‌11

‌How magic bullets travel: An account of ready-to-use therapeutic food in India

‌Aamod Utpal

Postcolonial studies of technoscience generally focus on technologies that circulate, change directions, and reverse their flows (Anderson 2002). They articulate a critique of the idea of universal and immutable technologies that would exist similarly in both the Global North and the Global South. However, certain technologies are emphasised as ends in themselves, circulating mostly one way – so much so that they seem to keep contesting the circular imagination of technical objects. A demonstrable example of such a technology is the lifestraw, a portable straw with filtering capabilities that can be used in any water source (rivers, ponds) to filter clean water, which was conceptualised and designed by a European company as a humanitarian good destined to end up in crisis situations in Africa (Redfield 2016). Humanitarian technologies belong to an original category of transnational commodities travelling through circuits of unequal exchange. They circulate in spaces dominated by moral economies and ethical considerations surrounding the wellbeing of ‘distant others’ (Redfield 2012) – the ‘other’ being the recipient of humanitarian aid in the Global South (Fassin 2011; Redfield 2012). Such technologies are designed to be used at a point of reception, and care, that is deeply merged in the identity of sites defined as underdeveloped, poor, in crisis – in other words, non-North. In this sense, humanitarian exchanges are unequal and unilateral by design, even if bottom-of-the-pyramid approaches geared towards finding market-based solutions do exist.

In spite of this deeply anchored identification of points of care, humanitarian logic mostly expects humanitarian technologies to be context agnostic, and their use value to be equivalent to their materiality (Scott-Smith 2013, 2016). As Collier et al. (2017) illustrate, such humanitarian life technologies are designed as small-scale and minimalist palliatives, as is the case of the lifestraw. Hence, these ‘little development devices’, as Collier and colleagues (2017) call them, can also be thought of as demonstrating a rather short-lived sociotechnical imaginary: humanitarian technologies do not promise food or health security for vulnerable populations, merely the survivability of children and vulnerable populations till the end of the current crisis. The stakeholders at the receiving end of such transcontinental humanitarian efforts are often disenfranchised, ‘geographically marginal’ (Collier et al. 2017), displaced people and weak or barely existent local social security systems. Premised on such a skewed power dynamic, the dichotomy between the innovative (and charitable – as humanitarian efforts are often charity funded) Northern actors and the Southern ‘beneficiaries’, between order/chaos and formal/informal, is inescapable.

Contrary to this view of technologies as context agnostic and overdetermined by use value, anthropologists of technical objects dispute the notion that the value of technical objects is inherent and fixed, but claim that along their social life, their value is dynamic and multiple (Appadurai 1988). As the object passes through its biography, it leaves and enters different phases or regimes of valuation, where different values are ascribed to it in relation to its sociocultural milieu (Appadurai 1988; van der Geest 1996). This concept has most notably been applied to pharmaceuticals to account for the fluidity of meanings attached to them in different situations, which has ultimately helped anthropologists understand why and how they work (or don’t) in certain situations (Ecks and Basu 2009; Hardon and Sanabria 2017; Whyte et al. 2002). The adaptability of such technologies has even been defined as a normative feature, as in the famous case study of the Zimbabwean bush pump (de Laet and Mol 2000), that shifted attention to the multiple ways in which global technologies create local, fluid contact zones (Anderson 2002), where actors of the Global South interact with the technologies meaningfully and creatively (de Laet and Mol 2000; Redfield 2016). But how definitive is this opposition between unchangeable technologies and fluid ones? And how can stability be performed through the multiplicity of appropriations? One way of answering is to look at the actual circulations and discussions surrounding technological movability.

In order to carry this discussion forward, in this chapter I critically examine the case of RUTF’s reception in India. Ready-to-use therapeutic food (RUTF henceforth) is a peanut- and milk-based paste used in humanitarian emergencies to save children suffering from severe acute malnutrition (SAM) from early mortality. In order to answer questions about its success as a humanitarian commodity, its material characteristics have often been analysed (Scott-Smith 2018). On the contrary, a critical approach to RUTF consists in looking at it in relation to the multiplicity of values attached to it, not restricted to its medicalised nutritional ambition. This will lead us to ask: What are the ways in which actors in the Global South question, resist, and appropriate the underlying premise of a transcontinental humanitarian ‘exchange’ in the context of RUTF and SAM?

In the following pages, I first try to establish why RUTF can be seen as emblematic of technoscientific expansion into issues of acute food insecurity, and consequently, what it means for the kinds of production models and exchanges it engenders and the specific markets it shapes. I also present the general scope within which humanitarian solutions for SAM are expected to operate and the rationale underlying these solutions. The chapter then revisits these encounters between the object and the humanitarian subject from the vantage point of actors in India. I organise the remainder of the chapter into three sections that describe the way in which different Indian stakeholders – civil society, the private sector, and the regulatory authorities – have engaged with the idea of RUTF. Ultimately, the chapter illuminates the fundamentally unequal premise of a contemporary humanitarian exchange, one that assumes passive Southern actors as recipients of technologically constituted globalised solutions from the North in the context of weak local institutions. I show that when confronted with RUTF, which is treated as a single-value technical product, the stakeholders in India question this aforementioned premise by employing their own unique valuing strategies to frame and value RUTF in a way that goes beyond its utilitarian imagination.

To trace the journey of RUTF in India, I draw on secondary data from available secondary literature, newspaper reports, publicly available government policy papers, publicly available company websites, grey literature, and regulatory texts; and I support this with primary data based on five in-depth interviews with stakeholders involved in discourse on SAM management, especially in India.1

RUTF as a magic bullet in changing humanitarianism

Severe acute malnutrition is identified as one of the leading causes of early childhood mortality worldwide2. Children who are diagnosed as suffering from SAM are reported to be as much as nine times more vulnerable to early mortality (Black et al. 2008). SAM is most common in emergency contexts, such as civilian emergencies (war and refugee crises), climate disasters, and acute crop failures. This condition primarily affects children (below six years of age) and can materialise in two ways: wasting (of body muscles – formerly called marasmus); and generalised oedema/swelling (previously referred to as kwashiorkor). Both can also be observed at the same time (Grover and Ee 2009). Currently, the scientific consensus is that SAM is multifactorial by nature; it is caused by a synergism between acute lack of food and childhood infections (Black et al. 2008).

Before the advent of RUTF and the Community-Based Management of Acute Malnutrition (CMAM) program, the treatment of SAM usually was clinic-based (Scott-Smith 2013). Children with SAM usually presented with heavy weight loss, loss of appetite, or oedema (swelling) (Grover and Ee 2009). These children were admitted to an in-patient facility either at an existing health establishment or, in case of infrastructure breakdown, at a makeshift treatment centre. The treatment protocol involved medical attention for complicated SAM cases (complicated cases here correspond to children with loss of appetite, a baggy-pants appearance, or bipedal oedema), along with a regimen of therapeutic milk (F-100 and F-75) for weight gain, after which the children were discharged into the community and put on home-based diets or certain protein supplements like corn-soy blend (Khanam et al. 1994).

The early 2000s saw famines in DRC, Sudan, Ethiopia, and Niger: this is where RUTF was introduced extensively by aid agencies for SAM management. As the story goes, it was first developed in a domestic blender by a paediatrician working for the IRD (Institut de Recherche pour le Développement, France), who improved upon the previous milk-based formula by replacing part of the skimmed milk with peanut butter paste3. A flurry of research activity around this promising product led to excellent results in field trials in Malawi, Chad, and Ethiopia (Collins and Sadler 2002; Diop et al. 2003; Manary et al. 2004). The product is composed of milk solids, peanut paste, and carbohydrates fortified with a mineral premix. It is an energy-dense high protein paste (per 100 gm paste, 520–550 kilocalories and 13–15 gm of protein). Packaged as a homogenous paste in 92-gm sachets, this product, combined with a simplified regimen of early identification and classification of children affected with SAM, showed significant improvement over other alternatives in solving the issues faced previously by these organisations when trying to organise efforts to cure or minimise damage due to SAM on scale (Briend and Collins 2010; Scott-Smith 2018). The key properties of RUTF as compared to other products were (a) lower water activity than older formulae used to treat SAM, such as F-100 therapeutic milk, leading to longer storage times and less chance of spoilage and subsequent infection (Manary et al. 2004); (b) higher energy density than older alternatives like F-100 and corn-soy blends, thus resulting in higher and quicker average weight gain in SAM children and improved recovery rates; (c) it needs no cooking but can be distributed to resource-constrained families directly; and (d) it can be used in the community, away from the costly setups of inpatient/facility-based treatment, and it can be rapidly deployed in emergency situations (Collins and Sadler 2002). The apparent success of RUTF in community feeding programmes (CMAM)4 helped launch humanitarian efforts at a bigger scale than before. More generally, it gradually became emblematic of deeper mutations in humanitarianism during this time. Let us now turn to these changes.

In the 1970s and 1980s, large-scale agrarian projects led by agronomists and national planners focused on improving farming practices in the South to improve food security (Jézéquel 2015; Ruxin 1996). Usually, these projects would be integrated with national planning goals and have cross-cutting horizontal emphasis. They were later replaced by projects more modest but technologically constituted in their goals. Helmed by different categories of experts such as nutritionists and doctors, these projects would favour vertical programs with tangible, measurable impact (Jézéquel 2015; Redfield 2017; Ruxin 1996; Scott-Smith 2020). The introduction of RUTF brought about a further narrowing and technologisation of malnutrition management programmes, while massively increasing the scale of operations. This tendency to promote unique products for modest survival goals has also been articulated by invoking another term – ‘magic bullets’.

‘Magic bullet’ in immunology refers to ‘drugs that go straight to their intended cell-structured targets’ (Strebhartdt and Ullrich 2008). In development projects, magic bullets are technical interventions aimed at quick, minimalist impacts, making them appealing for universal application in varied humanitarian contexts (Mason and Margetts 2017; Redfield 2017). The magic bullet analogy is further bolstered by the fact that RUTF is also understood as a vessel or ‘tool for delivering improved nutrition’, owing to its lipid paste being able to preserve micronutrient premixes well.

With the concept of paste, it was basically a very good tool to deliver improved nutrition. You could improve diet by putting essential elements that were missing in the diet in a novel way. (Interview with NGO representative)

RUTF exemplifies this concept by offering a standardised pharmaceutical solution to malnutrition, reflecting a shift towards medicalised and industrial food practices (Shukla and Marathe 2017).

The idea of RUTF as a magic bullet has been used to emphasise its insistence on this specificity of objective (to save the child suffering from SAM from mortality) and its technologisation/medicalisation of food insecurity. The concept of a magic bullet has also been mobilised for its symbolic purpose. If a metaphorical bullet is discharged, the assumption is that it must end up in its metaphorical target. By definition, its value lies in its efficacy and the minimalist, straight path it traverses. In the next section, we therefore examine this path to see how this ‘magic bullet by destination’ gets valued by stakeholders in India – and how its trajectory might be diverted.

A panoply of stakeholders – India, RUTF, and valuation strategies

In September 2017, a newspaper reported that India’s Ministry of Women and Child Development had written to the respective states cautioning against RUTF on the grounds that that there was a lack of evidence regarding the usage of RUTF and that its usage had the potential to impact ‘nutritional best practices’ and continued breastfeeding among children older than 6 months5. In November of the same year, another newspaper reported a change in the policy stipulating that the decision to procure RUTF should be left with the discretion of individual states in India6. Furthermore, newspapers reported that, responding to a petition filed in the high court of Maharashtra (a state in western India), the Maharashtra state government informed that it was stopping the procurement process of RUTF7 ‌8. In 2019, that state finally procured RUTF (now named EDNF – energy dense nutrition food) for large-scale deployment in a few districts9. This was again opposed by some civil society organizations.

As technological objects travel through their circuits, they are valued differently at different points and spaces by actors for their own respective purposes. Owing to India’s dual role as a site for both production and consumption, it assimilates within its confines a heterogeneity of valuation strategies and actors that are entangled in various ways, often leading to conflicting strategies. This entanglement allows us to present a contrast to how magic bullets are otherwise assumed to work in a humanitarian exchange, as a context agnostic technical projectile targeting a specific, narrowly defined problem. The following section expands on this tension that India’s position as a supplier and consumer of humanitarian goods and services produces to understand the stakeholders involved and their different valuation strategies.

United Nations Children’s Fund (UNICEF) and CODEX10 guidelines clearly specify the proportions of protein, energy, and micronutrients in RUTF, per kilogram of body weight and per day. RUTF is industrially prepared according to Good Manufacturing Practices (GMP) standards, and nearly 80% of it is procured by UNICEF from a list of accredited manufacturers based in Asia, Africa, Europe, and North America. RUTF was originally only manufactured under patent protection (brand name Plumpy’Nut) in France by the French company Nutriset. The company, under its PlumpyField network arrangement, had also tried to foster local manufacturing in countries where it was deployed. Since then, the number of manufacturers has expanded. Table 2 shows the manufacturers based on their locations; 5 of 21 of these accredited RUTF manufacturers were based in India until 202111, which is the highest for any individual country in this list.

‌

Continent	Total no. of producers	Of total, no. of independent manufacturers	No. of PlumpyField network members
Americas	3	1	2
Europe	1	0	1
Africa	11	5	6
Asia	6	5	1

Table 2 Number of UNICEF suppliers of RUTF and their locations, 2023 (UNICEF RUTF market update 2023)

In terms of gross value, the largest UNICEF order of all types of goods and services, in 2020, was sourced from India12. India was also the third largest procurement source in 2021 – it was the country with the highest number of vendors invited by UNICEF to bid for its procurement tenders13. Within the humanitarian supply chain organised by UNICEF, India clearly features prominently as an important site of production. In 2021, India was the sixth largest destination for all commodities procured from UNICEF (in gross value in US$)14. This positions India as an important site for consumption as well.

India’s high malnutrition numbers attracted attention from international humanitarian organisations, and it was in the aftermath of a devastating flood in the eastern state of Bihar in 2007 that RUTF was first introduced in the country by Médecins Sans Frontières (MSF). However, a sequence of events later, the Indian government had stopped another organisation, UNICEF, from conducting a similar intervention elsewhere in India, which included sending back shipments of imported RUTF. What caused such contrasting responses?

In‌ MSF’s case study of humanitarian negotiations, it outlines the conditions on the ground in 2008–2009, before the RUTF was about to be introduced in India. The report shows that a diverse range of stakeholders, including civil society groups like the Right to Food Campaign, central and state governments, and the Indian legal system (the High Court and the Supreme Court), were debating how best to cure children with malnutrition. MSF was committed to treating children suffering from SAM by first making the problem ‘visible’ (interview with NGO representative) using simplified SAM detection tools like the mid-upper arm circumference (MUAC) tape, followed by a quick intervention: ‘the priority is to treat the children and if their treatment is not to be delayed we have to use whatever therapeutic products are available’ (Doyon 2011). The priority was to act ‘immediately and locally’, owing to the precarity of children suffering from SAM, and to avoid what was understood by certain sections of MSF as ‘procedural straitjackets’ in the host country. RUTF was eventually introduced in an intervention in Bihar by MSF, responding to a devastating flood there. The difference in opinion with the Right to Food Campaign members was on the applicability of RUTF and what it represented. For MSF, RUTF was necessary in SAM mitigation programmes because it simplified distribution and use, mainly because under its community-based intervention, the ‘medical responsibility was to be delegated to the families of malnourished children’ (Doyon 2011). This individualised medical regime that prioritised quick interventions and minimalist procedures over bureaucratic delays was opposed by the civil society members, who saw it as representative of a commercial interest in a ‘common good’ (Doyon 2011).

Another manifestation of these contradictory valuation strategies happened when UNICEF introduced this intervention as an extension of its earlier institutional programme of treating SAM in Madhya Pradesh in 2008. This intervention was later struck down by the central Indian government, which was acting according to a previous Supreme Court ruling preventing procurement of commercial food in its feeding programmes. The central government issued a ban on subsequent RUTF shipments and asked the UN agency to take back the remaining stocks of RUTF. The same minimalist, quick intervention thus came to be seen as a contravention of the Indian state’s protocols and procedures. As per a Reuter’s news report, quoting a senior Indian official, ‘I can understand their sympathies, but sometimes emotions cannot sweep away the procedure and protocol involved’ (Reuters 2009). Ultimately, the result of this saga led to a more nuanced approach by the humanitarian organisations, who opted instead to take on board considerations from the Indian stakeholders and agreed to a consensus-building measure and to ‘Indianise’ RUTF (Doyon 2011).

Tom Scott-Smith (2013) observes that with the fetishisation of humanitarian commodities comes a tendency to obfuscate the multiple forms of valuation of these commodities to focus on just one: biological valuation. The product should save lives, at a scale that is at once minimalistic and universal. Going by the account of MSF’s own staff, however, the panoply of stakeholders who engaged in debates on how to articulate RUTF revealed a ‘repertoire of values’ being mobilised (Heuts and Mol 2013). While MSF staff were fixated on the use value of the product (‘its ability to save lives of children’), civilian stakeholders were concerned that the introduction of RUTF would pave the way for a commodification of nutrition solutions, opening these up to the market. To some of them, RUTF also represented a move towards the individualisation of nutrition solutions. But there were again other ways of assessing the product: the first usages of RUTF by an Indian state government signalled another value attached to RUTF, namely its ability to quickly deliver visible, tangible results. In contrast, the central government viewed this introduction of RUTF as a contravention of its sovereignty, a symbol of the transgovernmental overreach of humanitarian organisations. These multiple interventions give a first glimpse of the diversity of values attached to RUTF by Indian stakeholders. We can now detail some of these views, in relation to the dual status of India as a manufacturing and consumption site for these products.

R‌UTF as an idea and a product – evaluations by civilian stakeholders

While the previous section foregrounds the entanglement of the various valuation practices upheld by stakeholders, the next three sections go into the detail of these valuation practices, dealing successively with civilian stakeholders, private industry, and regulatory authorities. Let us first look at how civilian stakeholders have engaged with RUTF.

Civil society activists and other allied groups

This category comprises activist groups such as the Right to Food Campaign, which was an ‘informal network of individuals and organisations committed to the realisation of the right to food in India’. For the stakeholders in this category, RUTF was articulated as an idea that introduced technologisation and private interest into food security issues. The first argument is about the cause of acute malnutrition in India. SAM is recognised as an acute emergency due to its high case fatality rates, prompting rapid intervention. However, chronic undernutrition, such as stunting and low weight for the sufferer’s age, require holistic interventions. Dasgupta et al. (2014) highlight that India faces chronic undernutrition (termed severe chronic malnutrition), with seasonal SAM episodes exacerbating the issue. The lower anthropometric values in India are linked to the Multi-Dimensional Poverty Index, indicating broader causes beyond civilian emergencies alone. This is reflected in India’s lower SAM case fatality rates (1.2%) compared to WHO’s global estimates (10–20%) in a study of over 2,600 children aged 6–18 months (Prost et al. 2019). Moreover, a large-scale trial using RUTFs showed lower weight gain rates in Indian children with SAM than in Africa, despite better community care and more frequent therapy intervals (Bhandari et al. 2016). Prasad, Holla, and Gupta (2009), members of the Working Group on Children Under Six15, a group comprising paediatricians, nutritionists, and economists involved in nutrition and food security advocacy in India, noted that (at the time) the efficacy of RUTF had been demonstrated only in contexts of disaster and famine in a few African countries (Prasad et al. 2009; Working Group on Children under Six 2007).

RUTF is also articulated as a centralising force that concentrates resources, including centralisation of production models and centralisation of technological integration. Coming to the first category, the RUTF has been interrogated for the unique position it occupies as a food product that behaves like a pharmaceutical. This has variously been described as the medicalisation16 and the pharmaceuticalisation17 of food (Caremel and Issaley 2016). Critics of the prevalent model of production of RUTF in India point to the fact that centralised production models strip affected communities of the power to decide. One of my interviewees, a public health practitioner, pointed out that this does not constitute an ‘anti-technology’ approach. The real issue, in their opinion, was the level of technological integration, which does not take place at community level. They observe,

if you need calorie-dense high protein food then that is something we can do with community and community can do on its own when we need to add something we have always done it by giving supplements, so if you need a micronutrient particular mix to be added, let that be added at the level of house or community and so on.

The argument put forward here is that intertwining food with ‘technological’ elements (in mineral mixes, for example) creates a need for a certain type of production model that takes power away from communities. This is not to be understood as an ‘anti-private sector’ stance, but the idea is to achieve a better distribution of value generated from such an industry, which can be done through cooperatives.

Academic and programmatic evaluators

Beyond the analysis of RUTF as a nutritional and industrial product, what about the claim made on its behalf that it constitutes a magic bullet? What evidence is available about its ‘performance’ on the ground? Its efficacy, acceptability, and efficiency have been observed by practitioners, academics, and paediatric doctors in India, who employ knowledge-making procedures similar to the ones employed to prove claims about RUTF in the first place, such as field trials and randomised trials. For example, one of the attractive qualities of industrially produced RUTF is its sterility and resistance to contamination. However, in field trials comparing different RUTF formulations in India, diarrhoea is reported to have occurred after people drank unclean water in intervention areas (Garg et al. 2018). This is echoed by an interviewee, who is a practitioner of public health:

Somebody will put (RUTF) in spoon and take it out some and then keep it and then take another spoon, so all the sterility goes for … it goes for a big six [a colloquial cricket expression meaning some idea going to waste/out of contention] and then you have to give a lot of water on top of RUTF because it’s so dense and sweet (and) the water is not sterile anyway. Are you dealing with the water quality at household level?

Debates on the acceptability and appropriateness of RUTF are not new, as one single formulation is used across diverse cultures and geographies. In the proverbial ‘humanitarian reason’, taste is an afterthought to the more pressing need to save lives. A quotation from Micah Trapp’s (2016) paper perfectly captures the idea: ‘In the biopolitical domain of the refugee camp, food is a site of gustatory discipline’.

Against this reason, Indian stakeholders have generated evidence through field trials to sometimes argue for more locally tailored RUTF that aligns with people’s taste preferences. Trials in India have compared locally produced RUTF (LRUTF) with commercially produced RUTF (CRUTF) and home-prepared foods. The results are mixed. CRUTF shows higher mean weight gain in children with SAM in some studies18 (Dube et al. 2009). One large trial found higher recovery rates with LRUTF (Bhandari et al. 2016), though both RUTF types were less accepted than home-prepared foods (Dube et al. 2009) or LRUTF over CRUTF in some trials (Selvaraj et al. 2022). The costs of LRUTF and CRUTF are similar (Garg et al. 2018). Typically, RUTF is distributed with a clinical focus, ensuring strict adherence to the feeding regimen. Community-based programmes shift the responsibility of medical care to families, leading to the pharmaceuticalisation of food. Indian researchers emphasise RUTF’s acceptability and taste by comparing it with LRUTF and energy-dense foods, thus repositioning RUTF as food, as one public health practitioner comments: ‌‘food is something that we engage within our own kitchen, household, and in our own communities. And there is certain value in retaining rather than medicalizing food’. To summarize, civilian stakeholders articulate RUTF as an idea, a production model, and a product. The activist groups foreground questions of production models and centralisation of value addition/creation in the prevalent mode of RUTF procurement today. If we understand magic bullets (RUTF here) as single value objects, then asking these questions helps situate RUTF inside a web of complex sociopolitical interrelations falling within the evolutions of humanitarianism today. RUTF is not just a freestanding product; it also stands for its entire supply chain. The other group of academics and knowledge creators examine its programmatic claims by generating evidence using controlled and field trials. Emphasising taste in food aid is often understood as a way for recipients of aid to resist the agnosticism of humanitarianism, where taste is an afterthought (Trapp 2016). Comparing the acceptability of standard RUTF with locally available high-density foods, they reignite questions about taste and divergent usages of RUTF.

Private sector, appropriation, and production politics

The previous section focuses on how civil society stakeholders articulated the valuation of RUTF, illuminating questions about the centralisation of value creation, production models and hygiene/taste. Carrying forward the logic of technical objects moving through different regimes of valuation, we now focus our attention to what Appadurai (1988) would call the commodity phase of RUTF. This section presents a snapshot of the nascent RUTF industry in India and the role that it plays in transcontinental trade circuits. The section then puts forward the tensions created by the drop in domestic demand for RUTF in India to enquire what other values are attached to RUTF, and consequently, how they are leveraged to sustain business.

Since the beginning of large scale RUTF procurement by UNICEF, local producers in the Global South, especially Africa, have faced price disadvantages compared to offshore RUTF manufacturers due to taxes on raw material imports, low factory utilisation rates, and high business costs (Segrè et al. 2017). The patent for RUTF was owned by Nutriset, the French company that first started manufacturing RUTF under the brand name Plumpy’Nut. Under its PlumpyField arrangement, the company aimed to improve local manufacturers’ access to funds, expertise, and materials to lower costs (Sanderson 2016). Despite this, by 2022, only 64% of the total RUTF volume was procured from local manufacturers, even though nearly 90% were located in programme countries19.

UNICEF started first procuring RUTF in India from a PlumpyField network member in 2011, followed by an Indian subsidiary of a Norwegian company, Compact, in 2013. Since then, four more home-grown manufacturers have sprung up. From 2017 onwards, UNICEF reports show that RUTF procured from Asia (India accounts for five of the six suppliers from Asia) has a price advantage over other sources20 ‌21 In 2022, RUTF procured from Indian suppliers was cheaper on average (ranging from $38.18 to $42.86 per carton) than its African and European counterparts (ranging from to $41 to $54.75).22 Indian producers have also managed to reduce the prices of their RUTF to a lower level than their European and American counterparts. Furthermore, Indian producers appear to be better protected against price fluctuations. For example, between 2021 and 2022, in a period marred by protracted global crises and increased raw material and freight costs,23 compared to a major European producer (an increase of 13.77 euros per carton of RUTF corresponding to a 38.34% increase), Indian RUTF’s price increase remained between 4.89% to 16.12% for all manufacturers (author calculations, based on data available from UNICEF24. Of the five suppliers in India, four are independent manufacturers while one is under the PlumpyField franchise network. This is in contrast to Africa, which has six out of eleven manufacturers under the PlumpyField network and a lesser number of independent manufacturers. The network manufacturers produce the RUTF under the brand name Plumpy’Nut, whereas independent manufacturers are free to market their own unique brands of RUTF.

Despite this opportunity and a price advantage, the domestic demand for RUTF has dropped.25 In 2020, industry representatives of RUTF manufacturers came together to form an industry group called CMAM (Community Based Management of Acute Malnutrition), with the stated aim of ‘provid[ing] a platform for a national discourse on the eradication of malnutrition by catalysing the involvement of stakeholders and interested parties’ (Hindu Businessline 2020). The formation of groups such as the CMAM association of India can be seen as a strategy to create a discourse around RUTF. For example, CMAM has published press notes advocating the use of RUTF to treat children with SAM in the aftermath of the COVID-19 pandemic26 ‌27. An analysis of the press notes released by CMAM through various online media outlets reveals a focus on presenting the case for RUTF usage in India by citing its effectiveness in tackling SAM and extolling its alignment with the idea of domestic production (Atmanirbhar Bharat). While the powerful idea of RUTF appears to be appropriated to create a discourse on its usage, the focus on the idea of domestic production reveals one more way RUTF is valued as a critical, lifesaving product – hence the value in freeing it from issues faced by long transcontinental supply chains. Furthermore, some RUTF manufacturers demonstrate creativity in diversifying their product portfolio with other products in the consumable categories, by leveraging their manufacturing lines and certifications as assets.28 In the end, private players in India move beyond being mere sites for RUTF production. They demonstrate this by creating industry groups, some of them branching out into diversified categories of free market products and creating RUTFs with unique brand identities.

In India, on one hand, dominant modes of humanitarian aid delivery are problematised and questioned, while on the other hand, private entities operate on these very production logics. RUTF thus circulates through these apparently opposed regimes of valuation, where at one point it is valued as a mere commodity, sometimes laced with moral/ethical rhetoric, travelling through global commodity chains. At some other points in India, it is understood as emblematic of the technologisation of food aid and humanitarian overreach, sometimes even infringing on the public health apparatus’ purview to help children suffering from SAM. We will now focus on how these tensions are negotiated by the regulatory authorities in India.

Regulatory problems and boundary objects

RUTF has been variously articulated as a hybrid between food and medicine. The existence of such hybrids has often produced tensions for regulatory boundaries, which are set not just for administrative purposes, but also to regulate choice and risk (Frohlich 2021). These tensions are mostly resolved by boundary work, understood here as Gieryn (1983) has articulated: as a rhetorical device that uses creative language and philosophy to demarcate areas of influence where professional autonomy can be maintained, especially when such boundaries are not well defined. In this section, I look at the process of guideline setting for RUTF by the Codex Alimentarius29 Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU), especially in the light of India’s participation in these deliberations, to understand how regulatory bodies in India negotiate this tension and what valuation strategies are employed at this stage.

India’s domestic policy for handling uncomplicated SAM reflects a preference for locally prepared energy-dense foods. NITI Ayog, India’s apex public policy think tank, observes that special foods for children with SAM (without complications) are already being designed and provided in many Indian states based on local preferences. This recommendation aligns with the already existing Supplementary Nutrition Programme (SNP) and the Take-Home Ration (THR) provided by the Ministry of Women and Child Development’s flagship initiative, the ICDS (Integrated Child Development Services)30. At the same time, India hosts sites for the production of RUTF for export.

In 2016, at the annual meeting of the CCNFSDU, a proposal was made to draft guidelines for defining the scope, contents, and labelling of RUTF. This proposal was made with the explicit intention of providing a framework to guide the global supply of RUTF. Subsequent editions of the annual CCNFSDU reports reveal that subsequent negotiations have included issues like labelling, ingredients, and marketing (CCNFSDU 2016, 2017, 2019).

Against this backdrop, it is interesting to look at the RUTF guidelines newly adopted by the Codex. At the 45th session of the Codex Alimentarius Commission, held in November 2022, a host of key changes were made to the RUTF specifications, and a globally accepted standard was finalised31. A new categorisation of Food for Special Medical Purposes (FSMP) and the new globally accepted ingredients list present a clear case of boundary work. This new standard particularly addresses some of the criticisms levelled at RUTF in the past. For example32:

The new guidelines specify a protein quality score rather than limiting protein sources. This allows producers and researchers to propose other high quality protein sources that could be less expensive and still well-liked by babies and infants.

This change seems to have come in response to the criticism regarding the acceptability of RUTF’s formulation, which is milk- and peanut-based. At the same time, this change has the potential to encourage local production of RUTF, using locally acceptable protein sources. However, while this invalidates the earlier requirement of a specific type of protein (milk protein), it introduces a new measure of protein quality (PDCAAS) as the defining criterion for inclusion. This entails further technologisation of food ingredients that ultimately invites industrial production. As one NGO representative put it, ‘[The] more you put the norm, [the] more you professionalize’.

Similarly, while the reduced total sugar and fatty acid requirements seem to address earlier criticism of the high sugar content of RUTF (Bazzano et al. 2017), the technical guidelines regarding ingredients remain, further solidifying the necessity of an industrial production regime.

As per a FSSAI (Food Safety and Standards Authority of India) report available on its website, the Indian delegation at the CCNFSDU 2019 meeting intervened to add within the preamble of RUTF that it was only one ‘of the options for the dietary management of uncomplicated SAM (in 6 month-59 month age group)’ and advocated for deleting any text that may suggest its usage in other age groups. The report mentions that these suggestions were accepted. The final CODEX guideline reflects this:

Ready-to-use therapeutic food (RUTF) is a WHO recommended option for the dietary management of children aged from 6 to 59 months with SAM without medical complications. However, this does not preclude other dietary options including the use of locally-based foods. RUTF is not for general retail sale. (FAO.org)

We can argue that the regulatory environment agreed upon by all the Codex delegations (including India) seems to favour industrial production and a global trade regime, while India’s intervention mentioned above seems to create a space for potential alternatives to RUTF for treating SAM. The boundaries thus drawn, in my opinion, invite the conclusion that the regulatory body in India values RUTF in two different contexts. The participation in the global exercise seems to be indicative of the fact that RUTF is valued as an emergency commodity, especially one that can be traded, hence the need to formulate an internationally acceptable standard that does away with confusion and streamlines the global flows. Domestically, the limits of RUTF are defined to create a space for an indigenous way to tackle SAM (RUTF as one of the options, not marketed to any other age group). It is in this tightrope walk between industry interests and domestic public health priorities that the tensions mentioned in the beginning of the section appear to be resolved.

Discussion and conclusion

This chapter contributes to the volume by illuminating an arguably atypical example of technoscientific globalisation from below and market-making. It interrogates the alternative ways and strategies that actors in the Global South employ to reimagine and rearticulate their position as recipients of humanitarian aid. These include indigenous knowledge production, appropriation of production models to create economic value, and the use of formal institutions and regulatory or judicial measures to challenge the seemingly unilateral imposition of the RUTF humanitarian programme. The chapter also highlights the ways in which a heterogeneity of valuation practices are presented by a humanitarian palliative, demonstrating a colourful panoply of stakeholders that engage with a powerful idea to their own respective ends. From the dynamic interplay between the central and state governments to regulatory complexities, the vocal opposition of civil society stakeholders, and the burgeoning private sector’s capability to scale up RUTF production, the conventional categories of globalised humanitarianism have been questioned. These categories include the idea of an innovative North and a recipient South, and the notion that local institutions in the South are breaking down, necessitating humanitarian action. In the evolving discourse surrounding RUTF, there’s a discernible trend suggesting a shift from technology-centric and morally driven discussions to considerations of unjust production models and the importance of public healthcare.

The introduction of new treatment models like Community-Based Management of Acute Malnutrition (CMAM) and the incorporation of RUTF as a specialised therapeutic food within these initiatives have catalysed a profound transformation in the discourse on malnutrition. Introduction of easy-to-use methodologies to identify malnutrition made the issue of SAM ‘visible’ (Scott-Smith 2013), which ultimately incentivised tangible interventions and consequently has driven huge funding increases for RUTF-based interventions. RUTF and a clinical articulation of malnutrition remains at the epicentre of the discussions on malnutrition.

The chapter ultimately tries to trace the magic bullet’s trajectory, to see if it indeed followed a straight path. We see that in the case of humanitarian exchange with regard to RUTF and malnutrition, it is not quite so. The stakeholders in India deal with this ‘finality’ of a product ending up in the bodies of the disenfranchised malnourished in India with their own practices of valuation. It is in these examples that this chapter finds forms of resistance to the idea of a technological globalisation from above into matters of living.

Endnotes‌

References

Abraham, J., ‘Pharmaceuticalization of Society in Context: Theoretical, Empirical and Health Dimensions’, Sociology, 44.4 (2010): 603–22.

Anderson, W., ‘Introduction: Postcolonial Technoscience’, Social Studies of Science, 32.5–6 (2002): 643–58.

Appadurai, A., The Social Life of Things: Commodities in Cultural Perspective (Cambridge University Press, 1988).

Ashworth, A., ‘Efficacy and Effectiveness of Community-Based Treatment of Severe Malnutrition’, Food and Nutrition Bulletin, 27.3 Suppl (2006): S24–48.

Ashworth, A., S. Huttly, and S. Khanum, ‘Controlled Trial of Three Approaches to the Treatment of Severe Malnutrition’, The Lancet, 344.8939–40 (1994): 1728–32.

Bazzano, A. N., K. S. Potts, L. A. Bazzano, and J. B. Mason, ‘The Life Course Implications of Ready to Use Therapeutic Food for Children in Low-Income Countries’, International Journal of Environmental Research and Public Health, 14.4 (2017): 403.

Beesabathuni, K. N., and U. C. M. Natchu, ‘Production and Distribution of a Therapeutic Nutritional Product for Severe Acute Malnutrition in India: Opportunities and Challenges’, Indian Pediatrics, 47 (2010): 702–6.

Bhandari, N., and others, ‘Efficacy of Three Feeding Regimens for Home-Based Management of Children with Uncomplicated Severe Acute Malnutrition: A Randomised Trial in India’, BMJ Global Health, 1.4 (2016): e000144.

Biehl, J. G., ‘The Activist State: Global Pharmaceuticals, AIDS, and Citizenship in Brazil’, Social Text, 22.3 (2004): 105–32.

Black, R. E., and others, ‘Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences’, The Lancet, 371.9608 (2008): 243–60.

Briend, A., et al, ‘Ready-to-Use Therapeutic Food for Treatment of Marasmus’, The Lancet, 353.9166 (1999): 1767–68.

Briend, A., and Collins, S. ‘Therapeutic nutrition for children with severe acute malnutrition: summary of African experience.’ Indian Pediatrics 47 (2010): 655-659.

Burza, S., and others, ‘Community-Based Management of Severe Acute Malnutrition in India: New Evidence from Bihar’, The American Journal of Clinical Nutrition, 101.4 (2015): 847–59.

Caremel, J.-F., and N. Issaley, ‘Des Cultures Alimentaires “Sous Régime d’Aide”? Négociations Autour des Aliments Thérapeutiques Prêts à l’Emploi (ATPE) et de la Malnutrition Infantile (Sahel)’, Anthropology of Food, 11 (2016).

CCNFSDU, ‘Report of the 41st Session of the Codex Committee on Nutrition and Foods for Special Dietary Uses’ (2016) https://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FMeetings%252FCX-720-37%252FREP16_NFSDUe.pdf.

CCNFSDU, ‘Report of the 42nd Session of the Codex Committee on Nutrition and Foods for Special Dietary Uses’ (2017) https://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FMeetings%252FCX-720-38%252FReport%252FFINAL%252FREP17_NFSDUe.pdf.

CCNFSDU, ‘Report of the 44th Session of the Codex Committee on Nutrition and Foods for Special Dietary Uses’ (2019) https://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FMeetings%252FCX-720-40%252FREPORT%252FREP19_NFSDUe.pdf.

Collier SJ, Cross J, Redfield P, Street A. ‘Preface: Little development devices/Humanitarian goods’. Limn. (2017) Nov 1;9

Ciliberto, M. A., et al, ‘Comparison of Home-Based Therapy with Ready-to-Use Therapeutic Food with Standard Therapy in the Treatment of Malnourished Malawian Children: A Controlled, Clinical Effectiveness Trial’, The American Journal of Clinical Nutrition, 81.4 (2005): 864–70.

Collins, S., and K. Sadler, ‘Outpatient Care for Severely Malnourished Children in Emergency Relief Programmes: A Retrospective Cohort Study’, The Lancet, 360.9348 (2002): 1824–30.

Conrad, P., ‘The Shifting Engines of Medicalization’, Journal of Health and Social Behavior, 46.1 (2005): 3–14.

Dahdah, M. Al, A. Kumar, and M. Quet, ‘Empty Stocks and Loose Paper: Governing Access to Medicines through Informality in Northern India’, International Sociology, 33.6 (2018): 778–95.

Dasgupta, R., D. Sinha, and V. Yumnam, ‘Programmatic Response to Malnutrition in India: Room for More than One Elephant?’ Indian Pediatrics, 51 (2014): 863–68.

Daudet, A., and C. Navarro-Colorado, ‘Socio-Anthropological Aspects of Home Recovery from Severe Malnutrition’, Field Exchange, 21 (2004): 23.

De Laet, M., and A. Mol, ‘The Zimbabwe Bush Pump: Mechanics of a Fluid Technology’, Social Studies of Science, 30.2 (2000): 225–63.

Der Geest, S., and others, ‘The Urgency of Pharmaceutical Anthropology: A Multilevel Perspective’, Curare, 34.1 (2011): 2.

Dhar, A., ‘India’s Vaccine Diplomacy’, India ChinaInstitute (2021) https://www.indiachinainstitute.org/2021/03/04/indias_vaccine_diplomacy/.

Diop, E. H. I., and others, ‘Comparison of the Efficacy of a Solid Ready-to-Use Food and a Liquid, Milk-Based Diet for the Rehabilitation of Severely Malnourished Children: A Randomized Trial’, The American Journal of Clinical Nutrition, 78.2 (2003): 302–7.

Doyon, S., ‘India: The Expert and the Militant’, in A. Wilkins, ed., Humanitarian Negotiations Revealed: The MSF Experience (C. Hurst & Co, 2011), pp. 147–60.

Dube, B., and others, ‘Comparison of Ready-to-Use Therapeutic Food with Cereal Legume-Based Khichri Among Malnourished Children’, Indian Pediatrics, 46 (2009): 383–88.

Ecks, S., and S. Basu, ‘The Unlicensed Lives of Antidepressants in India: Generic Drugs, Unqualified Practitioners, and Floating Prescriptions’, Transcultural Psychiatry, 46.1 (2009): 86–106.

ENN, ‘Comparison of the Efficacy of a Solid Ready-to-Use Food and a Liquid, Milk-Based Diet in Treating Severe Malnutrition’, Field Exchange, 20 (2003): 4.

Fassin, D., ‘Humanitarianism as a Politics of Life’, Public Culture, 19.3 (2007): 499–520.

Fassin, D., Humanitarian Reason: A Moral History of the Present (University of California Press, 2011).

Fassin, D., ‘This Is Not Medicalization’, in M. Milhet, and G. Hunt, eds., Drugs and Culture (Routledge, 2016), pp. 107–16.

Frohlich, X., ‘Humanitarianism as Medicalization’, International Journal of Applied Medical Sciences, 22.2 (2021): 164.

FSSAI (Food and Safety Standards Authority of India), ‘Brief Report of the 41st Codex Committee on Nutrition and Foods for Special Dietary Uses’ (2020) https://www.fssai.gov.in/upload/uploadfiles/files/Brief_Report_41st_Codex_CCNFSDU_03_02_2020.pdf.

Garg, C. C., S. Mazumder, and others, ‘Costing of Three Feeding Regimens for Home-Based Management of Children with Uncomplicated Severe Acute Malnutrition from a Randomised Trial in India’, BMJ Global Health, 3 (2018): e000702. https://www.doi.org/10.1136/bmjgh-2017-000702.

Gera, T., ‘Efficacy and Safety of Therapeutic Nutrition Products for Home-Based Therapeutic Nutrition for Severe Acute Malnutrition: A Systematic Review’, Indian Pediatrics, 47 (2010): 709–18.

Gieryn, T. F., ‘Boundary-Work and the Demarcation of Science from Non-Science: Strains and Interests in Professional Ideologies of Scientists’, American Sociological Review, 48 (1983): 781–95.

Greiner, T., ‘The Advantages, Disadvantages and Risks of Ready-to-Use Foods’, Breastfeeding Briefs, 56.57 (2014): 1–22.

Grover, Z., and L. C. Ee, ‘Protein Energy Malnutrition’, Pediatric Clinics, 56.5 (2009): 1055–68.

Hardon, A., and Sanabria, E., ‘Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals’, Annual Review of Anthropology, 46 (2017): 117–32.

Heuts, F, and Mol, A. ‘What is a good tomato? A case of valuing in practice.’ Valuation Studies 1, no. 2 (2013): 125-146.

Indian Express, ‘Maharashtra Procures Ready-to-Use Food Despite Centre’s Notice’, Indian Express, 30 October 2017 https://indianexpress.com/article/india/maharashtra-nandurbar-procures-ready-to-use-food-despite-centres-notice-4912959/.

Indian Express, ‘Govt Set to Distribute Therapeutic Food to Malnourished Children, Activists Oppose’, Indian Express, 10 January 2019 https://indianexpress.com/article/cities/mumbai/govt-set-to-distribute-therapeutic-food-to-malnourished-children-activists-oppose-5531116/.

Jézéquel, J.-H., ‘Staging a “Medical Coup”? Médecins Sans Frontières and the 2005 Food Crisis in Niger’, Medical Humanitarianism: Ethnographies of Practice (2015): 119–35.

Khanum, S et al. “Controlled trial of three approaches to the treatment of severe malnutrition.” Lancet vol. 344,8939-8940 (1994): 1728-32. doi:10.1016/s0140-6736(94)92885-1

Khara, T., and C. Dolan, The Relationship Between Wasting and Stunting, Policy Programming and Research Implications (USAID, 2018).

Komrska, J., L. R. Kopczak, and J. M. Swaminathan, ‘When Supply Chains Save Lives’, Supply Chain Management Review, 17.1 (2013): 42–49.

Kopytoff, I., ‘The Cultural Biography of Things: Commoditization as Process’, The Social Life of Things: Commodities in Cultural Perspective, 68 (1986): 70–73.

Lakoff, A., Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (Cambridge University Press, 2006).

Lock, M. M., and V.-K. Nguyen, An Anthropology of Biomedicine (John Wiley & Sons, 2018).

Magone, C., M. Neuman, and F. Weissman, Humanitarian Negotiations Revealed: The MSF Experience (Oxford University Press, 2012).

Manary, M. J., and others, ‘Home-Based Therapy for Severe Malnutrition with Ready-to-Use Food’, Archives of Disease in Childhood, 89.6 (2004): 557–61.

Mason, J. B., and B. M. Margetts, ‘Magic Bullets vs Community Action: The Trade-Offs Are Real’, World Nutrition, 8.1 (2017): 5–25.

Mates, E., and K. Sadler, Ready-to-Use Therapeutic Food (RUTF) Scoping Study (Emergency Nutrition Network, 2020). https://www.ennonline.net/resource/ready-use-therapeutic-food-rutf-scoping-study

Ministry of Health and Family Welfare, National Family Health Survey (NFHS-5) Phase II (2021) https://main.mohfw.gov.in/sites/default/files/NFHS-5_Phase-II_0.pdf.

Ministry of Woman and Child Development, National Nutrition Policy (1993) https://wcd.nic.in/sites/default/files/nnp_0.pdf.

Ministry of Woman and Child Development, RUTF Guidelines (2017) https://wcd.nic.in/sites/default/files/RUTF.PDF.

Mint, ‘PMO States Will Take a Call on Ready-to-Use Food for Children’, Mint (2017) https://www.livemint.com/Industry/Q59PA6oEQoUdGJZmVoPwLK/PMO-states-will-take-a-call-on-readytouse-food-for-childr.html.

National Food Security Act (NFSA), NFSA Act (2013) https://nfsa.gov.in/portal/nfsa-act.

Ndekha, M. J., P. Ashorn, and A. Briend, ‘Home-Based Therapy with Ready-to-Use Therapeutic Food Is of Benefit to Malnourished, HIV-Infected Malawian Children’, Acta Paediatrica, 94.2 (2005): 222–25.

Patel, M. P., and others, ‘Supplemental Feeding with Ready-to-Use Therapeutic Food in Malawian Children at Risk of Malnutrition’, Journal of Health, Population and Nutrition, 23 (2005): 351–57.

Pordié, L., ‘Pervious Drugs: Making the Pharmaceutical Object in Techno-Ayurveda’, Asian Medicine, 9.1–2 (2014): 49–76.

Prasad, V., R. Holla, and A. Gupta, ‘Should India use Commercially Produced Ready to Use Therapeutic Foods (RUTF) for Severe Acute Malnutrition (SAM)’, Social Medicine 4.1 (2009): 52–55.

Prasad, V., D. Sinha, and S. Sridhar, ‘Falling Between Two Stools: Operational Inconsistencies between ICDS and NRHM in the Management of Severe Malnutrition’, Indian Pediatrics 49 (2012): 181.

Prost, A., and others, ‘Mortality and Recovery Following Moderate and Severe Acute Malnutrition in Children Aged 6–18 Months in Rural Jharkhand and Odisha, Eastern India: A Cohort Study’, PLOS Medicine, 16.10 (2019): e1002934.

Quet, M., ‘Values in Motion: Anti-Counterfeiting Measures and the Securitization of Pharmaceutical Flows’, Journal of Cultural Economy, 10.2 (2017): 150–62.

Redfield, P., ‘Bioexpectations: Life Technologies as Humanitarian Goods’, Public Culture, 24.1 (2012): 157–84.

Redfield, P., ‘Fluid Technologies: The Bush Pump, the LifeStraw and Microworlds of Humanitarian Design’, Social Studies of Science, 46.2 (2016): 159–83 https://doi.org/10.1177/0306312715620061.

Redfield, P., ‘On Band-Aids and Magic Bullets’, Limn, 9 (2017).

Reuters, ‘India’s Malnutrition Crisis: Therapeutic Food for Children’, Reuters, 4 August 2009 https://www.reuters.com/article/idUSDEL499363/.

Ruxin, Joshua Nalibow. Hunger, science and politics: FAO, WHO, and Unicef nutrition policies, 1945-1978. (University of London, 1996).

Sanderson, J., ‘Can Intellectual Property Help Feed the World? Intellectual Property, the PLUMPYFIELD® Network and a Sociological Imagination’, in The Intellectual Property and Food Project (Routledge, 2016), pp. 145–74.

Sandige, H., and others, ‘Home-Based Treatment of Malnourished Malawian Children with Locally Produced or Imported Ready-to-Use Food’, Journal of Pediatric Gastroenterology and Nutrition, 39.2 (2004): 141–46.

Sathyamala, C., ‘Nutrition as a Public Health Problem (1900–1947)’, ISS Working Paper Series/General Series, 510 (2010): 1–30.

Saunik, S., and others, ‘Safety, Tolerability, Efficacy and Logistics of Administration of Three Types of Therapeutic Feeds to Children with Severe Acute Malnutrition (SAM)’, International Journal of Nutrition, 3.1 (2018): 10–15 https://doi.org/10.14302/issn.2379-7835.ijn-18-2262.

Scott-Smith, T., ‘The Fetishism of Humanitarian Objects and the Management of Malnutrition in Emergencies’, Third World Quarterly, 34.5 (2013): 913–28.

Scott-Smith, T., ‘Humanitarian Neophilia: The “Innovation Turn” and Its Implications’, Third World Quarterly, 37.12 (2016): 2229–51.

Scott-Smith, T., ‘Sticky Technologies: Plumpy’nut®, Emergency Feeding and the Viscosity of Humanitarian Design’, Social Studies of Science, 48.1 (2018): 3–24 https://doi.org/10.1177/0306312717747418.

Scott-Smith, T., On an Empty Stomach: Two Hundred Years of Hunger Relief (Cornell University Press, 2020).

Scroll.in, ‘Maharashtra Puts on Hold Its Controversial Plan to Supply Malnourished Kids with Therapeutic Foods’, Scroll.in, 16 September 2017 https://scroll.in/article/850746/maharashtra-puts-on-hold-its-controversial-plan-to-supply-malnourished-kids-with-therapeutic-foods.

Segrè, J., G. Liu, and J. Komrska, ‘Local Versus Offshore Production of Ready‐to‐Use Therapeutic Foods and Small Quantity Lipid‐Based Nutrient Supplements’, Maternal & Child Nutrition, 13.4 (2017): e12376.

Selvaraj, K., R. S. Mamidi, R. Peter, and B. Kulkarni, ‘Acceptability of Locally Produced Ready-to-Use Therapeutic Food (RUTF) in Malnourished Children: A Randomized, Double-Blind, Crossover Study’, Indian Journal of Pediatrics, 89.11 (2022): 1066–72.

Strebhardt, K., and A. Ullrich, ‘Paul Ehrlich’s Magic Bullet Concept: 100 Years of Progress’, Nature Reviews Cancer, 8.6 (2008): 473–80.

Street, A., ‘Food as Pharma: Marketing Nutraceuticals to India’s Rural Poor’, Critical Public Health, 25.3 (2015): 361–72.

The Hindu Businessline, ‘CMAM Association Formed to Address Severe Malnutrition in India Among Children’, The Hindu Businessline, 26 May 2020 https://www.thehindubusinessline.com/news/cmam-association-formed-to-address-severe-malnutrition-in-india-among-children/article31676391.ece

Times of India, ‘No Quick Fix Solution, Don’t Use Packaged Food to Fight Malnutrition, Says Govt’, Times of India, 12 September 2017 https://timesofindia.indiatimes.com/india/no-quick-fix-solution-dont-use-packaged-food-to-fight-malnutrition-says-govt/articleshow/60471282.cms.

Trapp, M. M. ‘You-Will-Kill-Me-Beans: Taste and the Politics of Necessity in Humanitarian Aid’, Cultural Anthropology, 31.3 (2016): 412–37.

UNICEF (United Nations Children’s Fund), ‘Ready-to-Use Therapeutic Food Market and Supply Update – March 2021’, (2021), https://www.unicef.org/supply/media/7256/file/Ready-to-Use-Therapeutic-Food-Market-and-Supply-Update-March-2021.pdf.

Whyte, S. R., S. der Geest, and A. Hardon, Social Lives of Medicines (Cambridge University Press, 2002).

Working Group on Children under Six, ‘Strategies for Children under Six’, Economic and Political Weekly 42.52 (2007): 87–101 http://www.jstor.org/stable/4027713.

World Food Programme (WFP). Food assistance for children suffering from severe malnutrition: A toolkit for action (WFP, 2020) https://www.wfp.org/publications/food-assistance-severe-malnutrition.

World Health Organization (WHO). ‘Levels and trends in child malnutrition’, UNICEF, WHO, and World Bank Group Joint Child Malnutrition Estimates (2021) https://www.who.int/publications/i/item/jme-2021.

Ziegler, T. R., and T. D. Wilkins, ‘Nutritional Management of Severe Acute Malnutrition: The Role of Teady-To-Use Therapeutic Foods’, The American Journal of Clinical Nutrition, 100.3 (2014): 573–81 https://doi.org/10.3945/ajcn.113.080586.