Botswana’s PMTCT programme has put a great deal of emphasis on safer infant feeding, offering free formula to HIV exposed infants for a year. But as discussed in HATIP #74 (see http://www.aidsmap.com/cms1177384.asp), formula feeding in Africa is an example of an idea that is only as good as its implementation, and in the case of infant feeding, implementation has to be almost perfect.
One of the problems has been providing a consistent supply of formula. Some doctors at the Botswana conference told this reporter that they frequently ran out. This was such a problem, according to an article in the September 15th edition of Gaborone’s The Reporter, that the Ministry of Health sued to cancel its contract with its supplier for failure to supply over 90,000 cans of infant formula. According to the article, the Public Procurement and Asset Disposal Board approved the request from the Ministry of Health, which has now signed a contract with a new supplier.
However, this still may not be the end of the supply problems. “Sometimes it’s not an absolute shortage. On many occasions, it’s actually logistics, or distribution, which is actually the major cause of shortages,” said Dr Jibril.
“The challenge is that even when you want to take it to bigger settlements or health facilities, there is limited storage space; so they can only take so much at a time. Therefore, if you have limited storage space, the frequency of the shipments has to go up, and the higher the frequency, the more likely you are to encounter logistical problems,” said Mr Ramotlhwa.
According to Dr Jibril and Mr Ramotlhwa, the government has decided to build a warehouse in Francistown to stock both drugs and formula.
“With respect to the infant formula, there are a few warehouses with limited storage capacity in some of the strategic areas to supply health facilities within their defined catchment areas. But it’s always an issue of how much storage capacity is available locally, and what type of storage capacity; for instance, if it is bigger and air conditioned then you can keep more stock there for a longer period,” Dr Ramotlhwa.
“One solution might have been just to let mothers get it from supermarkets,” suggested Prof. Anabwani. “Give them vouchers and get out of the business of distributing it yourself because this formula is available everywhere [at groceries]. Or you could have a fail safe situation, where mothers would be given vouchers to go to any shop to get the milk.”
“The problem is that if the mothers run out of it, then they may do anything because of course they have to feed the children,” said Dr Jibril. As a result, the mothers often use age-inappropriate products that are harmful to the child. “They use whatever is available especially this long-life milk in the box. Then, of course, they end up with problems of diarrhoea.”
As noted in HATIP issue #74, (see http://www.aidsmap.com/cms1177384.asp) there was a diarrhoea epidemic in Botswana after unusually heavy rains at the beginning of the year. A US CDC analysis concluded that the water, which is normally safe, was contaminated — and there was an extremely high risk of diarrhoea and death among infants who were not breastfed.
But according to Prof. Anabwani, there are other local factors that need to be considered — such as the fact that most of the microbes identified in that study are ubiquitous in Botswana during the rainy season.
“Cryptosporidia are normal micro-organisms in cattle,” he said. “This is cattle country, and some studies done in South Africa showed that about 100% of all cattle carry it and they excrete it in the urine and the cow dung. So you have a lot of rain. You have flooding everywhere. You have kids playing all over the place. So you have kids playing, literally, in microsporidia. I think that maybe the contamination of water sources also may have played a role but I think that it was much more widespread. I think it was much more likely the way that it happened. Because of cattle and urine and cow dung.
I mean, children playing in the village, just imagine, water ponds, their huts are contaminated...”
“If you don’t take into consideration the cultural situation, you can completely miss the point,” said Mr Ramotlhwa. “What happens is that during the rainy season, people in Botswana want to drink rain water. Outside the rainy season, because there is not much rain water around, they normally use tap water. But during the rainy season, even some of the people coming from the towns, they just drink that rain water. So there is that element — that the water that people may normally use may be safe but during the rainy season people use rain water.”
Travelling across Botswana at the very start of the rainy season, it was easy to see that this is indeed the case. In many of the villages I visited while in Botswana, people said that they indeed preferred to drink rain water, or even water collected from ponds and running streams.
Of course, one of the virtues of breast milk is that it protects infants from common pathogens in the environment — while formula feeding doesn’t. But at present, the focus in Botswana is how to tackle the cultural factors associated with improper infant feeding.
“Malnutrition in infancy is related to bottle feeding in this country,” said Prof. Anabwani. “For me, it is a question of education and educating the right people. In Botswana, if the mother is not breastfeeding, there is this cultural period of confinement, when she is actually regarded as unclean. She has her own cups— they are not even shared by the rest of the family. She may not even prepare a feed for her own baby, some other people do it. So you need to include the ones who assist the women in that education plan.”
In response to the diarrhoea outbreak, the government redoubled its efforts to get mothers to boil water first, and women were also encouraged to feed their cups infants with cups, which are easier to sterilise. Prof. Anabwani thinks this is too impractical.
“Try to put that into practice,” he said. “You have to think about what that mother lives through every day. I have talked to hundreds of mothers, and I have said to them, ‘why don’t you use the cup?’ They look at me as though I am totally mad. You have to imagine: summer in Botswana, a woman in the massimo (a massimo is like a cattle post or the village, or the lands) surrounded by animals and so on, with a cup, in an atmosphere that has huge numbers of flies? You take the cup, and the child begins and “now how am I going to ward off the flies with an open cup?’ It’s not possible to use it! Secondly, at night. A child wakes up in the middle of the night and wants to feed. What is the mother likely to do? Feed the child with a cup in the dark, or is she going to use a bottle that she’s prepared?”
But many sites and healthcare personnel are telling mothers not to use bottles. “Most of [the messages] are opposing,” Prof Anabwani said. “ ‘Don’t use the bottle, it is bad. Use the cup.’ At Baylor, the nurses used to be so harsh, so the mothers would hide their bottles each time they came to the hospital and as soon as they leave the hospitals, they would begin to use them.”
“But the same people who are telling the mothers to use the cup don’t use the cup. The role models don’t use the cup. The nurses don’t use the cup. The women who are working in high offices, don’t use the cup. Nobody uses the cup. Nobody has ever used the cup at the population level! And yet, that is seen as theoretically being safer and therefore what people should do.”
“Mothers want to use bottles. So instead of insisting that they use something that is so impractical that no one would use it, work with them to how to improve the way they use the bottle. And that is something that is totally lacking. Nobody is teaching mothers how to use the bottles safely in these clinics and I think that is part of the problem.”