Field Exchange Dec 2006: No. 29
There are two major themes running through this issue of Field Exchange. The first is a focus on Southern Africa and the programmatic challenges presented by HIV/AIDS and the second concerns infant and young child feeding in emergencies (IFE). An extended visit to South Africa over the summer by ENN co-director, Marie McGrath, offered the opportunity to visit several collaborative WFP programmes in Swaziland and Namibia and also to identify significant HIV-related research in the region. Setting the scene in Southern Africa, George Aelion of WFP describes the 'hidden emergency behind the emergency' due to the HIV/AIDS pandemic in the southern Africa region. Many working in the region now consider the triple threat of HIV/AIDS, attrition of government staff resulting in diminishing government capacity to provide health care, food and education, and long-term chronic food insecurity, as one of toughest humanitarian challenges to be faced. WFP programmes in Swaziland and the Caprivi region of north-eastern Namibia are being implemented in environments with some of the highest prevalence of HIV/AIDS in the world (42.6% in Swaziland, 40% in Namibia). One of the main challenges facing agencies in the region is how to address the ever-increasing numbers of Orphans and Vulnerable Children (OVCs). The scale of response needs to be huge. A field article from Namibia describes how the WFP and the Ministry of Gender, Equality and Child Welfare are working together to target 111,000 OVCs, linking the WFP targeted food distribution to OVCs with the government grant scheme. Programmes also need to be 'holistic' and integrate a number of sectoral needs for what is effectively a generation of children whose parents and mentors are no longer around and for whom chronic food insecurity is a long-term reality. The FAO-led Junior Farmer Field Life Schools (JFFLS) approach aims to comprehensively provide for the needs of OVCs and has been well received. Experiences of this approach in Namibia and Swaziland are described by Kiwan Cato and Hlengiwe Nsibandze in a field article, along with observations by the ENN during a WFP assisted field trip in Namibia.
Botswana features significantly in our regional coverage of Southern Africa. A research piece by Siddharth Krishnaswamy studies the impact of HIV on Botswana's development and evaluates government policy. The country has the second highest HIV prevalence rates in the world (37.3%) yet is also one of the biggest spenders on health and HIV prevention in Southern Africa. Although on most development indicators Botswana has made progress, adult health has declined - between 1995 and 2002 total life expectancy fell by 36%. The author suggest that Botswana's HIV problem and its resulting impact on development is not due to lack of commitment or action on the government's part, but results from crucial delays made in making and implementing these commitments.
Experiences of HIV/AIDS and infant feeding in the region are illuminating in terms of highlighting the challenges ahead. Two research pieces on Prevention of Mother to Child Transmission (PMTCT) programming in Botswana illustrate just how vulnerable infants who are not breastfed are in resource-limited settings. In the MASHI study from Botswana, infants who were breastfed had a higher HIV transmission rate but a lower mortality rate at 7 months than infants who were formula fed. Both feeding strategies had comparable HIV-free survival at 18 months. The risks of not breastfeeding were critically exposed when flooding in early 2006 contaminated water supplies in Botswana and led to an overwhelming increase in morbidity and infant deaths. In three districts alone, the under fives mortality rate was four times the historical rate. A Centres for Disease Classification (CDC) investigation found that infants who were not breastfed were 50 times more likely to be admitted for diarrhoea. Furthermore, it was not only infants of HIV-positive mothers who were affected, since one-fifth of infants of mothers of unknown HIV status/HIV negative had been weaned from the breast before the age of six months.
The implications of inappropriate infant feeding choice for both HIV transmission and HIV-free survival are the topic of a third research piece by Tanya Doherty et al from South Africa. An observational study on infant feeding intention was carried out in three sites in South Africa, with baseline infant mortality rates ranging from 30 -99/1000 live births. Such levels would not be out of place in many emergency contexts. The study found that inadequate counselling led to both inappropriate choices to breastfeed and to formula feed. Inappropriate formula feeders had a three times greater risk of HIV transmission or death compared to women who appropriately chose to formula feed. The infant feeding choices and practices led to much higher than expected rates of late HIV transmission in two of the three sites.
Moving away from Southern Africa but keeping to the infant feeding theme, a third field article by Mary Corbett and Ali Maclaine (SC UK) details the widespread violations of the International Code of Marketing of Breastmilk Substitutes (the Code) and weak implementation of the Operational Guidance on Infant and Young Child Feeding in Indonesia and Lebanon. The SC UK experiences have also been shared at a recent international strategy meeting on infant feeding in emergencies (IFE) hosted by the ENN in Oxford and summarised in this issue. Attended by sixty delegates from around the world, the purpose of this strategy meeting, called by the IFE Core Group, was to identify key constraints to appropriate infant feeding in emergencies and steps to address these. New and compelling evidence from Indonesia presented at the meeting showed how donations of infant formula significantly increased formula milk consumption in under two year olds, that was associated with a significant rise in diar-rhoea. More positively, examples from Indonesia and Dadaab, Kenya showed that breastfeeding counselling can improve feeding practices in emergencies. Coupled with the Southern Africa PMTCT experiences, there is now accumulating evidence demonstrating the risks of not breastfeeding in emergency contexts. Yet, breastfeeding support as an early emergency intervention still does not feature on the response radar. Artificially fed infants fare little better, at best receiving inconsistent, and poorly monitored supplies of infant formula. So how can we move this forward? The IFE Meeting participants produced firm, practical action points. Good turn out at the meeting showed how concern about IFE has certainly grown in the last six years. ENN accepted the invitation to join the UNICEF led Inter-Agency Standing Committee (IASC) nutrition cluster to represent the IFE Core Group and increase the profile of IFE in this forum. But there is still a long way to go. Donors were conspicuous by their absence at the Oxford meeting - out of 22 invited, only one attended. Without greater commitment from all key actors we are unlikely to see significant improvements any time soon in the way infants are supported during humanitarian crises. Non-IFE or HIV related topics covered in this issue of Field Exchange include a field article by Mary Corbett, which describes the use of 'multi-storey' gardens in refugee Dadaab and Kakuma refugees camps in western Kenya. Using little more than tin cans, rocks and cereal bags, refugees have been able to grow vegetables all year round with limited amounts of water. As a result, dietary quality has significantly improved. There is also a research piece about the experience of using cash for work programming in conflict affected Somalia. The article seems to show that cash can be used effectively as a resource transfer in conflict situations. Finally, a summary of a the Ethiopian Child Survival Survey in 2004, which examined the impact of the 2002/3 drought on mortality, shows that although most mortality occurred in drought affected areas, the mortality was principally a result of chronic factors rather than acute food shortages. The authors concluded that intervention impact on mortality would have been greater if the focus of interventions had been more on water provision and livelihoods, e.g. livestock ownership, rather than provision of food aid. As you will see there are lots of new experiences to mull over in this issue of Field Exchange. Please keep your experiences from the field coming.
Experiences from Indonesia and Lebanon
Multi-storey gardens to support food security
Focus on Southern Africa
The Triple Threat: Southern Africa's emergency behind the emergency
Exit strategies in OVC programming in Namibia
Junior Farmer Field Life Schools in Namibia and Swaziland
Starting up JFFLS - Observations from Caprivi region, Namibia
Diarrhoea risk associated with not breastfeeding in Botswana
The effects of HIV on Botswana's development progress
Infant feeding strategies and PMTCT - Mashi trial from Botswana
Counselling on infant feeding choice: Some practical realities from South Africa
The Centre for Counselling, Nutrition and Health Care (COUNSENUTH)
Improving food security in vulnerable households in Swaziland Information System
Evaluation of WFP relief operations in Angola
Community-based Therapeutic Care (CTC): A Field Manual
Food Security, Nutrition and HIV/AIDS in Relief and Development
New UNHCR Policy on handling Milk Products
Commentary: Regional Training on Integrated Management of Severe Malnutrition
Nutrition Manual for Humanitarian Action
Strategy Meeting on Infant Feeding in Emergencies
New WHO growth standards
Support the Operational Guidance
Food Security Distance Learning Course Launched
Updated CD on IFE
People in Aid