Series of letters on ENN conflict of interest, by Noreen Prenderville, Mark Myatt, Steve Collins and Mark Manary
A word from ENN
In Issue 23 of Field Exchange, a letter by Mary Lunga'ho, Lida Lhotska and Rebecca Norton was published highlighting concerns they had regarding potential ENN conflict of interest, with particular reference to the company Nutriset. Nutriset responded with a letter that was published in Issue 24. Linked with this, a letter was submitted to ENN from Noreen Prendiville, published here, raising her concerns. Further communications around this have established that all agree the key issues raised would benefit from a wider, open airing and debate. To this end, a selection of people whom we thought would have an interest and an opinion on the subjects raised, were invited to submit an opinion to ENN. Three responded and their perspectives are published here. We hope that these mark the beginning of an ongoing discussion in which the Field Exchange readership will actively participate. Anyone who would like to feedback, offer an opinion or comment, should email the ENN at email@example.com.
As a follow up to the letter from R. Norton, M. Lung'aho and L. Lhotska in Issue 23 of Field Exchange (FEx), I would like to also express my concern about the ever increasing prominence given to commercial products in the articles presented in FEx on management of severe malnutrition, and the relative absence of ideas and research on alternative approaches.
Few will argue with the fact that management of severe malnutrition has benefited from substantial research and private sector involvement in recent years; with guidelines for improved regimes and increasing availability of commercially produced foods. These have no doubt helped to decrease mortality and morbidity in acute emergency settings where external resources are available, and have allowed international non-governmental organisations (INGOs) to reach a Gold Standard in the management of severe malnutrition during the period of their intervention.
However, typically in the Greater Horn of Africa, only the very peak period of an 'emergency' attracts external attention and interventions. High levels of severe malnutrition are present before INGOs arrive and continue long after the INGOs have left. For the periods when local health services have to manage with minimal support, little is available in terms of guidelines, support or training, to ensure adequate management of severe malnutrition. It is not a coincidence that areas experiencing continued high levels of severe malnutrition today are also those with the lowest levels of humanitarian access. Much as we might hope that this situation will change, it is unlikely to do so adequately in the near future. In the meantime, concerted efforts are needed to support the preparation of appropriate foods at household or health facility level. We should ensure that health workers are well convinced that 'new', imported, packaged foods while wonderful, are certainly not essential.
Technical recommendations of INGOs, publications etc. will have far greater credibility in the Horn of Africa and will certainly have the potential for wider application if de-linked from branded products. Nutrition professionals, publications and INGOs need to ensure that their efforts to provide a Gold Standard do not, in any way, undermine the existing Silver and Bronze Standards.
Finally, I believe that we 'do harm' when we convince local health workers that externally sourced food products are essential in the management of severe malnutrition in situations where long term uninterrupted access to these items cannot be guaranteed. While I fully appreciate the driving force behind the recent development in management of severe malnutrition, I urge INGOs to support existing capacity to manage severe and moderate malnutrition in a sincerely sustainable way and to exercise extreme caution in the marketing of foods not readily and consistently accessible in resource poor communities. Field Exchange can contribute very positively by ensuring that research and articles on severe malnutrition represent the majority of those involved in this field, who are located in resource poor countries. This is not at all an argument against these new special foods, but a call for a more balanced approach.
Your interest in broadening this discussion has been greatly appreciated.
Food Security Analysis Unit, FAO Somalia
This letter represents the views of the author and do not necessarily represent the views of FAO.
In issue 23 of Field Exchange, a letter by Lunga'ho, Lhotska, and Norton was published highlighting their concerns regarding a potential conflict of interest, with particular reference to the private sector company Nutriset that produces and markets a ready-to-use therapeutic food (RUTF) under the brand name of Plumpy'nut.
Lunga'ho, Lhotska, and Norton do not take a strong ideological position with regard to the involvement of the private sector in humanitarian interventions. This is both sensible and pragmatic. Without the private sector, we would be severely restricted in our work. Many international NGOs receive preferential terms when purchasing essential services and items such air travel, vehicles, and communication equipment from large multinational corporations. Even without such preferential terms, many such items would still be sourced from these, or similar, corporations. In addition, numerous private sector companies have been established that receive the bulk of their profits from trade with the humanitarian community. Many NGOs purchase items such as airline tickets and insurance from such companies.
The difference between these companies and Nutriset is that none of these companies has a monopoly position in the marketplace. NGOs can source products and services from a variety of competing suppliers but, at present, must source RUTF through Nutriset or one of their partners. Nutriset hold a patent not just on the specific formula for their Plumpy'nut product, but on spreads and pastes used as RUTFs. The company's website clearly states:
'Plumpy' type products are covered by an IRD/ Nutriset patent.
Nutriset have shown themselves to be both willing and able to enforce this patent. This suggests that Nutriset is seeking to maintain a monopoly position with regard to any and all similar products. It is generally accepted that what is good for a monopolist is bad for consumers and the consumers in this case are children in extreme need.
The economic rationale for seeking and maintaining a monopoly position is to maximise profits through the maintenance of high prices enabled by the suppression of competing products. It is fair, however, to consider whether another rationale may be informing Nutriset's actions with regard to patent enforcement. The obvious consideration is the desire to ensure the quality of RUTF. This is clearly an important issue but it should be considered whether monopoly is the only way of ensuring this. Certification of quality of generic RUTF products by an independent standards body is an alternative that merits consideration.
Quantity, as opposed, to quality is also an important issue. Monopoly of large-scale production of RUTF entails risk with regard to continuation of supply. It is not clear that Nutriset's model of maintaining a monopoly of large-scale production at one location, principally for use in emergency contexts, whilst allowing smallscale local production in developmental contexts is one that can provide continuation of supply or supply sufficient quantities to meet need in large-scale emergencies.
These concerns are not new. They have been raised in international meetings at which ENN / Field Exchange workers have either been present or have been responsible for recording and publishing proceedings. It has to be a matter of concern to readers that ENN / Field Exchange did not take the opportunity to report these concerns when they were raised and did not specifically address these issues when visiting and interviewing Nutriset's management. Instead we were treated to a "puff piece" on a company that, as far as RUTF is concerned, has little claim to being "an ideal model for potential public and private sector partnerships".
It is a matter of record that ENN / Field Exchange has accepted funding from Nutriset. I think we can assume that ENN / Field Exchange staff have also received hospitality paid for from Nutriset's marketing budget. Lunga'ho, Lhotska, and Norton suggest that this may have influenced the way Nutriset and their products are depicted in Field Exchange. To purchase such influence is the usual purpose of corporate funding and hospitality. Whether Nutriset sought and whether they succeeded to purchasing influence is something that we, as readers, will probably never know. What is clear, however, is that accepting money from a private sector company and then failing to report on a major issue regarding the conduct of that company creates the perception of a conflict of interest.
This is not an easy matter for ENN / Field Exchange to address. There is a potential for similar, perceived or otherwise, conflicts of interests to arise regarding any of ENN / Field Exchange's sources of funding. This could, perhaps, be solved by moving to a subscription model or by relying on advertising-revenue. I doubt that a subscription model would be sustainable or cheap for individual readers and ENN would probably have to rely on bulk subscriptions by its current donors. Advertising is also problematic. If, for example, Nutriset were to regularly place a double page spread to advertise their products, then the charge could be made that ENN / Field Exchange will not criticise Nutriset for fear of losing advertising revenue.
Perhaps the best way is to keep things as they are and rely on an active and informed readership to raise issues of conflicts of interest as they arise. The fact that ENN / Field Exchange published Lunga'ho, Lhotska, and Norton's letter and have encouraged and are committed to further discussion can only reflect well upon their integrity.
Institute of Ophthalmology
I have read with interest the lively debate over the role of commercial products and the sustainability of interventions to address severe acute malnutrition. The central question underlying much of this debate is how can effective interventions to treat severe acute malnutrition (SAM) be made sustainable? The reason that these debates are increasingly common is that the advent of CTC using RUTF now provides a model that offers the potential to convert our theoretical knowledge of how to treat SAM into effective and sustainable long-term strategies, even in the poorest countries of the world. This represents a major advance as hitherto, despite inpatient clinical management protocols capable of reducing case fatality rates to 1-5% being available for at least thirty years1, case fatality rates in developing country hospitals treating SAM continue to be at 20-30% and have remained largely unchanged since the 1950s2.
To clarify some of the issues in this debate, I would first like to correct some misconceptions that appear in these letters. The CTC model stipulates that wherever possible, intervention should work with or through local capacity, strengthening communities' abilities to treat and prevent acute malnutrition. Although first trialled as humanitarian interventions implemented by INGOs, CTC is increasingly being implemented by local actors often through local clinics. CTC is only 5 years old, but already its model of early case finding, simple outpatient treatment, peer support and the local production of RUTF is looking to be sustainable over the longer term. All longer term CTC programmes that Valid supports are trying to evolve towards using locally manufactured RUTF made either at the capital or better, at the district level. As Noreen points out, internationally procured Plumpy'nut is not only too expensive but it also gives out the wrong messages. I had to smile that the CTC Special Supplement edited by Tanya Khara and myself, apparently gave the impression of advertising Plumpy'nut3. In reality, I am a director of Valid Nutrition, a not for profit company producing and developing RUTF production in several developing countries in direct competition with Nutriset and Plumpy'nut. We obviously have a lot to learn about advertising and branding!
We set up Valid Nutrition because we also share Noreen's view that uninterrupted access to quality therapeutic products is vital if programmes to treat acute malnutrition are to have long-term impact. The success of the CTC approach is dependant upon the availability of cheap, effective, locally produced therapeutic products and whilst Noreen is correct is stating that these can be made in people's houses from local ingredients, the evidence from the past 30 years indicates that this is seldom achieved in practice. Therefore, in addition to the more traditional strategy of promoting the use of nutritious local food within people's homes, I believe that we must engage and support local businesses and farmers to develop economically viable local production of RUTFs. I do not see a conflict between the two strategies and believe that adding value to local crops by converting them into RUTF in local clinics (as happens in Malawi, for example) and delivering them through the local health infrastructure is completely compatible with Noreen's vision of sustainable and effective treatment that empowers people and communities.
However, for local RUTF to be both as cheap as possible and economically viable and therefore sustainable, there must be free competition to drive the price of RUTF down and local RUTF manufacturers must have free access to markets.
Nutriset's plans for a franchised group of producers as outlined in their recent letter4 to the ENN, will help to increase the number of local producers and should help increase access to quality RUTF. However, a single franchise is still a monopoly and still runs the risk that prices can be maintained artificially high. Other independent producers or networks of producers are necessary in order to introduce the cost benefits of real competition. To that end, Nutriset's public undertaking in Washington5 not to contest the rights of competitors to produced RUTF for humanitarian use, is in reality more important. Nutriset should be commended for taking this step. I feel that this very positive development is the direct result of the engagement between private business and the not for profit sector of which the ENN has been an important part. I see great potential for this cooperation to produce further lasting benefits to the lives of the poorest people of the world and although we of course, must be wary of conflicts of interest, I think that we should see things in perspective. By its nature, the ENN tends to attract contributions that serve both to inform and to advertise. Agencies, whether they be NGOs, UN or private companies, like to write about their successes and their innovations. These articles serve both to inform but also to advertise the agency to their customers, whether these customers be donors, the public, governments or the NGOs. It is a great shame that few have the confidence to write about their failures and this I believe is a more important factor undermining progress in international nutrition and humanitarianism. Indeed, if you only read the ENN without going to emergencies, you'd happily believe that all humanitarian interventions were innovative and of the highest quality. Would that this were the case.
Valid International and Valid Nutrition
I am joining this discussion concerning the ENN, Nutriset, conflict of interest and the variety of foods used in response to nutritional emergencies as someone who has taken care of thousands of malnourished children as patients in Malawi, and worked with, at central and regional levels, to improve the outcomes and care of these unfortunate children. The discussion was prompted by an article in issue 22 of Field Exchange about Nutriset, and I also have personal experience of working with Nutriset.
The article itself profiles Nutriset as a company in a very favorable light and does not feature or endorse any product that they sell. The article is consonant with my experiences and interactions with Nutriset. I was not suspicious in reading the article that Nutriset was being unduly 'promoted'. Conflict of interest refers to mutually beneficial relationships between two parties that provide so many benefits that objectivity with regard to each other is impossible. Often this involves the transfer of monies and income between the two parties. On an absolute level, conflicts of interest colour almost every relationship we have in this world. Practically, it is those significant conflicts of interest where the truth is distorted that we need to guard against. ENN portrays itself as foremost an advocate for malnourished people, not a champion of either NGO or business interests. Thus, it is fair for readers to ask the question, what is the relationship between ENN and Nutriset, and it is completely understandable that this question was raised given the cheery tone of the article in question. The codirectors of ENN have answered that the ENN has accepted a very modest amount of support from Nutriset, no more than from many NGOs. Their annual report verifies this. The track record of ENN remains one of uncompromised support for vulnerable populations, and their reputation is not tarnished by this questioning. Questions about conflict of interest only damage the parties involved when they are not forthcoming, and this is not the case with ENN.
The problem of finding effective, lower cost, local foods to therapeutically feed malnourished people is very important. 80% of the malnutrition worldwide is not associated with disasters, such as war or drought, but it is simply the result of grinding poverty. Disasters attract the INGOs, and they may appropriately bring imported, specialised foods with them. Malawi, the nation I have worked in for 11 years, is not one wracked by armed conflict or masses of people moving in search of food and security, yet we estimate that 13% of all Malawian children die before their fifth birthday from lack of adequate nutrition. We obtain our therapeutic foodstuffs locally. Field Exchange could be a forum where experience with local foods is reported, even though Field Exchange is not a scientific nutrition journal with institutionalized peer review. Ways for ENN to highlight this important element might be to have a dedicated column each issue where projects using indigenous foods are described, or to collect several articles and place them in a special section or issue.
To develop feeding regimens with local foods, I would encourage practitioners to use the WHO supported linear programming tool available free on the web at http://www.nutrisurvey.de/lp/lp.htm. The tool is an excel spreadsheet. If one lists the locally available foodstuffs on the sheet, the tool can determine the amounts of these foodstuffs necessary to provide a complete compliment of nutrients. This will give an idea of what foods should be used together in the therapeutic diet. Of course edible preparations of these foods must be made in local kitchens.
Mark Manary MD
College of Medicine, University of Malawi
1Golden M. The effects of malnutrition in the metabolism of children. Trans.R.Soc.Trop.Med.Hyg. 1988;82(1):3-6.
2Schofield C, Ashworth A. Why have mortality rates for severe malnutrition remained so high? Bull.World Health Organ 1996;74(2):223-9.
3Steve's comment refers to a point made in a circulated draft letter by Noreen Prendiville, which flagged the prominence of the product Plumpy'nut in the ENN Special Supplement on Community Therapeutic Care
4See Field Exchange 24.
5CTC meeting, Washington, March 2005. Report available from ENN online or email:firstname.lastname@example.org
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Reference this page
Noreen Prendiville, Mark Myatt, Steve Collins and Mark Manary (2005). Series of letters on ENN conflict of interest, by Noreen Prenderville, Mark Myatt, Steve Collins and Mark Manary. Field Exchange 26, November 2005. p23. www.ennonline.net/fex/26/letters