To prevent unnecessary deaths, the humanitarian response to famine needs to be rapid, well coordinated, and based on sound epidemiological evidence. Public health interventions, such as mass measles vaccination campaigns with coverage extended to children aged 12 to 15 years should be implemented as the first priority. The prevalence of wasting and undernutrition among children and adults, respectively, should be assessed in all prolonged, severe famines.

Objective: Distribution of breast milk substitutes (BMS) after the 2006 Yogyakarta earthquake was uncontrolled and widespread. We assessed the magnitude of BMS distribution after the earthquake, its impact on feeding practices and the association between consumption of infant formula and diarrhoea among infants and young children. Design: One month after the earthquake, caregivers of 831 children aged 0-23 months were surveyed regarding receipt of unsolicited donations of BMS, and on recent child-feeding practices and diarrhoeal illness. Setting: Community-level survey in an earthquake-affected district. Subjects: Primary caregivers of surveyed children. Results: In all, 75 % of households with an infant aged 0-5 months and 80 % of all households surveyed received donated infant formula; 76 % of all households received commercial porridge and 49 % received powdered milk. Only 32 % of 0-5-month-old infants had consumed formula before the earthquake, but 43 % had in the 24 h preceding the survey (P , 0?001). Consumption of all types of BMS was significantly higher among those who received donated commodities, regardless of age (P , 0?01). One-week diarrhoea incidence among those who received donated infant formula (25?4 %) was higher than among those who did not (11?5 %; relative risk 5 2?12, 95 % CI 5 1?34, 3?35). The rate of diarrhoea among those aged 12-23 months was around five times the pre-earthquake rate. Conclusions: There were strong associations between receipt of BMS and changes in feeding practices, and between receipt of infant formula and diarrhoea. Uncontrolled distribution of infant formula exacerbates the risk of diarrhoea among infants and young children in emergencies.

These data indicate that, by April 2001, a humanitarian crisis already existed in Kohistan. Essential humanitarian services, including food aid and public health programs, are urgently required in such regions of Afghanistan and will be crucial if a worsening humanitarian crisis is to be avoided. For these services and programs to be implemented, the international community needs to create adequate humanitarian space (ie, a secure and accessible location where humanitarian organizations can provide services to emergency-affected populations) to ensure that humanitarian organizations have access to populations within Afghanistan as well as to refugees who flee to surrounding countries.

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