The milk of human kindness

A simple battle

In six days, the American dailies had taken a highly contentious health issue—the merits of breast and bottle feeding in the era of AIDS—and turned it into a simple battle between the benevolent corporations and a seemingly malicious international health agency.

Unicef, whose mission is to “advocate for children's rights and help meet their needs” (http://www.unicef.org/), stood charged by the papers of infanticide. How had this issue become so polarised in the eyes of the US media?

The main answer is that Unicef's stance against the formula industry, and the complexities of mother to child transmission of HIV, are both difficult topics to present in a catchy and newsworthy way. Vilifying Unicef was an easy option.

Carole Bellamy, Unicef's executive director, made her position clear in an angry letter to the Wall Street Journal (14 December): “You fail to acknowledge,” wrote Bellamy, “that Unicef is leading the way in addressing mother to child transmission, and you fail to explain fully why Unicef so strongly supports breastfeeding.” Research showed, she said, that formula fed infants were four to six times more likely to die of disease than breast fed infants, and “exclusive breastfeeding can save lives, as many as 1.5 million a year.”

Was vilifying Unicef the easy option?

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A rush to promote formula feeding, she explained, could lead to the spread of other infectious diseases. Unicef's view is that if formula is to be used, it needs to be done in a targeted manner. The organisation is currently piloting projects in 11 countries to offer women HIV testing and counselling, offering formula to those who then chose to use it.

Alfred Ironside, Bellamy's press spokesman, told the BMJ that the article “didn't mention that only 5% or less of women in Africa have access to their HIV status, and therefore the idea of distributing formula to prevent mother to child transmission is moot, unless you send it to every woman in Africa—which would be a major public health disaster.”

Unicef has been highly vocal in its support for the International Code on the Marketing of Breast Milk Substitutes. It views improper marketing of formula—rather than formula itself—as dangerous, and refuses to accept donations from companies that have violated the code.

But the Wall Street Journal marginalised Unicef's policy, focusing instead on the much “racier” tensions between Bellamy and Peter Brabek, Nestlé's chief executive, and Geraldine Ferraro, the former New York vice presidential candidate now employed by Nestlé as a lobbyist.

And in presenting the feud, the newspaper sounded truly exasperated—if only Bellamy would soften her stance, it suggested, and take the corporate gifts on offer, millions now dying would be saved.

Accepting donations sparks controversy

Accepting donations from the formula industry seems to be tearing apart the UN health agencies, adding fuel to the paper's condemnation of Unicef.

“Even some UN officials,” said the Wall Street Journal reporters, “contend that Unicef's decades-old distrust of the formula industry should yield to a moral imperative to get formula to destitute, HIV-infected mothers.”

Who were these officials? None other than Peter Piot, executive director of UNAIDS, the Joint UN Programme on HIV/AIDS, who is quoted as saying that Unicef is “having difficulty accepting that the world has changed.”

Perhaps the papers, then, were merely reflecting a growing polarisation of opinion within the UN itself. I put this to Julia Cleves, chief at Dr Piot's office, who told me that Dr Piot's comments were taken out of context, and that the quotation was an oversimplification. “Peter made these comments,” she said, “about those in Unicef who pursue a hard line on baby milk, the so-called ‘lactation police.’ The point is, it wasn't a comment on Unicef as an institution.”

But I then spoke to Dr Piot himself, who stood by his attack and expressed frustration that it was taking “too long to find practical solutions” to the HIV crisis. “The solution,” he said, “will have to involve both industry and breastfeeding activists.” The old mantra of “breast is best,” he said, was no longer appropriate. He admitted that “there is a divide across organisations about what is right and wrong, and there are strong feelings.”

Despite the attack by Dr Piot, Unicef remains firm in its stance against accepting donations. “The other agencies aren't being offered formula,” said Alfred Ironside. “We're the target of these offers and we need a policy to deal with them.”

Is the industry cashing in on the crisis?

Many breastfeeding activists say that the formula industry is capitalising on the HIV epidemic to promote its products in the developing world—and the US papers have interpreted this as a charitable mission. Alison Linnear, coordinator of the International Baby Food Network, said, “It would seem that the manufacturers of breastmilk substitutes are seeking to exploit the dilemma posed by HIV/AIDS.”

This was certainly the view of the Swiss newspaper Le Courrier on 18 December, when it gave its version of events under the headline “Nestlé and its milk powder haven't yet won the battle against AIDS.”

“In countries ravaged by AIDS,” said the article, written by Robert James Parsons, “children of HIV positive mothers, infected by breast milk, are the target of powdered milk manufacturers who would like to flood southern Africa with their product.” His view was that “the Wall Street Journal supports the manufacturers.”

Dismissing the report, Nestlé's vice president, François-Xavier Perroud, told me: “He [Parsons] is well identified as a breastfeeding advocate,” and Le Courrier is the “last Marxist rag in Switzerland.” He thought, in contrast, that the Wall Street Journal article was “well researched and 100% correct.” Asked whether Nestlé was trying to cash in on the HIV crisis, he had “no comment.”

A missing voice

One voice that was remarkably absent from the Wall Street Journal story was that of the World Health Organization. Was it playing hard to get, after recent claims that it has a close relationship with industry? (BMJ 2000;320:1362).

In fact, the reporters interviewed many WHO officials, including the director general, Gro Harlem Brundtland, and executive director David Nabarro.

Dr Nabarro told me: “The reporters spent several weeks travelling the world researching the story, and they spoke with some of us for hours at a time. We cannot understand why they wrote what they did.”

The journalists, he said, failed to capture the central dilemma facing HIV-infected mothers and their health advisers in Africa: “Risk the death of the infant through HIV infection via breast milk? Or risk the death of the infant through feeding with contaminated supplements? High risk, either way.”

He expressed his frustration at the paper for implying that formula donations were the easy answer to a difficult crisis. Donating formula, he said, “does not overcome the problem of shortage of clean water, lack of a fridge, lack of the brushes and soap needed to clean feeding bottles, and shortage of means to boil bottles and sterilise them between feeds.”

No apologies from Wall Street

The Wall Street Journal rejects the powerful criticisms it has received from the international health community. It makes no apologies whatsoever for the story and the hard hitting editorial, nor for suggesting that donating milk substitutes is the answer to the HIV epidemic. Dick Tofel, a spokesman for the paper, said, “Our view is that these are the facts. If there was more formula available, babies would not be dying.”

The procedure is simple: take one very complicated public health issue; add a large dose of scientifically dubious rhetoric; dilute out the complexities. Makes great copy every time.