Posted by Sanjay Basu
Nyaya Health has recently expanded its clinical reach to address one of the most basic, and yet widely unaddressed, health issues to affect the rural poor: malnutrition. Introducing micronutrient supplementation, fortified milk, and ready-to-use therapeutic foods, Nyaya hopes to attain the highest clinical standards to treat malnutrition as a chronic source of future debilitating illness and ever-present infant mortality. In Achham, estimates of malnutrition are 60%, likely related to the fact that over 80 of every 1,000 children don’t survive past their 5th birthday [1].
But as we proceed to treat malnutrition as a healthcare-focused organization, we ask the basic question: in the era of vast technologies to grow and transport food, why are people still starving? The simple and typical answer is that hunger results from “lack of food”, but this observation stands in opposition to recent public health data [2-8], which shows that that in resource-denied communities of even the poorest countries, the same households are increasingly being faced with a wave of (often undiagnosed) diabetes, heart disease and even obesity at the same time that they are dealing with persistent malnutrition and hunger. How can this be? As Amartya Sen, a Nobel-winning economist, has clearly demonstrated, famine has not resulted from the lack of food per se, as often as it has from the inability to purchase food that is available to buy [9].
The reality of the food crisis, and its resulting malnutrition and obesity epidemics, can be understood by the recent rise in the price of wheat around the world [10]. Just as the economic crisis of 2008 started, the price of wheat around the world rose so high that common breads and cereals were priced out of reach for millions of the world’s poor, sparking widespread famine. How did this happen? Was it lack of production resulting from drought, creating a scarcity? Actually, the production of wheat had expanded, such that there was a surplus at the beginning of this year. What actually happened is explained by financial speculation: when Wall Street bankers decided that they can make money by artificially propping-up the price of a commodity (usually something like oil or cotton, but more recently applied to food) they do so by hoarding it on the market, trading deals so that investor funds purchase large amounts of future stocks in the commodity (“futures markets” or “derivatives”) and essentially generate high demand, causing rising prices, which attracts more investors, creating a cycle that artificially inflates the price of a good before it is even produced (or harvested, in the case of produce). Goldman Sachs, starting in 2001, decided to create a special way of cornering the market of world wheat production (just as they did with home mortgages years before), and by 2009 the price of wheat had been inflated so severely that the UN declared it to be the cause of a new global famine, the likes of which our patients in Achham are facing this year. (For complete details, see the recent Harper’s magazine article by Frederick Kaufman, entitled “The food bubble”).
What’s more, the fact that food has become a weapon of investment means that all too often, nutritious foods grown locally and traded for their local value are replaced by mass-produced foods which can sell to large numbers, be manufactured cheaply, and take over markets with sugary and sweet temptations at the expense of micronutrients and protein. Increasingly, insulin resistance (pre-diabetes) and heart disease (including heart failure) is being found in the same households as malnutrition in Nepal, because essentially obesity is a form of malnutrition–the consumption of an imbalanced array of pre-packaged, high-sugar, low-nutrient foods in a setting where these are cheaper than healthy produce because the former are imported en masse while the latter are part of a market that requires reimbursement for hard labor and local transport (this is not just true in the US, but increasingly among developing countries).
In other words, in Nepal, Nyaya Health is faced with an evolving set of medical malnutrition challenges that are essentially all problems of food access and food quality–problems that are ultimately generated by the decisions we make as a society about how to invest our money, what sort of social system of nutrition to support, and whether famine and feasts will be determined by the fickle tendencies of market mayhem. At Nyaya, we’ve decided that there are both short- and long-term ways to address this problem. In the long-term, through blogs like this one, we choose to expose the underlying problems that are leading to famine and diabetes, obesity and vitamin deficiencies; these are common problems that often have their origins in policies that US taxpayers, some of the key funders of Nyaya Health, can weigh on as they elect their political representatives in a few months.
But in the short-term, Nyaya also recognizes the dire need to address the nutrition problem posed by the recent price increases of food. To buffer the communities we serve requires not simply introducing plain foods into the diet, but also treating the medical consequences of malnutrition, which extend beyond “hunger” into a medical condition that requires sustained support and clinical attention. That is, going hungry cannot be solved by having food alone. What has been increasingly recognized in the medical literature is that going hungry for long periods creates such profound nutrient deficiencies and protein imbalances in the body that it requires more than just “good food”–it requires “medicinal” food [11]. That’s why Nyaya has procured “ready-to-use therapeutic foods” (RUTF), which are fortified and enhanced foods that help people recover from severe malnutrition. These sound like science fiction, but in reality the results of numerous clinical studies reveal that they can make the difference between a community becoming stunted or altogether wiped-out by famine, or alternatively fully recovering their economic and social well-being after a time of food shock [12-25].
In public policy, it is often said that healthcare costs need to justify their benefits; in the case of RUTF, some international aid agencies have refrained from commenting on fortified foods because of their cost. But this cost-benefit analysis has ignored the downstream consequences of persistent famine, stunting, and lost economic productivity (as anyone familiar with the history of Ethiopia can attest). For these reasons Nyaya uses the Doctors Without Borders clinical recommendations for RUTF, which have gone beyond low international standards to advocate that we must provide supplementation and adequate recovery for a community suffering from famine, not simply ignore the shock they have been through and leave the famished permanently disabled (for more information on this debate, see the Doctor’s Without Borders “Food is not enough” campaign).
The idea may sound extreme, but to Nyaya it is a practical matter. To address malnutrition, and the persistent problem of famine, we must address the root causes of ill health while supporting the poor through their hardest times, by examining the underlying social and economic causes of these crises, and by responding to them with an eye towards recovery rather than simply placing a small bandage on a large wound. We thank our donors for their support of these ideas as we work to eliminate malnutrition in Achham.
References
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