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"Resisting the temptation to ration” The MSF campaign to increase and extend the use of therapeutic foods in areas with a high malnutrition-related infant mortality rate has been welcomed by United Nations agencies and donors, who consider it a legitimate request. Only practical obstacles could explain why access to therapeutic food is restricted to a minority of the most at risk children. According to Jean-Hervé Bradol, President of Médecins Sans Frontières, these obstacles could easily be overcome, given the political will. What counter-arguments are put forward when you call for an increase in the use of these highly nutritious, ready-to-use foods in malnutrition hotspots where mortality rates are high? When we address United Nations agencies (the WHO, UNICEF, the World Food Program) or donors, their first reaction is invariably to express an interest. No one can deny that current policies are ineffectual, while every year millions of undernourished children die before their fifth birthday. Nor can anyone ignore the excellent, large-scale success of these ready-to-use therapeutic foods. The question was settled in Niger in 2005, when tens of thousands of severely malnourished children were treated and cured. We come up against two types of response: the United Nations agencies are reluctant to seriously consider the question of extending the recommendations because of so-called economic realism. The donors say they agree, but wait for official recommendations from the United Nations before committing themselves. The buck gets passed around and no-one accepts responsibility. This is a vicious circle that can be extremely time-consuming, when in fact we are facing a medical emergency! Isn’t there a shortage of scientific arguments to backup the medical advantages of this type of foodstuff, over and above cases of severe malnutrition? There is a clear shortage of scientific arguments to justify not giving essential infants’ food – milk – in countries where one child in five dies before the age of five! This has all been demonstrated for decades, the medical libraries are full of publications establishing infants’ specific nutritional requirements and the high nutritional value of milk. More simply, you only have to read the Codex Alimentarius*. Until now, it was quite dangerous to give out milk in countries with an inadequate water supply and poor conditions of hygiene. This is why milk, given under medical control, was exclusively reserved for the most severely undernourished in the developing countries. Today, with ready-to-use therapeutic foods, we can at last distribute an effective treatment under proper conditions in malnutrition hotspots where infant mortality rates are high. There is no reason to keep on rationing, refusing sick children access to milk-based food, the nutritional value of which is well known. There is no need to prove the obvious, the scientific literature and past experience bear witness to the efficacy of highly nutritious food in reducing malnutrition-related infant mortality. The question is rather why do we refuse to apply the very policy we have successfully implemented in our own countries to the countries in the South? When a family is too poor to buy adequate food for a child, do we need scientific proof before we can give them milk, oil or sugar? Do we hesitate because they are too expensive?You yourself admitted that the price was an obstacle, at three euros a kilo. Is it realistic, economically? At three euros a kilo, it is not, in fact, realistic to think that the families who need it will be able to buy it at market prices. But it is completely realistic economically to give these families access to the products! The idea of subsidizing therapeutic foods to combat malnutrition in the major infant mortality prevalence areas is not utopic. The last major initiative aimed at reducing infant mortality in the world was the Extended Programme on Immunization (EPI) at the beginning of the 1980s. To extend access to 6 basic vaccines**, the price of some vaccines was divided by as much as twenty. Specific economic models have been found to provide large scale access to treatment and vaccines. Let’s be clear about this, we are talking about milk, oil, sugar and forty essential vitamins and minerals, not leading edge technology or rare products! These nutritional products could be manufactured locally. There are several possible options: we can channel a small part of international aid into manufacturing these foodstuffs or find new funding. On an international scale we are talking about several hundred million euros for the major prevalence spots of malnutrition-related infant mortality. The recent example of the Unitaid tax contribution on air tickets proves that it is possible to mobilize sums of this order of magnitude quickly for a public health cause. In the report he submitted to Jacques Chirac in 2004, Jean-Pierre Landau, French Inspector-General of Finances, concluded that it was possible, through voluntary or obligatory contributions, to raise hundreds of billions for development, without disturbing the economy. It is not a question of recommending a particular economic model; that is not our specialty, but we cannot accept the argument of economics to justify inaction. Not only is it achievable, but according to the World Bank it is also an excellent investment! In a recent report, this international institution recommended targeted actions to improve nutrition in the developing countries, noting that the absence of an effective policy to combat malnutrition was an obstacle to growth. So neither the United Nations agencies nor the donors have the political will to combat the mortality of children under five? This cultural resistance was supposedly coming from the mothers of malnourished children, who did not want to take their infants to a care centre, and did not know how to use the ready-to-use food. On the contrary, they have clearly shown that if offered the possibility of giving their children suitable food, they are willing to walk for hours, on a regular basis, and to follow the guidelines every day. On the other hand, it is sometimes difficult to convince the authorities who are the most concerned, because malnutrition is a problem that carries a stigma. In addition, United Nations agencies and donors are very reticent about the massive distribution of highly nutritious products to young children, irrespective of medical or economic proofs. Until now, efforts have mainly been directed towards development projects aimed at changing family eating habits or increasing the quantities of food available, from the all too often illusory standpoint of imminent independence. But, up till now, there has been no policy able to prevent millions of children risking death each year due to a lack of suitable food. The use of these treatments could be scaled-up without upsetting the world, the economy or the way societies are organised. The revolution we are advocating can easily be achieved, on condition that the political will is there. In the absence of real commitments to this end, the United Nations agencies and the donors must assume political responsibility for the rationing of these potentially life-saving therapeutic foods * The Codex Alimentarius was created in 1960 by the United Nations Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO) to protect the health of consumers and promote loyal practices in food retail.
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