The reality of research in emergencies

Marie McGrath is a qualified paediatric dietician/nutritionist. She has an abundance of experience in emergencies, working previously with Merlin. SCF (UK) employed her to carry out research on infant feeding in emergencies in collaboration with the Institute of Child Health. The following article describes some of the trials and tribulations of research in the field.

Having spent the last few years working as a field nutritionist with an NGO and with a background in paediatric dietetics, the opportunity to carry out some infant feeding research was my picture of the perfect job. In June of last year, a sudden phone call and rapid interviews suddenly found me embarking on a six-month research project on infant feeding during the 1999 Kosovo crisis. The combination of key players in the project was ideal, an active NGO providing field access and experience and an academic institution providing technical input and support. The plan had been to spend a few weeks in London preparing for the research which was scheduled to take place in Albania and FYR Macedonia. Having hastily jumped on planes at a moment's notice in my previous fieldwork life, finally I thought I was going somewhere where I would be truly organised and ready for anything. My new found state of preparedness was short-lived. Days after starting my work in London, the NATO bombardment of Kosovo was suspended, peace deals were arranged and the refugees were on the starting blocks for home. Plans for an assessment in Albania were shelved as refugees returned in their masses. I again found myself all askew on a plane heading into the great unknown.

Family in Cegrane camp located two and a half hours drive west of Skopje.

How my great research plans would fit into a mass repatriation of refugees was not clear on my flight into Skopje. It was not much clearer on my flight out again, so much was the complexity and unpredictability of the situations in which I found myself. My personal concept of some of the essential elements of research involved comprehensive planning, clear aims, tight methodology, objectivity of the researcher at all times, and measuring what you set out to measure. The reality of field research in emergencies set out to test these preconceptions to the limit.

One of the main objectives of the research had been to carry out an infant feeding practice survey in a number of the refugee camps. Although key issues had been identified back in London, I still had managed to produce a questionnaire with every question imaginable on it. So quick had been the departure there had been no time to edit it down. Armed with this giant questionnaire I went in search of some unsuspecting surveyors. As luck would have it, I managed to make contact with four female workers who had just taken part in the large nutrition and health survey that had been carried out in the camps. They had also just completed a local breastfeeding course run by the local MOH in liaison with a number of international agencies. On the positive side they were well up to speed on breastfeeding. However their newfound undying belief in breastfeeding risked biasing responses in a population with varying infant feeding practices. There wasn't time to comprehensively address many of these issues. Since arriving, the refugees were already on the move, the dilemma was whether to spend another day training, but in doing so risk missing the refugees altogether. The buses and taxis were already lined up outside the camps, tents were disappearing and people were heading home undeterred by talk of landmines. I decided to limit the training and see what information we could gather in the thick of the confusion.

We started with Neprostino camp, smaller, well laid out and therefore a possibility of more organised chaos. However after six hours of hunting for mothers and children I had to rethink the tactics and reschedule to Stankovec I camp, bigger, more chaos but more people and, we hoped, more kids. The survey proved possible, but only just. The camp was alive with activity. No one knew how many people were there, the tally changing from hour to hour, varying by thousands. The camp layout plan had been scuppered by tents abandoned or removed by families returning to Kosovo. Fortunately the surveyors had previously surveyed in the camp and so had a concept of its layout, whether it now existed or not. Over the next four days, we hunted down carers of children under two years. A systematic sampling of the camp turned into an 'as systematic as possible' visit to all tents. Despite the undoubted trauma and uncertainty of returning home, mothers patiently answered questions. However sometimes a bus would appear and they would disappear home on it. The length of the questionnaire meant that both the surveyors and the mothers may have got weary of answering what may have seemed the same thing, over and over again. Against a few odds, the survey was completed. It proved just a taster of things to come. The next challenge was to gather information from the agencies on the ground.

Baby bottles, commercial infant foods and high protein biscuits included in a distribution of baby and hygiene parcels targeted at all infants. This programme was implemented by an international organisation (anonymity requested) and funded by ECHO).

Infant feeding is often a very emotive subject, in emergencies it can be highly political as well. Many of the issues I was investigating relating to infant feeding were also current field issues. By becoming involved as an outside assessor of a specific area, it can sometimes be easier to see potential solutions. My field background meant I was used to being involved and found it very difficult to limit this tendency. By offering opinions and actively becoming involved in field issues relating to infant feeding, I became part of the process I was researching. Although this may have compromised the objectivity of the research, I gained a lot by observing a process and the difficulties from within rather than from the outside. Information is often more forthcoming from busy field staff who feel that you are doing something to help a situation rather than if you are purely seen as documenting how it is all going wrong.

Poster advertising tea for infants in the hospital pharmacy, Tetovo Government Hospital. This advertisement violated Article 6 of the International Code.

The timing of the research with the mass repatriation of refugees meant that extracting information from field workers was difficult. The high turnover of staff during humanitarian interventions, particularly emergencies, meant that many of the field workers who had arrived in the beginning had since returned home. For many of those staff that remained the priority was now repatriation, not chats on infant feeding in camps that were soon no longer going to exist. A smaller proportion had a high interest in infant feeding issues and were willing to share their experiences. In interviewing the willing, there was a risk that field responses would reflect the experiences of the minority but be interpreted as the voice of the majority.

The response to a questionnaire on infant feeding aimed at field personnel was poor. Some organisations registered as operational in Macedonia had recently left. Others had arrived who had not yet registered. Some operations had downscaled and moved to Kosovo. Files relating to infant feeding had been packed away into unknown cupboards. In many cases there were no records. Over the next month in Macedonia, I sought responses, information and any kind of action or reaction from field personnel by phone, fax, e-mail and in person. Meetings were attended and even bars were targeted, the latter often the source of the most honest information. Response rates improved but, as they were not ideal, they represented yet another complication, and challenge, for gathering research in this situation.

The risks of using bottles in conditions where hygiene standards are compromised are elevated considerably and cup feeding is the preferred mode. Donated baby bottles were available to mothers on request!!

During the field research many issues arose and rapid decisions were made regarding how and from whom information was gathered and what infant feeding issues were investigated. An essential element of this process was (having experienced input from an academic and a field perspective) to develop an acceptable middle ground. My biggest concern on returning was the degree to which the research ideal had been compromised, whether this was acceptable and if not, should we be even attempting research in emergencies. My conclusion is that field research in emergencies is critical. Field guidelines and recommendations, without consideration of the practicalities and the context, will remain a paper exercise. The absence of clear information and data on new issues in emergencies risks basing interventions on guestimates and presumptions. However, one of the essential requirements of research in emergencies is complete transparency regarding methodologies, limitations and problems. The particular characteristics of an emergency situation will have a great bearing on any research findings which need to be presented and interpreted in this context. My guiding principle for research in emergencies is aim for the sky, don't be surprised if you hit the treetops and if you hit the ground, say so. Better luck next time!

For more information contact Marie McGrath, email: marie_mcgrath@hotmail.com; c/o Andy Seal, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, England.