VIEWPOINT
Viewpoint
Changing the way we address severe malnutrition during famine Steve Collins 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 Lancet 2001; 358: 498–501 Valid International, Oleuffynon, Old Hall, Llanidloes, Powys, SY18 6PJ (S Collins MD); and Centre for International Child Health, Institute of Child Health, London WC1N 1EH, UK (S Collins) Correspondence to: 37 Squires Court, Binfield Road, Stockwell, London SW4 6TD, UK (e-mail:
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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 THE LANCET • Vol 358 • August 11, 2001
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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
Sphere indicators for therapeutic feeding programmes3 Proportion of exits from a therapeutic feeding programme who have died is 75% Proportion of exits from therapeutic feeding programme defaulted 8 g Nutritional and medical care is provided to people who are severely malnourished, according to clinically proven therapeutic care protocols ● Discharge criteria include non-anthropometric indices such as: good appetite; no diarrhoea, fever, parasitic infestation or other untreated illness; and no micronutrient deficiencies ● Nutrition worker to patient ratio is at least 1/10. ● All carers of severely malnourished individuals are able to feed and care for them.
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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 500
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 (
