Feeding the Future: Dr. Mark Manary's Mission to End Childhood Malnutrition
Transcript
Lauren Stenger: Thank you so much for meeting with me, I really appreciate it. I am taking this biology class right now, and one of the chapters was all around you and your work, and that's how they presented the topic of nutrition, enzymes and metabolism. I thought your Project Peanut Butter was so interesting, and I wanted to reach out and chat with you a little more about the whole experience of how you've been created such a transformative product. First of all, where are you located right now? Are you in St. Louis?
Dr. Manary: I am sitting in St. Louis now. But I spend about eight months a year in Sub Saharan Africa.
Lauren Stenger: Wow. So when will you be going back?
Dr. Manary: Right after Thanksgiving.
Lauren Stenger: So are you currently a teacher at WashU? How do you manage both?
Dr. Manary: Yeah, I'm a professor. But my whole job is working in Africa. I don't teach classes and I am a pediatrician but I don't take care of patients in St. Louis anymore. My whole focus is on projects to improve nutrition in Africa, mostly with children and malnourished pregnant women.
When you were younger, maybe my age, 20 years old, did you have a passion for the medical field? Or is it something you developed over time?
Dr. Manary: I didn't have a particular passion for medicine. I'm pretty far out there, I’m a couple standard deviations out there for most people, and was just pretty singularly interested in making the world a better place. Pretty early on, I first thought that might have to do through politics or governance, but it only took a couple of years of working around those areas to figure out no, I thought it was going to be through technology and science. My self image is, in part being a scientist. And so being a doctor is a scientist who's has more of a chance, I think, of helping people. So that was the kind of most major motive to get into that. I went to college, I came from a town in Michigan, which was the headquarters of a big chemical company. I went to college and got a degree in chemical engineering; I was working for an aluminum company. And then pretty much on the basis of the discussion and an offer, decided to go into medical school. So I didn't have a really strong background in biology. But this is a really long time ago, this was 1978. But it was fine, you could learn quite a bit and I chose pediatrics. And then right away, when we were done with my pediatrics, my wife and I, we moved to Tanzania, and that was 1985.
What was it like moving from St. Louis to Malawi?
Dr. Manary: My wife has never even to this day, been to Washington, DC or New York. And here we are getting on a plane, and three or four planes later, we were in Nairobi, we get on a little plane that takes a couple hours and lands in a field not too far from Lake Victoria. And they throw us and our four duffel bags out on the grass, and there we were. It's totally unelectrified, we didn't really have any reason to need to transport anywhere. We lived right next to the hospital. My wife is a nurse, and she was teaching other young African women to be nurses. I was working in the hospital; I was the only doctor in about a 450 bed hospital. The thing that was so compelling, I would say is that every day, when you're there, you get the chance to make the difference between life and death, or health and disability. So, you know, you get to make a difference and when you’re not there, there's nobody there to do it. So I am not working in St. Louis, but the children in St. Louis have plenty of other resources. So that's really what hooked us on that, that opportunity for service.
Do you mind sharing a little bit about the inception of Project Peanut Butter?
Dr. Manary: I have some principles that usually guide the choices I make. One of them is that if you're going to make a difference, you need to go after a big problem. Don't try to cut the problem down in size to match your skill set, but rather increase your skill set to go all the way around the problem. When I arrive in a in a new situation, I usually am asking, what's the biggest problem here, and that can be a health problem, or it can be something else. So when we worked in Tanzania a couple of years, and we were doing some short-term stuff and other places in Africa. Then, in 1994 we moved to Malawi, and there the biggest problem was that kids were sick because they were didn't get enough to eat. So I went after that as my problem. And I asked, how are these children treated in other situations? When I walked into the job in Malawi, children were put in the hospital when they were malnourished. About a third die, about 25% recovered, and the others just remained malnourished. We cleaned up everything in a literal way, but also in the practices, standardizing them, getting good micronutrients. What we found is that the death rate can go way down, but the recovery rate was running into a ceiling of about 45%. And we couldn't get through that. We did a lot of things from 1994 to 2000 or so. I was very interested in treat treating children at home at that point. There was something not working about being in the hospital. I lived in a village in 1999 for 10 weeks. It was a cooking project. and I was working with some women. Every day I was cooking with them, I was hauling water, finding firewood every day. I quickly noticed that these women don't have a spare moment. If you tell them that their child is vulnerable and needs to eat seven times a day, that's kind of like telling you, “Hey, you really need to get over this building and jump up 10 stories”. It's not possible for those women. So at the time, I said if we do home based therapy, it's going to have to be something full of fat and protein, no firewood necessary, something that bacteria can't grow in, something that doesn't spoil in tropical conditions. I'm an American, so that's peanut butter. So fortuitously, I would say, when I got out of the village, I had gotten an email from a colleague in France, not somebody I knew. It was an era when you didn't get many emails. Now you can get emails from everybody every day. But he was thinking about home based therapy, and we had a discussion for a year or so. And we came up with a peanut butter based formula. The beauty of the peanut butter was chosen because it could be given at home, and it was shelf stable. We started abruptly in Malawi through a clinical trial, treating everybody at home in early 2001. It was so powerful. So powerful because the kids weren't dying, they were coming back. We were seeing recovery rates of 85% and 90%. We never saw that before. That was a very powerful experience. It was sort of like if you're climbing a mountain, and you've got a 40 pound pack, you know, it's tough to manage, it's heavy. And then somebody comes and takes that pack, the rest of the trip goes easy, right? You're no longer feeling a burden even if the uphill is pretty steep. It just really worked in a powerful way. There was something about being at home and something about the energy density of the food.
At the time, was everybody on board with this new idea? Or did you ever receive any backlash from other doctors or scientists in this field?
“People were saying, ‘Reckless, careless, dangerous, killing children, why would you take people out of the hospital who were so sick’ But the personal experience was so powerful, I had no doubt about it. It wasn’t an idea that I had about treating children at home, it was a reality.”
Dr. Manary: Yes, yes. The first couple years we did. People were saying, “Reckless, careless, dangerous, killing children, why would you take people out of the hospital, who were so sick”. But the personal experience was so powerful, I had no doubt about it. It wasn't an idea that I had about treating children at home, it was a reality. When you treat them at home, they do a lot better. So I stuck with that. We did a few different projects, in Malawi. In the in the third year, it was a famine year, so the international agencies are gearing up, they can see the famine coming six months ahead. They were putting their best small hospital units and nurses and foods on the ground, and I said, let's go head to head, you know, mothers feeding their kids peanut butter food versus the best that the relief world can offer. We did a clinical study that showed that the best that the international relief effort could offer was 47% recovery, and mothers feeding their own children peanut butter food were getting 83% recovery. It had held up, it was robust. The thing about severe malnutrition is that a kid with severe malnutrition without treatment, half of them will die in three months. These are not just poor kids or kids who don't have shoes. This is sick because you don't have enough to eat. That was so convincing to me that we're going to stick with it. And that colleague Andre that I told you about in 2001, he and I were talking in 2004, and we said, “What are we going to do to make this available to kids that we never can treat?” We have to change that policy. And Andre, God bless him, got a job at WHO and changed that policy. And I said, we're going to need to make a lot more of this food because we were making it in a small clinic room, in a bakery sized mixer, which is maybe five times as big as a kitchen top mixer, but not really large or anything. So I said, we need to have a way to make a lot of this food and that's why we started Project Peanut Butter.
“We did a clinical study that showed that the best the international relief effort could offer was 47% recovery, and mothers feeding their own children peanut butter food were getting 83% recovery. It had held up, it was robust. ”
Do you make all the food locally in Malawi, or do you make it in America and ship it over? How does the production work?
Dr. Manary: It’s all made locally. We have four factories in Africa, in Ghana, Ivory Coast, Sierra Leone, and Malawi. Those places make food for those countries.
With your partner who worked at World Health Organization, was it hard for him to get your ready to use therapy therapeutic food (RUTF) as an official statement? Was that a long process or was it pretty obvious that this is the right solution?
Dr. Manary: He got it done in three years. WHO is a legislative organization, so it's a process of working with your fellow legislators, if you will, and getting them on board. And he was fairly singular in his focus. So he got it done.
I was wondering why peanut allergies in developing countries are very rare.
Dr. Manary: Well, when a baby is first born, the reaction of an allergy is the same kind of reaction as toward a germ, except it's not a germ. So when you're first born, you don't know what's food and what's germs, right? Stuff comes into your gut, is this a food is this a germ? So the kind of triage system that we learned during development is that if I see a lot of it, and if I see it in large amounts, we're going to call that a food. If I don't hardly ever see it, or in just trace amounts, let's call that a germ and make an allergic reaction against it. So food allergy is primarily a process of people who have not as young children had something to eat, and then they have, and it's kind of an unusual food, and then they have later in life, could be four years old, you know, nothing so later. So in Africa, food allergies are just unheard of because what do mothers feed their babies? The same food that they're eating. And the foods being used in a society are not changing all the time. So mom grows up eating peanuts. And she feeds her baby that. So there's no food allergy to speak on. It's a modern issue, if you go back to 1970 in the US, you wouldn't see hardly any food allergies either. But with the growth of processed foods, and doctors/health professionals saying, “Oh, don't introduce too many new foods with your baby, at one time, take it easy, go slow,” that really helped to create this food allergy.
Has there been someone in your journey with PPB that's served as a mentor/role model/someone that's kind of helped you along the way?
Dr. Manary: I would say that there have been people that have been very supportive. When I think about somebody that I did meet in Malawi, Robin Broadhead, he was the head of the pediatrics department when I was there. Robin is just so selfless and so singularly focused, and in that he was definitely a strong inspiration. You know, he's amazing.
Lauren Stenger: The work you do is incredible. It’s very cool that you've devoted your whole career to making such a huge change in people's lives. It's just incredible. So you're definitely a definitely role model for a lot of people. It's very cool, what you're doing.
Dr. Manary: Thank you. I can’t tell you why that is. I mean, I grew up in a very average kind of family. My dad worked in a chemical factory, my mother was the receptionist at the hospital, you know. Tere wasn't lots of travel in my life or anything or I didn't really have any teacher mentors at any level, at the university level or the high school level. It was just something within really. I can kind of proceed without much, I don't feel much peer pressure about things.
Do you mind talking a little bit about your new women's mental health program with PPB?
Dr. Manary: The most important time for anybody in their life in terms of their development is when they're in the womb. That’s when the whole body's being put together. Having an inadequate diet at that time, it's going to scar and can carry out through the rest of the lives. When we started with working with kids, we found that basically, if we started using a much better food, we got a much better result. But with the pregnant women when we started, we did some trials with much better foods, and we didn't get any better results in terms of the babies at all. They were still just the same size and so forth. In the second trial, we said, we've got to do two things: we've got to improve the diet and make the food really good. But also, we've got to cut down on the burden of infection. So we're going to give them antobiotics and we're going to use some malaria chemoprophylaxis. Ot was pretty dramatic to the results that we got. That was more recent. So the RUTF stuff that I was talking about, we started doing in 2001, that was our first trial. With the pregnant women, that started in 2017. When we did that second trial in Sierra Leone, what we found was that babies were longer, babies were heavier, and the death rate, neonatal mortality was cut in over half. It was again, very dramatic, the kind of result you can't walk away from. It wasn't like there's some little differences, and we've got a statistician here. It was dramatic. So we have gone on and started a third project with adding fish oil to the food, which we think is going to prevent premature labor. Of course, it'd be a terrible thing in a place without functional hospitals, a very small baby at birth will just pass away. Or even a least a little bit small baby at birth.
When you have been tweaking the formulas, do you ever feel nervousness? That's a lot of pressure to have on you, if one small tweak could end up harming someone. Did you ever feel any negative emotions?
Dr. Manary: I’m always trying to build on the platform of what's best and add to it. The things we're working with are not high risk; it's food. So that way, I don't worry a lot about the interventions. I'm also an empiricist, which means I'm going to try things and if they work, I want to try more of them. If they don't work, I'm going to back off from them. I'm more like, “Poke it, doesn't move. Okay, let's not poke it over there”.
Where would you like to see PPB in 5 to 10 years?
“If you walk along the edge of something, where it so you could fall off and enough people walk along there, somebody’s going to fall. Now, if you’re walking back away from the edge, and they fall, nothing happens; they skin their knee and they get up and move on. But if they’re in a dangerous place to start with, they fall off, then something can really happen with severe malnutrition. ”
Dr. Manary: I'm hoping that by 2050, we see this problem dramatically reduced, so that less and less and less people are becoming malnourished. And that's going to happen through agriculture. That's going to happen through using new and better sources of protein, like micro proteins or spirulina. In the meantime, we need to rescue kids and women that get into trouble. I want to get into a little bit more prevention. One of the things that made homebase therapy really work is because people would come seeking help earlier. I mean, if you think about having to go into the hospital in Malawi with your kid, well, that's not the only kid you have you got some other people at home that you take care of. So you're gonna have to leave those people alone. And woman of the society are farmers. They're growing the food for the next season, so if you have to stay in the hospital with that kid, that's a choice not to be a farmer in a sense. So all of that meant that women were seeking help pretty late with their kids after the malnutrition was more severe. Home based therapy opened an opportunity to reach those kids sooner and earlier. So I would like to see more along the lines of prevention, PPB developing mixtures of local foods, that's kind of where we want to go. Also, I spend not an insignificant amount of time advocating with UN bodies, and in the food aid community.
What can someone like me do to help?
Dr. Manary: I would say that, that you can do a few things, you know, depending on your orientation. On one hand, you can keep an advocacy position that is in favor of alleviating poverty, or coming to rescue folks in need. One thing I think that that is poorly understood is that people think if there's somebody starving in the house, the whole caring structure in that family must have disintegrated. Or that this has a lot to do with wars and Gaza and tremendous violent eruptions. But over 80% of the severe malnutrition in the world isn't about that. And it isn't in famines, in people stuck somewhere because it never rained. It's just average people that got unlucky. The analogy, the way I think about that is if you walk along the edge of something, where it so you could fall off, and enough people walk along there, somebody's going to fall. Now, if you're walking back away from the edge, and they fall, nothing happen; they skin their knee and they get up and move on. But if they're in a dangerous place to start with, they fall off, then something can really happen with severe malnutrition. The kinds of things I'm talking about that happen are maybe the kid gets two or three infections in a row, maybe somebody loses their job at home, maybe the mother’s sister has AIDS- really common things, not extraordinary things like rebels come into your village and burn all your crops, or something like that. It's really about some bad luck. So, seeing these people as real people that just have had some bad luck, and how to reach out to them is an important thing. Also, PPB has volunteers. People go and work on our teams in Africa. And most of the demographic of those people are probably like you, they're not usually 50-year-olds. People can do fundraisers or that kind of stuff too. Also from a perspective that, you have the power to make the world better. And that isn't going to happen by developing the Windows operating system or something that just reaches out into all corners and changes lots of things; that's not the way it happens. It happens little by little, by that iceberg chipping off a little by little and you yourself can be an instrument that saves several people's lives. It's not inevitable. I think we've lost a little bit of that notion that we are empowered, the we have the power to do that. That's why I like talking to people like you. That's definitely in our volunteer program. Our goal isn't to reach the most people and to have lots of lectures and name recognition. Our goal is to empower the people that do come to work with us.
Lauren Stenger: Thank you so much for taking the time to connect with me, I definetly learned a lot.
Dr. Manary: You’re so welcome. Be strong.
