PPB: from a bird's view

Matzuka bwanji! Its a gorgeous bright sunny morning here in Blantyre, temperatures hovering near the low 70s. Winter really can't get much better than this. A jacket for the cool before the sun rises is about all you may need now, for by early afternoon its rising to the low 80s with the sun beating down. I'm coming to appreciate greatly those clinic sites with a bit of shade.

I've returned now from two weeks worth of clinic visits, which, as we rotate on a week A week B schedule, means that I've fully seen all of my current sites. It feels a little like finishing the border of a puzzle--I've at least got a foothold now on what things are going to look like for the year, but I've still no clue on how its all going to fit together. Names like Mbiza, Ndaja, Chikweo, Mposa, Nkhate are running through my head as I'm struggling to connect health assistant faces with sites, roads with districts. Last week we covered close to 500km of distance as we leave the 'comfort' of blantyre and drive deep into the countryside daily.

I've much to say on these experiences but this morning its seems more permanent for me to share and reflect on the history of this project a bit. I may not get all the facts and details just right as the story has unfolded in pieces to me over the last two weeks from a plethora of sources, but I'll do my best here to summarize what has developed from Dr. Manary and his family over the course of the last 15 years (and hopefully as briefly as summarizing 15 years permits)... Graduating from wash u med school and after a stint with the National Health Service Corps as a doc on a reservation, Dr. Manary and his wife Mardi took a trip to Tanzania for a brief rotation in a district hospital there. This was to be the first of many trips to Africa, for from Tanzania the 'professor' was invited for a brief time to the neighboring country of Malawi in the early 90s to work in the Queen Elizabeth Hospital in Blantyre. As a pediatrician by training, the story goes that while touring the maternity and child health services departments at this dismal national hospital (which I can attest remains just that today), the professor asked from a distance of a ward that was set away a bit from the hospital and overflowing with people: "Thats our NRU, you don't want to go there" came the answer, and so started what is now almost 15 years of malnutrition work in Malawi for the Manary family.

What the professor found inside the NRU (nutrition rehabilitation unit) was shocking: two, three, or more mothers and their children sharing one bed, thirty beds jammed shoulder to shoulder in a small room, sanitary conditions less than unsatisfactory, one doctor with spotty treatment available, and all of this creating the environment of care for children so severely malnourished that they are 3 standard deviations below their proposed developmental weight, facial bones protruding through tought skin and mid upper arm circumferences easily encompassed by one's thumb and forefinger. As imagined, these little ones were not getting much better in those conditions, with dismal recovery rates of 25%, and mortality rates equally high. So began musings on PPB, though what was exactly to be done was yet unknown.

At that time the standard of treatment for malnutrition of all kinds and in all regions of the world was something called 'F100,' which is a therapeutic milk-based product fortified with vitamins and minerals produced in France. The benefits were its calorie and nutrient capacity as well as its consumability (word?)--kids love milk. However, the benefits were equally its curses as milk is not a local commidity in much of the world, certainly not in the developing world. And in addition, we all know milk must be refrigerated (or does it Sellers?), and these two strikes against F100 meant its availability was limited by 1) its cost, and 2)its necessary upkeep (refrigerators are hard to come by in places that have no electricity). Does F100 work when administered? Sure, but to say the least, F100 was not a practical solution to the causation of 58% of world mortality: malnutrition. So began the search for a calorie and nutrient rich product both cheap and accessible. To make a long story encompassing several key figures, sleepless nights in back-room kitchens, and lots and lots of taste testing--to make this long story short (in the interest of doing something else today), meet 'RUTF.'

When I tried it, something came out along the lines of "This is medicine?" Up there with the childhood greatness of amoxicillin. So good in fact I'm worried about potential project losses given my initial rates of consumption:> Ready to Use Therapeutic Food (RUTF) is something like sweet peanut butter, composed of the following : 1/4 peanut paste, 1/4 milk powder, 1/4 oil, 1/4 sugar, all with a blend of vitamins and minerals specially prepared for malnutrition in subsaharan africa mixed in. This is 'Chiponde' as its called: non-refrigerated, locally produced (we have a small factory here in blantyre), with a shelf life nearing a year. And the kids love it. So do I.

I mentioned before that the site of origin for the project was the Queen Elizabeth hospital here in Blantyre, which is the main hospital to which all surrounding district hospitals refer patients if unable to manage a particular patient. As an expensive and refrigerated treatment, F100, the original milk therapy for malnutrition, was in the 90s only being used at Queen Elizabeth. This meant that malnourished children at the district hospitals were being treated with porridge and maize products--which for some were the only foods the children were able to eat at home, and the subsequent lack of non-carbohydrate nutrients (vitamins and proteins) was leading to their further malnourished status. RUTF was quickly instituted in Malawian hospitals in the early 2000s, but it quickly became evident that a better approach to the gigantic problem of malnutrition (later blog entry...) involved village screenings to catch children hopefully before they progress to a complicated severely malnourished status seen in the hospitals. And thus was born project peanut butter (thereabout in so many words), and now it may be clear why it is that we as team chiponde drive to these remote sites everyday to host chiponde clinic, as its affectionately called here.

Since its development, RUTF has now been chosen as the standard of treatment for malnutrition worldwide by the WHO. Yet, PPB has continued, together with a French company called Nutriset (who were the original manufacturers of RUTF, or plumpy nut as you may know it), to work toward better products. Last year students in the project ran a study to establish a soy blend of RUTF as the standard treatment for moderate malnutrition. This year we are working on a slightly different blend of RUTF with less milk powder content (the most expensive ingredient) to establish its equal efficacy in comparison to the standard RUTF as described above. More on this later surely... And in the pipeline is a line of chiponde for HIV wasting. So, much happening around this place on the topic of childhood malnutrition. For now I'm attempting to get my address and phone number memorized, but soon enough I'll be working to improve my kwash and maras diagnoses, and looking at preliminary data on our results for this research project. Chao for now, I hope this finds you well!!