Saying "Nuts" to Hunger

The general public should be helped to understand the difference of acute and chronic hunger, so that both are addressed appropriately. The product Plumpy'Nut is not a miracle cure for global hunger or for global malnutrition.
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By Jeffrey Sachs, Jessica Fanzo and Sonia Sachs

We read with concern this week's (September 5) New York Times magazine article "The Peanut Solution," since it is likely to propagate a very serious misunderstanding about the solutions to global hunger, and especially about the role of specially fortified foods such as Plumpy'Nut, the main focus of the article. We commend journalist Andrew Rice for writing an interesting piece on an important and under-covered topic. Nonetheless, it is extremely important to correct certain ideas left dangling by the article.

The article describes a special peanut-based fortified "ready-to-use therapeutic food" (RUTF) with the brand name Plumpy'Nut, which is produced under a patent held by the French company Nutriset. This peanut-based and micronutrient rich paste has proven to be effective in addressing acute malnutrition in famine conditions resulting from crop failures, war, and other causes. Plumpy'Nut can save famine-stricken children in an advanced stage of wasting (severe low weight for height) and at a high risk of death.

This severe form of acute malnutrition affects around 20 million children under five years of age each year and contributes to around 1 million child deaths per year. Plumpy'Nut has the advantage that it is a way of treating serious acute malnutrition on an outpatient basis (at home) rather than requiring an in-patient treatment (in a hospital). It also requires no additive water that can introduce bacteria and other contaminants. At a reported $60 per child for a two-month course, Plumpy'Nut is far less expensive than alternatives involving hospitalization.

It is critical, however, that we not confuse the many types of hunger and malnutrition (poor nutrition) around the world. Plumpy'Nut is not a miracle cure for global hunger or for global malnutrition. Plumpy'Nut addresses only one kind of hunger -- acute episodes of extreme food deprivation or illness, the kind mainly associated with famines and conflicts. Plumpy'Nut is not designed for the other major kind of hunger, notably chronic hunger due to long-term poor diets. Nor is it designed to fight long-term malnutrition that is due to various kinds of chronic micronutrient deficiencies, such as iron, zinc and vitamin-A deficiencies.

The chronic kind of hunger is by far the most prevalent kind of hunger in the world, though it is more hidden and less recognized by the American public. As part of the UN Millennium Project, which one of us (Jeffrey Sachs) directed on behalf of then-UN Secretary General Kofi Annan, the Hunger Task Force found that chronic undernourishment accounts for more than 90 percent of global hunger, while acute undernourishment (starvation) addressed by Plumpy'Nut accounts for less than 10 percent. Of course, the acute episodes are far more widely known to the US public because those are the ones seen on TV in the context of wars, droughts, and other upheavals.

For the vast majority of the world's hungry, the main solutions lie in more productive local agriculture (higher food output per acre), a more diverse mix of nutritious crops, and much greater public awareness regarding feasible and low-cost approaches to a healthy diet. Plumpy'Nut has little role to play in circumstances of chronic hunger. Nonetheless, some people are apparently promoting its as a cure-all.

The article quotes the owner of the sole US Plumpy'Nut manufacturer suggesting that her product is the solution to global hunger. Here is how the article describes the pitch:

There are over a billion people in our world that are malnourished,' Salem said. 'It's a shocking statistic. The good news is there's a very simple solution.' And that, she said, was Plumpy'nut. 'It's really revolutionary, because it doesn't need to be mixed with water or refrigerated,' Salem continued. 'And the most miraculous part is, it will transform a child from literally skin and bones to certain survival in just four to six weeks.

Navyn Salem is right about the therapeutic value of Plumpy'Nut and her efforts should be commended in ensuring this product gets to children in need, but her statement, as reported, can be seriously misconstrued. Of the billion or so people in our world suffering from undernourishment, Plumpy'Nut is appropriate only for a small fraction. Most of the chronically under-nourished need not a solution to acute under-nutrition through food aid but regular access to a long-term, balanced healthy diet. Ms. Salem and we agree on this combination approach: RUTF's for acute under-nutrition, and regular access to a balanced healthy diet and adequate health care to overcome chronic under-nutrition.

Plumpy'Nut comes into relevance when an emergency has struck. And while the $30 per child per month is a very low cost for saving the child, it would in any event be an impossibly high cost for a "solution" to hunger based on food aid! Suppose that the billion hungry people in the world were put on a permanent Plumpy'Nut diet (a totally misguided idea) at a cost of $30 per month, or $360 per year. The result would be a direct cost of some $360 billion per year, an absurdly high cost compared to the real solutions of improved local agriculture, improved household dietary practices, and expanded access of the poor to basic healthcare.

The article agonizes over the patent status of Plumpy'Nut. We have two observations. First, it is absurd to think that a patent should legitimately give a monopoly right to use a fortified peanut-paste to fight acute hunger. The ingredients are simple: peanut paste, vegetable oil, powdered milk, powdered sugar, vitamins, and minerals. The nutritional values of peanuts and the other ingredients have been known for ages, and only the worst misuse of patent law would grant a broad monopoly claim to such knowledge.

Second, as the article mentions, but does not adequately emphasize, it is a standard solution of global intellectual property law that urgent public health needs supersede patent rights. Poor countries should exercise their full right of "compulsory licensing" and other legal protections to produce or to import urgently needed low-cost nutritional supplementation in the face of famines, just as they do to obtain low-cost AIDS medicines. Of course, any RUTF should ensure quality control in the preparation, packaging, and shipment of the foodstuffs. Nor should UNICEF, the world's leading and highly effective organization on behalf of the world's children, give any comfort to a private company seeking undeserved and ultimately life-threatening price markups for basic and widely held nutritional knowledge, especially since those price-markups demonstrably limit UNICEF's and others' ability to deliver emergency foodstuffs to all of the children in acute need.

We also note that Nutriset cannot claim that it expended vast R&D outlays to come up with Plumpy'Nut. It would be fine public policy to award Nutriset a one-time public payment to cover and even exceed its past R&D costs, but the public-health community should insist on the right of any producer to bring to the market low-cost, quality-controlled, peanut-based, fortified, ready-to-use foods in response to famines and other food emergencies.

Our recommended solutions therefore include the following. In cases of acute malnutrition, UNICEF and other agencies should promote locally produced, quality-controlled, ready-to-use fortified foods and should resist claims of patent protection that impede local production or low-cost imports, as needed. In cases of chronic undernourishment, rich and poor governments in partnership should promote improved agriculture and dietary diversity.

The general public should be helped to understand the difference of acute and chronic hunger, so that both are addressed appropriately. And we will need more scientific research in future years to secure even more nutritious crops, and to develop varieties that can withstand the more extreme climate change that is on the way. Of course, slower population growth in poor and hungry countries must also be a key part of any long-term equation.

Jessica Fanzo is a Senior Scientist of Nutritionist at Bioversity International in Rome. Dr. Sonia Sachs is a pediatrician and health coordinator for the Millennium Villages Project.