FEATURE — Summer 2008

Ready-to-use therapeutic food (RUTF) is an inexpensive, lipid-dense paste made with peanuts, sugar, oil, powdered milk, and added nutrients. Above: A mother feeds her young son RUTF in Malawi.
A Recipe to Save Young Lives

Professors Mark Manary and Patricia Wolff work tirelessly to end child malnutrition in Africa and Haiti, respectively. Their use of a peanut-based ready-to-use therapeutic food shows encouraging results.

By Terri McClain

Worldwide, half of all child deaths are caused by malnutrition, and nearly 20 million children under the age of 5 are severely malnourished. In countries such as Bangladesh and Sierra Leone, the mortality rate for these children is 20 percent or more, and among those who survive, recovery rates are low. Malnourished children are prone to infection and disease; many never achieve normal growth.

For decades, doctors and relief organizations treated malnourished children with a milk-based feeding program in health facilities. However, the mortality rate remained high, the recovery rate was dismal, and children succumbed to infections or diseases acquired from others in crowded health wards.

For Mark Manary, M.D. ’82, professor of pediatrics, the battle against childhood malnutrition has become the fight of his life. Perhaps his biggest talent is converting research into real-world solutions. And these solutions are radically changing the way doctors treat severe childhood malnutrition today.

“For every good idea that we test in a research project, only one in 10 actually works,” says the former Fulbright scholar. “Often, we’ve emphasized innovation, but not operation. However, for people who want to make the world a better place, it’s not simply good ideas that make good science. It’s good outcomes.”

After earning a bachelor of science degree in chemistry and chemical engineering from Massachusetts Institute of Technology, Manary decided to pursue a medical career. He attended Washington University School of Medicine, followed by an internship and residency at St. Louis Children’s Hospital.

When Manary finished his pediatric training in 1985, his wife, Mardi, suggested they work in Africa. “My wife is a nurse, and she taught nursing students,” Manary says. “I was the only doctor in a 150-bed hospital that usually had more than 300 patients at any one time.” And they loved working there because they could see the difference they were making every day.

“Our first child was born in Tanzania, but, sadly, he died there,” Manary says, “and that was very hard on our families. We came back to the States for them, but we didn’t give up on going back to Africa again.”

In 1989, after serving two years as the medical officer at the Cheyenne River Indian Reservation in Eagle Butte, South Dakota, Manary returned to St. Louis to work as an instructor in pediatrics at the University’s medical school. He also was an attending physician in the emergency unit of St. Louis Children’s Hospital, a position he still holds.

But Manary retained a passion for international work. In 1994, he took a leave of absence, moving with his wife and two young children to the small, impoverished African country of Malawi. As senior lecturer in pediatrics at the Medical College of Malawi in Blantyre, he took charge of the malnutrition ward at Queen Elizabeth Central Hospital.

“It was an awful place, overcrowded and unsanitary, and it had rats,” Manary says. “So we threw our hearts and souls into that particular unit. I didn’t know much about taking care of severely malnourished kids, but I learned a lot over those first months.”

He quickly saw that the standard therapeutic approach was a failure. During times of famine, relief organizations swooped in to address the crisis, then left without a long-term solution. The key to success, he realized, was to create a program that could function within the framework of the country’s own limited resources.

Malawi, a densely populated, land-locked country with few resources, suffers from relentless poverty. Most Malawians are subsistence farmers whose diet consists almost entirely of corn and beans, which have limited nutritional value. During the lean months, families may share just one meal a day. For children between the critical developmental ages of 6 months and 3 years, simply getting enough food can be impossible.

As the mortality rate in his ward declined from 30 percent to around 10 percent, Manary began outreach programs to other hospitals to teach and encourage better nutrition. “We wrote management manuals in the standard language and figured out good recipes to feed these children from foods that were available there,” he says. “The number of children dying went down, but the recovery rate was stubborn—most weren’t getting any better.”

It was time to try something new.

Mark Manary (left), professor of pediatrics, began field testing peanut-based ready-to-use therapeutic food (RUTF) in 2001. In Malawi, children fed a complete six-week RUTF diet at home had a 95 percent recovery rate.

In 1999, Manary lived in a rural village for 10 weeks. The experience was important, because understanding village life in Malawi became key to developing a workable solution to childhood malnutrition.

“We decided it was time to think outside the box,” he says. “It was time to commit medical heresy: to take these children out of the hospital and treat them at home.” Having lived in a village where mothers had to walk great distances to get firewood and clean water, Manary understood what mothers would need to feed their children at home. They would need food that was clean and energy-rich, and did not require cooking.

In France, meanwhile, another doctor devoted to fighting world hunger had developed a revolutionary, peanut-based ready-to-use therapeutic food (RUTF). Collaborating with the Normandy-based company Nutriset, which packaged the new product in small foil packets under the brand name Plumpy’Nut®, pediatric nutritionist André Briend searched for someone to test his creation.

Briend, now a medical officer with the World Health Organization’s Department of Child & Adolescent Health and Development, approached many academic institutions and also NGOs (nongovernmental organizations) treating children with severe malnutrition about field testing the product. “Very few people listened to me,” Briend says. “Then a visiting colleague from the United States gave me Mark’s e-mail address and told me about his work in Malawi, which I already knew from reading his publications.” Briend contacted Manary, and Manary eagerly agreed to help.

“Now Malawi has an advanced program for the management of severe malnutrition that is often held up as an example,” says André Briend, creator of the original RUTF.

Manary began field testing RUTF in 2001. He emptied the hospital’s malnutrition ward and treated the children at home. Children fed a complete six-week RUTF diet at home had a 95 percent recovery rate—compared to 25 percent among those receiving standard care in the hospital. They also fared significantly better than children whose diet was supplemented with RUTF or whose family was given generous amounts of traditional food. Six months to a year later, these children remained healthy. This effort launched Manary’s Project Peanut Butter (www.projectpeanutbutter.org).

RUTF is an inexpensive, lipid-dense paste made with peanuts, sugar, oil, powdered milk, and added nutrients. Because it is not made with water, it can be stored without refrigeration and transported to remote areas without spoiling. After importing RUTF from France for the 2001 trials, Manary knew what must be done to achieve long-term success in Malawi. His team members would have to make the product, with modifications, themselves.

“Together, we simplified a recipe that could be produced locally,” Briend says.

Manary tested the new recipe and found it effective. He then worked to develop the facilities needed for production. He also attracted the attention of Malawi’s Ministry of Health to the potential of this new approach.

“Now Malawi has an advanced program for the management of severe malnutrition that is often held up as an example,” Briend says. “All this can be traced to Mark’s hard work over many years. He also actively promotes improved treatment in all regions of Africa.”

A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Children’s Fund (UNICEF) recently endorsed home-based RUTF therapy as the standard treatment for children with severe acute malnutrition. It is now being implemented successfully in numerous countries, including Ethiopia.

In Malawi, Africa, a team of health-care workers (background) distributes ready-to-use therapeutic food to village mothers.

Today, Project Peanut Butter’s factory in Blantyre, Malawi, employs local workers and produces enough RUTF to supply the emerging national program. It also provides food at cost to relief organizations such as Doctors Without Borders and UNICEF. In November 2007, Manary received the World of Children Health Award at UNICEF House in New York, along with a $50,000 grant for Project Peanut Butter. He plans to use the grant money to expand operations in Sierra Leone.

“Implementing change in Malawi,” Manary says, “is a matter of working with other relief organizations, of training the village health workers, and putting an ongoing auditing system in place. Our factory has the capacity to make enough food for the whole country. The limiting factor now is funding all the ingredients to do this.”

Manary continues to develop a range of therapeutic foods and adapt the RUTF concept to other groups, such as adults with HIV and children with mild malnutrition. In the long term, he hopes to add preventive solutions such as combining nutritious baby food with immunization.

One preventive strategy aims to improve staple crops. Manary recently joined an international team of plant scientists, plant geneticists, and field researchers—including scientists at the Donald Danforth Plant Science Center—to develop a better cassava. A root plant similar to a potato, cassava is a staple throughout much of Africa. However, it is low in protein and other nutrients, vulnerable to disease and rot, and can be toxic if not properly prepared.

“The overlap between better plants and human health is natural,” Manary says. “Traditionally doctors and agriculture have remained separate, but we now see an opportunity for new partnerships. The Danforth Center and Washington University are going to lead the way. Failure is not an option.”

Terri McClain is a freelance writer based in St. Louis.

Patricia Wolff, clinical professor of pediatrics, founded Meds & Food for Kids to treat malnourished children in Haiti.

Nurturing Children in Haiti

In Haiti, the poorest nation in the Western Hemisphere, they call RUTF “Medika Mamba,” Creole for “peanut butter medicine.” Patricia Wolff, clinical professor of pediatrics in the medical school, has volunteered there since 1988. She knows firsthand that a staggering number of Haitian children are chronically malnourished, and this drives her work to provide Medika Mamba to as many as possible.

“I was treating children with pneumonia, malaria, typhoid, diarrhea, but mainly they were sick because they were malnourished,” Wolff says. “We tried a variety of standard treatments, but the children never seemed to get any better. Every time we came back, we’d see the same ones with the same or similar illnesses. After many years of doing this, I knew that we needed to address the underlying malnutrition.”

After visiting Malawi to observe Mark Manary and Project Peanut Butter in action, she founded the nonprofit Meds & Food for Kids (MFK) in 2004 for the purpose of bringing RUTF to this small Caribbean nation.

“Mark put me in touch with Nutriset, and they actually donated, at his request, the first year of vitamins and minerals. We bought a grinder and started making RUTF in a church classroom.”

Now with eight grinders and 20 employees, MFK operates an RUTF factory near Cap-Haïtien in northern Haiti and delivers Medika Mamba to eight sites. Like Project Peanut Butter, MFK targets vulnerable children under the age of 5, when they are at the highest risk of dying from malnutrition. And, like Malawi, working in the poverty-stricken nation poses practical problems.

“You know, Haiti is very close, but it’s like a different planet,” Wolff says, “because Haiti is a country without electricity, without running water, with terrible roads. We have generators, and we have our own well and pumps. We use propane for the stoves that roast the peanuts. As the project has grown, it’s become less medical, because providing the Medika Mamba to the children in the clinic is the simple part. The difficulty is obtaining the milk, sugar, oil, vitamins, and minerals, then shipping them, getting them out of customs, and storing them in a safe way.” Other challenges include teaching the workers about food safety, getting the peanuts from the peanut farmers, and teaching the farmers about irrigation methods.

MFK hopes working with Haitian farmers will contribute to Haiti’s economic development. The organization, which competed in Washington University’s first Social Entrepreneurship and Innovation Competition in 1996, received a $25,000 Skandalaris Center Award and a $5,000 Student Award for its business concept. The goal is to sustain the program through the sale of RUTF (see above right) to large organizations that can afford to pay for it, while giving it away to as many small clinics as they can.

In 1997, Wolff won a $200,000 grant from the World Bank’s Development Marketplace to partner with Haiti’s public sector in the fight against malnutrition.

“We’ve provided a lot of training, mentoring, and supervision. We hope to be able to treat 3,000 to 4,000 children in public clinics over the next two years,” she says.

“And we’re hoping to get UNICEF food safety certified in the next few months,” she continues. “There are no food production standards in Haiti, and nobody in Haiti has ever met the international UNICEF standards for food production. We will be the first and only, so that’s high on our agenda. As a result, we are hoping to be the producers of safe Medika Mamba for the whole country. We have the real possibility of eliminating childhood malnutrition in Haiti in 10 years.”