Editorial

This rather large issue of Field Exchange has a typically wide range of material from field practitioners and researchers. Some examples of innovative practice include an article by the International Rescue Committee (IRC) that has developed and is field testing approaches for treatment of uncomplicated severe acute malnutrition (SAM) by low-literacy community health workers, as part of community case management in South Sudan. We also have a summary of research conducted in Sierra Leone on an integrated moderate acute malnutrition (MAM) and SAM treatment programme. It is good to see adolescent care featuring, a huge gap area when it comes to nutrition programming; International Medical Corps (IMC) share experiences of adolescent targeted programming in Nigeria and Zimbabwe. The low profile of and access to SAM treatment in emergency-prone East Asia and the Pacific, despite the high burden of wasting, and actions to address this are the subjects of a thoughtful article by the UNICEF regional team. It complements nicely an article on the progress made in the Philippines on this front, which has partly come about through the capacity gaps identified and addressed with external humanitarian support. As ever, the pros and cons of mid upper arm circumference (MUAC) and weight-for-height measures in determining access to acute malnutrition treatment programmes remain a hot topic amongst some of the nutrition fraternity; we feature a cross-section of research that no doubt will fuel discussions that will feature in future issues of Field Exchange.

This editorial would like to focus on two sets of material in particular; namely the new Lancet series on breastfeeding and related articles, and a series of case studies on Global Nutrition Cluster (GNC) experiences in six recent emergencies (Ukraine, Somalia, South Sudan, Yemen, Philippines and Bangladesh).

The first paper in a recent Lancet breastfeeding series reinforces that where infectious diseases are prevalent, exclusive breastfeeding (EBF) is critical to infants under 6 months of age in terms of mortality and infectious disease, and remains significant for children aged 6-24m in reducing mortality and infectious disease morbidity. It’s a worry that in resource poor settings, EBF rates remain stubbornly low. The Lancet paper calls for the need to tailor breastfeeding support strategies to specific patterns recorded in each country. Research from the Democratic Republic of the Congo (DRC), summarised in this issue, reflects such an approach, where a short-cut version of the Ten Steps to Successful Breastfeeding programme made a difference to EBF rates in the target group. Interestingly, adding in community support groups to the clinic-based programme probably made things worse – misinterpretations and mixed messages by the wider interested community were, in all likelihood, behind this finding.

Behaviour change communication (BCC) on feeding practices is a common thread to so-called ‘nutrition sensitive’ programming. It would be interesting to examine – through literature review and likely research - the impact of such BCC, since many factors influence infant feeding decisions. A selection of these are reflected in an article on the social impact of the Kenyan government’s Baby Friendly Community Initiative. Whilst some expected and unexpected social returns were positive (e.g. having healthier children, more paternal support of mothers), some significant negative outcomes of improving maternal and infant and young child feeding (IYCF)were also identified. Mothers reported they were now more worried knowing how they should be feeding their children but in reality, not being able to do so in their circumstance. Key informants reported less income due to job loss as a result of following optimal feeding practices, increased household expenditure on food and health care, increased workload of healthcare providers, financial strain on, and increased stress of, community health volunteers.  

The investment case for breastfeeding is the focus of the second Lancet paper. The costs of not breastfeeding in terms of lost Gross Domestic Product (GDP) is used to support the case for breastfeeding investment. However the costing - based on economic calculations around cognitive development consequences of not breastfeeding and increased health costs of sicker non-breastfed children – does not capture the significant opportunity cost to mothers of feeding options, in terms of lost income and time. Such costs need to be monetised and captured in economic calculations or explicitly stated as absent; breastfeeding is not free. This paper reflects a lack of data that is critical to moving forward (or to halt us fighting a losing battle) on the feeding front.  Six actions are proposed related to advocacy, societal attitudes, political will, breastmilk substitute (BMS) industry regulation, scale-up of interventions, and removal of structural and societal barriers. But reliable estimates of the costs and benefits of the actions needed to support optimal breastfeeding, including maternity entitlements, are missing. Just one available study estimates that it will cost $17.5 billion globally for a large range of interventions, much of which is maternity entitlements for poor women. Asia and Africa account for 80% of the millions of women with no or inadequate maternity protection; the economic implications and feasibility for governments of recommendations, and how accessible changes would be for the poorest women, is poorly understood. How fair is it to engage in BCC with individual mothers in these challenging contexts, in the absence of the societal and community support to enable change, and how much has it cost us trying and largely failing to do so? It would have been valuable if the Lancet economic analysis could have gone further and scrutinised what investments have been made to date and for what gains; it was not possible to ascertain national or overseas aid budgets for the protection or support of breastfeeding.

One of the challenges for humanitarian programming is how to appraise relative risk in mixed feeding contexts and minimise risks for all infants.  The Syria and Ukraine crises pose particularly challenging contexts given the low rates of EBF and increasing tendency prior to the crises to use BMS (the Lancet series calculates that global infant formula sales in 2014 were US$44.8 billion, most of the 50% growth  by 2019 projected in the Middle East, Africa and Asia-Pacific regions). Middle income countries inhabit a grey area between high income and low income settings with declining breastfeeding rates (improved rates more likely amongst the better off women), yet still carrying some of the infectious disease burden that fuels morbidity and mortality risk. There are also inconsistencies been global perceptions of best practice and field experiences. Increases in infant mortality have not been demonstrated amongst the refugees in Jordan, Lebanon and Turkey amongst refugees nor reported in the Europe migrant crisis, despite widespread infant formula use in risky environments. Children may well be sicker and undernourished (we just haven’t measured it) but it may also reflect that mothers engage their own risk minimisation strategies and adapt more effectively than we give them credit for. An article by Save the Children on their IYCF response in Croatia reflects the challenges of meeting the needs of both breastfed and formula dependent infants in a rapidly transiting population and the necessary compromises in terms of assessment and support offered. These and many more experiences will be reflected in in an update of the Operational Guidance on IYCF in emergencies currently underway (see news piece in this edition).

Our second editorial focus relates to findings from recent and ongoing GNC coordination experiences summarised in this issue. Three themes and challenges from the GNC case studies are worth mentioning here. The first relates to the default response in emergencies (first reported on extensively in the Field Exchange special issue (49) on the response to the Syria crisis) to focus on treatment of acute malnutrition in young children and IYCF to the exclusion of other groups and nutrition challenges. There are many questions for us to ponder. For example, do we have sufficient capacity and understanding to address the needs of the elderly in emergencies (including non-communicable diseases (NCDs)) and do we know how to address high levels of stunting. Emergency contexts are rapidly changing and yet our protocols and institutional capacity seems to be lagging behind these changes.

A second challenge appears to be how to effect inter-sector planning and coordination so that nutrition objectives can become part of so called ‘nutrition sensitive’ planning in emergencies. Again, the response to the Syria crisis first highlighted the lack of influence of nutrition actors on widespread social protection planning. The GNC case studies in this issue again demonstrate lack of coordination between the nutrition sector and other sectors to enhance the nutrition sensitivity of programming in water, sanitation and hygiene (WASH), food security, health and social protection. A key question is whether the overall cluster mechanism does enough to support the potential for inter-sector collaboration and planning and what role the nutrition cluster can have in realising this potential.

Finally, the case studies show a highly variable engagement in preparedness and longer-term coordination mechanisms – especially where a formal inter-agency standing committee (IASC) activation of the cluster is not needed or wanted. Engagement of the cluster with Scaling Up Nutrition (SUN) actors and mechanisms may provide an excellent opportunity to strengthen links between humanitarian and development planning. The new ENN programme of work to support the SUN Movement’s knowledge management work in fragile and conflict affected states should ensure that ENN is able to fully capture this type of collaboration in the future.  The new thematic areas on SUN opened on en-net should also, we hope, help cross-fertilise experiences between cluster/SUN mechanisms (for example, see online) and develop connections between humanitarian and development practitioners.

A final word on Field Exchange itself. As you’ll have noticed, the size of our print edition has grown over the last couple of years (issue 24 was just 28 pages!). This reflects, no doubt, the appetite to share and learn from each other and the breadth of programming and research now relevant to nutrition. However, we do need to consider what is manageable to sustain (in terms of resources) and digest (for our readership). So over the coming months, we’ll be looking to innovate a little on how we deliver Field Exchange content to you, such as selected content for print, online editions, changes in format, etc.  We’ll contact those of you who have shared your email addresses for feedback and welcome unsolicited suggestions anytime; make sure your contacts are up to date (or add them) online here. 

Jeremy Shoham & Marie McGrath

Field Exchange Co-editors