Issue 20 Editorial

Mother with malnourished childern in Benadir Hospital, Mogadishu, Somalia, 1991

I stood perplexed in the bomb blasted shell of what had previously functioned as the regional children's hospital in Somalia's capital, Mogadishu. It was 1991, Somalia was a country gripped by the most brutal of civil wars. Benadir Hospital, Mogadishu acted as a therapeutic feeding centre for malnourished children. I had just been presented with a new admission, a tiny and malnourished infant of about two months of age - Zenab I think her name was. Apparently her mother was severely injured and fighting for her life in another hospital in the city, after the family home had been hit by a shell. Zenab was accompanied by a young aunt who had no children of her own. I remember feeling ill-equipped to deal with Zenab or others like her. She fell outside the standard guidelines for the treatment of severe malnutrition that we had established in the centre. She was 'supposed' to be breastfed and therefore protected from malnutrition. But clearly breastfeeding was not an option here. There were not many like Zenab at the time in Mogadishu but there were some. I remember the correct, but not very helpful, public health message 'breast is best' resounding in my ears. Everything I had learned told me that to buy formula (even if it was available) for this infant was not the right thing to do. I also remember thinking 'how come I don't know what to do with this case - someone somewhere must have been in this situation before and what did they do?'

Field Exchange was established to help field workers like me in similar situations. By providing a forum for sharing field experiences, the hope was that Field Exchange would allow challenges and lessons to be captured rather than lost and that guidelines would, as a result, become more contemporary and better reflect the field reality. It was also hoped that a publication like Field Exchange would help expose 'experts' and researchers to greater field reality.

Twelve years on and much has changed. Significant advances have been made in the food and nutrition sector of emergency response. Field Exchange has attempted to keep its audience up to date. However, there are still many areas where there is inconclusive research and where there is insufficient consensus and guidance. For example, in spite of all the advances in the management of severe malnutrition as well as in therapeutic foods, consensus among experts on how to manage young severely malnourished infants has yet to be achieved (see Debate on the Management of Severe Malnutrition, page 16).

There are also times when the need to demonstrate consensus seems to stifle debate and advance. It appears that in some situations, 'experts' would rather ignore field experiences (that often fail to meet rigorous research design standards due to the emergency context) which may call into question aspects of current guidelines. This may be done in order to ensure there is consensus between guidelines, out of a legitimate concern that those in the field will be confused if there is more than one message. Whatever the reason, I believe Field Exchange has a responsibility to report independently, encourage debate and advance. This is not always easy and there have been several occasions where the ENN has come under considerable pressure not to publish what was seen as controversial debate or sensitive information.

Readers of Field Exchange will also be aware of the lack of unanimous guidance on supporting safe infant feeding strategies in emergency affected areas, where bottle and mixed feeding is common. This situation may partly reflect the blind adherence to 'dogma' and the fear that recommending anything other than breastfeeding will open the flood gates for the formula industry who will then go on to win 'the battle against the breast'. The assessment findings on infant feeding in Iraq (page 6) highlight how, for political reasons, formula milk is part of the general ration distribution. Though this contravenes best practice and negatively influences the prevalence of breastfeeding, there is a lack of clear practical guidance on appropriate interventions in such a context.

The experience contrasts with recent findings from Uganda (page 15), where HIVpositive mothers whom, after counselling, chose to use formula were not able to access the commodity. Both situations leave a lot to be desired if safe and appropriate infant feeding is to be achieved. Some agencies and institutions are working on this issue but more research is required. I commend the interagency 'core group on infant feeding in emergencies' for their strident efforts to develop practical guidance for field practice in this area.

In the absence of conclusive research, the sharing of programmatic experience is vital. Field workers need to 'keep it real', write in and describe the actual problems which are being encountered and the measures taken to overcome these, so that appropriate guidance can follow. Technical experts need to be open to debate and allow field experience to influence guidance and policy. They need to be pragmatic and develop guidelines for situations which actually occur e.g. where breastfeeding is not an option. More than anything, child well being should be the focus of efforts to improve practice.

So what happened to Zenab? The fact is I made the best of a difficult situation - something field workers often have to do. I scoured through the limited resources available to me, mainly from Oxfam feeding kits or what hadn't been looted from the agency's office and eventually found a 'homemade BMS recipe'. Zaneb survived, mainly as a result of the care provided by her aunt, but did not grow very well. Today I would manage cases like this differently, thanks to the guidelines that have been produced and work done in this area resulting largely from the sharing of field experiences.

As this is my last issue of Field Exchange as ENN director, I would like to thank the Interagency Group of Nutritionists responsible for conceiving of the ENN and supporting it's work over the years. I wish Marie Mc Grath and Jeremy Shoham every success in continuing the ENN and Field Exchange.

Fiona O'Reilly

Fiona O'Reilly

We would like to draw your attention to the fact that this is the last issue of Field Exchange in phase three of the ENN. Sadly, this coincides with the departure of our colleague, Fiona O'Reilly, who is retiring from the ENN as co-director. Fiona and I established the ENN in Trinity College, Dublin at the end of 1996. As a resident of Dublin, it fell to Fiona to establish the office and deal with all practicalities related to running a publication as well as the other activities that the ENN have become increasingly involved with over the years. Fiona managed many of these tasks single-handedly and had to learn a huge variety of skills 'on the hoof'. These included desktop publishing, financial accounting, company legal affairs and staff management. Fiona has made many invaluable contributions to the ENN. Most notable amongst these has been the development of a unique presentational style for Field Exchange, which is the envy of many other publications. Fiona has also insisted on establishing procedures, which ensured that information in Field Exchange was corroborated and correctly attributed. She effectively became the 'political editor' in that she ensured that potentially sensitive pieces were thoroughly verified and opportunities given for others to present their views. The fact that we have never been involved in litigation (so far) is largely due to Fiona's developed 'political antennae'.
Fiona has also been enormously influential in the area of infant feeding in emergencies, where ENN has been an active member of a core group of agencies involved in developing training material for field workers. Fiona's ever practical and pragmatic approach, and insight into field reality has greatly contributed to field-friendly guidance. No doubt Fiona will remain engaged with this work in the future, however her contribution so far is marked by some words from the core group members below.
The ENN owes Fiona a considerable debt of gratitude. We wish her every happiness and success in her future career.

Jeremy Shoham
(editor)

A personal word from the core group members

Fiona has had a long-standing involvement and commitment to the issue of infant and young child feeding. She brought to the group her varied experience with emergency issues, was a source of energy and ideas and was passionate about what she believed - sparks sometimes flew before we reached an agreement! But this was tempered by a willingness to listen and learn - to participate in the discussion, debate and challenge.

Ultimately, Fiona gets things done, does not beat about the bush and goes straight to the point, no matter how challenging, difficult or sensitive it may be. A breath of fresh air, we look forward to her continued involvement - there is no escape!

Kornelius Elstner has been a central and invaluable member of the ENN team over the past five years. Kornelius has been responsible for the design and layout of Field Exchange as well as the design and maintenance of the ENN website. But Kornelius's input did not stop there-as well as sorting out all things to do with computers and IT, 'K's perfectionist tendencies and linguistic excellence meant that he often found himself picking up errors in Field Exchange content and correcting the editors grammar! Having recently completed his computer science degree Kornelius is embarking on a career in the IT business. We wish him every success in the future.