Milk Matters: Improving Health and Nutritional Status of Children in Pastoralist Communities

By Dr Kate Sadler and Dr Andy Catley

Kate Sadler is a nutritionist and currently senior researcher with a focus on nutrition in emergencies at the Feinstein International Centre, Tufts University. She worked previously with Valid International for 6 years and with Concern Worldwide for 4 years before that.

Andy Catley is a research director for policy process at the Feinstein International Centre. Previously he worked with Save the Children UK in the Horn of Africa and the International Institute for Environment and Development. He now heads Feinstein's Africa Regional Office where his team supports the design and facilitation of policy reform processes around livestock relief and development and pastoralism in the Horn of Africa.

This work was made possible with funding from the Office of Foreign Disaster Assistance (OFDA) United States Agency for International Development (USAID). Many thanks go to the dedicated research team of data collectors who include Rashid Ibrahim Osman of Save the Children USA, Almaz Mulugeta and Yusuf Ali of Save the Children UK, Habon Osman Aden, Abdiyo Bilow, Habiba Ismaiel, Ambiyo Dahiye and Sugay Osman. The author would also like to thank Michael Manske, Tina Lloren, Alemtsehay Greiling and Adrian Cullis of Save the Children USA and Matthew Hobson, Themba Nduna and Abdirahman Ali of Save the Children UK for providing considerable support for this study.

The authors examine the role of milk in the diets of children in pastoralist communities in Ethiopia, including the links between seasonal availability of milk with child nutritional status and priority interventions to address this.

Animal milk has long been recognised as an important component of pastoralist diets across the world¹. In addition, milk is a nutrient dense food and is thought to contribute a high proportion of the nutrients required by the many pastoralist groups that rely on it.^2,3 However, children that live in pastoralist areas of Africa are increasingly referred to as some of the most nutritionally vulnerable in the world. Nutrition surveys in Eastern Ethiopia⁴ and other pastoralist areas of Africa⁵ have long identified seasonally high rates of acute malnutrition. Discussion of the reasons behind this malnutrition often refer to a broad spectrum of direct causes that include the health environment and infection, infant feeding and maternal caring practices, and reduced availability of milk and cereals, but have rarely examined the relative importance of any one of these causes. Whatever the causes, the dominant nutrition programming response from the international community to malnutrition in these areas continues to be the delivery of an often limited commodity food basket that rarely includes a protein source suitable for older infants and young children.

Part of Save the Children's African Region Pastoral Initiative⁶, 'Milk Matters' is a joint venture between the Feinstein International Centre at Tufts University, Save the Children USA and Save the Children UK in Ethiopia. It aims to improve the nutritional status of children in pastoralist/semi pastoralist areas in the Horn of Africa through improved livelihood programming. The first phase of 'Milk Matters' examined the role of milk in the diets of children in pastoralist communities, how seasonal availability of milk in these communities might be associated with the nutritional status of children, and priority interventions that could reduce vulnerability to malnutrition in this group. The work has involved a literature review, which aimed to ascertain those aspects of pastoral child nutrition and nutrition programming that are well established and those issues that remain debated or poorly covered by the literature⁷. A subsequent qualitative study focused on Save the Children's programme areas in the Somali Region of Ethiopia. This aimed to examine what pastoralist women and men themselves think about the important causes of child malnutrition, links between child nutritional status and milk supply, and 'best bet' interventions for addressing malnutrition in their communities. The methods and the main findings of this study are summarised below.

Methods

Study location

The study was conducted in two areas of Somali Region, Ethiopia: Liben Zone in the south of the region where Save the Children USA was implementing programmes, and Shinile Zone in the north of the region where Save the Children UK was implementing programmes. The Zone Administrator and the Save the Children team in each area supported the identification of two study areas (or kebeles) that were considered to be of a purely pastoralist livelihood type: Boqolmayo and Bioley in Liben, and Gad and Lasdhere in Shinile.

Study Participants

Participants at each of the 4 locations included:

• Eight to 12 pastoralist women of mixed wealth group. These women were the focus of most of the data collection activities, including structured exercises. For most exercises, the group was split into two smaller groups, and findings were then compared when the entire group came back together again to discuss results and key issues.
• Four to 10 male participants, including community leaders and family members of the female participants, were involved in some exercises that required a specific knowledge of livestock movement, health and nutrition.

Participatory methods

Participatory methods were used with each group of participants over a two day period.

Number of informant groups = 6

Main Findings

The demand and perceived benefit of animal milk for young children is high and generally much higher than that for cereals. In Liben and Shinile, the milk of camels and goats is held in particularly high regard. This is linked to these animals' ability to produce milk through the dry season, for the perceived health benefits of the milk and for the taste.

In both areas, the large contribution that animal milk makes to the dietary intake of young children in the study communities was startling. When milk is available, it is frequently given fresh to children to drink and is added to most complementary foods in both Liben and Shinile. On average, the quantity of animal milk fed to a young child of 1-2 years was 0.85 litres per day in the wet season⁸. This provided 560 kcals which is approximately 100% of the energy required and 27g of protein which is more than 100% of the protein required by a breastfed child of this age⁹.

However, season plays a crucial role in milk supply and by the end of a 'normal' year milk intake of young children has reduced by more than 70%. In a drought year this reduction in milk intake was far more pronounced and by the end of a drought year it had fallen to negligible amounts in both areas. This was shown in both the consumption calendars (Table 2) and the seasonal calendars of dietary intake, one of which is shown in Figure 1.

"We like all milk. It satisfies hunger, we become strong and healthy and playful and happy. It is given to us during Gu and Deyr [the rainy seasons]. During Hagaa and Jilaal [the dry seasons] we get soor, tea with milk and ambula. When milk becomes less we get less playful and weak." (a group of young boys in Liben Zone)

Although the seasonal calendars clearly demonstrate a change in the dietary intake of young children across seasons, they do not adequately reflect the deterioration in the quality of the diet that occurs. When milk is in short supply it is replaced, in the most part, by an increase in grain consumption, and by the end of a long dry season or drought year the grain is cooked and consumed with little else but water. Such a severe reduction in milk intake is likely to have a serious impact on dietary quality by reducing the amount of high quality protein, fatty acids and micronutrients that young children consume.

"Milk is reduced in everything during drought. We drink black tea and rice as a soup with chili. The name for shuro without milk is yaabis (dry), even though the taste of shuro changes without milk we have to eat it because sorghum is one of the cheapest flours." (women in Shinile Zone).

Study participants perceived a direct and important association between reduced milk intake and weight loss among their young children. They used the phrase Cano la'an to describe 'the suffering due to lack of milk' which is known by local people as the pre-cursor to malnutrition as they define it. In future, it will be important to examine the implications of this seasonal availability of milk for patterns of nutritional status as defined by international indicators and how this overlaps with pastoralists own definitions of malnutrition in this context.

In the opinion of the pastoralists who participated in this study, the most effective way to improve availability and access to milk for young children is clear; through the maintenance of the health and nutritional status of their livestock. They identified broad areas for possible intervention, including animal health, fodder production and water supply that could help to maintain the supply of milk to children during the dry season and drought. The separation of larger stock from young children during seasonal migrations was also highlighted as an important factor that disrupted children's access to animal milk. It is these areas therefore that have potential to form the basis of any intervention that aims to improve children's resilience to drought and malnutrition.

Many of the programmes that might fall into the broad categories discussed are not new, and there is already some evidence that they can lead to real improvement in livestock health and milk production. There is far less evidence, however, of any impact of such interventions on the nutritional status of children, and it is here that more work is needed. Given the issue of milk access for young children during late dry season and drought, especially access to camel milk, it is possible that the benefits of interventions that aim to improve child nutrition, such as veterinary care for camels, would not be fully captured in terms of milk consumption by children at critical times. This suggests there is a need to review these projects and look more carefully at ways to ensure that milk reaches young children when they need it most.

Figure 1: Seasonal calendar of foods consumed by young children, Liben Zone

* Represents the relative quantity of the food consumed by young children (greater value = larger quantity consumed).

A bowl of animal milk

Guide to Figure 1

The number of informant groups = 3 For each food, the female participants were asked to distribute stones across the seasons according to child intake at different times of the year, with more stones representing higher intake. Women were asked to redistribute stones (add to, or subtract from piles) for a drought year. The number given in Figure 1 is the median number of stones (minimum and maximum value)

For rainfall, the number given is the length of stick (in inches) that participants used to represent rainfall by month.

Gu=long rainy season; Hagaa=dry windy season; Deyr=short rainy season; Jilaal=dry hot season

Meat soup: pieces of meat in a watery soup. The watery component is given to young children.

Ambula: whole grain millet, wheat or maize cooked and served with milk (or garoor preferably), sugar or ghee.

Ouji: a soft thin porridge made with flour (usually wheat, maize, millet, rice or a blended flour), cooked with milk or ghee, water and sugar.

Soor: a solid paste made from sorghum, maize, wheat or millet flour cooked with water and served with milk or ghee and sugar.

Future work planned

This now paves the way for the second phase of Milk Matters, which aims to deliver a number of small scale community-defined livestock interventions in pastoral areas, with the specific objective of improving access to and consumption of animal milk by young children over the dry season. The work will use a combination of quantitative and systematic participatory approaches and methods to link human nutrition, access to milk, and livestock information. These, for external actors at least, tend to exist as separate bodies of knowledge. The funding for this next phase has just been secured from the US Office for Disasters Assistance (OFDA).

For more information, contact Kate Sadler, email: Kate.Sadler@tufts.edu The full report 'Milk Matters: the role and value of milk in the diets of Somali pastoralist children in Liben and Shinile, Ethiopia' can be downloaded from the FIC website. Visit http://fic.tufts.edu and search for the report.

¹Sadler, K., C. Kerven, et al. (2009). Milk Matters. A literature review of pastoralist nutrition and programming responses. Addis Ababa, Feinstein International Center, Tufts University and Save the Children. This review can be downloaded at: http://fic.tufts.edu and search for the report.

²Fratkin, E., E. A. Roth, et al. (2004). Pastoral sedentarization and its effects on children's diet, health, and growth among Rendille of Northern Kenya. Human Ecology 32(5): 531-59.

³Barasa, M., A. Catley, et al. (2008). Foot-and-mouth disease vaccination in South Sudan: benefit-cost analysis and livelihoods impact. Transboundary and Emerging Diseases 55: 339-351

⁴Ethiopian Health and Nutrition Research Institute, UNICEF, et al. (2009). Final Report from Nutrition and Mortality Surveys conducted in Seven Mega Livelihood Zones in Somali Regional State, Ethiopia.. Addis Ababa, Ethiopian Health and Nutrition Research Institute

⁵Mason, J. B., S. Chotard, et al. (2008). Fluctuations in wasting in vulnerable child populations in the Greater Horn of Africa. Working Papers in International Health and Development, No. 08-02 New Orleans, Department of International Health and Development, Tulane University.

⁶The goal of Save the Children's Africa Region Pastoral Initiative is to "deepen and replicate innovative approaches to improve access to basic services and reduce vulnerability to drought in pastoralist populations in order to create positive change for children in this unique and harsh environment."

⁷Sadler, K., C. Kerven, et al. (2009). Milk Matters. A literature review of pastoralist nutrition and programming responses. Addis Ababa, Feinstein International Center, Tufts University and Save the Children

⁸This amount compares to the required daily fluid intake, recommended by WHO guidelines, of between 600 and 1300ml/day for children of this age (inclusive of breastmilk) and therefore appears to be a plausible intake. Young children in this context are likely to consume fluid intakes at the higher end of this spectrum due to the average temperatures of 30+ degrees celsius.

⁹Dewey, K. Guiding Principles for Complementary Feeding of the Breastfed Child. 2003. Washington DC, World Health Organization.