1. INFANT FEEDING IN A REFUGEE CAMP Experience from Bangladesh UNHCR

2. Outline Overview of the camp situation Infant feeding in the camps Case #1 Case #2 Wet nursing advantages and disadvantages -1- Cultural background -2- HIV considerations Conclusion

3. Overview of the camp situation

4. A general food ration is distributed to 22,000 registered refugees in the official camps but omits 5,000 unregistered refugees Refugees have no access to land for cultivation and are officially not allowed to work; household income is minimal

5. Overview of the camps situation UNHCR survey in 2007(implemented by HKI) global acute malnutrition prevalence in 6 to 59 months = 12.1% and 64% of 6 to 59 months are anemic (Hb< 11g/dl) General lack of food diversity especially animal protein is reported

7. Case #1

8. Case #1 in the feeding center Nutritionist: Hello, good morning, how are you today? Refugee with baby: Good Thank you! N: How is your child doing today? R: This is not my child, it is an orphan. His mother died while giving birth to him 25 days ago. N: Oh, I see, and you are taking care of him R: yes N: Are you a relative? R: Not really, his mother was a friend. N: I am so sorry for her death. Are you finding trouble feeding him? R: I put water with some white powder

9. Comments on the discussion “White powder” could be inappropriate Please share your thoughts:_______

10. Case #1 in the feeding center N: White powder? R: yes, the same they use in the inpatient center N: Did they provide you with that powder or did you purchase it R: no I bought it N: Ok, so how can you make sure that it is the same powder, did anything or anyone indicate it to you? R: No, I cannot read but the powder was white and it looked the same N:I understand. What about the dosage, how many teaspoons do you use? R: Oh just a little bit, I don’t have enough and cannot afford to buy more

11. Comments on the discussion Inpatient center provides F100 Caretaker cannot read Preparation is not appropriate Caretaker cannot afford the powder Please share your thoughts:_____

12. Comments on the discussion ItemCost in Taka Daily labor70 -80 /day Cheapest rice27 /kg Lentils30 /kg Vegetables70 /kg Fish and shrimps60 /kg Meat and Dairy Products 170 /kg Infant formula tin300 / tin

13. Case #1 in the feeding center N: I see! And do you boil the water you use? R: No, the water is clean, I prefer to save cooking fuel N: I see! Do you feed the child anything else? R: Yes, often I give him some rice N: Would you please provide us with the packet of powder you purchased? R: sure, {5 minutes later comes back with a full cream powder packet with a large inscription saying ; “is not appropriate for infant below 1 year”}

14. Comments on the discussion Water is not boiled Caretaker cannot afford fuel Not exclusive artificial feeding/mixed feedings Full cream powder not appropriate for infants Please share your thoughts:________

15. Imagining that this is not a refugee camp, what conditions would lead to the same answers? Illiteracy Poverty Lack of community awareness Presence of misconceptions Healthcare: the “money making machine”

16. Case # 2

17. Case # 2 Summary Mother died shortly after delivery and an aunt naturally became the wet nurse. “it is highly viewed in the Muslim community, you know, since Mohammed the prophet had a wet nurse”. The caretaker wet- nurses the child and attends to all his needs

18. Comments on the case Culturally appropriate practice naturally undertaken in the community Supported by religious beliefs

19. Wet-nursing Disadvantages Breastfeeding is a risk for HIV transmission and wet nurses should undergo Voluntary Counseling and Testing (VCT) Night feeds are problematic if the wet nurse lives far away from the orphan and caretaker Wet-nurses day to day duties that interfere with attending to the orphan

20. Wet-nursing Advantages Infant formula is not AFASS in this context Wet-nursing is done naturally and is culturally accepted Wet nurses (as are all lactating women) are provided with a package services/interventions to promote optimal health and nutrition status Some of this also aims to decrease the risk of HIV transmission (malaria prevention and treatment, breast care and nipple care, detection and treatment of oral candidiasis in the infant)

21. HIV Situation Bangladesh is experiencing a low level HIV epidemic Level of HIV infection in southern Bangladesh where the refugees are located is extremely low (no HIV detected in sex workers or injecting drug users in nearest sites in 2006 surveillance) However, wet nursing need to ensure that the “donor” is HIV negative But many challenges in this regard…

22. Challenges: wet nursing and HIV National HIV capacity, including in HIV VCT, is very weak Availability of quality HIV VCT is very limited and closest sites outside of the camp are targeting most- at-risk populations Level of knowledge relating to HIV is poor and stigma is prevalent A minimum care and support package needs to be put in place before undergoing VCT

23. Conclusion HIV and Wet nursing Despite the operational and contextual constraints UNHCR will work with its implementing and operational partners to ensure that before potential wet nurses begin to breastfeed infants, they are HIV negative This will require the provision of VCT

24. Thank you