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From:
Susan Burger <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 10 Feb 2013 10:41:20 -0500
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Dear Alice:

In the 1980s, the Executive Director of Unicef, James Grant featured prominently in some of our health management classes at Johns Hopkins in contrast to the WHO leader at the time -- whose name I forget write now.  Unicef was very proactive about a few key interventions which started out as GOBI.  Actually two of these are not interventions at all.  

Growth monitoring can be used for assessment and evaluation but is not in it of itself and intervention.  It only works when it is coupled with growth promotion.  Most of the work that has been done shows it is best used as an educational and counseling tool.  At the time, there were some who claimed that small was beautiful and therefore it was perfectly fine to allow children to be malnourished, but there have now been numerous studies showing that growth faltering has long term permanent effects on health -- including increasing the tendency later in life to become obese.  

Oral rehydration was implemented because there was abundant evidence that dehydration was causing death and that death could be prevented by its use.  Oral is better than IV due to the need for a greater degree of sterility with an IV -- something that can be challenging in developing areas.  Later, people realized that this was merely treating the emergency state of immanent death and not dealing with the underlying cause, diarrhea.  So, diarrhea control programs were implemented, as well as water and sanitation programs.  Diarrhea control was easier for public health professionals because it is involves health clinics.  Water and sanitation is more costly because it involves construction.  Many of the programs also ran afoul of cultural attitudes and failed to include women, who collect water and clean the household, into the design of water supply and sanitation facilities. 

Breastfeeding also is not an intervention.  It is merely the normal state.  Promotion of the normal state was necessary because of Nestle.  One of my professors at Cornell was Dr. Michael Latham who witnessed the devastating effects of Nestle up close and personal in Tanzania where he grew up and followed his father by choosing to become a doctor.  Then along came HIV and the formula industry once again capitalized on an opportunity and pushed breastfeeding promotion into the background. 

Immunization was the other true intervention.  Measles kills.  Measles kills faster when there is vitamin A deficiency.  When children who are vitamin A deficient get measles they decline much faster.  It can push them from night blind into xerophthalmia and then they go blind and then they die.  90% of those who go blind die.  Even without vitamin A deficiency, malnourished children die from measles at a much higher rate than non malnourished children.  Polio was still rampant at that time as well.  In the polio outbreaks in the United States, water and sanitation did not prevent it at all.  In fact, children who were in the most pristine households tended to suffer more, probably because they had less exposure to small doses of the virus.  Both of these are droplet spread diseases and hard to contain.  

The critique of this method was that it did not provide comprehensive care and so the first wave was to expand out into "Primary Health Care".  We were supposed to achieve "Health Care for All by the Year 2000".  Personally, I believe that this would have improved the global economy immensely.  Unfortunately, at least in the United States we have gone down the path of having the most amazing technological interventions for those who can afford private for profit insurance.  Those who cannot afford it are actually creating a huge burden on emergency medical technicians such as my brother (who is a firefighter EMT) because people without insurance can't afford preventive care.  To me this would be like not fixing a leak in your roof and waiting leak go so bad that your whole roof fell down and then expecting FEMA to pay for it.  The dialogue has gone from "Health Care for All" to "Health Care is a Benefit only for those who deserve it and pay for it".  

Subsequent to Jim Grant, the mission of Unicef drifted further from its first mission of improving health and survival.  Instead of focusing on prevention, the put more money into emergency conditions.  They also started drifting into education and rights of the girl children. All of this would have been well and good except that they appear to have dropped the most fundamental of all rights - the right for infants to be fed human milk.  It is hard to find mention of breastfeeding on Unicef's website.

Sincerely, 
Susan Burger, MHS, PhD, IBCLC

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