Supporting breastfeeding in emergencies: protecting women's reproductive rights and maternal and infant health

Women have the right to support that enables them to breastfeed. Supporting breastfeeding in emergencies is important because artificial feeding places mothers and children at risk. In emergencies, artificial feeding is dangerous to the infant, difficult and requires substantial resources. In contrast, breastfeeding guards infant health. It is also protective against postpartum haemorrhage, maternal depletion, maternal anaemia and closely spaced births and should therefore concern not only nutritionists, but also those involved in reproductive health. However, it is common for women's ability to breastfeed to be undermined in emergencies by the indiscriminate distribution of breast-milk substitutes and the absence of breastfeeding support. Controlling the distribution of breast-milk substitutes, providing supportive environments, and appropriate medical and practical assistance to breastfeeding women safeguards the health and well-being of mothers and babies. Greater collaboration between the nutrition and reproductive health sectors is required to promote best practice in protecting breastfeeding women and their children in emergencies.     

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.     

Zimbabwe's Child Supplementary Feeding Programme: a re-assessment using household survey data

In 1992-3 and 1995-6, Zimbabwe used a Child Supplementary Feeding Programme (CSFP) to combat child malnutrition during drought-induced emergencies. Previous evaluations of the CSFP relied on routine administrative data and key informant interviews and made only cursory use of available household survey data. These evaluations concluded that the CSFP was effective in preventing an increase in malnutrition among children under five, especially in 1992-3. The more-detailed analysis of household surveys provided in this article suggests that CSFP coverage was generally patchy and disappointingly low, especially in 1995-6. There is little evidence that children from poor or nutritionally vulnerable households got preferential access to supplementary feeding. The CSFP failed to feed many malnourished and nutritionally vulnerable children even in areas where the programme was operating. Household survey evidence suggests that the CSFP's impact on nutritional status was likely marginal, especially in 1995-6.     

Human immuno-deficiency virus and infant feeding in complex humanitarian emergencies: priorities and policy considerations

Issues surrounding mother-to-child transmission of HIV/AIDS pose considerable challenges in complex humanitarian emergencies. The risk of vertical transmission through breastfeeding is well recognised, but safe alternatives are limited by the social, economic and environmental conditions of emergency situations. In 2000, the World Health Organisation published a technical report on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-agency Task Team on Mother-to-child Transmission of HIV which outlined revised recommendations for infant feeding by HIV-positive women. This paper outlines reasons why these recommendations may be insufficient during the initial stages of complex humanitarian emergencies and proposes recommendations for establishing infant-feeding policy. Methods of mother-to-child transmission of HIV are reviewed and recent research findings are discussed. Rationale for modifying the 2000 UNFPA/UNICEF/WHO/UNAIDS infant-feeding recommendations in complex emergency situations is explored from the perspective of the infant, the mother and humanitarian field staff. Ethical limitations and future priorities are considered. The paper concludes with recommendations and a policy decision-making framework for consideration during the initial stages of humanitarian crises.     

Infant feeding in emergencies

Recent experience of emergency relief operations in middle-income countries has shown that infant feeding issues can greatly complicate attempts to protect infant health. The two main problems are: how to protect and support breastfeeding in communities where it is no longer the norm and how to assist artificially fed infants without exposing them to the dramatically increased risks associated with artificial feeding under disaster conditions. This article explores the underlying issues and makes a number of recommendations for policy and programmes.     

Innocents Abroad: Western Fantasies of Childhood and the Iconography of Emergencies

In this paper I explore the emotional interests maintained by the imagery of children used in Third World emergencies. Boundaries between adult and child are reproduced through relations of paternalism between North and South, such that the infantilisation of the South exemplified in imagery of children works to secure the competence and maturity of the Northern donor. Drawing on both analyses of the cultural origins and meanings of concepts of childhood and psychoanalytic perspectives, I suggest that media coverage of disasters arouses both identification and strategies to ward off and protect from the anxiety this brings. The gendered as well as geographical distribution of qualities of children's innocence and experience are discussed, drawing on both general imagery of children and recent coverage of children and child-saving, particularly in the former Yugoslavia. Developing analyses of 'disaster pornography', the paper explores how children appear as the principal focal objects onto which attention is pinned and as the signifiers of distress. This is at the cost of dehumanizing both children, their families and their cultures, and rendering them passive objects of a western gaze which seeks to confirm its own agency and omnipotence to ward off its own insecurities. While aid organisations and campaigns necessarily engage with, and sometimes collude with, these reactions, the paper ends by suggesting that there may be strategies whereby images of children can function to comment on rather than maintain prevailing colonial and paternalistic relations.     

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.     

Targeting the Vulnerable: A Review of the Necessity and Feasibility of Targeting Vulnerable Households

This article examines whether it is possible to target vulnerable households within a geographically defined area. It looks first at the justification for targeting and then reviews recent practical experience in actually trying to reach vulnerable groups. As complex emergencies increasingly last longer, strategies to target vulnerable households are common in the protracted phase of the emergency. While this is often necessary because of a decline in resources, it is not always justified by an improvement in nutritional status or food security of the beneficiary population.
Common target groups are the poor and the malnourished, but in complex emergencies these are not always the most vulnerable. Moreover, recent practical experience has shown considerable difficulties in targeting the poor. Methods to target the poor rely on community-based relief committees, whose priorities are not necessarily the same as those of external agencies. This paper gives examples of such targeted assistance programmes in Kenya, south Sudan and Tanzania. The paper concludes that situations where targeting vulnerable households is justified and feasible are extremely limited. It is suggested that if targeting has to be done because of scarce resources, this should be done on a geographical basis and on the basis of nutritional status. Case-study material shows that it is essential to understand the political determinants of vulnerability and to design methods that will reach the most vulnerable.     

Targeting the vulnerable: a review of the necessity and feasibility of targeting vulnerable households

This article examines whether it is possible to target vulnerable households within a geographically defined area. It looks first at the justification for targeting and then reviews recent practical experience in actually trying to reach vulnerable groups. As complex emergencies increasingly last longer, strategies to target vulnerable households are common in the protracted phase of the emergency. While this is often necessary because of a decline in resources, it is not always justified by an improvement in nutritional status or food security of the beneficiary population. Common target groups are the poor and the malnourished, but in complex emergencies these are not always the most vulnerable. Moreover, recent practical experience has shown considerable difficulties in targeting the poor. Methods to target the poor rely on community-based relief committees, whose priorities are not necessarily the same as those of external agencies. This paper gives examples of such targeted assistance programmes in Kenya, south Sudan and Tanzania. The paper concludes that situations where targeting vulnerable households is justified and feasible are extremely limited. It is suggested that if targeting has to be done because of scarce resources, this should be done on a geographical basis and on the basis of nutritional status. Case-study material shows that it is essential to understand the political determinants of vulnerability and to design methods that will reach the most vulnerable.     

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.     

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.     

Humanitarian emergencies and military help: some conceptual observations

In 1988 the International Peace Academy, New York, sponsored a study exploring the interface between security and the delivery of humanitarian aid. The aim was to evaluate the possible use of military help to support humanitarian relief workers during armed conflicts. As part of this pioneering work, the authors of this paper discuss the conceptual questions that must be raised before dealing with the associated practical difficulties. It examines those circumstances in which foreign military organizations might offer help in humanitarian emergencies; the nature of contemporary examples of humanitarian need that result in international responses; and the importance of factors which affect how these are perceived. The paper then analyses the pertinent functions that military units might undertake and finally examines the constraints that would apply if such forces were to become involved.     

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.     

Matching response to context in complex political emergencies: 'relief', 'development', 'peace-building' or something in-between?

There is an ongoing debate over the value and pitfalls of the policy and practice of 'linking relief and development' or 'developmental relief' in aid responses to complex political emergencies (CPEs). Driven by concerns about relief creating dependence, sometimes doing harm and failing to address root causes of emergencies despite its high cost, pursuit of both relief and development has become a dominant paradigm among international aid agencies in CPEs as in 'natural' disasters. In CPEs a third objective of 'peace-building' has emerged, along with the logic that development can itself help prevent or resolve conflict and sustain peace. However, this broadening of relief objectives in ongoing CPEs has recently been criticised on a number of counts, central concerns being that it leads to a dilution of commitment to core humanitarian principles and is overly optimistic. This paper addresses these issues in the light of two of the CPEs studied by the COPE project: Eritrea and Somalia/Somaliland. It is argued that the debate has so far suffered from lack of clarity about what we mean by 'relief', 'development' and, for that matter, 'rehabilitation' and 'peace-building'. The wide spectrum of possible aid outcomes does not divide neatly into these categories. The relief-development divide is not always as clear-cut, technically or politically, as the critics claim. Moreover such distinctions, constructed from the point of view of aid programmers, are often of little relevance to the concerns of intended beneficiaries. Second, there has been insufficient attention to context: rather than attempting to generalise within and across CPE cases, a more productive approach would be to examine more closely the conditions under which forms of aid other than basic life support can fruitfully be pursued. This leads to consideration of collective agency capacity to respond effectively to diverse needs in different and changing circumstances.     

Improving the Efficiency and Cost-effectiveness of Food Aid Grain Delivery

Grain food aid averages 13 million tonnes per year. Donors have a duty to deliver food aid grain in an adequate and acceptable condition at least cost. This paper reviews commodity procurement, packaging, inspection, shipping and storage with regard to overall quality assurance and cost-effectiveness. Experience at ports of loading and discharge and in food aid delivery programmes indicates that sufficient attention is rarely paid to quality assurance and loss minimisation. Grain procurement specifications that are normally appropriate for safe handling and storage in temperate climates, particularly moisture content, are commonly inappropriate for tropical climates. The technology for safe delivery of food aid grain is well established but not always implemented. Procurement of food aid grain in developing countries has increased recently, creating a need to improve operational and management aspects of tendering and quality assurance procedures. Such purchases entail potential cost savings but are associated with lengthening delivery lead times for non-urgent consignments. Although woven polypropylene sacks are cheaper to buy than jute ones, the losses associated with handling and storage problems indicate that jute sacks are preferable for food aid delivery.     

Global factors shaping the future of food aid: the implications for WFP

Food aid is a key component of a humanitarian response but its use in other programming contexts is subject to numerous criticisms. Even in humanitarian emergencies food aid is often late, unreliable and out of proportion to other elements of the response. Three major factors will shape the future of food aid. First, mechanisms of food aid governance are being reviewed and may undergo major changes—particularly the Food Aid Convention now that hopes have diminished for an Agreement on Agriculture at the World Trade Organisation. The second significant factor is donor agency trends. Overall levels of food aid have dropped fairly steadily in recent decades and there are several discernible trends in resource allocation, procurement and the use of food aid. The third factor is an emerging body of best practice that will define acceptable standards of food aid programming in the future.     

Conflict, the Continuum and Chronic Emergencies: A Critical Analysis of the Scope for Linking Relief, Rehabilitation and Development Planning in Sudan

The concept of the ‘relief-to-development continuum’ has been the subject of renewed interest in recent years. Concerned by the rise in relief budgets over the past decade and the absolute fall in development aid resources, support has been growing for the concept of developmental relief. In the context of complex political emergencies, it has been argued further that as effective development aid can reduce vulnerability to the impact of natural hazards, so it might also be used to contribute to a process of conflict prevention. In this way, the concept of the relief-development continuum has become entwined with broader discussions about the contribution of official development assistance to conflict management. Drawing on a Review of Operation Lifeline Sudan (OLS), this paper cautions against uncritical application of the concept of the continuum in complex political emergencies, and of rehabilitation in particular, in the current Sudanese context. It argues that in order to move legitimately from relief aid programming to development aid programming, three fundamental conditions must be in place: first, a minimum level of security, respect for human rights and humanitarian access. Second, empirical evidence from the field needs to demonstrate that the emergency is over. Finally, moving from relief to development aid programming is contingent on donor governments accepting the legitimacy of national governmental structures and of the rebel movements. In other words, for donor governments, moving along the continuum is in significant part determined by foreign policy considerations, not only technical ones. Consideration needs to be given to the actual and perceived legitimation of the different movements that a move to rehabilitation might be seen to imply. The paper argues that none of these conditions had been satisfied in Sudan by mid-1997. Instead of a process of normalisation paving the way to long-term development, the current situation in Sudan is better described as a chronic political emergency. In such a context, uncritical pursuit of developmental strategies may negatively affect the welfare of conflict-affected populations.     

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.     

Rehabilitation in Complex Political Emergencies: Is Rebuilding Civil Society the Answer?

The paper examines the challenge of rehabilitation from complex political emergencies (CPEs) and identifies a strategy that is characterised as a civil society rebuilding approach. It focuses on Somalia and a case study of a CARE project that aims to build the capacity of local NGOs. The paper argues that civil society in CPEs is simultaneously being undermined and contested by warring parties and emerging after state collapse. The scope of the paper is limited to one case study and that case study examines only a single aspect of civil society: national and international NGOs. The paper therefore presents tentative and preliminary results based on limited research. However, in reviewing the literature and presenting a way of approaching the subject, it aims to suggest a starting-point for developing a theoretical framework for such research. The paper finds that international agencies have tended to focus on civil society institutions simply as conduits for aid money and that this has tended to create organisations which lack downward accountability, are dependent on donors and are not addressing the wider roles for civil society envisaged in the approach. Rebuilding civil society does hold out the promise of giving non-military interests a stronger voice and starting a process of changing the aid delivery culture. Achieving these objectives, however, will be a slow and largely indigenous process and there is a need for lowered expectations about what outside assistance can achieve