10/25

"Weight height z severe. Edema positive. Enroll in 10/25."


I wrote it 19 times between 7 and 11 on thursday morning. By far it was the most we had enrolled for any of the clinics yet. Ntaja, a q-14 days site, seemed slow as we pulled up shortly after seven. Only a handful of mothers sat waiting under the big tree outside Ntaja general clinic with a couple of HSAs lingering nearby. Yet the line for screening seemed to grow each and every time as I glimpsed up periodically from my station #3 post. All in all around 70 mothers and their children attended clinic on advice from their village HSA, 19 of which were--by our admission criteria--"severely" malnourished and another 15 who were "moderates."


"The harvest was bad this year man. Too much rain. Things will be hard this year."


Robert is the "Senior HSA," as they call him, which in the medical hierarchy of Malawi places him as the leader of 24 HSAs assigned to the Ntaja catchment, part of the greater Machinga district, and reporting only to the clinician assistant. He is the voice of the HSAs, and the commanding voice of the communities which he represents. And across Ntaja he reports that early rainy season flooding severely damaged much of the crops, yielding a substantially low harvest, and little surplus. Therefore many subsistence farmers have food enough starting from March, but beginning to run low even now, forcing many to make the annual switch from two meals a day to one meal a day 4 months early. And to further compound an already huge problem, low surpluses mean high food prices. In front of me I have today's "The Nation," which is reporting that the average 50kg maize bag is running 3500 kwacha (140 kwacha to the dollar), and in a country where the average monthly salary is 3000 kwacha, this spells problems...


All this goes to say that we may be distributing more of an already substantial amount of chiponde this year. The factory operation here in blantyre (termed project peanut butter) will certainly be busy producing its prized product--locally produced Chiponde RUTF (for severe malnutrition) and now its recently operationally implemented Soya Chiponde RUTF (for moderate malnutrition). This factory operation I can describe in detail later, but suffice to say that it produces somewhere close to 1 ton of chiponde every week. So whats the big deal with this local production you may ask...


1) Originally, a company in france called nutriset was behind the production of RUTF for global malnutrition. Together with the good doctor here in Malawi, a way was pioneered forward to produce Chiponde RUTF, which has become now the standard of care for outpatient malnutrition therapy. This Chiponde was produced in france and shipped to Malawi at a cost. Local production avoids this cost, and guarantees the presence of chiponde when needed (insofar as local ingredients are available).


2) Local production ensures that the ingredients used for production of Chiponde RUTF are from Malawi (excepting milk powder and the vitamin/mineral mix--more on this later), pouring financial resources back into the Malawian economy while producing therapy for Malawi. As Chiponde is 25% peanut paste, 25% oil, 25% sugar, 25% milk, this means that project peanut butter has contracts with local peanut paste producers, sugar companies, and oil companies.


3) Local production means local jobs. Altogether the project now employs close to 30 employees for the production and distribution of Chiponde RUTF. Last week's employee cookout was a blast. (I thought Americans liked meat. I was busting with steak, sausage, and chicken when a night when a bucket of goat meat was brought out. Long night indeed...)


The 'fortified' portion of Chiponde is produced by nutriset in france, and as a specialized ingredient, this portion of chiponde must be outsourced. Likewise, milk is purchased from outside malawi from places including south africa and germany as Malawi as of yet contains no endogenous milk-producing industry. As you might imagine, at 25% ingredient load, the purchase, import, and transport of this particular ingredient runs a steep cost, and consumes a correspondingly unequal portion of the total cost of producing chiponde.


So all the more reason for research to find a cheaper solution with equivalent nutritional and caloric value. Insofar as milk proteins are crucial to development, milk is an absolutely essential ingredient. But insofar as milk is the most expensive ingredient, it severely limits its production (by those good ole bottom lines). And like any enterprise in this world, project peanut butter (and MSF and Clinton Foundation and any other NGO that buys and distributes chiponde from project peanut butter) runs a bottom line, but as we sell at cost of production, the amount of chiponde produced is directly dependant on the cost of its ingredients. Without an existent production or plausible future of a milk industry here in Malawi (or most other developing nations for that matter), it became evident that a product with equivalent calories and nutrients with less milk content and equal therapeutic value would greatly enhance the fight against childhood malnutrition.

Every evening after clinic I swing by the Chiponde factory to load up on small mountains of boxes of RUTF labeled "1" and "2." We (myself and El, a Wash U med student) are running a controlled, randmomized, double-blinded trial to determine if the new 10% milk RUTF is therapeutically equivalent to the 25% milk RUTF now being operationally distributed. The unaccounted 15% in the new RUTF formulation is actually soya, a crop produced and supplied here in Malawi. However, though the caloric value and micronutrient percentages are statistically equivalent in the two formulations, one must never assume hypothesized outcomes.

Hence, once a child is identified as severely malnourished, the mother is informed as to the study. If agreeing to participate in the study, an informed consent (the study as been approved by the Wash U and U of Malawi med schools) is signed or stamped (many women can't write their own names) and the mother selects one of many brown envelopes which contain a code for food. Once this randomization process is complete, the mother gathers the corresponding food--either a "1" or a "2"--and its correct dosage, and is advised as to appropriate feeding techniques before leaving.

Neither myself or El is aware of the identity of 1's or 2's, really!! Every two weeks the mother's return with their children and we track the progress of the child. 2500 of these enrollees will be tracked over the course of 8 weeks to complete our study and allow us to analyze to find the results (we have in four weeks already almost 300!). But most importantly, until then we will be periodically entering the new data and analyzing to ensure no therapeutic failure of any food type.

So we're simultaneously feeding kids and searching for better food--they are somehow inextricable from each other. The service informs the research and the research informs the service. The implications are great either way the results turn out, for we could find how (or how not) to effectively double the output of chiponde.