Summary
This year, yet again, saw widespread food insecurity and famine across the horn of Africa. Again, humanitarian agencies set up operations to implement various relief programmes. Nutritional interventions included general ration distribution to the whole of an affected population; blanket supplementary feeding to all members of an identified risk group; and targeted dry supplementary feeding centres for moderately malnourished and therapeutic feeding centres for the severely malnourished. As is usual in emergencies, many of the therapeutic feeding centres were hard to set up and did not achieve an adequate coverage of all the severely malnourished. This combination of delays and low coverage meant that many therapeutic feeding centres achieved little overall impact on mortality. I believe that the present focus on therapeutic feeding centres as the sole mode of treating severely malnourished people during famine is inappropriate and often counter-productive. A new concept of community-based therapeutic care is necessary to complement therapeutic feeding centres' interventions if famine relief programmes are to address the plight of the severely malnourished in an efficient and effective manner. During an emergency, the community-based therapeutic care approach could quickly provide good coverage and appropriate treatment for large numbers of severely malnourished people. The principles behind community-based therapeutic care are, however, developmental, empowering communities to cope more effectively with crisis and with transition back to normality. This is very different to the therapeutic feeding centres' approach that disempowers communities, requires very large amounts of external staff and resources, and undermines the infrastructure. Although emergency community-based therapeutic care programmes could be large-scale and implemented quickly, they could also evolve into developmental Hearth model nutritional programmes without changing their conceptual basis. Conversely, Hearth programmes, although largely sustainable, could in times of crisis quickly scale-up into rapid effective emergency interventions. Creating such a continuum between emergency and developmental approaches has long been a holy grail of humanitarianism.
At present, all emergency therapeutic feeding programmes depend upon therapeutic feeding centres as their only mode of intervention. They often provide high quality individual patient care. Inpatients receive Formula 75 and Formula 100, highly appropriate therapeutic milks,1 in quantities tailored to the individual's metabolic needs. Systematic medical and supportive care complements this approach. This highly intensive care is essential for the initial phase of treatment of patients with complicated malnutrition associated with anorexia, septicaemia, hypothermia, hypoglycaemia, or severe dehydration. However, severe malnutrition is a complex condition with important economic, psychological, and social elements, in addition to individual diseases. The medical emphasis of the therapeutic feeding centres' model of care ignores these other aspects of the condition and in doing so often inadvertently aggravates the situation.
Most nutritional emergencies are chronic or cyclical in nature. In these protracted emergencies, the centralised and resource-intensive therapeutic feeding centres' model of care is maladaptive. A therapeutic feeding centre's huge requirement for resources, skilled staff, and imported therapeutic products makes the operation very expensive and highly dependent upon external support. The centralised approach to care and high staff requirements undermine local health infrastructure, disempower communities, and promote the congregation of people. Congregation of severely malnourished patients inside the centres promotes centre-acquired infection, a major problem in many feeding centres. The congregation of communities around them promotes breakdowns in public health, an important cause of mortality and morbidity during famine.2 Admission of a patient into a therapeutic feeding centre requires that the carer, usually the mother, leaves the family for about 30 days. Nobody has studied the effects of this factor; however, given a mother's importance to household food security and food supply, it is likely that the negative effects are substantial. The absence of a mother would be particularly damaging for younger siblings, many of whom might also be moderately malnourished.
These negative consequences of therapeutic feeding centres might be acceptable if the therapeutic feeding centres' model could deliver effective short-term relief to populations suffering from famine. In my experience, gained from working in most of the major famines during the past 10 years, this is not the case. Therapeutic feeding centres' coverage is always low and this consistently limits their overall humanitarian impact. Furthermore, attempts to increase coverage often prove detrimental to the local health infrastructure and communities. My recent trip to Ethiopia, to assist a large international non-governmental organisation in planning and setting up emergency famine relief programmes in a small highland district, illustrates this point. The target population was 400 000 people living within a 40 km radius of the district town. About 20% were under 5 years of age and the estimated prevalence of severe malnutrition was 20%. This gave a planning figure of 16 000 severely malnourished children requiring therapeutic feeding. Internationally accepted standards stipulate that a therapeutic feeding centre should have a maximum capacity of 100 inpatients and one carer for every ten patients. To treat this number of people according to these standards would have required 40 therapeutic feeding centres operating at full capacity for 4 months, with 40 skilled centre managers, at least 20 logisticians, 160 nurses, and 400 carers. No agency, be they United Nations, Red Cross, or non-governmental organisations could implement a quality therapeutic feeding centre programme of this size. Even if it were possible, the huge requirements for skilled local staff would place intolerable demands on the local health infrastructure. In the event, our therapeutic feeding centre programme took several months to become operational and never achieved a capacity of more than 100 patients. Data on mortality do not exist, but most people involved with the programme believe that many of the children must have died before adequate treatment became available.
During the summer of 2000, similar problems with coverage limited the impact of many of the therapeutic feeding centre programmes in Ethiopia. By September, 2 months after the peak of the nutritional crisis, agencies had finally started many centres throughout the country. Their programmes will last about 6 months and most will be due to close between January and April, 2000. This closure coincides with the hunger gap in the area, during which time the numbers of severely malnourished will probably increase. This poses difficult questions for agencies. Should such centres remain open to cater for the growing numbers and risk being drawn into prolonged costly interventions? Alternatively, should they close just when the need for them increases? Neither solution is desirable.
Last year's nutritional problems in Ethiopia were no worse than in many other recent African crises. In South Sudan during 1993 or 1998; Angola during 1993 or 1999; Liberia during 1996; or Somalia in 1991–93, an exclusive therapeutic feeding centre approach to the treatment of severe malnutrition did not achieve adequate coverage or viable exit strategies. These problems with this type of model of care are seldom acknowledged and rarely show up when programmes are assessed against internationally accepted standards for therapeutic feeding centre programmes. At present, the Sphere standards1 developed by a consortium of all the leading relief non-governmental organisations and international humanitarian organisations, is the sole set of internationally accepted standards. These standards are centre orientated and do not include indicators for programme coverage or indicators to assess the negative impacts on health infrastructures and communities (panel).
Community-based therapeutic care
The concept of community-based therapeutic care proposed here is new to emergency relief programmes. Community-based therapeutic care aims to treat most people with severe acute malnutrition in their homes, not in therapeutic feeding centres. Such care combines two techniques of nutritional rehabilitation used in development work; and the management of severely malnourished children using outreach workers and the Hearth method4 of home-based nutrition education and support. Researchers have shown that home-based treatment of severe acute malnutrition is successful and costeffective. In Bangladesh, the recovery rate of very severely malnourished children treated with 1 week's inpatient care followed by home management was similar to those treated in a specialised nutrition unit.1 Home treatment was more than four times cheaper and very much preferred by mothers.5 The educational programme for the mothers benefited not only the mothers themselves but achieved a ripple effect, improving the educational levels of other mothers in the community. During a 1-year follow-up, there was evidence that the children treated at home had less morbidity.6 The Hearth method of nutritional intervention has been very successful in rehabilitating children with chronic malnutrition in several lessdeveloped countries. The technique uses so-called community mothers who are selected on the basis of their ability to raise well-nourished children even in the face of poverty. These mothers educate other mothers and treat malnourished children in their own villages. In all sites, the technique has produced sustainable improvements in nutritional status cheaply and with little external input. Community-based therapeutic care combines these two techniques and adds the use of a new ready-to-use therapeutic food (RUTF), specially designed to treat severe malnutrition in the community. RUTF is a new food, designed to be nutritionally equivalent to the Formula 100 used in therapeutic feeding centres, but is a paste that patients can eat directly from the packet. Preliminary trials suggest that RUTF is popular with malnourished children and highly resistant to contamination with bacteria.7 RUTF is made from peanuts, dried skimmed milk, sugar, and a specially formulated mineral and vitamin mix, and will keep for several months in a simple pot. All the ingredients apart from the CMV are available in less-developed countries. Instead of relying exclusively on therapeutic feeding centres, imported foods, and large numbers of external experts, community-based therapeutic care offers the potential to establish community structures to address the problems of severe malnutrition with local knowledge and locally manufactured therapeutic food. Initially, community-based therapeutic care programmes will require considerable external facilitation with staff and imported RUTF. However, during the course of an emergency, these requirements will decline as the community base becomes stronger and local production of RUTF increases. At the end of an emergency, the socalled Hearth groups can easily reorientate themselves towards more developmental goals, while leaving the core structures in place for reactivation should another emergency occur.
Community-based therapeutic care would target three distinct groups of severely malnourished people. During the first few weeks of an emergency, before agencies have built any therapeutic feeding centres, there is usually little choice but to manage the severely malnourished in the community. At this early stage, community-based therapeutic care would be the only viable treatment alternative available and would therefore have to attempt to treat all those severely malnourished. Once therapeutic feeding centre care became operational, communitybased therapeutic care would be appropriate for patients in the rehabilitation phase of treatment. In a conventional therapeutic feeding centre, the rehabilitation phase lasts from day 7 until discharge at day 30 and includes about 75% of the patients. During rehabilitation, a patient's metabolism has stabilised, his appetite has returned and any infections are under control. Discharging all these people to community-based therapeutic care would greatly reduce the need for therapeutic feeding centres, allowing them to be smaller and, therefore, quicker to establish. In addition, community-based therapeutic care would be appropriate for the treatment of people with uncomplicated severe malnutrition (those with an appetite and who are not seriously infected), admitted direct from the community.
An important issue is whether such community interventions can be set up quickly. Initial studies indicate that they can. Emergency relief programmes must prioritise lower-input interventions with a large coverage of the vulnerable population over high-input services treating only a few. Access to a life-sustaining general ration, providing at least 8786 kJ/day from grains, legumes, and vegetable oil; adequate water; sanitation; basic health care; and dry supplementary feeding therefore form the basis of any famine relief programme. Dry supplementary feeding programmes aim to deliver about 5000 kJ/day of fortified blended cereal and bean flour to malnourished children on a weekly or fortnightly rotation. These programmes can be set up within a matter of days. Pilot programmes in Ethiopia suggest that community-based therapeutic care can evolve out of supplementary feeding programmes, attaining a good coverage of the severely malnourished faster than conventional therapeutic feeding centres programmes.
At the beginning of an emergency, therapeutic feeding centres take several weeks to open and often much longer to meet performance standards. During this time, people identified as severely malnourished at supplementary feeding programme anthropometric screenings usually receive only a dry supplementary ration and a single dose of vitamin A. Initial experience in Ethiopia, however, indicates that it is easy to give these severely malnourished people additional nutritional support, education, and systematic medical treatment, right from the outset. In Ethiopia, during the initial anthropometric screening, our supplementary feeding programme workers gave a red wristband to anybody they identified as severely malnourished. Those with red bands then entered an intensive supplementary programme, receiving a ration of RUTF in addition to their usual ration. Increasing the numbers of staff just allowed sufficient capacity to give soap, and additional medication, such as a single dose of mebendazole and measles vaccination, to these children. This intensive supplementary programme admitted over 1000 severely malnourished children (<70% of the median weight for height or having a middle upper arm circumference <110 mm) within a month.8
In a full community-based therapeutic care programme, they could also give a single dose, longacting antibiotic such as chloramphenicol in oil. The severely malnourished returned each week to the supplementary feeding programme distribution point where workers monitored them using a brief clinical examination and anthropometry. At these follow-up sessions, community health care workers delivered an education session supervised by staff.
Although untried, transition from the intensive supplementary programmes piloted in Ethiopia into full community-based therapeutic care would require the identification of successful mothers, around whom a structured community treatment and education programme could be constructed. With the intensive supplementary treatment, some children will respond well and some will not. The mothers of those who respond well could be used as a focus to promote behavioural change in the other carers. As in the Hearth method, programme staff could work with these successful mothers to establish a basic treatment plan, based upon the behaviours that the mothers have already used successfully. At a minimum, this would include giving the RUTF often and only to the severely malnourished child. In addition, the treatment plans are likely to include other behaviours identified by the successful mothers. Once the programme workers and the mothers agree on a basic treatment plan, the successful mothers would team up with other mothers from their communities to educate them in the fundamentals of successful treatment. This education would take place via small daily gatherings of the mothers and carers at one or other of the recipients' homes. Local community health care workers, if available, could attend these group meetings to ensure that the groups were using appropriate techniques and to identify any patients who were not responding. Initially the programme would probably have to use imported RUTF. Gradually, as the programme became more established, these same women's groups could be used to start making the RUTF locally, thereby generating local economic benefits targeted specifically at those most affected by the food insecurity.
Establishing community-based therapeutic care programmes will require different human and material resources compared with conventional therapeutic feeding centres. Material requirements will be lower because community-based therapeutic care programmes can be based around supplementary feeding centres or local health posts. Fewer expatriate staff will be required and consequently there will be less need for materials, such as four-wheel drive cars, radios, and accommodation, to support them. Effective implementation will require that community-based therapeutic care programmes are tailored to the specific situation and local people are involved in programme design. Such consultation requires more experience, imagination, and communication and anthropological skills from project managers than does the implementation of generic therapeutic feeding centres. The most important non-local human resource will therefore be culturally sensitive managers who can interact positively and openly with local communities and are able to motivate and manage effectively large teams of outreach workers. Local staff requirements will be substantially different, with many more village-level outreach workers and fewer trained medical staff. Some medical staff will still be required to supervise patient selection, screening, and referrals, but the numbers will be much lower than in a therapeutic feeding centre. Agencies must ensure that community-based therapeutic care programmes are integrated with other interventions, such as support to local health infrastructure and food security interventions, to facilitate referrals, and ensure that the community-based therapeutic care programmes have viable exit strategies.
Conclusion
Including a community-based therapeutic care component in famine relief programmes offers many potential advantages. Community-based therapeutic care is likely to improve coverage of therapeutic programmes and provide socioeconomic and educational benefits for the families of malnourished. The improved coverage should increase the numbers of severely malnourished people treated, thereby reducing overall death rates from starvation. The communitybased and outpatient nature of community-based therapeutic care would reduce the negative effects of attendance at therapeutic feeding centres on families and communities. Taken as a whole, the combination of all these separate benefits should create a synergy to increase substantially the overall impact of therapeutic programmes.
It is important to realise that all these benefits come at the price of less intensive medical and nutritional intervention for malnourished individuals. Ideally, community-based therapeutic care is complementary to therapeutic feeding centres and should operate alongside a centre to which complicated cases can be briefly admitted for initial rehydration, antibiotics, and to reestablish appetite. As the length of stay in such centres would be short, less than a week, they could be far more rudimentary than conventional therapeutic feeding centres. Initial experience in Ethiopia suggests that with appropriate support, local clinics and health posts can provide this function. Small decentralised stabilisation centres, based in local health posts, would reduce the transport problems associated with centralised feeding centres and help to embed the programme within local communities. This intervention would also help ensure that some of the emergency funding went into supporting the existing health infrastructure. In reality, given the usual delays in implementation and low coverage of therapeutic feeding centre programmes, it is likely that community-based therapeutic care programmes will often operate without associated feeding centres. When such centres are not available, people who require therapeutic feeding centre care but of necessity are treated in community-based therapeutic care, are likely to suffer a higher mortality. At present, such people tend to die out of sight in their homes and do not show up in feeding programme statistics, at best appearing only as defaulters from the supplementary feeding programme. In this way, substantial numbers of deaths go unreported. When community-based therapeutic care programmes operate, reporting rates for mortality are likely to be much higher and in such situations, community-based therapeutic care programmes will give the impression of having higher mortality rates. Reporting an increase in the numbers of people dying will be difficult for humanitarian agencies, donors, and the media to accept or understand. Rigorous research to compare the impact of community-based therapeutic care and therapeutic feeding centre programmes must therefore accompany the introduction of community-based therapeutic care. The chaotic environments characteristic of war and famine make such research difficult.9 The potential benefits are however, great.
The leading humanitarian agencies are already starting to explore this opportunity to change radically the way in which they address severe malnutrition during famine. In the first instance, this will involve starting small pilot community-based therapeutic care programmes and monitoring their operation and effects. Subsequently, larger projects combined with controlled studies to compare their effects to those of traditional feeding centres will be needed.
As published in "The Lancet" with full references:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(01)05630-6/fulltext