Review of Policies and Guidelines on Infant Feeding in Emergencies: Common Ground and Gaps

Recent crises in regions where exclusive breastfeeding is not the norm have highlighted the importance of effective policies and guidelines on infant feeding in emergencies. In 1993, UNICEF compiled a collection of policy and guideline documents relating to the feeding of infants in emergency situations. In June 2000 Save the Children, UK, UNICEF and the Institute of Child Health undertook a review of those documents, updating the list and identifying the common ground that exists among the different policies. The review also analysed the consistency of the policy framework, and highlighted important areas where guidelines are missing or unclear. This article is an attempt to share more widely the main issues arising from this review. The key conclusions were that, in general, there is consensus on what constitutes best practice in infant feeding, however, the lack of clarity in the respective responsibilities of key UN agencies (in particular UNICEF, UNHCR and WFP) over issues relating to co-ordination of activities which affect infant-feeding interventions constrains the implementation of systems to support best practice. Furthermore, the weak evidence base on effective and appropriate intervention strategies for supporting optimal infant feeding in emergencies means that there is poor understanding of the practical tasks needed to support mothers and minimise infant morbidity and mortality. We, therefore, have two key recommendations: first that the operational UN agencies, primarily UNICEF, examine the options for improving co-ordination on a range of activities to uphold best practice of infant feeding in emergencies; second, that urgent attention be given to developing and supporting operational research on the promotion of optimal infant-feeding interventions.     

From Policy to Practice: Challenges in Infant Feeding in Emergencies During the Balkan Crisis

The preparation and dissemination of policy statements are necessary but insufficient to prevent the inappropriate use of infant-feeding products in emergencies. The widespread failure of humanitarian agencies operating in the Balkan crisis to act in accordance with international policies and recommendations provides a recent example of the failure to translate infant-feeding policies into practice. This article explores the underlying reasons behind the failures which include: (1) the weak institutionalisation of policies; (2) the massive quantities of unsolicited donations of infant-feeding products: (3) the absence of monitoring systems; (4) inadequate co-ordination mechanisms; (5) the high costs of correcting mistakes; and (6) the cumulative effects of poor practice. Efforts to uphold best practice during the crisis are also documented. Finally, the article identifies actions that could be undertaken in advance of and during future emergencies to enhance the application of infant feeding policies in emergencies.     

Humanitarian information systems and emergencies in the Greater Horn of Africa: logical components and logical linkages

Natural and man-made emergencies are regular occurrences in the Greater Horn of Africa region. The underlying impoverishment of whole populations is increasing, making it more difficult to distinguish between humanitarian crises triggered by shocks and those resulting from chronic poverty. Shocks and hazards can no longer be seen as one-off events that trigger a one-time response. In countries that are both poor and exposed to frequent episodes of debilitating drought or chronic conflict, information needs tend to be different from the straightforward early warning/commodity accounting models of information systems that have proven reliable in past emergencies. This paper describes the interdependent components of a humanitarian information system appropriate for this kind of complex environment, noting the analytical links between the components and operational links to programme and policy. By examining a series of case studies from the Greater Horn region, the paper demonstrates that systems lacking one or more of these components will fail to provide adequate information--and thus incur humanitarian costs. While information always comes with a cost, the price of poor information--or none--is higher. And in situations of chronic vulnerability, in which development interventions are likely to be interspersed with both safety nets and emergency interventions on a recurrent basis, investment in improved information is a good investment from both a humanitarian and a financial viewpoint.     

HIV risk and prevention in emergency-affected populations: a review

While basic guidelines on HIV prevention in emergencies have been available for several years, international agencies involved in the provision of health services have not placed sufficient priority on the prevention of the human immune deficiency virus (HIV) and other sexually transmitted infections (STIs) in complex emergencies. This paper reviews the factors that may increase the risk of HIV transmission in populations affected by complex emergencies and outlines recommendations for research and programmes. Research into the most appropriate methods of carrying out HIV surveillance and interventions in these settings is needed. In the post-emergency phase programmes need to be far more extensive than those offered under the Minimal Initial Services Package (MISP). While the potential for stigmatization represents an important constraint, there is a need to prioritize HIV/STI interventions in order to prevent HIV transmission in emergency-affected populations themselves, as well as to contribute to regional control of the epidemic.     

Violence and complex humanitarian emergencies: implications for livelihoods models

This paper explores the nature of the violence that characterises complex humanitarian emergencies and the related implications for modelling livelihoods systems. While noting the importance of livelihoods approaches in complex humanitarian emergencies, it deliberates the limitations of sustainable livelihoods frameworks when applied in environments marked by protracted instability. Adaptations to the model are discussed, with a particular focus on the relationships among violence, assets and liabilities within livelihoods systems. Political economy of violence theories intimate that the assets on which livelihoods systems are constructed in peaceful times may instead become life-and livelihood-threatening liabilities in periods of conflict. Adaptations to livelihood systems in violent settings require that analysts consider violence from policy, institutional and process perspectives. It is suggested that vulnerability should be re-conceptualised as endogenous to livelihoods systems in violent settings. Building on the work of others, a livelihoods model adapted for complex humanitarian emergencies is presented.     

Estimating the Capacity of Warehouses

The required capacity of warehouses for use in humanitarian emergencies is very often overestimated. This paper reviews some of the principal factors affecting warehouse capacity for emergency humanitarian operations in developing countries. The growing difference between modern commercial warehousing practice and the approach typically used in humanitarian emergencies is highlighted. The principal constraints on capacity are identified and discussed. A simple method for estimating the storage capacity of warehouses for emergency operations is then presented.     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.     

The Afghan experiment: the Afghan Support Group, Principled Common Programming and the Strategic Framework

From 1997 to 2001, the international community put in place unique mechanisms to address the challenges to providing humanitarian assistance in Taliban-run Afghanistan. The Afghan Support Group (ASG), Principled Common Programming (PCP) and the Strategic Framework (SF) constituted a precedent-setting experiment that consumed thousands of hours in implementation in donor capitals and in the field. This article, written from the perspective of the leading donor of humanitarian assistance to Afghanistan, assesses the extent to which this Afghan experiment succeeded in increasing coherence on assistance policy issues, improving efficiency in assistance programmes and added synergy between assistance and peace efforts; identifies factors that limited further achievements; suggests how the mechanisms could have been improved; and analyses whether the overall effort politicised humanitarian assistance. The article concludes that the record of achievement was sufficiently promising that the ASG/PCP/SF experiment should be considered for application in other complex humanitarian emergencies.     

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health‐related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.     

Changing tracks as situations change: humanitarian and health response along the Liberia–Côte d'Ivoire border

In recent years, protracted crises and fragile post‐conflict settings have challenged the co‐existence, and even the linear continuum, of relief and development aid. Forced migration has tested humanitarian and development paradigms where sudden‐onset emergencies, violence and displacement arise alongside ongoing development work. Drawing on Médecins Sans Frontières interventions in the region from December 2010 to May 2011, this paper examines aid and healthcare responses to displacement in Côte d'Ivoire and Liberia; it focuses on challenges to the maintenance of preparedness for such foreseeable emergencies and to adaptation in response to changing situations of displacement and insecurity. This ‘backsliding’ from development to emergency remains a substantial challenge to aid; yet, in exactly such cases, it also presents the opportunity to ensure access to medical care that is much more urgently needed in times of crisis, including the suspension of user fees for medical care.     

The application of geographic information systems and global positioning systems in humanitarian emergencies: lessons learned,programme implications and future research

Geographic information systems (GIS), global positioning systems and remote sensing have been increasingly used in public health settings since the 1990s, but application of these methods in humanitarian emergencies has been less documented. Recent areas of application of GIS methods in humanitarian emergencies include hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and programme integration; and programme monitoring and evaluation. The main use of GIS in these areas is to provide maps for decision-making and advocacy, which allow overlaying types of information that may not normally be linked. GIS is also used to improve data collection in the field (for example, for rapid health assessments or mortality surveys). Development of GIS methods requires further research. Although GIS methods may save resources and reduce error, initial investment in equipment and capacity building may be substantial. Especially in humanitarian emergencies, equipment and methodologies must be practical and appropriate for field use. Add-on software to process GIS data needs to be developed and modified. As equipment becomes more user-friendly and costs decrease, GIS will become more of a routine tool for humanitarian aid organisations in humanitarian emergencies, and new and innovative uses will evolve.     

Revisiting Sphere: new standards of service delivery for new trends in protracted displacement

The proportion of people living in protracted displacement, as well as the duration of this displacement, is increasing. International humanitarian standards for services provided in protracted displacement are based on the Sphere Standards, which were formulated using evidence and experience from acute phase emergencies. However, the majority of protracted emergencies are in the post‐emergency phase. This paper discusses trends in displacement, outlines reasons why using the Sphere Standards as minimum standards of service provision in protracted displacement does not adequately meet the needs of these populations, and analyses areas where greater standards of service provision are necessary. An expansion of the evidence base regarding determinants of morbidity and mortality in protracted emergencies is needed. This, followed by a joint approach to designing new, effective standards focused on proactive policies, will allow the humanitarian community more appropriately to serve and enable the millions of people currently living in protracted displacement.     

Apples, Pears and Porridge: The Origins and Impact of the Search for ''Coherence'' between Humanitarian and Political Responses to Chronic Political Emergencies

During the 1990s a consensus emerged within the international humanitarian system that there was a need to enhance the 'coherence' between humanitarian and political responses to complex political emergencies. Closer integration between aid and political responses was seen to be necessary in order to address the root causes of conflict-induced crises, and to ensure that aid did not exacerbate political tensions. This paper explores the theory and practice of coherence over the past decade. It argues that, by sleight of hand, the coherence agenda has been reinterpreted such that humanitarian action has become the primary form of political action, rather than merely a substitute for it. The coherence agenda has been driven by geopolitical events, domestic policy considerations in donor countries and the more parochial concerns of aid policy, and is reflected in a number of substantive changes in the humanitarian architecture. Many of the tenets of this 'new humanitarianism' have been embraced by the majority of relief agencies, and thus legitimised it. The paper concludes that political humanitarianism, as opposed to active engagement by political and military actors, is flawed ethically and technically. It will provide neither an effective palliative for the ill effects of war, nor address its causes.     

Establishing moral bearings: ethics and expatriate health care professionals in humanitarian work

Expatriate health care professionals frequently participate in international responses to natural disasters and humanitarian emergencies. This field of practice presents important clinical, logistical and ethical challenges for clinicians. This paper considers the ethics of health care practice in humanitarian contexts. It examines features that contribute to forming the moral landscape of humanitarian work, and discusses normative guidelines and approaches that are relevant for this work. These tools and frameworks provide important ethics resources for humanitarian settings. Finally, it elaborates a set of questions that can aid health care professionals as they analyse ethical issues that they experience in the field. The proposed process can assist clinicians as they seek to establish their moral bearings in situations of ethical complexity and uncertainty. Identifying and developing ethics resources and vocabulary for clinical practice in humanitarian work will help health care professionals provide ethically sound care to patients and communities.     

Normalising the Crisis in Africa

Developmental relief has become the central doctrine of 'good practice' in humanitarian responses to complex political emergencies. This is despite the fact that a proliferation of such emergencies reflects a failure of development for people in those countries in crisis. Drawing on case study material from Sudan, Somalia, Rwanda and Uganda, this paper challenges assumptions made about the efficacy of developmental relief models in complex emergencies. The trend towards developmental relief practices coincides with an increasing acceptance of higher levels of humanitarian distress in Africa. Myths of aid dependency and the pursuit of sustainable programming in the midst of war are linked to a global reduction in aid. The mantra of 'local solutions to local problems' locates the causes of crises firmly within those societies in crisis. It provides a premise for international disengagement, and the denial of international responsibility for the genesis and prolongation of humanitarian crises in Africa. Assigning solutions to the poor, the marginalised and victimised through enhanced 'participation' and local financing of services sustains a myth that development is occurring, when in fact levels of distress are rising.     

Preventing corruption in humanitarian assistance: perceptions, gaps and challenges

Corruption is a threat to the purpose of humanitarian assistance. Until fairly recently, humanitarian assistance has not been considered an important arena in broader efforts aimed at curbing corruption, and corruption has not always been considered a particularly important concern for humanitarian assistance despite the obviously challenging nature of the context of humanitarian emergencies. Corruption, though, is a threat to humanitarian action because it can prevent assistance from getting to the people who most need it, and because it can potentially undermine public support for such assistance. This paper examines perceptions of corruption and its affects, documents best practices, and outlines gaps in understanding. It suggests recommendations for improving the capacity of humanitarian agencies to prevent and manage the risk of corruption. Agencies have taken steps to combat corruption and improve accountability--downwards and upwards--but scope remains for improvement and for greater sharing of learning and good practice.     

Media messages and the needs of infants and young children after Cyclone Nargis and the WenChuan Earthquake

Infants and young children are vulnerable in emergencies. The media plays an important role in aid delivery and has a positive impact when reports are accurate. However, the media has been implicated in encouraging harmful aid in the form of donations of infant formula and other milk products. Internet‐based media reports were collected after Cyclone Nargis in Myanmar and the WenChuan Earthquake in China (2008) and examined for content related to infant and young child feeding. Common messages identified included that: babies are vulnerable; stress prevents breastfeeding; and providing infant formula saves lives. Messages rarely reported included that: artificial feeding is dangerous; and breastfeeding protects infants. This analysis suggests that current patterns of media reporting may encourage harmful aid and increase child morbidity and mortality. Aid organisations should encourage the media to report accurately on the needs of infant and young children in emergencies so as to improve aid delivery.     

Humanitarianism and Local Service Institutions in Angola

The role of local service institutions is not a major focus of current discourse on humanitarianism and complex emergencies. These institutions, in the few places where they are mentioned, are usually presented as either the seed of civil society and future democracy, or as pawns and components of the predatory economic, political and military élites. Few would deny that examples can be found which conform to both of these stereotypes. This simplistic representation of local institutions ignores the perspectives of the actors themselves — the nurses, extension agents, school teachers and others who actually staff most NGO-supported projects. The debate has focused on what ‘we’ should do; the moral dilemmas of aid agencies and their expatriate staff, inevitably leading to the question of whether or not humanitarian workers should stay or leave situations in which aid may be causing more harm than good. Without denying the fundamental importance of these issues, it is important to consider also how the discourse has unfortunately moved away from those humanitarian workers who have no such choice, since they live there. Current concerns about keeping humanitarian aid from feeding local political and military struggles may inadvertently and paradoxically serve to constrain room for man?uvre in the field, particularly among those individuals with the greatest tacit understanding of the predatory environment. There is a need to understand how actors in local service institutions make sense of their own situations, including the factors which frame their moral dilemmas and their day-to-day choices. By analysing the organisational processes within local service institutions, this study is intended to provoke consideration of how these individuals and their institutions may be effectively supported in complex emergencies through a focus on how they themselves deal with danger and complexity. It is suggested that there is a value in considering the lessons learnt in recent years about how service organisations in the North function in turbulent environments. This experience points to the importance of allowing workers the discretion to develop a relationship with their clients, and in so doing make sense of a confusing and ambivalent environment.     

The humanitarian common logistic operating picture: a solution to the inter‐agency coordination challenge

Although significant progress has been made in developing the practice of humanitarian logistics, further improvements in efficiency and effectiveness have the potential to save lives and reduce suffering. This paper explores how the military/emergency services’ concept of a common operating picture (COP) can be adapted to the humanitarian logistics context, and analyses a practical and proven approach to addressing the key challenge of inter‐agency coordination and decision‐making. Successful adaptation could provide the mechanism through which predicted and actual demands, together with the location and status of material in transit, are captured, evaluated, and presented in real time as the basis for enhanced decision‐making between actors in the humanitarian supply network. Through the introduction of a humanitarian logistics COP and its linkages to national disaster management systems, local communities and countries affected by disasters and emergencies will be better placed to oversee and manage their response activities.     

Humanitarian Crises: What Determines the Level of Emergency Assistance? Media Coverage,Donor Interests and the Aid Business

This paper proposes a basic hypothesis that the volume of emergency assistance any humanitarian crisis attracts is determined by three main factors working either in conjunction or individually. First, it depends on the intensity of media coverage. Second, it depends on the degree of political interest, particularly related to security, that donor governments have in a particular region. Third, the volume of emergency aid depends on strength of humanitarian NGOs and international organisations present in a specific country experiencing a humanitarian emergency. The empirical analysis of a number of emergency situations is carried out based on material that has never been published before. The paper concludes that only occasionally do the media play a decisive role in influencing donors. Rather, the security interests of Western donors are important together with the presence and strength of humanitarian stakeholders, such as NGOs and international organisations lobbying donor governments.