‘Whatever it takes’ to Solve Malnourishment Among Children in Africa, says Founder of Project Peanut Butter

Posted: October 31, 2013

Dr. Mark Manary speaks about the relentless problem-solving that has helped 500,000 children and revolutionized treatment of deadly malnourishment among children in Africa
A young girl embraces rescue food from Project Peanut Butter in Malawi

A young girl embraces rescue food from Project Peanut Butter in Malawi

Feeding dangerously malnourished children in Africa a peanut butter-like food instead of milk-based foods has helped 4 million children and led to a 23 percent drop in childhood mortality, said Dr. Mark Manary, founder of the non-profit Project Peanut Butter, who spoke Oct. 22 on the Penn State campus about innovation and entrepreneurship.
Project Peanut Butter, the social enterprise that worked to make “ready-to-use therapeutic food” the standard of care and figured out how to cost-effectively produce and distribute the food, has helped about 500,000 children.
The idea was a good one and was certainly innovative, said Manary.
But the determined solving of one problem and roadblock after another over more than a decade is the entrepreneurial part of the story, he said, of how his group’s effort led childhood mortality in Malawi to drop by 23 percent to 7 percent.
Manary, the Helene Robeson Professor of Pediatrics at the Washington University School of Medicine, told his story as part of the Gaelen Entrepreneurship Speaker Series, which invites world-class entrepreneurs to campus to encourage entrepreneurship among Penn State students, faculty and staff. The series was endowed by Norbert and Audrey Gaelen of Short Hills, N.J.
A Devastating Problem

When Manary first visited Malawi in 1994 he came face-to-face with the problem of malnutrition, the killer of more than half of the 23 percent of Malawian children who die before their fifth birthday. There, an estimated 60 percent of children do not reach their physical and intellectual potential because they do not have enough to eat.
“This is what kills children,” said Manary.
In Malawi—an African nation smaller than Pennsylvania—85 percent of the people are peasant farmers, growing and cooking their own food with their own hands. The extreme poverty makes people vulnerable to unexpected problems, like when rats have eaten a batch of the stored corn or a sick family member and extra children move into the household.
Nearly two decades ago, when malnourished children arrived at the hospital, the standard treatment was to feed them milk-based foods and supplemental traditional corn and soy foods. 
For five years, Manary said, he worked to improve results within that treatment structure. But only one-quarter of those kids got better with that treatment, said Manary.
A Sticky Solution

There had to be a better way, said Manary, who saw a need for a food that was energy-dense, ready-to-eat and wouldn’t spoil and could be fed to the kids at home, outside of the hospital setting.
“I’m an American. So I thought of peanut butter,” said Manary, who soon began a partnership with Dr. Andre Briend, a pediatric nutritionist who was also working on the problem. 
They set about developing a ready-to-use, peanut-based food product and testing it. Researchers were working on the RUTF concept in the late 1990s, but Manary was the first to conduct clinical trials of the product, administered in the home.
By the first studies in 2000-2001, the children who were treated at home instead of the hospital with that peanut butter-like, therapeutic food did better. Eighty percent reached weight and height targets after 12 weeks. 
By 2005, large-scale trials had shown the combination of RUTF fed to children at home produced 95 percent recovery rates.
Overcoming one Roadblock After Another

Manary and Briend set about making this treatment — ready-to-use therapeutic food, or RUTF — a reality for any African child who needs it. They worked to convince the international community that RUTF should be the standard-of-care, produce RUTF locally from locally sourced ingredients and demonstrate real-life outcomes.
Soon, the approach had treated 12,000 kids and achieved a 90 percent recovery rate. 
The solution was tedious work. Briend went to work for the World Health Organization to convince the international aid community — which had initially rebuked the idea — that it was a more effective treatment than milk-based foods fed in the hospital.
Now, RUTF is the standard of care. 
According to the WHO:  “A recently developed home-based treatment for severe acute malnutrition is improving the lives of hundreds of thousands of children a year. Ready-to-use Therapeutic Food (RUTF) has revolutionized the treatment of severe malnutrition – providing foods that are safe to use at home and ensuring rapid weight gain in severely malnourished children.”
Key to the effort was treating kids outside of the hospital and away from a higher risk of disease, and getting them through the critical, early years to four years of age, said Manary. 
At age 4, the risk of malnutrition decreases because they are more mobile and can more easily find food on their own. The product is “rescue food.” Children with moderate malnutrition eat it for two weeks and those with severe, acute malnutrition eat it for about six weeks. Individual children typically do not need it on a long-term basis. 
“They’re in a terrible place,” he says. “We rescue them with this food. We put them over here where they’re not in a terrible place.”
Another problem was finding a food company to use their recipe that called for peanuts, sugar, oil, milk powder and micronutrients to produce large quantities of the product.But no food company wanted to help. 
Manary and Briend decided to make the product themselves. “We can’t just surrender when we can’t find a partner,” he said. “So we decided to start our own enterprise.”
Project Peanut Butter was created as a non-profit organization to produce the RUTF as cost-effectively as possible. They use donations to build the food processing infrastructure in a particular geographic area, then charge their customers —like the government of Malawi, UNICEF, Doctors without Borders and the Clinton Foundation — the actual cost for a batch of RUTF.  
Working with the Local Work Culture
To solve the problem of a work culture in which people may or may not consistently show up for work, they pay a living wage at least five to 10 times the average wage for working in a production facility. 
What was most important in finding workers, said Manary, was integrity not education.To earn those healthy wages, workers first have to prove themselves to be reliable during a probation period. 
“We have a set of rules. The first day you violate any of them is the last day you’re there,” said Manary. “They have a chance to make a great wage. But they have to rise to the occasion.”Factory managers make $50,000 to $60,000 salaries. Manary and his team learned Africans are stricter, better managers of local workers and often can achieve greater efficiency than an American manager can.
Sourcing the Safest Peanuts
Another problem was meeting stringent quality control specifications that came along with RUTF becoming the international standard-of-care for acute malnutrition.
Aflatoxin, for example, is a fungal toxin that can contaminate crops like maize and peanuts and lead to liver failure and death. It took five years for Project Peanut Butter to meet the standard of less than 5 parts per billion of aflatoxin in the RUTF.
They had to keep working farther back in the supply chain, said Manary. First, they learned they would have to change the purchase culture. Typically, peanut farmers are paid by weight, so it was in their best interest to soak their peanuts in water — ideal breeding grounds for the fungus that produces aflatoxin.
So, Manary and Project Peanut Butter pledged to pay a premium price for peanuts delivered dry within a week of harvest.The first year, they struck a deal with a co-op, but at harvest time there was no delivery of peanuts. Next, they used a middle-man, but there was still no delivery of peanuts at harvest time.
Finally, they went directly to farmers and struck effective relationships that delivered fresh, dry peanuts in exchange for a premium price.
Entrepreneurial Mindset Leads to Scale-Up
Had he stopped at an innovative idea, said Manary, that would have helped 3,000 kids. The entrepreneurial, basic problem-solving, meant helping hundreds of thousands of children and driving down childhood mortality in Malawi. 
Now, Project Peanut Butter operates two factories, in Malawi and Sierra Leone, makes 1,000 to 1,250 tons of RUTF annually and operates multiple sites in both countries providing the rescue food, staff, training and outreach. 
It is beginning work in Ghana, where 18,000 children a year die of malnutrition. 
“Whatever it is going to take to get the job done,” is his mindset, says Manary.
The behind-the-scenes look at Project Peanut Butter inspired many who heard it, says Dan Azzara, the Alan R. Warehime Professor of Agribusiness.
“Dr. Manary demonstrated the passion and commitment required to build a successful social entrepreneurial enterprise,” says Azzara.
The Gaelen Entrepreneurship Speaker Series features up to six speakers each year, three each semester, with each initial speaker sponsored by the engineering entrepreneurship minor. Future speakers will be hosted by other colleges, including the Smeal College of Business and the College of Agricultural Sciences.
Vytas Pazemenas, founder and chief executive officer of the Aubrey Group Inc., served as the inaugural speaker for the series September 25. Dr. Manary was the second speaker in the series.