David E Bratt MD

?Some years ago, I was in­volved in an at­tempt to stop a group of well-in­ten­tioned women from do­nat­ing for­mu­la milk to Laven­tille, so that "the poor chil­dren could have some­thing to eat."

Noth­ing I said or did could change their minds and the for­mu­la du­ly ar­rived in the Laven­tille Health Cen­tre where it con­tributed to that year's out­break of gas­tro. A side-ef­fect of this move would have been a de­cline in the num­ber of chil­dren be­ing breast­fed, some­thing that is seen, to the de­light of those with mon­ey in­vest­ed in for­mu­la com­pa­nies, when­ev­er for­mu­la is in­tro­duced in­to a cul­ture as an emer­gency short-term mea­sure. Un­til about five years ago, it used to be manda­to­ry for NGOs send­ing sup­plies to dis­as­ter ar­eas to beg, in the first in­stance, for for­mu­la. Pae­di­a­tri­cians have long known that this is a recipe for fur­ther dis­as­ter but it has tak­en many years and deaths for this les­son to be learned by of­fi­cial and non-of­fi­cial or­gan­i­sa­tions. It has still to be recog­nised in civ­il so­ci­ety but the re­cent earth­quake dis­as­ter in Haiti has brought the prob­lem in­to fo­cus in the Amer­i­c­as. Unicef, WHO and the World Food Pro­gramme have just made an of­fi­cial state­ment that do­na­tions of for­mu­la to Haiti are not ap­pro­pri­ate.

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Breast­feed­ing is the norm in Haiti and Unicef da­ta shows that 87 per cent of ba­bies are breast­feed­ing at ages six-nine months and 35 per cent are breast­feed­ing at ages 20-23 months. This is why their in­fant and child mor­tal­i­ty rates are not worse. It might be of in­ter­est for us to re­flect on the strength of Hait­ian women who in the midst of pover­ty and hard­ship, the like we have not seen in this coun­try for years, are able to main­tain this re­la­tion­ship with their chil­dren and do it while work­ing full-time. Spe­cial con­cerns in coun­tries like Haiti (even with­out an emer­gency of this mag­ni­tude) in­clude lack of trans­porta­tion, vul­ner­a­bil­i­ty to storms and flood­ing/mud­slides, rough ter­rain that makes trav­el dif­fi­cult, and lack of re­sources like elec­tric­i­ty and clean wa­ter. In an emer­gency, these is­sues are com­pound­ed.�Af­ter a dis­as­ter, when long-term re­cov­ery is un­der­way, the worst thing to have to deal with is a breast­feed­ing cul­ture that sud­den­ly be­came a for­mu­la-feed­ing so­ci­ety. The reper­cus­sions on mor­tal­i­ty and mor­bid­i­ty could take gen­er­a­tions to over­come.

Breast­feed­ing is an in­fant's first line of de­fence in any sit­u­a­tion and more so in a dis­as­ter. For the many or­phaned, in­jured, and ill ba­bies in Haiti, di­rect breast­feed­ing is the on­ly fea­si­ble op­tion. Moth­ers there­fore need sup­port and en­cour­age­ment to breast­feed their ba­bies to the point that if a moth­er has ceased breast­feed­ing, it is crit­i­cal to of­fer her the op­por­tu­ni­ty to restart or "relac­tate." Feed the moth­er to feed the ba­by is the new cry. Breast­feed­ing is so im­por­tant that even if a child is moth­er­less or sep­a­rat­ed from his moth­er, oth­er moth­ers can be asked to step in to share their milk by breast­feed­ing the ba­by. Breast­feed­ing saves lives by be­ing the per­fect food with an­ti-in­fec­tive prop­er­ties to pro­tect a ba­by from the germs that cause di­ar­rhoea, pneu­mo­nia, and oth­er dis­eases that are ram­pant in a con­t­a­m­i­nat­ed en­vi­ron­ment. It al­so de­liv­ers per­fect nu­tri­tion when food sources are scarce, in­clud­ing wa­ter. It is the per­fect de­liv­ery sys­tem, al­ways avail­able, al­ways clean, it con­stant­ly re­places it­self, pro­vides warmth, is lov­ing, and al­lows for the im­por­tant skin con­tact that low­ers stress lev­els for both the ba­by and the moth­er. There are a num­ber of prob­lems with us­ing for­mu­la in a dis­as­ter but, above all, it in­creas­es the in­fant death rate. In the 2004 tsuna­mi in In­done­sia, a breast­feed­ing cul­ture, 72 per cent of fam­i­lies were giv­en for­mu­la which re­sult­ed in an out­break of di­ar­rhoea and deaths among the for­mu­la-fed in­fants.

Even in the best, most hy­gien­ic con­di­tions, ar­ti­fi­cial­ly-fed ba­bies are five times more like­ly to suf­fer di­ar­rhoeal dis­eases. In un­san­i­tary, crowd­ed con­di­tions, the lack of safe wa­ter and the lack of fa­cil­i­ties to ster­ilise feed­ing bot­tles and pre­pare for­mu­la safe­ly and cor­rect­ly (soap, a stove, fu­el to boil wa­ter, clean mea­sur­ing cups, re­frig­er­a­tion) means that ar­ti­fi­cial­ly-fed in­fants are more than 20 times more like­ly to die from di­ar­rhoea and oth­er in­fec­tious dis­eases than in­fants who are ex­clu­sive­ly breast­fed. For­mu­la feed­ing re­quires in­ten­sive sup­port from aid agen­cies, di­vert­ing them from their most im­por­tant tasks of pro­vid­ing re­lief. It cre­ates de­pen­den­cy and con­tributes to un­der­nu­tri­tion. When a moth­er feeds her ba­by for­mu­la, she pro­duces less milk. What hap­pens when the do­nat­ed for­mu­la runs out? If the fam­i­ly can­not pur­chase for­mu­la, they wa­ter down what­ev­er is left or in­tro­duce cheap­er but in­ad­e­quate milks like con­densed milk with the re­sult­ing mal­nu­tri­tion, di­ar­rhoea and death. Do­nat­ing for­mu­la seems on the sur­face to be a good way to help out, but there are many un­in­tend­ed con­se­quences. For­mu­la is a recipe for dis­as­ter in an emer­gency sit­u­a­tion. If you want to do some­thing, do­nate funds to re­lief or­gan­i­sa­tions that can, in turn, ac­quire sup­plies as need­ed to meet the spe­cif­ic, iden­ti­fied needs on the ground.