Changing the way we address severe malnutrition during famine.

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.