Letter on nomenclature used in malnutrition programmes, by Mike Golden

Nomenclature used in programs for tackling malnutrition

Dear Editor,

The following terms, inter alia, have been used in describing programs/centres.

CTC Community Therapeutic Care
TFC Therapeutic Feeding Centre
TFP Therapeutic Feeding Program
NRU Nutrition rehabilitation unit
NRC Nutrition rehabilitation centre
SNU Special Nutrition Unit
HT Home treatment (of severe malnutrition)
OPT Out-Patient Therapy (for severe mal nutrition)
AC Ambulatory care (for severe malnutrition)
SC Stabilisation centre
P1C Phase 1 centre
DCC Day care centre
RDCC Residential Day care centre
SFC Supplementary Feeding Centre
SFP Supplementary Feeding Programe

The fact that there is such a myriad of terms poses difficulties.

1. It is very confusing especially for those not actively involved in the field.
2. Many of the terms are being used incorrectly (not in the way the originator of the terms intended). For example CTC is frequently used as a synonym for out patient/home treatment of severe malnutrition.
3. Many of the terms are in fact descriptors for the same, or nearly the same, activity. They have been given different names by different organisations. To many readers this leads to the impression that the activity is different or new when in fact this is a minor "variation on a theme".

Community Therapeutic Care.

CTC, according to Collins.S (the originator of the term) - is a holistic concept of an integrated program that includes many other elements. Indeed almost every activity that leads to a good "Nutrition Program" seems to be included under this rubric. Thus, it includes a minimum of:

1. residential care for selected severely malnourished,
2. outpatient management of eligible children with severe malnutrition,
3. supplementary feeding program,
4. active case finding/community screen ing,
5. active community involvement, mobilisation, etc.. However it also includes, among others,
6. integration with existing food security programs, demonstration gardens, diversification of local crops,
7. local manufacture of therapeutic products (RUTF),
8. mother-to-mother and Hearth type programs,
9. integration with local public health programs.

The term knows no bounds: it is a utopian all-encompassing program that includes everything that may impact upon the nutritional status of the population. Indeed, the inclusion of "therapeutic" in this context is confusing and inappropriate - what Collins describes is a "Holistic Nutrition Program". Many use the term CTC and home 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