The malnutrition bazaar
India is shouldering a huge burden of malnutrition—in the absence of government figures, a dipstick survey by non-profit HUNGaMA in 2012 suggests that 59 per cent of the country’s children could have stunted growth and 42 per cent could be underweight. While the government is still struggling to tackle the problem, the food and nutrition industry sees it as a burgeoning market and is rushing to tap it, by hook or by crook. One such attempt became evident on June 28 when British medical journal Lancet launched a compilation of its articles on maternal and child nutrition in Delhi. The series had angered health activists ever since the articles were published online on June 6.
| Therapeutic food, a myth
Ready-to-use therapeutic foods (RUTF) are energy-dense and are typically made of full-fat milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals. This is not the first time the industry recommended RUTF as an answer to malnutrition. Health activists say several agencies have been trying to push RUTF in India despite stiff opposition. In one such instance in 2008-09, Unicef supplied an RUTF, Plumpy Nut, in Khalwa block of Madhya Pradesh and in areas affected by 2008 Kosi floods in Bihar without approval from the Centre and in contravention to the government guidelines. When the matter was brought to the government’s notice, it directed Unicef to ship the supplies out of the country and restore the funds of equivalent value—US $880,000—to the Government of India-Unicef Country Programme for child development and nutrition.
Interestingly, the launch of the Lancet series coincides with the publication of another research which states that the current evidence about RUTF is limited. The research was published in Cochrane Library, a collection of databases in medicine and other healthcare specialties.
One of Lancet’s papers, ‘Evidence-based intervention for improvement of maternal and child nutrition: what can be done at what cost?’ says, children who received RUTF gained weight faster and had 51 per cent greater likelihood to recover than those receiving standard care. The study published in Cochrane Library reports otherwise: “...we cannot conclude that there is a difference between RUTF and flour porridge as home treatment for severely malnourished children, or between RUTF given in different daily amounts or with different ingredients.” Their conclusion is the result of analysis of four studies conducted in Malawi, including one involving children who have HIV. Another review of RUTF on moderate acute malnutrition children published in Cochrane Library on June 22 had similar conclusions.
Back home, Maharashtra has reduced stunting from 39 per cent to 23 per cent and severe stunting from 15 per cent to 8 per cent in six years. Vandana Krishna, director general and principal secretary of Rajmata Jijau Mother Child Health and Nutrition Mission, says the government brought about this change by relying only on cooked food prepared in anganwadis.
Vandana Prasad of National Council for Protection of Child Rights says Cochrane Library reports support indigenous solution of malnutrition. There should be experiments comparing the impact of local nutritious food and RUTF. She also cites a Bangladesh research that says malnutrition can be addressed by counselling.
Arun Gupta of Breastfeeding Promotion Network of India says, “We have been opposing RUTF because it is expensive and not sustainable. It consists of 65 per cent fat which shows some bodily improvement, but that is only due to fat.” A number of children can be treated with home food at the same cost, he adds.
Robert E Black, one of the lead researchers of the Lancet series who works with Nestle Creating Shared Value Advisory Committee, told Down To Earth that the Lancet series did not recommend any particular type of food. It shows RUTF could be useful. Now it is up to the administration whether it purchases from local producers or take from multinationals.
Activists do not seem to buy his clarification and claim such techniques are to create pressure on policy makers and get result in their favour.
Several nutrition experts and members of the Indian Academy of Paediatrics had warned the government even before the Lancet series was launched in India, that it “should not be allowed to become an opportunity for commercial exploitation of malnutrition”.
The articles outline 10 key interventions and claim these can help reduce global prevalence of stunted growth and acute malnutrition by 20 per cent and 60 per cent. But majority of the interventions include supplementation with micronutrients or ready-to-use therapeutic food (see ‘Therapeutic food, a myth’). The articles also call for engaging with private players to achieve the goals.
Some of the authors have links with big food multinationals and the micronutrient industry.
One of the lead researchers, Robert E Black, is on the boards of Micronutrient Initiative, Vitamin Angels, the Child Health and Nutrition Research Initiative, and a member of Nestle Creating Shared Value Advisory Committee (NCSVAC). Another researcher, Venkatesh Mannar, heads Micronutrient Initiative and member of NCSVAC.
Nestle is the largest food company in terms of revenue and has been in controversy in several countries for promoting its baby food products by undermining breastfeeding. In India, a court in Delhi has charged it for violating the Infant Milk Substitutes, Feeding Bottles and Infant Foods Act, 1992.
Even some of the articles Lancet used as reference are equally bogus. An article by Veena Rao, published in British Medical Journal in 2012, claimed that India’s national policy does not allow private players to produce cheap fortified complimentary food for children. Later, it came to light that Rao was associated with Britannia Nutrition Foundation of Britannia Industries Ltd.
The conflicts of interest in such publications need to be considered particularly because these have the potential to influence policy making. India does not have a mechanism to check this.
In February, Arun Gupta, regional coordinator of Breastfeeding Promotion Network of India, filed RTI queries to departments under the Union Ministry of Health and Family Welfare and the Union Ministry of Women and Child Development, asking whether guidelines exist to check the conflict of interest of people engaged in policy making or its implementation. The departments’ response was in negative.
On May 3, responding to a letter by Gupta, the child health division of the health ministry stated: “Six sub-committees were constituted in order to facilitate discussion and engage with various stakeholders who could potentially bring their skills, experience and resources to support the cause of child survival and development in the country.
These stakeholders include the private sector, NGOs, CSOs and professional bodies…” It further notes that the efforts to engage constructively with the stakeholders should not be construed as the government’s intent to absolve itself from its roles and responsibilities.
Gupta says it would be difficult to check motives of people engaged from private sector without any mechanism to check conflict of interest. It is a general perception that private players do not have concerns about the problem, rather they take it as their market. It gets problematic when their profit grows instead of eradication of the problem.
In 2011, in the first ever attempt to check conflict of interest, E M Sudarsana Natchiappan, then a member of Parliament, introduced a private bill in Rajya Sabha. The Prevention and Management of Conflict of Interest Bill aimed at “setting of an Institution for prevention and management of conflict of interest.” But it lapsed. Natchiappan is now Union Minister of State for Commerce and Industry.
India is not the only one facing the problem. Industry lobbies are also pressuring topmost policy making organisations in the world. Recently, director general of WHO, Margaret Chan, indicated the harsh reality. Speaking at the 8th Global Conference on Health Promotion in Helsinki, Finland, she said, “Efforts to prevent non-communicable diseases go against the business interests of powerful economic operators… (So,) Public health must also contend with Big Food, Big Soda, and Big Alcohol.
All of these industries fear regulation, and protect themselves by using tactics. Research has documented these tactics well. These include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuse the evidence and keeps the public in doubt. ...the formulation of health policies must be protected from distortion by commercial or vested interests.”
Says Vandana Prasad of the National Council for Protection of Child Rights: “We have fought for long to keep private players far from any advisory groups.” Its impact was visible recently. On June 26, while reconstituting National Technical Advisory Group on Immunisation, the Union health ministry said all members should be free from “conflict of interest”.
This was a major victory, Prasad adds. But there’s a long way to go. To meet the Millennium Development Goals by 2015 and 12th Plan targets by 2017, child health division plans to rope in private players.