Field Exchange Oct 2008: No. 34
Issue 34 of Field Exchange has a special focus on infant and young child feeding in emergencies (IFE) and is dedicated to the memory of Tom Marchione.
Leading the IFE 'show' is an extended field article from the UNICEF team in Indonesia, sharing their IFE experiences in the aftermath of the earthquake in 2006. On reading the piece you may well get that 'deja-vu' feeling - mass arrival and untargeted distribution of infant formula, milk powder, and commercial baby foods to mothers and children. Monitoring was almost non-existent. Coordination proved a big challenge despite the cluster mechanism being in place - infant and young child feeding falling between cluster 'camps' until finally being integrated into the Reproductive Health Cluster. We have described similar experiences many times in Field Exchange, including my own in FYR Macedonia in 1999. But this article goes further than any of the others we have featured. First, the team presents evidence that indiscriminate distribution of breastmilk substitutes (BMS) makes babies sick. Eighty per cent of under 2 year olds had received BMS in the previous 24 hours. Less than one-third of the infants (32%) under the age of 6 months old had ever consumed infant formula before the earthquake increasing to 43% during the emergency response. Pre-earthquake diarrhoea prevalence stood at 1% - 7%, increasing to 29%. Furthermore, diarrhoea prevalence in under 2 year olds was double amongst those who received donations of BMS (25.4%) as compared to those who did not (11.5%).
Faced with deteriorating feeding practices and increased morbidity in a population with typically poor feeding practices and now awash with milk powder, the team rose to the challenge. They responded through a combination of high level advocacy, of targeted media materials and developed an innovative system of skilled breastfeeding support to mothers, 'cascading' from trainer to peerto- peer support. This had an immediate effect - amongst 54 post-earthquake newborns assessed, nearly all initiated breastfeeding within one hour of birth and over 63% were exclusively breastfeeding regardless of access to free BMS. Months later, reported exclusive breastfeeding rates in a surveyed group were still way above pre-emergency levels. The intervention had a knock on effect on national breastfeeding awareness and capacity, and strengthened ongoing national programming.
But why should staff have to intervene to prevent the damaging effect of aid? This type of experience was one of the driving forces behind a regional workshop on IFE held in Bali, Indonesia earlier this year and summarised in this issue. Funded by the UNICEF-led Nutrition Cluster and organised by the ENN/IFE Core Group in collaboration with UNICEF and the MOH Indonesia, the focus was on improving emergency preparedness and the early humanitarian response on IFE. Participants from 16 countries in the region attended. Almost all countries at the workshop had experienced receiving large, unsolicited donations of infant formula and other milk products during emergencies. The experiences of two countries, in particular, gave some valuable insight into the complexities behind handling this aid response, and have been written up as field articles in this issue.
Sawsan Rawas, a Nutrition Specialist with UNICEF DPRK, describes the extensive diplomatic efforts, at national, regional and international level, to avert donations of BMS coming in aid in response to severe flooding in August 2007. Significantly, even when pending donations were identified, there was great difficulty in preventing or diverting them. Staff spent considerable time on advocacy and 'containment'. The author concluded that advocacy and raising awareness were essential in preparedness for these challenges and the experiences from the Philippines provided some inspiration for how to to go about doing this.
The Philippines initiative to prevent donations of BMS, described by Ms Florinda Panlilio, of the Department of Health, Philippines, was prompted by the "fragmented, independent and donor-driven assistance" that arrived for the victims of Typhoon Reming in 2007. Early, widespread, and often unmonitored donations of infant formula and assorted powdered milk were made by non-governmental organisations (NGOs), government agencies, and schools to the disaster sites. One key action taken by the Philippine Disaster Management System to prevent this recurring has been the development of an administrative order on the acceptance of foreign and local donations during emergencies and disasters, prohibiting the acceptance of donated infant formula, breastmilk substitutes, feeding bottles, artificial nipples, and teats. This has been communicated to foreign embassies represented in the Philippines. Both the DPRK's and Philippines' experiences highlight the tensions that can exist between the politics of aid and best practice.
Aluded to earlier, the regional workshop on IFE in Bali was considered a success and an engagement at country level that really marked new territory. Outputs included country action plans, a model regional joint statement on IFE and a pledge for action by the individual participants. However, lack of donor involvement was frustrating - none of the invited regional or international representatives of bilateral donors attended, breaking their previous attendance record of one at an IFE strategy meeting in Oxford in 2006. Lack of donor commitment to addressing undernutrition is the subject of a summarised research paper in this issue of Field Exchange. Here, the authors describe how nutrition in the EC and DFID is everybody's concern but no one's responsibility. Sadly, the ENN only has to scan its participant lists from previous meetings, as well as its Field Exchange distribution list, to confirm these findings. With some notable exceptions, nutrition remains a low priority amongst many major donors.
Some sense of the evolution of collaborative efforts on IFE over the past 8 years or so, is reflected in the interview with IBFAN-GIFA on page 39, one of the founding members of the 'IFE Core Group' in 1998, and a stalwart member ever since. There is always the risk that those who are passionate about a subject are seen as extremist by another - indeed, the area of infant and young child feeding seems to be one particularly fraught with emotive 'baggage'. Critically, what the interview with Lida Lhotska and Rebecca Norton reflects is that breastfeeding protection and support, as one of the cornerstones of IFE, is less an idealology and more a well-grounded and evidence based strategy in child survival. How to 'make it happen' in emergencies is fundamentally what drives this group.
'Making it happen' on the infant and young child feeding (IYCF) front is certainly picking up pace on the international agenda. As we go to press, a number of large initiatives/meetings to address child undernutrition in high burden areas are taking place, spearheaded by MSF's global malnutrition campaign "Starved for Attention: the neglected crisis of childhood malnutrition". This impetus offers a real opportunity to target attention, resources and innovation to maternal and reproductive health and feeding and care of children 0-2 years of age. However much of the attention currently centres on the scale up of Ready to Use Foods (RUFs) for treatment and prevention of moderate malnutrition, encouraged by the success of their use in community-based management of severe acute malnutrition. Certainly the development of the Ready to Use Therapeutic Foods (RUTF) formulation that allowed high specification take-home rations was a key element of its success, but community mobilisation and engagement is, many would argue, just as important. Infant feeding may be the mothers' final responsibility, but is a family affair, and community-based approaches to managing malnutrition offer a great 'window of opportunity' to address IYCF early and at ground level.
There is a risk that in our drive to move forward on child undernutrition, we limit ourselves (perhaps unconsciously) to what we as individuals or as agencies consider is 'doable' or that conforms with the 'status quo'. Locating interventions to address child undernutrition in a comprehensive global framework on infant and young child feeding should help - both to establish an individual agency's own capacity and/or to create the right alliances to address infant and young child feeding in a sustainable and sensitive manner. We should take care that in our race to deal with malnutrition and all the talk of 'medicine foods', we do not medicalise infant and young child feeding any more than is necessary. We should not, as one seasoned humanitarian at a recent international meeting on child undernutrition cautioned, let self-interest and ideologies get in the way of making progress. And, perhaps most fundamental of all, we need to re-appreciate the "inherent human value" of food, eloquently described by Tom Marchione in his views piece (p25).
Although this issue has a special focus on IFE, there are many non-IFE related pieces to enjoy. An interesting 'take' on the global food crisis is explored in a field article that considers the role that financial speculation in food commodity markets has played in contributing to increases in food prices. The authors - Noemi Pace, Andrew Seal, and Anthony Costello at CIHD - feel there is "compelling evidence" that speculation in food derivatives has artificially increased demand and has had an adverse effect on global food prices. Predicting the effect of escalating global food prices on the cost of putting food on the table may be one application of a novel tool developed by Save the Children UK and described in an article by Vicky Sibson. The 'Cost of the Diet' software programme is used to determine the affordability of a nutritionally 'ideal' diet, using local foods. Case studies from Bangladesh and Tanzania, found that the cost exceeded the income of the poorest households, and were likely an underestimation. This tool may have valuable application in monitoring and predicting the impact of food price rises on the poorest households. Soaring global food prices has seen agencies rise to the challenge of optimising the use of food as aid and expand the use of cash based interventions. A field article by Hanna Mattinen and Loreto Palmaera of ACF describes a voucher milling scheme piloted amongst the displaced population in Dafur. As well as reducing the sale of the general food ration (to meet the costs of milling) and greater purchase of fresh foods, beneficiaries were able to invest in their children's education and the local economy was boosted through the support of the local millers.
Finally, I'd like to highlight some good news on a number of projects the ENN will be undertaking and on which we look forward to collaborating with you all on. Two research projects deal with emergency SFPs - the first to define and implement minimum reporting standards on SFP, and the second to increase understanding of the role of default and access in programme performance. We will also be piloting an online interactive forum (in essence 'NGOnut revisited') to establish timely technical assistance to field workers - watch our website for details and as ever, contact us with suggestions and feedback, as well as submissions for Field Exchange. Busy times!
Any contributions, ideas or topics for future issues of Field Exchange? Contact the editorial team on email: email@example.com