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treatment programs as interchangeable terms.
This is not the case.
What Collins further proposes is that there
is a logical order in which the various activities
are instituted in situations where few programs
exist. He has deliberately chosen this
order to give some relief/treatment to as
many children as possible rather than very
good treatment to some (possibly few) and no
treatment to others (possibly many). There is
merit in this approach; it emphasises active
case finding in the community and uses the
coverage of a program as one of the primary
indicators of success. However, this emphasis,
which I believe to be correct, is perfectly
compatible with traditional forms of management,
particularly where many severely malnourished
patients are managed as out
patients at home either initially or as soon as
their condition and home circumstances allow.
The priorities often involve context specific
judgements to be made. Complex or sudden
emergencies, particularly those that involve
population movement are unlikely to pose the
same priorities as a stable development environment
with no security threats, where traditional
livelihoods are ongoing and yet there
are malnourished children. Indeed, usually
the order in which the elements are instituted
are determined pragmatically by what
resources are available, what programs are
agreed and understood by local authorities,
by the expertise and mandates of the agencies
involved and, in particular, by the wishes of
the donors.
Nearly everyone is agreed that the order in
which “relief” should be given is:
1) food to keep people alive (general ration,
food for work, etc).
2) prevention of deterioration of moderately
malnourished children (SFP etc).
3) programs for the severely malnourished.
Thus, the many should get before the moderate
numbers, who should get before the few.
Unfortunately, the few (severely malnourished)
are high profile in terms of visual/
political impact and are relatively cheap programs
(per person input is relatively high but
the population served is small, so that the
overall cost is much less than providing food
for a large section of the population).
Collins, quite rightly, argues that many programs
have a low coverage and that this is
critical for having a high impact in tackling
the magnitude of the problem. He argues,
again correctly, that there should be greatly
increased geographical outreach of the programs
and increased community participation
in the treatment of severe and moderate malnutrition.
The other element is the emphasis
upon integration of emergency and development
programs, the integration of programs
for moderate and severe malnutrition, and the
recognition by those who run development
programs that they should integrate the management
of malnutrition into their overall
plans and evaluations. I do not think that
there is any one who disagrees with these
points. These are goals of us all. The question
is how best to bring them about in practical
terms.
Nevertheless, CTC as described by Collins
is a catch-all term for ALL-best-practice-nutrition-interventions
in both emergency and
development contexts and their active integration
with all community, health and other
developmental prgrams. Of course this is
what everyone has always wanted – well run
nutrition and health services. However, if this
is the case, then the term Community
Therapeutic Care is not appropriate – as much
of the program is not “Therapeutic”. It would
perhaps be better to have been much more
restrictive in the definition of CTC to include
only those activities aimed at finding and
treating severely malnourished children. Of
course “community Therapeutic care” could
equally refer to the management of malaria,
diarrhoea, RTI etc in the community. Further
more, the term “care” has a parallel meaning
which is increasingly deviating from the
layperson’s concept of care. However, the
term CTC has been defined in such a way that
to restrict its use at this stage would simply
add to the confusion.
Severe Malnutrition.
Traditionally severe malnutrition has been
managed in a unit within a hospital, if there is
a functioning hospital and reasonably low
numbers of patients, or in a purpose built
unit/centre if there are sufficient patients to
overwhelm local medical services. These are
called, respectively, a SNU or TFU and a TFC
respectively.
There are various protocols and organisation
that are implemented in these structures. The
units have no other function than to treat
severe malnutrition. The centres/units do not
necessarily run 24h residential care from
admission until discharge, although many
who have not worked in these centres perceive
that this is always the case.
The “types of TFC/TFU/SNU are generally as
follows:
1) Full 24h residential care from admission
until discharge (traditional TFC).
2) Residential day-care centres. In these
centres the staff give care during the
working week, and often at week ends,
but not at night. The patients can stay in
the centre at night (if there is insecurity
or a long way to travel etc), or return to
their residence as they desire.
3) A non-residential day-care centre. In this
type of centre the patients come to the
centre each day and return home at
night. This is often managed in a similar
way to the DOTs programs for TB,
where the patients distant from the centre
“lodge” with relatives or friends
close to the centre.
4) More recently, TFCs have run either 24h
or residential Day care for most of the
children when they first present, when
they reach the phase 2 of treatment they
either stay in the centre for phase 2,
progress to day-care or have treatment
at home. The latter has been termed
“home treatment”, “ambulatory care” or
“out-patient Treatment/Therapy”. Such
programs can be run from a TFC/TFU/
SNU.
5) With the development of RUTF, the daycare
centres can be very small and the
management decentralised to health
centres of health posts with each health
structure having a few severely malnourished
children.
6) Home treatment program – this is similar
to an SFP, with the exception that an
antibiotic, folate, etc are given at the first
visit and RUTF is given instead of the
usual CSB/Unimix.
The terms “stabilisation centre” or “phase
one centre” are not necessary. They are in
essence no different from a TFC or a TFU/SNU
that organise and run the first phase of treatment.
Such centres are TFC/SNU’s which provide
conventional treatment for patients that
are at high risk before they can be discharged
to complete their treatment elsewhere.
The idea of such centres is that the patients
will be transferred to outpatient treatment
/Home treatment/Ambulatory care at some
stage during their treatment. Whether this is
possible depends upon the clinical state of the
patient and the home circumstances. Some
patients will need to remain in the centre until
recovery – (orphans, young babies for which
there is no product suitable for home-treatment,
and perhaps some children with complicating
diseases or who fail to respond to
treatment). Nevertheless, it is now clear that
many children who were previously admitted
to a TFC can go straight into an outpatient
treatment program provided that they fulfill
the criteria for home treatment (appetite, presence
of a willing caretaker, etc) when they
present.
I see no cogent rationale for introducing a
new nomenclature for these centres which
“mostly” care for sick anorexic malnourished
children during phase 1. The terms SC and
Phase 1 centre are not only unnecessary but
are also confusing and lead to the impression
that quite different activities/treatments take
place in these centres than in a TFC/SNU –
this is not the case.
The new nomenclature is unnecessary, confusing
and has led some government officials
to question whether the management that
occurs in such centres agrees with international
or national guidelines for the management
of severe malnutrition. Equally a TFP (therapeutic
feeding program) easily accommodates
all the modalities of treatment of severe malnutrition
that have been used – including
home treatment/ outpatient treatment. It is
perfectly compatible with decentralisation to
provide care close to the patient’s home and
integration with SFP.
Much of the reason for the increased coverage
of the so-called CTC programs is the community
screening/active case finding. This
should be part of every program irrespective
of where those that are identified as having
severe malnutrition are treated. Unfortunately,
such active case finding in the community is
rarely part of a therapeutic program for severe
malnutrition. Agencies and donors should
always include this activity in their proposals
and programs.
Mike Golden
Dear Editor
The huge increased impact of selective
feeding interventions since the introduction
of CTC (see ENN Special
Supplement 2 and HPN #48) demonstrates
clearly the effectiveness of this
new model of selective feeding (see
HPN #48 and ENN Special Supplement
2). The new nomenclature is important
to clearly define the different elements
of CTC and to distinguish CTC from
other less effective intervention models.
Steve Collins (Valid International)
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