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Time for a New Formula

It’s World Breastfeeding Week.

You might be wondering why there’s a whole week devoted to breastfeeding. Haven’t women been doing this for countless thousands of years? Is this focus really necessary?

The answer is yes, and no. Women have always fed and nurtured humankind, but in the 1950s, breastfeeding began to fall out of favor. Women’s expertise was called into question (surely, a modern “formula”—created right in the laboratories where life-saving medicines are invented, and then pumped full of vitamins, precisely measured, and factory sealed—must be far superior to anything nature could produce? Miraculous, even.) Food and pharmaceutical companies eyed the ever-growing global market: another one hundred million-plus babies born each year, bolstered by a post-World War II baby boom in the West. They rushed to exploit a man-made bias that was already going strong in every culture on earth: anything women do, men can do better.

Never mind that what men in lab coats had concocted to replace breastfeeding was based on milk custom-made for a 65-pound calf, was vastly inferior to mother’s milk in nutritional content, contained no human antibodies, and cost more than most households in developing countries spent to feed their entire extended families. Never mind that the powdered product became toxic unless carefully measured according to written instructions, mixed with clean water, heated to the right temperature for feeding or refrigerated at the right temperature for later use, poured into sterilized feeding bottles…all processes requiring literacy, time, resources, fuel, and commodities that simply weren’t available. Corporations had a product to sell and mothers to transform into ‘consumers’, so of course, none of these risks were made clear. Mothers who found that they couldn’t keep up with the time and cash demands of infant formula learned the hard way that reverting to breastfeeding wasn’t an option; their bodies no longer produced milk. Diarrhea and upper respiratory infections in babies spiked. The World Health Organization warned that millions of infants were dying for lack of breastfeeding; activists chose infant formula’s largest manufacturer, Nestle, as the target of a campaign that would grow into what is still ranked the most successful product boycott of all time. Soon even the formula manufacturers had to relent – a bit. Before extolling the virtues of their man-made products, they began with the concession that “breast is best”—BUT...  

By 1981, the fact that a UN-led International Code of Marketing of Breastmilk Substitutes (1) was needed to protect nature from cutthroat corporate competition shows just how far the pendulum had swung in the direction of patriarchy and profit.  

Thirty-five years later, have we learned our lesson?

Hardly. Societies, government health departments and institutions, including the UN, are still dominated by men. Most still can’t bring themselves to share power equally with women in any domain, much less entirely relinquish authority over one area to women. They still don’t trust women’s own ability—superpower, really—to create an automatically replenishing, custom-made, nutritionally perfect food for their babies. It doesn’t matter that breastmilk adjusts to the growing child, costs nothing, requires no preparation, packaging, heating, refrigeration or storage, is infused with the natural immunities that mothers acquire over their lifetimes, and has a built-in delivery system that involves the skin-to-skin and eye contact necessary for every baby’s healthy cognitive and social development. But for the overwhelming majority of male “leaders” and medical doctors—people accustomed to calling the shots—infant feeding isn’t a question of common sense, or even of survival; it’s a question of control and of profit.

That’s why, in 2016, a message from the heads of UNICEF and WHO calling breastfeeding the “cornerstone of a country’s healthy development” rings hollow. The two agencies have all but abandoned infant feeding, leaving ministries of health without clear guidance and lawmakers swinging in the wind. That seems odd; after all, in the 80s and 90s, UNICEF and WHO were making good progress on protecting and supporting women’s rights to full, correct infant feeding information. What happened?

Things got complicated.  

You’ll recall that 1981 was the year of the International Code of Marketing of Breastmilk Substitutes. That’s also the year that the first cases of HIV were detected. Because women’s health is generally sidelined, and HIV research—back then, and to this day—was overwhelmingly focused on adult male subjects, it took most of a decade for experts to begin noticing that the HI virus could survive in the breastmilk of women who’d acquired it from a sex partner, a blood transfusion or an infected needle. Their breastfed infants could become the next link in the long chain of transmission. By that time, HIV was exploding among women of reproductive age, particularly in sub-Saharan Africa, south Asia and the Caribbean, and rates among infants were keeping pace.

It seemed counter-intuitive that nature would be stacked that way against mothers and their babies. That puzzle didn’t take long for career lactation experts from organizations such as IBFAN to solve. Babies fed only breastmilk for the first six months, as nature intended, could still receive nutrients and immunities from their HIV-positive mothers; the milk would travel smoothly through the gut. But since introducing any other liquid or solid into the fragile digestive tract of a baby under 6-months was known to open tiny ‘leaks’ in the gut, it followed that breastmilk containing the virus could enter a baby’s system through a gut that had been compromised. Their conclusion: all babies were still far better off—nutritionally, disease-wise, developmentally—if exclusively breastfeed, regardless of the HIV status of their mothers. The crisis was caused by “mixed feeding”—some formula, juice, water—followed by breastmilk containing some HIV.   

And the solution? The UN would simply have to apply its considerable communications expertise to deliver, to mothers who are or might be HIV-positive, a message that at first seems to defy logic: breastmilk-only is great for your baby, but some formula and some breastmilk can be lethal. And the UN would have to trust that if they conveyed the message clearly, the women most affected would be perfectly capable of understanding and acting on it. They lacked resources, not intelligence.

That leap of faith proved to be too much for UNICEF and WHO—which by now had been joined by UNAIDS, a new agency created to focus entirely on HIV. Women’s rights advocates pointed out that a communications campaign was absolutely essential, but woefully inadequate. The UN couldn’t skip the research and rely on best guesses. And they certainly couldn’t just issue a warning to women living with HIV that they might be pointing their babies toward irreversible disaster—and then leave them with no help to avoid it. How was a mother to breastfeed exclusively for six months if she had to return to a job outside the home? For that matter, how was an employee of UNICEF or WHO to pull that off, given the UN’s 4-month maternity leave policy?   

It’s hard to imagine—historians will certainly shake their heads in disbelief—but the UN went into reverse, back to the bad old days when sexually transmitted infections were called “venereal diseases,” visited upon hapless men by Venus, that nefarious goddess of love and vector of disease. In lieu of clear information and explanations sent not just to women, but to their husbands and partners and mothers-in-law as well; in place of social supports such as 6-month maternity leaves, on-site infant care and breastfeeding breaks; instead of nutrition supplement programs for lactating women, what the UN would provide for pregnant women was instruction, and a two-tiered solution, one for mothers in wealthy countries that removed nearly all the risk of transmission to infants, and another for everyone else. For the vast majority of mothers affected—women from countries with the highest levels of HIV burden and the lowest levels of control over their sexual and reproductive lives—the directive was terrifying, and it left no room for choice. Get tested for HIV; if you test positive, sign up for a quick-fix drug that can halve the chances that your infant will contract the virus during labor and delivery; and then, avoid all breastfeeding and rely on formula. How? We hope your government will help out, but if it can’t, we hope you’ll figure things out. The new program’s name? Not ‘vertical transmission’—that term was considered far too complicated (apparently as compared with other entries in the AIDS lexicon, including anti-retroviral therapy and post-exposure prophylaxis, that rolled right off the tongue). No, in order to get through to women, it had to be called “Prevention of Mother-to-Child Transmission.” That way, there wouldn’t be any doubt about whom to blame and shame, should a child acquire the virus.

Over many, many years, through an unnecessarily prolonged process of trial and error, grief and guilt, the science and the political will to prevent vertical transmission have improved. The attitude hasn’t. As recently as 2011, the UN developed a roadmap to address vertical transmission: “Countdown to Zero: Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive.” Mothers are tacked on at the end, devoid of agency and merely “kept alive” so that their children could thrive. You could excuse that as simply a really clumsy title. Or you could look at the UN, then and now, and wonder if it reflects an atavistic aversion to seeing women as men’s equals, paired with a pathological disregard for the singular ability of mothers to make the best decisions for themselves, their infants, and the rest of their families.

Last year, the UN trumpeted the ‘elimination of mother-to-child transmission’ in several countries, and heralded the fact that we’re a stone’s throw away from a generation of children “born HIV-free.” The roll-out of lifelong antiretroviral treatment for pregnant women and their newborn infants has resulted in huge gains, to be sure. But in the same breath, virtually every UN article and report on new HIV infections among children admits, without qualification, that “over half of new pediatric HIV infections occur during the breastfeeding period.” (2) The latest, On the Fast Track to an AIDS-Free Generation, explains why: “not enough mothers living with HIV are being retained in care and on antiretroviral therapy, which protects against transmission.” Note the passive voice. It’s no one’s fault that mothers aren’t getting the clear information or  support or follow-up they need, or that they’re not being asked why it’s proving difficult to keep up with drug regimens. Stuff just happens—or doesn’t.

Here’s what ought to happen: The Executive Director of UNICEF and the Director-General of WHO should revisit the World Breastfeeding Week message they signed off on, and for perhaps the first time since they took their respective jobs, they should give serious thought to the obligation that this assertion places directly on each of them, personally: “Breastfeeding is the cornerstone of a country’s healthy development.” If that’s true, then UNICEF and WHO, as well as UNAIDS, have a responsibility to press for more and better and sustained research, to answer all the questions that have lingered for decades. It’s time that UN language about women and mothers were subjected to a scrupulous ‘gender review.’ And it’s well past time for the UN to get its messages right, ensuring at a minimum that its agencies’ guidelines on HIV and infant feeding bear some resemblance to one another. Meanwhile, enough of the unsubtle messages that good mothers figure out how to breastfeed exclusively for six months, with or without support. The UN, for one, has no business taking that supercilious stance when its own staff are given just four months’ paid maternity leave.  

In the coming weeks, AIDS-Free World will post a short series of essays to delve further into some of these questions, and to ponder just what policy and decision-makers must do to swap double standards where women are concerned for a single, gold standard that’s one-size-fits-all. The theme of World Breastfeeding Week this year hits the nail on the head: Breastfeeding, A Key to Sustainable Development. If the UN won’t turn that key, one wonders how long it will be until women can walk through the doors to equal rights, respect and agency.  

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(1) President Ronald Reagan refused to allow the US to join the 118 countries that signed; President William J. Clinton reversed that decision in the 1990s.

(2) UNAIDS. 2016. On the Fast-Track to an AIDS-Free Generation. http://www.unaids.org/en/resources/documents/2016/GlobalPlan2016, p.15