Dear All:

I was thinking that the differences between what we do in cultures that do not support 
breastfeeding compared to those countries that do is very similar to what I encountered with 
projects in developing areas of the world.

I worked on the projects that addressed fundamental changes that would enable populations to 
improve their nutrition.  This meant working with health care workers on many levels to improve 
their counseling skills, encouraging other family members to provide support women in their 
efforts to feed their infants appropriately, improving food availability through training women to 
grow gardens, etc.  When properly implemented these programs actually do work and better yet 
are sustainable when the local population fully participates and are engaged in changing practices 
in ways that are culturally appropriate.  Moreover, when the programs work, they are highly cost-
effective.

I also worked in situations that were emerging from refugee or war conditions.  So I got to know 
the emergency refugee junkies.  There is quite an adrenaline rush to that type of work and most of 
them are characters.  This is the type of program that hits the news with the starving baby 
pictures that cause people to pause for a moment and either write a check or say -"See, you can't 
fix these problems" if they are burnt out.  These programs reduce death but they do nothing for 
the underlying problems in any fundamental way.

I'd say that many of us in the United States are in the position of those working on emergency 
refugee situations and some of us in the position of working in the long-term programs.  I'd say 
many of those who work in Norway and Australia are in the long-term programs and rarely in the 
short-term programs. In the US we are just band aids until we fix the larger problem of societal 
support.

Finally, for Magda, I’d say she is in the situation I was in when I trained Peace Corps volunteers in 
Niger.  They weighed babies, didn’t use the information from the scales, never talked to their 
Nigerien colleagues and gave out food according to the centiles on the charts.  The Nigerian 
health care workers were not respected, totally burnt out and demoralized.  While the perpetual 
drought in Niger does produce huge obstacles, I would say the whole system had changed 
dramatically in part because of a Quality Assurance program that trained Nigerian primary care 
workers how to collect and use information and make decisions themselves. This also led them to 
treat their clients differently.  I would argue the measurement tools were irrelevant - it was the 
decision making process that was important.

Its not really about the tool, it is about looking at the health care structure and using information 
in a way that is empowering for everyone involved.  The short-term fix in the UK system would be 
to have the home visiting nurses refer cases to someone who could do in-depth observation and 
history taking so that appropriate advice was given while building up the counseling skills of the 
nurses.  Taking the scales away would not improve the advice at all.  Whether to use the scales or 
not during the visits is not the problem in the UK system - it is the advice giving process.

Best regards, Susan Burger  

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