Community care: addressing the management of severe malnutrition
Summary of published paper1
Bedessa TFC, Ethiopia (May 2000)
The long-held traditional approach to treating severely malnourished individuals in emergencies is challenged in a recent 'viewpoint' article published in the Lancet. Dr. Steve Collins argues that a therapeutic feeding (TF) centre's huge requirement for resources, skilled staff and imported therapeutic products makes the operation very expensive and highly dependent upon external support. Furthermore, the centralised approach to care with its high staff requirements undermine local health infrastructure, dis-empower communities, and promote the congregation of people and resulting centre-acquired infection. In addition, admission of a patient into a TF centre requires that the carer, usually a mother, leaves the family for about 30 days. Absence of a mother would be particularly damaging for younger siblings left at home.
Current practice and limitations
In Collin's considerable experience over the past 10 years, coverage of TF programmes is often low thereby limiting their overall impact. In a recent trip to Ethiopia where out of a population of 400,000 there were approximately 16,000 severely malnourished children (20% severe wasting), it would have been necessary to establish 40 TF centres based on international standards of 100 per feeding centre. This would have necessitated employing 40 skilled centre managers, at least 20 logisticians, 160 nurses and 400 carers. In the event, the TF centre programme took several months to become operational and never reached this sort of scale. There was a similar picture elsewhere in Ethiopia with coverage limiting impact of many agency TF programmes. By September 2000 many agencies had finally started programmes (2 months after the peak of the nutritional crisis). The article also points out that SPHERE standards do not include indicators for programme coverage nor indicators to assess the negative impacts on health infrastructure and communities. Collins advocates Community Based Therapeutic Care (CBTC) as an alternative.
The components of CBTC
CBTC aims to treat the majority of people with severe acute malnutrition in their homes. This type of care combines the management of malnourished children using outreach workers and the 'Hearth' method of home-based nutrition education and support. The author asserts that the Hearth method has been very successful in rehabilitating children with chronic malnutrition in several less developed countries. The approach uses mothers from the community who are selected on the basis of their ability to raise well-nourished children even in the face of poverty. CBTC would combine these two features and in addition utilise the newly developed Ready to Use Therapeutic Food (RUTF), specially designed to treat severe malnutrition in the community. RUTF is nutritionally equivalent to F100 but is a paste that patients can eat directly from the packet. Trials have shown RUTF to be popular and highly resistant to contamination. It is prepared from peanuts, dried skimmed milk, sugar and a specially formulated mineral and vitamin premix (CMV). All the ingredients apart from the CMV are available in the vast majority of less developed countries.
Phasing in CBTC
The article states that during the first few weeks of an emergency, there is usually little choice but to try to manage the severely malnourished in the community. Once therapeutic feeding centres become operational, CBTC would then become appropriate for patients in the rehabilitation phase of treatment. This normally lasts from day 7 until discharge and includes about 75% of patients. During rehabilitation a patient's metabolism has stabilised, appetite has returned and any infections are under control. Treating the stabilised cases through CBTC would greatly reduce need for TF centres allowing them to be smaller and therefore quicker to establish.
Experience in Ethiopia shows that a form of CBTC centre can evolve from dry Supplementary Feeding Programmes (SFPs) and can then be set up within a matter of days. Currently, in the early stages of an emergency before TF centres are established people identified as severely malnourished at SFPs will be given a dry supplementary ration and single dose of Vitamin A, the minimum for clinical management of a moderately malnourished individual. In Ethiopia it was relatively easy to provide additional nutritional support, education and systematic medical treatment to the severely malnourished right from the outset. The severely malnourished were identified by a red wrist band and given a ration of RUTF in addition to the usual ration for supplementary feeding. Increasing the numbers of staff allowed sufficient capacity to provide soap and additional medication, e.g. a single dose of mebendazole and measles vaccination for children. In a full CBTC facility (intensive first phase with community care for rehabilitation phases) they could also be given a single dose of long acting antibiotic such as chloramphenicol in oil.
Role of the carer
Although not fully explored in an emergency, transition from the 'intensive SFP' piloted in Ethiopia into full CBTC would require identification of 'successful' mothers, around whom a structured community treatment and education programme could be constructed. The mothers of those children who respond well i.e. 'successful mothers' could be used as a focus to promote behavioural change in other carers. As in the Hearth method, programme staff could work with these successful mothers to establish a simple treatment plan based on the behaviours that the mothers have already used successfully. These mothers could then educate other mothers at daily meetings. Initially RUTF would have to be imported but eventually could be made locally.
Using local clinics and health posts
Ideally, CBTC could operate alongside a therapeutic feeding centre to which complicated cases could briefly be admitted for initial rehydration, antibiotics and to re-establish appetite. 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 existing health infrastructure.
Collins acknowledges the reality that given the usual delays before implementation and consistent low coverage of current TF centres, it is likely that CBTC will often operate without associated feeding centres. When such centres are not available, people who require TF care will be treated through CBTC and will be exposed to a higher risk of mortality than if treated in a TF centre. Currently, due to limited coverage and people's inability to access centralised TF centres the majority of severely malnourished tend to die in their homes and are not recorded in statistics, at best only appearing as defaulters from SFPs. Therefore when emergency CBTC is operating in the absence of 'stabilisation centres', reporting statistics may indicate higher mortality rates than is normally reported in therapeutic feeding programmes, particularly at the initial stages of an emergency.
A final point made in the article is that rigorous research to compare the impact of CBTC and TF centre programmes should accompany the introduction of emergency CBTC programmes and initially it will be necessary to start with small pilot programmes.
For further information contact Dr. Steve Collins at email: firstname.lastname@example.org
1Collins.S (2001): Changing the way we address severe malnutrition during famines: The Lancet, Vol 358, August 11th, pp 498-501.
Taken from Field Exchange Issue 14, November 2001