Steve Collins is changing the architecture of nutritional treatment by bringing treatment out to afflicted people rather than afflicted people to the treatment. By using a decentralized care model and orchestrating the spread of a range of Ready to Use Foods, Steve is revolutionizing the way the world prevents and responds to malnutrition.
The New Idea
Steve Collins, a medical doctor with a doctorate in nutrition, is changing the architecture of nutritional treatment, and transforming the practices, principles, and strategy towards the care and prevention of malnutrition. Traditional centralized feeding centers – formerly the primary method for treating acutely malnourished people - are ineffectual, incubators for disease, and require extended in-patient treatment regimes that uproot lives. Steve is decentralizing treatment programs, creating many local centers, bringing treatment out to homes and villages and equipping communities with the know-how and tools to diagnose and administer their own treatment through a method called “community-based therapeutic care.” He has also helped orchestrate the spread of Ready to Use Therapeutic Foods (RUTFs), a highly nutritious and portable feeding option that is locally produced and distributed, and applied as an emergency remedy as well as a preventative method against malnutrition. RUTF is an oil-based nutritional paste (in large part peanuts or corn/soya, milk powder, sugar, and vitamins and minerals) that comes in safe, contaminant-resistant packets.
Steve has established the first hybrid business citizen sector organization in Ireland, coupling a for-profit company with a non-profit arm to manufacture and distribute the food source and disseminate his methods. Building on the infrastructure built by existing COs in the field, six years after initial pilots Steve’s organization is has been active in thirty-five countries and his innovation has been adopted by the main United Nations organizations involved in the treatment and prevention of malnutrition (World Health Organization, UNICEF and World Food Program) as recommended policy under the name Community-based Management of Acute Malnutrition. Over twenty developing countries and the majority of governments and citizen sector organizations working in nutrition in the developing world are moving towards adoption of his model.
Acute and chronic malnutrition is widespread in much of the developing world. Approximately eighty million children under the age of five are acutely malnourished, and up to five million of these children die each year. The majority of these deaths are preventable. There are 200 to 300 million other children (approximately 30 percent of the developing world’s children) that suffer from chronic malnutrition, a condition that is recognized as the single most important cause of poverty, ill health, and underdevelopment in the world today. Both acute and chronic malnutrition in the developing world lead to reduced lifetime achievement. In addition to the immediate effects negative effects on health, acute malnutrition results in immune suppression, leaving children open to life threatening infection. Chronic malnutrition stunts growth and brain development, undermining all aspects of a child’s future life such as health, educational attainment and earning potential. Unless the condition is prevented or treated before the age of twenty-four months, these children never attain their full potential in any sphere of life.
Feeding centers, previously the only model of treatment for acute malnutrition, are ineffective, costly and dangerous. Centers are a band-aid solution to the problems of malnutrition that do not address underlying issues, and often make difficult situations worse. The system brings together large numbers of people—already with compromised immune systems—in unsanitary conditions that often compound the circumstances, leading the spread of diseases such as diarrhea and pneumonia that spread with close contact and poor hygiene. Moreover, existing centers reach only a small fraction of those requiring care, and offer low recovery rates for those that are reached: studies have shown that in developing countries twenty to thirty percent of those with severe acute malnourishment die even if they reach a hospital, due to ineffective treatment. Treatment programs often require more than a month in residence at the centers, and are extremely disruptive to patients or parents who have other children and work or farm responsibilities. The long journey required for people from rural areas also adds an extra burden to weakened populations. High-nutrient re-feeding milk based formulas are expensive and made with water, which opens up new channels for contamination and spoilage that make them only suitable for use in medicalized centers.
These difficulties have meant that often the treatment center model has been implemented by outside actors (multinational organizations, international citizen organizations) with little community input or involvement, and a tendency to create parallel structures that can undermine existing national public health interventions. The feeding center mentality is rooted in a passive recipient model, addresses a problem after it is severely advanced, and is primarily imported rather than locally produced or administered. Traditional treatment is based in removing people from their communities rather than changing what is available in communities.
Steve started working as a volunteer in the 1984 famine in Ethiopia and Sudan. During the 1990s he specialized in treating severe adult malnutrition, drawing attention the plight of starving adults, developing criteria and treatment protocols and eventually establishing the treatment of starving adults as a standard element in famine relief programs. During the 1990s he worked in most of the famines and wars occurring in Africa during that time, and was led to realize that the existing treatment models could not address the problems of acute malnutrition and often made things worse. In the midst of a severe famine in South Sudan in 1998, he began a radical community-based approach, abolishing the need for treatment centers, instead treating people in their homes before they became too sick and required inpatient treatment. In the 2000 famine in Ethiopia, the government abolished the practice of therapeutic feeding centers due to years of ineffectiveness, giving Steve an opening to test his idea. In two small projects implemented in partnership with international COs, he tested his new model, now called Community-based Therapeutic Care (CTC), demonstrating that it could work and could dramatically reduce death rates. During the next three years, he worked in partnership with agencies such as Concern World Wide and Save the Children UK, and established an organization called Valid International to build an evidence base for humanitarian action. He and a small group of dedicated staff began to collect data on the effectiveness of this new approach.
Steve’s CTC has deconstructed the feeding centre model, bringing treatment out to afflicted people rather than bringing afflicted people to treatment. Steve’s strategy gets those affected by malnutrition to understand the condition and the methods of preventing the condition. Tapping into word of mouth, CTC sparks a village-to-village, mother-to-mother dialogue to spread the information about treatment, methods of use, and effectiveness. It decentralizes nutrition programs from one hospital center location to many local health centers. Local health staff at each location receives simple training and simple tools for diagnosis, prioritizing referrals based on need, and registering children with severe acute malnutrition but with no complications to outpatient programs that can be implemented at home.
Steve’s approach utilizes a product created by French doctor Andre Briend, a Ready to Use Therapeutic Food product (RUTF) that, although invented in the mid nineties, had not been used due to the lack of a viable delivery model. The product, a peanut/milk/oil-based, nutrient-enriched paste provides a perfect balance of nutrients for the treatment of acute malnutrition and is safe to store and use at home. Much like an extremely fortified peanut butter, the product is already mixed and packaged, impervious to external contaminants, and easy to transport in single doses. Spread in partnership with Steve’s organization and the existing infrastructure of citizen organizations on the ground, the program equips patients with the tools and knowledge to treat themselves and their families at home. After the initial pilot trials in Ethiopia, larger scale trials were conducted in Malawi, Ethiopia, Sudan, and Niger resulting in a data base of almost 25,000 cases treated with the new model, demonstrating a quantum leap in impact. Mortality rates were reduced to fewer than 5 percent, and data showed that CTC programs regularly reached over 75 percent of all those requiring care—a considerable advance over the 5 percent rates usually seen in center based models.
Steve is moving beyond an ineffective volunteer model, designing an approach where professional local people guide projects, and work with existing local health services, strengthening rather than undermining them. His organization advises governments and agencies how to build decentralized programs using existing distribution points, and how to make sure that implementation is responsive to community needs opportunities and constraints.
Steve is implementing his strategy in two parts. Throughout his work across Africa, he has understood the importance of collecting data and performing research on impact and effectiveness. Working as a traveling doctor and consultant, he had “no continuity,” and data was lost frequently as he moved from site to site. Valid International, a for-profit consultancy, serves the data collection function, driving research on his models and refining and developing new models to treat malnutrition associated with other illnesses such as HIV. Valid International specializes in training and supporting governments and other organizations to implement effective nutrition programs and to monitor their impact and learning experiences. Valid has partnered with many other governments and organizations to provide tech support for starting up the model, documenting and disseminating evidence though major medical journals such as The Lancet.
The development of CTC has required changes in the way malnutrition is assessed and measured. Traditionally, malnutrition had been measured through calculations involving height, weight, age, and other clinical factors; however, difficulties in obtaining these measurements reliably and the requirement of workers to be numerate and literate prevented these assessments being carried out at community level. Steve realized that the upper arm circumference was an accurate and simple method of determining malnutrition (many hundreds of patients can be measured in an hour), so Valid has developed and distributed simple colored bracelet measuring tools to facilitate diagnosis. Despite considerable resistance, the WHO, UNICEF, and WFP have endorsed the armband bracelets as an acceptable tool for the diagnosis of acute malnutrition. Steve has also established a new method and approach for assessing the impact of CTC programs. Typically, organizations counted the number of patients at a feeding center and compared this with the prevalence of the condition obtained from nutritional surveys to determine the coverage of programs. As prevalence does not predict incidence, Steve pushed Valid to work with expert epidemiologists to develop a new approach to determine direct estimates of coverage, by dividing districts into quadrants and studying them exhaustively to get an accurate picture of coverage.
By 2003, Steve realized that CTC worked and would become the standard method for addressing acute malnutrition. At this stage he saw that the provision of the RUTF would become the major constraint to the global roll out of these programs. At that stage the only RUTF available was called Plumpynut, a patented product made in France by a commercial company. This European production by a single commercial company restricted access, maintaining a high price and complicating distribution. In response he set up Valid Nutrition, a not for profit citizen organization—based in Ireland—following best business practices in order to make the product in developing countries out of locally grown ingredients. Steve believes, especially against the background of the world economic climate, that the development of a highly competitive company, based on the business model and following best business practice but established on a not-for-profit basis, is the most effective way to extend CTC and expand access to life saving nutritional products. Lowering the cost and expanding the range of RUTF into products designed for the prevention of chronic malnutrition, and improving integration with agricultural development activities are central elements in the strategy. Valid Nutrition works closely with a range of national governments, the United Nations, international development agencies, and COs to leverage access to these products through public delivery systems, specifically health and education.
Valid Nutrition currently produces products in its own factory in Malawi and through a local food manufacturing business in Kenya, which acts as a subcontractor to produce Valid Nutrition branded products under license. These factories have already met the stringent quality control standards required to achieve UNICEF certification, opening the door to more widespread adoption of their products by any government or organization involved in the treatment or prevention of malnutrition.
Valid Nutrition has its own purpose built factory in Malawi, supplying local demand as well as exporting to neighboring countries. It employs some thirty personnel locally, sells to local and international CO’s, and sources many ingredients locally. The capacity in Malawi is growing exponentially, with an important element of the additional capacity destined for exports to other African countries. Valid Nutrition currently has collaborations with third party food manufacturers in Kenya and Ethiopia; Uganda and West Africa are on the horizon.
In addition, Valid Nutrition’s research and development program is developing and testing a range of new ready to use food formulations designed to reduce the cost of these vital products and adapt them for the treatment and prevention of other forms of malnutrition. They are working with a network of public sector and university research departments, and other collaborators. These new recipes increase the ingredient options to include food products from locally relevant crops such as rice and lentil for Asian markets, sorghum and maize for central Africa, and chickpea and sesame for southern Africa. As production volumes increase, this diversification of the ingredient base will create an increasing demand for a variety of agricultural ingredients that require rain at different times of year, provide an incentive for local farmers to diversify their crops and thereby increasing their resilience against changing rainfall patterns associated with climate change. Valid Nutrition’s small holder purchase program will increasingly use this demand to improve the incomes and food security of poor farmers in all countries where Valid Nutrition is operational.
In 2008, Valid Nutrition received Ireland’s very first hybrid model designation—a “humanitarian business” that within the next two years is set to become self funding and therefore able to provide the continuity required to achieve lasting impact on alleviating malnutrition at a global scale.
Steve is evolving Valid from an organization focused on the most pressing, emergency cases to one that can prevent malnutrition. His focus on education for mothers about the signs of the condition, coupled with widespread availability and ease of access for ready to use food will allow for self-administered prophylactic treatment. Valid Nutrition is focused heavily on research and development, expanding the product line to include a specific food for those affected by HIV/AIDS and others that prevent chronic malnutrition. In June of 2007, four United Nations agencies, including WHO and UNICEF, issued a joint statement—in an unprecedented agreement among disparate bodies—advocating the community-based management of acute malnutrition using RUTFs, an explicit endorsement of Steve’s model. Valid currently work to expand both the ranges of products and the delivery mechanisms to address other forms of malnutrition promise to grow this impact to new heights.
A native of the United Kingdom and resident of Ireland, Steve has spent most of his life working in areas of great poverty. He chose to study medicine to help address the great need he saw in the developing world, but found himself a mediocre student at the outset. He stumbled across Buddhism while in India and began to pursue a daily practice. Slowly, he found himself achieving top-level scores at university, and now credits much of his insight and innovation to his meditation. As a medical student, he had cycled and hitch hiked through the Congo, Chad, and Uganda during wartime, and experienced famine conditions firsthand in Darfur, Sudan. While in Sudan, he realized “you can’t be a tourist in a famine,” and began surveying local villages by foot and by horse, talking to families about their needs—it was here he realized that “nutrition is the basis of everything.” After completing his medical internship in Jamaica working alongside a major international nutrition research institute, he sailed across the Atlantic in a refurbished boat despite having no experience on the water. The journey was lengthy and at times life threatening. While on the water, he resolved to undertake risky activities only if there was some larger human benefit—he did not want to risk his life “for an indulgence.”
Upon returning to dry land Steve began working in some of the refugee re-feeding centers in famine-ridden Somalia. In his work, he began to realize the large gaps present in nutrition and the sorely lacking procedures and strategies in place to help the starving. The centre in Somalia was the first adult feeding centre since World War II, and patients were dying inexplicably. Drawing from his exposure to cutting edge nutritional research in Jamaica, Steve altered the diets in the center and cut death rates by more than three quarters. He published an article in the scientific journal Nature Medicine and was surprised to find himself established as an expert in adult malnutrition, so he began traveling widely to set up treatment programs across Africa. Hitherto famine relief programs had catered exclusively for children but as a result of Steve’s early work, research and publications, within a few years adult treatment centers were to become a standard element of relief programs wherever they were needed.
Setting up a feeding centre in Liberia, he was organizing groups of people traveling from far villages, who did not know the areas and the established community rules, such as where to gather water. The patients, already weakened from hunger, began dying of cholera. Driven away by violence, when he and other doctors returned they found eighteen people had died. Steve realized his own approach had influenced the tragic outcome—he had been asking the wrong questions. He realized the importance of asking open-ended questions such as “What do people die from?” rather than “Do people die of cholera?” to build a strategy around the reality of a situation from the people living in it, and engaging with people rather than imposing on them. The sum of these experiences led him to create Valid Nutrition and Valid International.