malawi and Zambia – each one based upon recipes that use locally available ingredients. And Project Peanut Butter operates a factory in Malawi dedicated to the production of a life-saving lipid/vitamin paste.

Meanwhile, new partnerships are forming between commercial food companies and microcredit companies. Jonathan Gorstein is a University of Washington associate professor whose business, Sagilo Solutions, is working together with GAIN to help forge these partnerships. In Bangladesh, he said, the Grameen Group is providing microcredit to dairy farmers so they can purchase hybrid cows, which produce significantly more milk than local cows. French-based Danone Foods then buys the milk from the farmers and makes yogurt fortified with essential vitamins and minerals. The yogurt is sold to consumers for a small profit by local women who then use the proceeds to improve their lives.

“It’s very exciting for us to have all these new products to prevent and treat malnutrition,” said Ellen Piwoz, a senior program officer with the Gates Foundation, which is backing GAIN and several other organizations. “We think of nutrition as a neglected global health problem that has a solution.”

 

---

 

Bobbi Nodell, a veteran journalist, is the communication specialist for the University of Washington Department of Global Health.