The Big Letdown

by Kimberly Seals Allers

  The commercial also begins with a flawed premise—the mommy wars must exist or why else would there be a commercial urging them to end? Instead, the ad actually perpetuates the same war that it pretends to end. In this narrative, breastfeeding is just another choice—like cloth diapering or which color to paint your kid’s room—but one that completely ignores the medical and scientific fact that breastfeeding provides optimal nutrition for babies. Instead, the commercial says, It’s all the same, don’t judge. And if you do, you are a bad mom, a confrontational one. It’s the corporate vision of a united world—one big happy marketplace. It also implies that mothers should save their energy for the really big, life-threatening stuff that really matters. These are underhanded ways of sending mothers mixed messages that rouse emotions but don’t address the structural barriers that need to be dismantled for all women and babies to thrive. Creating emotional campaigns to encourage formula feeding while executives count on employment limiting breastfeeding to boost profits shows the profit-seeking behavior that has continued for years.

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  The co-opting of language includes the co-opting of consumer marketing trends. For example, when cola giant, Coke (formerly a longtime, major donor to the American Academy of Pediatrics) realized they were on the wrong side of the growing eat-healthier movement and the mounting evidence directly linking sugar consumption to obesity, they decided that instead of trying to buck the trend or constantly defend their product, that it was better to actually follow the consumer. In effect, if you can’t beat ’em, join ’em. Don’t want aspartame? Fine, Coca-Cola now markets an all-natural stevia-based low-calorie cola called Coca-Cola Life. Advertisements use the language of “moderation,” encouraging customers to have a little rather than none at all.

  Monsanto, the world’s largest maker of genetically modified seeds, now markets itself as being “part of the bigger conversation about food,” even while actively working behind the scenes to stop widespread consumer efforts for GMO labeling legislation. Following the consumer means that in 2015 Abbott introduced the first non-GMO infant formula in the U.S, in response to growing demand for GMO-free products. This is smart consumer marketing but it is still marketing junk food to babies.

  While closely following lifestyle trends for their consumer marketing efforts, they also closely watch medical professionals to gauge their latest needs. Since doctors cannot be directly paid to endorse infant formula, drug companies moved to less obvious forms of compensation: subsidizing office furnishings, research projects, conferences, publications, and travel junkets for medical professionals. There were the infamous “ski and learn” conferences, and less expensive maneuvers like bringing free coffee and donuts and other food to the hardworking, time-strapped nursing staff as a way to curry favor. The most insidious of these perks was a free service to renovate or build newborn facilities in hospitals around the world. A 1982 report by the Action for Corporate Accountability found that Abbott Laboratories helped design at least two hundred maternity departments a year in the United States alone. Abbott is still involved with hospital design, engaging in humanitarian efforts, such as Design 4 Others (D4O), which uses volunteers to design and build health care facilities for communities with limited resources across Africa and Asia. In the United States, the Abbott-designed wards included central nurseries that place mothers far away from babies, a practice that disrupts the natural rhythm of breastfeeding. A mother’s physical contact with her baby stimulates the production of prolactin, the milk-making hormone. With babies separated from mothers, important unique feeding cues can also become illusory. Babies may turn their head, open their mouth, stick out their tongue, or even make small noises to indicate they are ready to feed. These relatively small movements often go unnoticed by nurses attending to several babies. If a baby has to resort to crying in order to communicate hunger, he or she may be too exhausted to nurse properly. But in order to pick up on these cues, mothers need to be near their babies. Infant formula marketers know this and used this knowledge and their deep pockets to their commercial advantage.

  One proposal from Ross Laboratories revealed by the Action for Corporate Accountability in the late 1980s showed that a New York City hospital would be paid $1 million to use Ross’s architectural services for its nurseries. In exchange for the payment, the hospital would be required to provide gift packs with formula to all new mothers. The proposal also required the hospital to use promotional videos made by Ross for any of its prenatal childbirth and breastfeeding classes at the hospital. These videos were known to have flawed information and send subliminal messages that breastfeeding is difficult and often fails while promoting the convenience of bottle feeding. The video packaging also contained formula samples and coupons. Beyond the general maternity wards, formula manufacturers also seek to infiltrate where the sickest babies are kept. In 1991 the Ross Products division of Abbott Labs convened twenty-five physicians, nurses, planning officials, and architects to discuss the role of the neonatal intensive care unit (NICU) design environment on very low birth weight babies (VLBW). This group’s findings, again convened by the infant formula maker, became design recommendations that were presented to and later incorporated into the Federal Guideline Institute’s Guidelines for Design and Construction of Health Care Facilities. According to FGI, a nonprofit founded in 1988 to guide the health-care built environment, the guidelines have long been a document written jointly by federal and private agencies. However, somehow the process was infiltrated by infant formula companies, who have been directly involved in creating the national recommendations for the NICU environment. This is particularly concerning since low birth weight and preterm infants are the ones who need breast milk the most—for them it is lifesaving. The two leading causes of infant death among preterm babies—necrotizing enterocolitis and lower respiratory infections—are significantly lower among breastfed infants.

  While infant formula manufacturers plow money into defining the physical space at hospitals and influencing the cultural environment when you leave one, hospitals are woefully understaffed with lactation consultants, and lactation consultants are often underpaid. In the United States there were 15,144 International Board Certified Lactation Consultants (IBCLC) as of 2015. But, according to preliminary numbers for 2015 from the National Vital Statistics Report, more than 3.9 million babies were born. Let’s dig a little deeper into some state data. In California, there were 2,258 IBCLCs in 2015. According to the preliminary birth data available for California, there were 491,487 live births in 2015. That means there were approximately 217 mother-baby couplets for each IBCLC. But in Mississippi there are only 74 IBCLCs, where in 2015 there were some 38,390 live births. That’s about 518 babies for each IBCLC. Across the country, there’s a huge gap in the number of professionals providing lactation support compared with the number of mothers who need support. While there may not be enough money or staff for every mother to receive the time and quality of breastfeeding help she needs, there is always a discharge bag or formula freebies in the mail for every mother who leaves a hospital.

  Today, the practice of direct promotion to doctors and nurses in the hospital is no longer allowed. Hospitals, in response to pressure from breastfeeding advocates and the Baby-Friendly Hospital Initiative—a campaign and ten-step hospital accreditation backed by the WHO to reduce infant formula influences in hospitals and create more breastfeeding support—have voluntarily changed their policies for formula reps on the maternity wards. Instead, infant formula reps use social media and other tactics to reach doctors and nurses directly. Nurses often tell me that they miss the free donuts or free lunch. Yet, infant formula companies still pay million-dollar rebates to hospitals and provide equipment and training for medical staff. But there is no such thing as a free lunch or donut. When companies are willing to put so much money on the table and into hospital coffers, it is clear the discharge packs are anything but benign. The payoff is worth it. As one Abbott training manual from the early 2000s p
ut it, “When one considers that for every 100 infants discharged on a particular formula brand, approximately 93 infants remain on that brand, the importance of hospital selling becomes obvious.” It’s also obvious how hospital balance sheets have grown to rely on the refunds, rebates, and other incentives that formula companies pay.

  These discharge bags insinuate that the hospital endorses formula as a general practice and a specific brand in particular. Compelling research proves that women who receive formula discharge bags at the hospital do not meet their stated breastfeeding goals. Studies published in the American Journal of Public Health, the Journal of Human Lactation, and Pediatrics (see especially the comprehensive 2010 analysis “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis”) document the link between formula samples and reduced breastfeeding. Yet hospital decision making about whether or not to give away formula is mostly driven by finances—can they afford to financially function without the handsome rebates, refunds, and other incentives that the infant formula companies provide? The implications of infant and maternal health are often an afterthought to hospital profitability.

  It’s no wonder that since 2006 there has been a nationwide effort to “Ban the Bag.” Among the nation’s forty-five top-ranked hospitals, 67 percent have stopped distributing formula samples and formula-company-sponsored discharge bags, according to a recent analysis by Public Citizen, a nonprofit advocacy organization. All mothers who medically need formula receive it, but it is not given away at discharge as a default. Massachusetts and Rhode Island have statewide bans on formula discharge bags. All public hospitals run by the New York City Health and Hospitals Corporation banned formula bags and promotional materials in 2007 because of their negative impact on breastfeeding rates. Twelve private New York City hospitals made the same move when they voluntarily signed on to the city’s Latch On initiative. Latch On doesn’t go as far in eradicating formula use in hospitals or as far as a Baby-Friendly hospital designation, but it is a step in the right direction toward removing the financial incentives of formula marketing in hospitals.

  Hospitals aren’t the only organizations benefiting financially from the profit making of infant formula companies. The pharmaceutical companies also work indirectly through physician organizations, such as the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG). In 2013 the Academy of Breastfeeding Medicine and several women’s health and breastfeeding organizations joined forces to petition the AAP—an organization representing over sixty thousand pediatricians whose recommendations form the basis of pediatric preventive health care—to terminate its ongoing financial relationships with infant formula manufacturers. In the summer of 2012, the AAP entered into a sales agreement with Mead Johnson, the maker of Enfamil formula, to put the AAP logo on the tags of formula discharge bags. The Enfamil bags with AAP materials give an implied endorsement by the academy—the agency trusted to champion infant and child health. Parents turn to the AAP expecting unbiased advice, not conflicts of interest, when it comes to infant health. However, the commercial prowess of infant formula manufacturers has allowed them to pay their way into hospitals, professional organizations, and the hearts and minds of doctors and nurses with offerings as expensive as new hospital wings and conferences and gifts as cheap as donuts.

  But the business environment favoring infant formula companies goes even higher up the chain of command. This kind of billion-dollar success couldn’t occur and continue for decades without the right regulatory environment and government collusion. Third World countries are not the only places with severe cracks in their regulatory controls. In this case, a key factor supporting the success of infant formula in the United States is the FDA’s odd designation of infant formula as a food versus a drug. This designation was changed in 1992. It should be noted that infant formula is made mostly by pharmaceutical companies and being able to land clearly in the food camp may explain the Bristol-Myers spin-off of Mead Johnson. Being in the food category means any ingredient added to food, including infant formula, must only be “generally recognized as safe” (GRAS) for its intended use. A drug would have to be tested for its safety and effectiveness—that is, does it do what it says it does?—but infant formula, as a food, does not have to meet this measure. Manufacturers must only provide the FDA with “assurances” and “reasonable certainty,” attested to by competent scientists, that the requirements specific to infant formula have been met for each new infant formula and that the ingredients are “safe” before it is sold to the public. Those competent scientists can be selected by the manufacturer. In the end, manufacturers use their own scientists, who assure the FDA that their products are safe and then technically “test” their products on infants and wait for adverse responses to make adjustments. Therefore, infant formulas are not FDA approved. There is no test for nutritional adequacy, only a requirement to comply with a list of required ingredients, such as protein, B12, and vitamin D. Infant formula is judged by the government only on its composition and not on its nutritional benefit to a child. This simplistic approach to something as important as infant formula is particularly concerning. The underlying assumption that any infant formula that simply contains the specified ingredients in the required amounts is both safe and nutritionally adequate grossly underestimates the complexities of breast milk, which is more than the sum of its components. Throwing a bunch of ingredients into a blender is not the same as preparing each ingredient in the way that maximizes its nutritional content; how those ingredients are processed is critical to their nutritional value. Eating a protein bar is not the same as getting protein naturally from food. Infant formula lists its fat content, but it is usually from beef tallow—not the same as the complex fats in mother’s milk. Food scientists have acknowledged that breaking food down into its chemical components and simply marketing those components is dangerous for public health. Allowing food manufacturers to swap out one ingredient and add others ignores the processing that occurs. “Identification of food mainly with its chemical constituents at best has limited value, and in general has proved to be unhelpful, misleading, and harmful to public health,” wrote Carlos Monteiro, a professor at the Center for Epidemiological Studies in Health and Nutrition at the University of São Paolo and a leading expert on processed foods.

  A popular November 2010 editorial in the online Journal of the World Public Health Nutrition Association, argued that nutritionists’ focus on nutrients, rather than foods, has led to the assumption that if foods contain the same nutrients, they are the same—even though it is never possible to fully replicate the nutritional content of foods because too much about their chemical composition is still unknown. “This notion is an exquisite combination of stupidity and arrogance, or else of intelligence and cunning. For a start, similar results can only be of those chemical constituents that are at the time known, and actually measured,” the unsigned editorial said. If this “stupidity” can be acknowledged when thinking about basic nutrients such as protein, how much more so must it be considered with the complexities of breast milk. If the danger of ignoring “process” is a concern that nutritionists have for the general public, it should be an even greater concern for infants. Infant formula may contain nutrients, but they are processed in an unhealthy way and then marketed as being similar to breast milk.

  Scientists have argued for years that infant formula actually needs more regulation than regular food because it is the sole source of nutrition for many infants during such a developmentally critical time. But the FDA has been slow to act on the recommendations of several professional task forces to create more controls. Several meetings of the Food Advisory Committee on Infant Formula took place from 1996 to 2002, but the FDA did nothing until September 2014, when the agency published the final rule regarding standards for infant formula manufacturers. After being virtually unregulated for over forty years, the formula industry was forced to comply with the first infant formula law, p
assed in 1980. The law was finally passed after somewhere between 20,000 and 50,000 infants were exposed to chloride-deficient soy formula and thirty children were diagnosed with hypochloremic metabolic acidosis because of chloride deficiency in the late 1970s. These infants developed loss of appetite, muscular weakness, vomiting, and failure to gain weight, among other problems. Four to nine years later, the same infants were found to have cognitive impairments, including attention deficit disorders with repetitive behaviors, problems with word finding, and autism-like behaviors. That’s when additional, federally enforceable requirements were enacted, including required testing for harmful pathogens, such as salmonella. Infant formula manufacturers also had to prove that the formulas support normal physical growth and to test for nutrient content in the final product stage, before entering the market and at the end of the product’s shelf life. But these regulations have no punitive measures and don’t include all infant formulas.

  Meanwhile, if infant formula has been basically nutritionally adequate (as determined by the government) since the 1980s, how do you explain the countless number of variations of infant formula on the market? Lactose-free, ones for allergy-prone infants, and soy-based formulas. New varieties of formula with all sorts of additives come to market all the time, without any independent clinical data that these different components improve infant health. Are these improvements in nutrition made to benefit babies or are they just small variations to enhance profits? “We are constantly adjusting the quality of our products and the components in our products in order to make them more attractive to consumers,” Mead Johnson CEO Jakobsen said in the June 2016 conference call with analysts. No mention of babies. “The overarching theme is that we’re trying to add value to ensure that we can build on the inherent volume growth in the category by gradually persuading consumers that they should be willing to pay more per serving. And that’s a theme [that] plays out differently in different countries. In the U.S., we might execute this by persuading consumers to move from powder form to liquid form, or we might ask them to move from non-hydrolyzed formula to easier-to-digest, partially hydrolyzed products.” No mention of why the easier-to-digest isn’t their only product.