Philippine Nutrition Cluster’s battle for the best: the breast
By Ms. Florinda Panlilio, Department of Health, Philippines
Ms. Florinda Panlilio is a Nutritionist-Dietitian IV in the Department of Health -Health Emergency Management Staff, which she joined in 2003. Her current responsibilities include training of nutritionists/dietitians in relation to emergencies and disasters and the development of training modules for nutritional assessment and management during emergencies/disasters.
The author would like to acknowledge the technical and funding support of the UNICEF - Philippines Office, which enabled participation in the regional IFE workshop in Bali at which these experiences were shared, and Dr. Nicholas Alipui, UNICEF country representative in the Philippines at the time, whose work was consulted in preparation for this article.
The Philippines lies along the typhoon belt of the Western Pacific, making it prone to various hydro-meteorological hazards. The country experiences about 20 typhoons annually, which is almost one quarter of all typhoons that occur in the world. Five to six of these typhoons are considered to be of the strongest types and usually cause major damages to life and property. Aside from the destructive winds brought about by typhoons, these can also trigger floods, landslides, and mudslides. Out of all the natural disasters which affect the Philippines, typhoons prove to be the largest killers followed by earthquakes, volcanoes and floods. An inter-agency government team, representing the National Disaster Coordinating Council, has identified 27 out of the 80 provinces as the most prone to hydrological hazards.
The occurrence of strong typhoons always has severe consequences for affected communities, especially if followed by secondary hazards such as floods, landslides and mudslides. Death, loss of livelihoods and destruction of infrastructure frequently occur. Access to food supplies may be constrained while food interventions like school feeding may be disrupted. A significant number of food warehouses and commercial stocks are often destroyed/damaged.
The Cluster Approach in the Philippines
UNICEF supported a mass breastfeeding event
that earned a Guinness World Record for
The National Disaster Coordinating Council (NDCC) Memorandum Circular No.5 of May 10 2007 called for the institutionalisation of the Cluster Approach1 in the Philippine Disaster Management System. With the introduction of the Cluster Approach by the UN-Office for Coordination of Humanitarian Affairs (OCHA) eleven clusters were organised. The Nutrition Cluster is led by the Department of Health (DOH) with the Health Emergency Management Staff (HEMS) as its lead, the National Nutrition Council (NNC) as its Assistant Lead and UNICEF as the Inter-Agency Standing Committee (IASC) Focal Agency Counterpart. The leads and member agencies2 participated in a National Clusters' Contingency Planning Workshop in Pampanga on September 18-20, 2007 where agreement was reached on the general objective of the Nutrition Cluster. This is 'to ensure that the nutritional status of affected populations will not worsen or deteriorate due to the impact of a disaster'. Specific nutrition cluster objectives are enumerated below:
- To ensure that the foods provied/distributed are nutritionally adequate and safe especially for vulnerable groups (such as infants, under fives, pregnant and lactating women, elderly, women heading households, men involved in disaster response, etc.).
- To conduct rapid assessment of the affected areas and ensure timely delivery of appropriate response.
- To conduct promotion, support and protection of infant and young child feeding (IYCF) practices, including infant and young child feeding in emergencies (IFE), as well as provision of micronutrient supplementation.
- To provide supplementary feeding to children who are diagnosed as moderately malnourished and treatment to children who are diagnosed as severely malnourished.
- To promote distribution and consumption of fortified foods.
- To conduct training, seminars and other capacity-building activities related to nutrition education, and to provide counselling to affected populations.
- To establish an effective and efficient coordination, networking and reporting mechanism/ system among all cluster members and related organisations and agencies.
- To facilitate initiation of early rehabilitation efforts, i.e. community kitchen set-up, food production.
Challenges to protection and support of IFE
Prevailing infant and young child feeding practices
One of the priority areas for the Nutrition Cluster is the protection and support of infant and young child feeding in emergencies. However one of the key challenges is the poor prevailing IYCF practice. Survey data from 20033 found that half of all infants were exclusively breastfeeding for less than 24 days, down from 1.4 months in 1998, and only 16% of babies were exclusively breastfed for 4-5 months - well short of the recommended six months. Reasons given by surveyed mothers were: not enough breastmilk (30%), mother working (17%), and nipple/breast problems (17%)4. These responses indicate that women were not properly informed and supported to initiate and sustain breastfeeding. Other significant constraints include the limited government resources for breastfeeding promotion, strong and persistent marketing by milk/infant formula companies, penetration of the health care system by infant formula marketing and little concern, support or protest from the public, civil society or media.
The power of marketing
In the Philippines, the legislative enactment of the International Code of Marketing of Breastmilk Substitutes is reflected in the national Milk Code. Efforts to strengthen it in 2006 - in the form of the Implementing Rules and Regulations (IRR) of the Milk Code - were challenged in court (see Box 1 for details). Despite an initial restraining order, the eventual ruling in favour of the DOH and the IRR has proved an inspirational test case for many other countries. While the Nutrition Cluster considers the Supreme Court's ruling to be a major victory for children in the Philippines, it recognises that the work has just begun if the breastfeeding culture in the country is to be revived, especially during emergencies/disasters. An enormous challenge is the battle against the milk companies, with their multi-billion peso budgets and widespread influence. UNICEF has been consistent in supporting the DOH in pushing the 'BREAST' brand through strong communication and advocacy principles. It is also recognised that public awareness must be increased and institutional involvement strengthened through initiatives such as the provisions of 'Breastfeeding Corners/Stations' in selected malls like the Shoemart located nationwide and the New City Commercial Centre Malls in the Visayas and Mindanao Regions.
Donor driven assistance
A record was kept of 'in kind' donations channelled through the Department of Social Welfare and Development (DSWD) in April 2007 for the victims of Typhoon Reming. The donations by non-governmental organisations (NGOs), government agencies, and schools included infant formula and assorted powdered milk. In the disaster sites, evacuation camps typically had no space to promote breastfeeding. Forty per cent of all that arrived in the first three days was mostly from foreign sources and was not monitored. The humanitarian response was fragmented, independent, and reflected the donor driven assistance of NGOs. Generally, NGOs preferred to have their own system of distributing aid, at times choosing areas with the widest media coverage. Some donor agencies went directly to communities without prior consultation and coordination with national and local disaster coordinators to assess needs. Unsurprisingly, therefore, there was an abundance of relief goods available and inefficient distribution systems in place.
Formula for Disaster DVD
In order to resolve certain issues and generate policy from best practices, the DOH-Health Emergency Management Staff (HEMS) in collaboration with the World Health Organisation (WHO) conducted a series of Post-disaster Evaluation Workshops:
- WHO/DOH-HEM Collaborative Post- Disaster Workshop on the Development of a Health Sector Rehabilitation Plan for the Most Affected Municipalities of the Philippine Floods of 2004 (February 22, 2005)
- Department of Health/NGO Coordination Meeting on the Health Emergency/Disaster Response (May 03, 2006)
- Workshop to evaluate the health cluster response to the typhoon disasters of 2006 (conducted on 15 May - 30 June 2007).
These evaluations concluded that the lack of guidelines and clear-cut strategies for managing the flood of donations post-disaster meant that there was a lack of local capacity to handle the volume of aid, and inappropriate as well as inequitable distribution of donations. There was an immediate 'Call for Action', specifically the development of a national policy for managing humanitarian aid and strengthening of local capacities to prepare for and manage relief supplies. This initiative was primarily aimed at increasing public awareness, sustaining public support, promoting breastfeeding practices especially in the evacuation centres/ camps, establishing a better relationship with donors, setting standards and procedures on management of donations, and enhancing local capacities in handling donations.
Box 1: The Code/Milk Code in the Philippines
The International Code of Marketing of Breastmilk Substitutes was adopted by the World Health
Assembly Resolution in May, 1981. The Code has been further clarified and augmented through subsequent
World Health Assembly Resolutions. Companies are urged to ensure their practices comply
with the Code at all levels. It is a global recommendation and all States are urged to incorporate it into
Reflecting this, in 1986, the Philippines adopted legislation to control the marketing of BMS - called the Milk Code. However a move to strengthen it in 2006 (Implementing Rules and Regulations of the Milk Code) was met by opposition from the Pharmaceutical and Health Care Association of the Philippines (PHAP), and a temporary restraining order was placed by the Supreme Court on the new regulations. In June 2007, the Supreme Court heard arguments from both sides. Their decision in October 2007 agreed partially with PHAP in relation to a total ban on advertising of all products under the scope of the Milk Code and that administrative sanctions exceeded the power conferred upon DOH by the Milk Code. However, they ruled in favour of the DOH and lifted the TRO - based on the fact that other parts of the RIRR were consistent with the objective, purpose and intent of the Milk Code and it constituted reasonable regulation of an industry whose activities affect public health.
The experience from the Philippines is significant because the ruling very much supports the principles and implementation of the International Code and has relevance to other countries. The second unique and significant lesson about the Code fight in the Philippines was that despite the size, power and resources behind the PHAP case, the DOH, with the support of UNICEF, WHO and many national and international NGOs, was able to develop a massive, powerful lobby for breastfeeding protection and support, that has been sustained.
The International Code is available at: http://www.ibfan.org/english/resource/who/fullcode.html
The availability of a number of key national and international guidelines and policies facilitated the drafting of the policy. The observed organisational support and agency collaboration was an added strength in pursuing the initiative. The Health Department's budget for breastfeeding promotion for 2008 was increased to $818,000, in addition to funding support from international organizations like UNICEF and WHO. Notable sectoral support included:
- The Catholic Church produced a special newsletter on breastfeeding and made announcements about breastfeeding on the Catholic Radio Station, Radio Veritas.
- Environmental groups distributed press releases, letters to the editor and articles extolling the benefits of breastfeeding in preserving the environment.
- Legislators filing new bills to support breast feeding and reinforce the Milk Code
- Breastfeeding promotion activities organised by the private sector, such as the 'Mommy Milkshake Marathon'.
- The popularity of the short documentary film, Formula for Disaster5, has meant it has undergone translation into Italian and Khmer and caught the attention of breast feeding groups in UK, Australia and United States where the film was distributed. The film exposed the ways that milk companies were using health care workers to market their products directly to women, offered incentives to health workers, and caught on film how health workers themselves marketed breastmilk substitutes, even to the poorest women.
Box 2: Philippine's National Policy on acceptance and handling donations in emergencies
Administrative Order 2007 - 0017 "Guidelines on the Acceptance and Processing of Foreign and
Local Donations During Emergency and Disaster Situations
This shall provide a rational and systematic procedure for the acceptance, processing, and distribution of foreign and local donations that are exclusively for unforeseen, impending, occurring, and experienced emergency/disaster situations.
Definition of terms
DOH Package List for Emergencies and Disasters - shall refer to a listing of items for donation, such as, drugs/medicines, medical supplies, medical equipment, processed foodstuff, micronutrients, environmental supplies, and others. Such list shall be issued by the DOH, in consultation with other government agencies, NGOs, GOs, and other concerned entities.
Items for donation may be in any form, such as drugs/medicines, medical supplies, medical equipment, processed foodstuff, micronutrients, environmental supplies, and others that may be substantial in addressing emergencies and disaster situations.
Guidelines for Acceptance
Infant formula, breast-milk substitute, feeding bottles, artificial nipples, and teats shall not be items for donation. No acceptance of donations shall be issued for any of the enumerated items.
In the process of writing the policy, the Technical Working Committee led by the DOH - Bureau of International Health Cooperation (BIHC) was engaged in a series of critiquing, revisions, and securing clearances from relevant and concerned agencies before the policy was finally approved and signed by the Secretary of Health. This was immediately followed by intensive dissemination by cluster members at a national convention on HEM, cluster and sectoral meetings, IYCF training and donor conferences. BIHC further endorsed the policy to the foreign embassies based in the Philippines through the Department of Foreign Affairs, in order to safeguard arrival and receipt of foreign donations. The key points of the Signed National Policy that supports IFE is presented in Box 2.
The Nutrition Cluster commits to remain active and vigilant in protecting, promoting and preserving breastfeeding practices in the Philippines, especially in times of emergencies/disasters. Since every disaster is unique, each experience offers an opportunity to learn and strengthen emergency/ disaster management systems. The Nutrition Policy in Emergencies/Disasters is nearing finalisation. Furthermore, the cluster membership will now be guided by a Terms of Reference (TOR) in order to strengthen partnership and clearly define areas of collaboration. The wide dissemination of the policy guidelines and the IRR of the Milk Code are among priority concerns. The advocacy campaign is being reinforced but nutrition workers need to be oriented in nutrition management in emergencies/disasters. At the end of this process, it is hoped that sound nutrition management in emergencies will be a way of life for every Filipino.
For further information, contact: Florinda Panlilio, email: email@example.com or firstname.lastname@example.org or Florinda V. Panlilio, Health Emergency Management Staff , 1st Floor , Bldg 12 Department of Health Central Office, San Lazaro Compound, Tayuman, Sta. Cruz Manila or tel: +6329275343287
1For more information on the Cluster Approach, visit http://www.humanitarianreform.org/
2Member agencies include DOH-National Center for Disease Prevention and Control (DOH-NCDPC), Department of Science and Technology - Food and Nutrition Research Institute (DOST-FNRI), Philippine National Red Cross (PNRC), World Health Organization (WHO), Save the Children, Plan International, Hellen Keller International, Department of Social Welfare and Development (DSWD), Department of Interior and Local Government (DILG), Department of Education (DepEd), and United Nation's Population Fund (UNFPA)
3National Demographic and Health Survey, 2003
5View the film at http://boycottnestle.blogspot.com/2007/05/watch-film-fromphilippines-here.html or order the DVD from Baby Milk Action, http://www.babymilkaction.org/shop/videos.html
Taken from Field Exchange Issue 34, October 2008