I recently reviewed copy of Donna Sillan's “cook book” for Hearth and have found it excellent! I am still very active in Haiti with a number of PVO nutrition projects and just participated in a review of the effects of the targeted dry ration distribution program that Haiti has under CARE (in the Northwest) and Catholic Relief Service (across the Southern peninsula and elsewhere). I have the following comments concerning non-Hearth options for nutrition rehabilitation: 
 
A.  Nutrition Rehabilitation Centers 

Nutrition rehabilitation centers and wards were extensively studied and written up in the 1960s and 1970s. For example, Warren and I were active in the use of nutrition rehabilitation wards in the Congo and in Haiti for over 20 years.

Cross-infection of such children is a serious problem; case fatalities in “nutrition wards” may be as high as 30%, and were shown to be significantly related to cross infection in the 1970's. Children with severe malnutrition (those no longer able to walk and often requiring feeding, at first, by gastric sound) cannot be handled in village level nutrition rehabilitation centers and if hospitalized need to be isolated from children hospitalized with infections; this is ideal but an impossibility in many developing countries. (ref: See book by Scrimshaw et al, “Nutrition and Infection.”)

A new book, “Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers,” WHO Geneva, summarizes 50 years of experience in treating very severe malnutrition, and should be required reading for anyone treating moderate or severe malnutrition. Pages 1-19 are essential and outline the protocols for Rx of hospitalized cases, and should be widely disseminated in my opinion. Such children are often over-hydrated by well meaning but misinformed physicians who interpret the typical loose stools of kwashiorkor as “diarrhea,” who give iron too early or try to correct the anemia with blood transfusions, who omit from the milk formula essential micro-nutrients such as zinc, and the like. Moving such children to rehabilitation centers is covered in the last chapters of the book. You can order it from WHO Publications, 1211 Geneva 27, Switzerland.

A serious problem is that mothers or caretakers attribute the recovery of the child in a hospital setting or a nearby rehabilitation center to the medications rather than to food, even when caretakers are educated in the last phase of the recovery to prepare the food themselves. In East Africa, such mothers were educated to go home as “teachers” for their own village, armed with flip charts and other educational materials. They found themselves to be lonely messengers. Even if they attributed the change in their child mainly to foods made more calorie-dense and given more often, they could not convince other mothers.

 B.  Community-Based Nutrition Education and  Rehabilitation Centers 

Community-based nutrition education and rehabilitation "centers" (CERNS or Motherkraft Centers) were extensively tried throughout Latin America in the 1960s and 1970s. Warren and I visited them in Guatemala and Mexico and ran them in Haiti at a time when they were widely dispersed throughout the country. I will be happy to report on the methodology, their success rates, the studies that were carried out, and the reason they were abandoned. 

The best of the CERNS were itinerant in nature, rotating from village to village, and involved mothers in preparing and feeding local foods to their own malnourished tots under the supervision of a trained nutrition aide. They had the advantage of getting “fall out” of information to the surrounding community, and were meant to reintegrate the recovering child into the local growth monitoring/counseling (GMC) program. In many countries, these CERNS became more permanent than itinerant in nature, drawing children from further and further away, and absenteeism became a problem. Furthermore, these rehabilitation centers kept children for 2 - 3 months, not unreasonable since the antibody production in malnourished children takes 5 - 6 months to recover.

But the cost per child was very high, and these centers could not begin to meet the need on a widespread population basis. Over the three-month period that their child was daily at the Center for a part of the day, mothers gradually tended to view the centers as “child care” drop-offs rather than an educational opportunity for themselves. Hence the short-term “Hearth” method was born, and enriched with the “Positive Deviance” approach. Jerry and Monique Sternin have so perfected this method that to ignore it in any kind of approach to changing child-feeding practices would be an error, in my opinion.

Nutrition centers attached to hospital rehabilitation wards have their own problems. The one we studied in a “referral village,” where children were sent from the hospital to complete recuperation, had high short-term and long-term case fatality rates, largely due to the fact that children were sent there still in need of medication and able to cross-infect others, and also due to the fact that mothers were strangers to each other, having come from far and near, and so were unable to get the “peer support” they needed to continue good nutrition practices.

C.  Domiciliary Treatment 

Domiciliary treatment of malnutrition where the child is rehabilitated in his/her own home under close supervision using local foods was tried in India and is being re-developed by Dr. Dominique Roberfroid of the Antwerp Institute of Tropical Medicine and others. There is emerging information on the method, which looks promising, and is being applied in one area of Haiti. The “home trainers” and their costs are beginning to emerge from the data as well as long-term results.

Under the MARCH project (Management and Resources for Community Health) in Mirebelais, Haiti, we are currently developing a way to combine Hearth training using local foods with a preceding dry-ration distribution program. I will be working on this method over the next few months.