Magic bullets vs community action: the trade-offs are real

Abstract Magic bullets refer to single interventions, vertically delivered (i.e. from the centre), expected to have a dramatic effect, and often in practice circumventing or displacing more locally appropriate and sustainable activities. Once policies have defined intended outcomes – here childhood malnutrition is considered – decisions on programme specifics should take full account of trade-offs (including opportunity costs), and these decisions at present are often unduly influenced by vested interests. Magic bullets have times-and-places where they may be effective. These may get superseded, for example with changing disease patterns or other conditions, or because of new technologies. Regular transparent assessments of current applicability, with some estimate of benefits and costs, are essential, but uncommon. Six examples of single purpose interventions are summarized considering times-and-places: protein supplements, infant formula, high dose vitamin A capsules (HDVAC), the vitamin supplement industry, ready-to-use therapeutic foods (RUTFs), and oral rehydration therapy (ORT). HDVAC and RUTFs are compared to community-based nutrition programmes. Protein is rarely the binding constraint in preventing or treating infant and child malnutrition. Infant formula is hardly ever to be preferred to breastfeeding; and in poor countries with inadequate hygiene its use carries much increased mortality risk. HDVACs were shown to have a mortality impact in the 1980’s and early 90’s, leading to global programs now covering a reported 200 million children; however recent studies have shown that this effect is no longer seen, but policies and programmes have yet to change in most countries. The vitamin supplement industry is included as it contributes to misguided views of nutrition and health, which should be mitigated. RUTFs are very useful for the narrowly defined group of children with severe acute malnutrition still with an appetite (most severely malnourished children have a poor or zero appetite, and require liquid diets first). However, the off-label use of these sweetened peanut butter pastes for moderately (or less) malnourished children is becoming widespread: it has many immediate and long-term disadvantages, including on children’s food preferences; local foods, maybe enhanced with micronutrient mixes, are far preferable, including for rehabilitation of severely malnourished children. Oral rehydration provides a further example of where local solutions are preferable – but still seldom applied. Community-based programmes have known effectiveness, are more sustainable than magic bullet approaches, and in all the examples above can contribute to local problem solving. The implications for resource allocations are that shifting resources from magic bullet programmes to local, community- (and facility-) based activities will have many advantages. While cost estimates are hard to find, it seems that some such as HDVAC cost around $1 per child per year, and RUTFs for SAM around $5 per child per year (in the overall population; per SAM case treated the estimated cost is more than $100). Effective community-based programmes cost about $10 per child per year, but address not one but most of the nutrition problems faced by children in those communities. Major donors have allocated 50% or so of their budgets to such supplies, and these funds go to the manufacturers in the rich countries, not to the countries in need. Allocation of resources to the countries themselves, and to local activities, could amount to billions of dollars, leading to improved nutrition, if single purpose interventions like HDVAC and RUTFs were no longer soaking up time, efforts of frontline workers, and funds.