Sometimes whilst blogging I go searching for the right quote to fit my reflections. This quote seemed perfect for today’s story relating to the small Islamic community I am currently working with. I had never heard of Ali ibn Abi Talib, who according to Wikipedia “…. was the cousin and son-in-law of Muhammad, the last prophet of Islam. He ruled as the fourth caliph from 656 to 661, but is regarded as the rightful immediate successor to Muhammad as an Imam by Shia Muslims”.
Innocent misinformation stemming from poverty continues to throw regular blows at me from left field with scenarios such as today’s encounter seeming inconceivable and taking my slow first world brain some time to process.
In my March 12 blog I first mentioned, under the heading of Infant Feeding, the baby I met early in February when she was just 18 days old, whose mother had been supplied a free can of artificial infant formula by the maternity clinic. Mum’s ability to breastfeed had already been disrupted when we met. Mum is illiterate and was struggling to feed the baby using bottles. Since then my colleague and I have put in a great deal of effort including some community level education to promote breastfeeding, but also teaching this mother 1:1 what to do around how to make the milk; volumes and frequency of feeds; cleaning equipment; monitoring baby’s faltering growth; and preparing for changes in feeding instructions as baby gets older. We have also devised, with the support of a nutritionist colleague in Australia, a poster with pictorial instructions to reinforce what we are teaching. Soon I will leave Cambodia for a few months and my untrained colleague is going to have to pick up the responsibility of monitoring and supporting this mother, and probably many others, so the teaching material will serve a dual purpose. Some of our lessons have included:
- Powder to water ratios. These are specific depending on manufacturer instructions which require a level of literacy and numeracy that Mum does not have;
- Requirement to add the correct volume of water first, followed by the correct number of scoops of powder. This ensures accuracy of the required ratio, which is usually 30ml water to one scoop or 60ml water to one scoop, depending on the written instructions on the can.
- Reassurance around the confusion that the ratio instructions can cause. For example, if baby needs 150ml volume of milk, but powder to water ratio is 1 scoop to 60ml, then 180ml water should be measured out then 3 scoops of powder, being the nearest correct measurement to ensure an adequate feed is made. This not only leads to some wastage, but the three scoops of powder also increase the volume of liquid in the bottle to more than the initial 180ml. All of this can be quite confusing to the untrained mind.
- Discard remaining milk which baby will inevitably not drink if the volume is too much, in an environment where there is no refrigeration. This is a difficult instruction for a mother with extreme financial constraints, but necessary to avoid the opportunity for, and dangers of, bacterial growth.
[21 March: I’ve since realised that she likely does not discard anything and it could be why baby got diarrhoea, if she is saving leftover formula in the heat. So on advice from my mother I am going to suggest that she take any leftover out of the bottle at the end of a feed and give it to her 5yo, perhaps added to rice].
- Proper cleaning of bottles and teats.
- Recommended volume and number of feeds per 24 hours, which changes (at times rapidly) with age.
This mother could have breastfed her child freely and safely if she lived in an environment where breastfeeding is supported, rather than an environment where artificial infant formulas (aka “breastmilk substitutes”) are ruthlessly marketed. We have since invested many hours informing her appropriately so that she can protect her child from all manner of risks associated with bottle feeding in an impoverished environment. Everyday that I work on this activity, I wonder at the thousands and probably millions of other mothers around the world who have fallen prey to the marketing of breastmilk substitutes.
It is impossible to reflect on the victims of this global horror without simultaneously wondering at its beneficiaries. In May 2016 World Health Organisation published a document Guidance on Ending the Inappropriate Promotion of Foods for Infant and Young Children. WHO predicted in 2016 that by 2019, the market value of breastmilk substitutes would reach US$70.6 billion. That’s some extreme wealth being accumulated somewhere. Certainly not anywhere on the shores of the Mekong River where I tread, and where the chances of living safely let alone in comfort, are asphyxiated by all manner of adversity. WHO also stated that women and children have the right “to be free from inappropriate marketing of baby formula and related products”, which are “not in the best interests of maternal and child health”.
It still astonishes me that the “Baby Killer” scandal of the 1970s never really ended; that I ever believed, after reading of the global response to this scandal during my studies almost 20 years ago, that it had been resolved; and that in 2019 I now find myself working so closely with its ongoing ramifications.
Today when we met this mother and weighed her baby, the promise of her growth pattern improving had vanished and this week her weight has plummeted. As I pondered on what might be wrong given our intense efforts, Mum spoke at length in Khmer with my colleague. I then received a translation that – again – left me in a state of shock.
On Sunday, some weeks after Mum began following our instructions for bottle feeding, baby developed a distended abdomen and some diarrhoea. Mum took her to hospital. In hospital she was told that the reason her baby got sick, was that she was not making the bottles correctly, and was given a completely different (and incorrect) set of instructions as follows:
“If you plan to give your baby 60ml of formula, fill the bottle to the number 2 with powder, and then add water until it reaches the number 60. If you plan to give your baby 90ml of formula, fill the bottle to the number 3 with powder, and then add water until it reaches the number 90“. And so forth. Thankfully the relationship my colleague has with this family means she was able to encourage Mum to follow our instructions and ignore the hospital staff’s unfathomable advice. Not before 3 days of incorrect feeding on top of a bout of diarrhoea had worsened her previously-improving malnutrition. During our conversation Mum also asked, “why is she vomiting a lot now?”. How long has she been vomiting? “Since two days ago”. It was useful information to help convince her that the hospital’s instructions were obviously incorrect and had upset baby.
As an aside, but keeping with the theme of the power of marketing, Cambodia’s Ministry of Health announced recently that cases of the mosquito-borne virus Dengue Fever are expected to rise markedly this year. Media reports have stated that in 2018 approximately 25,000 people fell ill with Dengue Fever in Cambodia, 23 of whom died. Today with my colleague translating, we delivered a community education session to five women and 18 children, on Mosquito Prevention. One of my messages, relating to female mosquitoes relying on blood to nourish their eggs, was around the fact that male mosquitoes feed on flower pollen whilst female mosquitoes feed on human blood. The presentation on my computer screen included the following two slides:
At the end of our session we held a quiz with some prizes to those with the fastest correct responses. When we shared the cartoon captioned “Only female mosquitoes bite” we asked, what is the boy mosquito drinking? A crowd of children shot their arms into the air and my colleague translated (unnecessarily), “they think he is drinking Coca Cola”!
In the midst of it all Cambodia’s only three helicopters, which I talked about in my 15 February blog post, once more flew directly overhead, forcing a pause in our quiz game while we waited for their raucous chopping to pass.
I came home, lay on the couch and slept for two hours. Because sometimes the battle…..