The Big Letdown

by Kimberly Seals Allers

  Since 2000 the price of regular infant formula has increased 100 percent from about eleven cents per ounce to a recent 2016 price of twenty-two cents per ounce, while the base product has essentially remained the same.

  Profits are made not just for the infant formula makers but by the ancillary industries they support, from the dairy industry and soybean growers to bottle and nipple manufacturers. As with many innovations, new products arise out of the desire to profit from waste or surplus. In the late nineteenth and early twentieth centuries, the mechanization of the dairy industry resulted in large surpluses of whey from an increase in butter and cheese production. The dairy industry needed new outlets for this surplus in milk and milk waste. As human milk substitutes began to be developed and with government subsidies propping up the dairy industry, cows’ milk became the foundation of the baby milk industry. Cows’ milk was not used because research proved it the most suitable substitute for breast milk, but because it was plentiful and cheap. Improved mechanization led to dried milk powder, produced through roller and spray drying, which added to the availability of inexpensive and transportable milk. The dairy industry would continue to grow, with much government support.

  Much of that industry’s initial growth was buoyed by the new market among infants. Dairy industry subsidies totaled $5.6 billion from 1995 to 2014. Today, the dairy industry is one of the most powerful lobbies in Washington, D.C., and a strident and visible supporter of infant formula. However, we only have to look back at the government’s role in subsidizing tobacco farmers and the federal and state tax revenues from cigarette sales to see how the government has supported and profited from a dangerous product. It is clear that even the government does not always put public health ahead of financial interests.

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  It’s a rainy day in early May 2016 and I’m in Washington, D.C., headed to the Hubert H. Humphrey Building for a landmark event. The U.S. Department of Health and Human Services (HHS) Office of Global Affairs is preparing to represent the U.S. Government at the 68th World Health Assembly in Geneva in a few weeks where it will vote, among other agenda items, on the WHO’s “Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children.” The guidance document would be a clarification and update to complement the WHO code’s existing recommendations. HHS has invited input from stakeholders to help shape the U.S. position on whether to endorse the guidance and is hosting a public, informal stakeholder listening session.

  The room is fairly full for such a convening. Weeks earlier, e-mails went out that comments would be reduced from five minutes to two minutes to accommodate the long list of speaking requests. As expected, the Infant Nutrition Council of North America, the industry association of infant formula manufacturers, was in attendance. But what was surprising was the number of large dairy-related trade groups that offered comments, obviously encouraging a vote against the measure. Representatives of the International Dairy Foods Association (IDFA), the National Milk Producers Federation, and the U.S. Dairy Export Council took turns calling the guidance “draconian,” “highly flawed,” and “lacking an impact assessment,” and warning that it would “limit families’ ability to make informed decisions.”

  To understand the scope of this presence, consider this: The IDFA, which represents the nation’s dairy and manufacturing and marketing industries, has over 530 member companies. IDFA’s 220 dairy-processing members run more than 600 plant operations, and range from large multinational organizations to single-plant companies. Together they represent more than 85 percent of the milk, cultured products, cheese, and frozen desserts produced and marketed in the United States. When an organization of that size and scope sends a vice president to offer comments on a guidance document on infant formula promotion, you know the stakes are high.

  The guidance passed in Geneva. But in response to the vote, IDFA issued a press release. “We were very disappointed that the guidance was still accepted as is by WHO members, in spite of the significant deficiencies we uncovered regarding the evidence base and procedures used by WHO,” said John Allan, IDFA vice president of regulatory affairs and international standards, who helped lead industry efforts to build awareness of the guidance’s shortcomings and request changes before it was adopted. “Thanks to the strong stand taken by the U.S. delegation and several other countries, the adopted resolution does provide significant protections for nutritious dairy products,” Allan said in the release.

  The press release also alluded to months of behind-the-scenes lobbying efforts to derail the resolution. “Since January, when the guidance was introduced, IDFA has been coordinating with member companies and other trade associations to educate members of Congress and officials from U.S. agencies and foreign governments on the weaknesses of the guidance, as well as the potential for unintended health consequences for young children and violations of international trade obligations.” By acknowledging coordinated industry efforts to influence elected and government officials on a policy to improve infant health by a global health organization, the dairy industry shows how lucrative the infant formula business is to their future fortunes.

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  If you can’t digest dairy-based infant formula, there are soy-based formulas. This is not because a preponderance of evidence shows that soy is the best nondairy protein source for babies, but because the influential and profitable soybean industry aggressively sought out new outlets for its products. The soybean industry is a critical sector for the U.S. agriculture market. U.S. soybeans have been a subsidized commodity since 1941. Even food giant Monsanto has a large stake in the sale of soy. At nearly every turn, infant formula is connected to the big business of food.

  These competing economic interests have directly affected the variations of infant formula and their profitability but not necessarily their benefit to babies. But there are other contributing factors to the business of undermining breastfeeding. By nature, breast milk has an intrinsic packaging and distribution system—the breast and nipple. Infant formula does not. Big business needed to solve that problem, and companies needed to figure out how to package formula in an appealing and cost-effective way. The “solution” was a bumper crop of other commercial products, such as bottles, containers, and artificial nipples. Nestlé was a big player in the bottle world. Invented in 1860, the long-tube feeding bottle responded to this demand: the glass flask equipped with a rubber tube allowed the infant to more or less feed itself. Although initially acclaimed for its practical nature, this “killer tube” was banned in 1910 because it proved a real breeding ground for bacteria. In 1897 a bottle was patented that hung over the crib so a baby could feed alone, and another was released that stood on a baby’s chest. The introduction of artificial milk and then bottles and nipples disrupted the normal feeding process, and the natural bonding that occurs between most infants and mothers was also strained as a result.

  While much effort was put into creating the perfect feeding receptacle, re-creating a woman’s nipple proved an ongoing technological challenge. The human nipple is pliable and can reach two to three times its normal size when sucked on by an infant. It contains fifteen to thirty pores, each of which spurts milk in a fine stream in different directions. These spurts occur rhythmically when a baby is nursing. After experimenting with different forms and materials, including glass and the actual teats of a cow soaked in preservatives, the first rubber nipple was patented in 1845 by Elijah Pratt. It was not well received. Only after several modifications was the ring and teat improved and accepted. It took until the twentieth century before the materials and technology improved enough to produce a soft nipple that could withstand the heat of sterilization. Today, the market for bottles and rubber nipples is worth $2 billion annually.

  While billions are being made selling and delivering artificial mother’s milk, the social costs of becoming a predominantly bottle feeding nation continues to rise. In 2016 the WHO released a report that concluded that if every child were breast
fed within an hour of birth, given only breast milk for the first six months of life, and continued breastfeeding up to the age of two years, about 800,000 children’s lives would be saved globally every year. A recent study in the journal Pediatrics found that “the United States incurs $13 billion in excess costs annually and suffers 911 preventable deaths per year because our breastfeeding rates fall far below medical recommendations.” The researchers calculated $10.56 billion for the estimated 741 infant deaths, based on 80 percent of families complying with the medical recommendation of six months of exclusive breastfeeding. Ninety-five percent of infant deaths are attributed to the following three causes: sudden infant death syndrome (SIDS), necrotizing enterocolitis (a devastating intestinal disease), and lower respiratory infections, like pneumonia. Breastfeeding has been shown to reduce the risk of all of these and seven other illnesses covered by the study. In that study, the researchers also included the direct costs of health care and parents’ time missed from work. Their tally did not include the cost of formula, another added cost for families that don’t breastfeed. Although the United States spends more on health care than any other country in the world, a baby born in the United States is less likely to see his or her first birthday than one born in Hungary, Poland, or Slovakia. According to the CDC, the United States has a higher infant mortality rate than any of the other twenty-seven wealthiest countries.

  Breastfeeding also provides health benefits for mothers. It burns extra calories, so mothers often lose pregnancy weight faster. Retaining that extra weight can lead to heart disease and high blood pressure, doctors say. Nursing also releases the hormone oxytocin, which helps the uterus return to normal size and may reduce uterine bleeding after birth. Breastfeeding lowers the risk of breast and ovarian cancer. It may also lower risks of osteoporosis. All of these benefits are lost when women do not breastfeed. That same study in Pediatrics found that a 90 percent breastfeeding rate could prevent over 53,000 cases of hypertension, over 13,900 heart attacks, and nearly 5,000 cases of breast cancer among women. That’s because breastfeeding reduces these risks. The study in Pediatrics also estimated that society would save $18.3 billion if mothers were prevented from dying from these diseases.

  Not only is breastfeeding a cost saving, it’s a powerful investment in the foundation for a healthier future. In fact, an economist from the World Bank, the world’s largest source of multilateral development finance for developing countries, recently presented to the Academy of Breastfeeding Medicine on how and why the bank views breastfeeding promotion as a powerful economic investment. “We feel this is one of the premier potential altering transformational investments that developing countries can make and that is currently being underused, to say the least. We are emphasizing breastfeeding more and more in our support to countries, not just as a health investment but as a true powerful economic investment in their futures,” said Keith Hansen, Global Practices Vice President at the World Bank, which invests in everything from agriculture and water to urban development and education, with the goal of eliminating extreme poverty. Hansen said the World Bank has set a goal to eliminate extreme poverty and boost what they call “shared prosperity” by the year 2030.

  Hansen noted that while many development goals, from bridges and roads that have to be rebuilt following natural disasters to the construction of new buildings, “the gains from early childhood nutrition are forever. And to a large extent, many of them are free because they have come prepackaged in this unbelievable intervention called breastfeeding. This is, of course, what defines us as a mammalian species. And the proof of this is in the lifelong impacts.” Hansen says that children who avoid undernutrition are not only much more likely to survive but also to stay in school and are therefore more likely to escape poverty—about 33 percent more likely on average. “And their wages are anywhere from 5 percent to 50 percent higher than their peers who were not able to escape. These data are from very rigorous longitudinal studies … studies that have been done over decades now with fairly substantial cohorts and very robustly tested, and the impact, correlations, and causations are very strongly established.”

  From the position of the World Bank, breastfeeding is an important foundation for economic development and one of the most critical investments a country can make for good nutrition and child health. With the advantages of breastfeeding proven in cost saving, economic development, and human capital gains, it would seem that the only entities that benefit from the commercialization and widespread use of infant formula are the manufacturers.

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  When commercial interests dominate the infant feeding market, women pay not just with their health but with their confidence: women’s ability to perform their unique biological function is undermined during the particularly vulnerable days of early motherhood, which is extremely disempowering. Instead of having a positive, supportive experience at the start of motherhood, women find themselves in a maelstrom of mixed messages, confusing information, and profit-driven propaganda.

  The toxic environment can frame our later parenting experiences and determine where and how we get support. It creates more obstacles, and women deserve better. Our babies have become profit centers for hospitals and physicians. Our breasts have become profit centers for pharmaceutical companies and breast-milk substitute manufacturers who benefit from selling us messages that we will fail. What do women gain from this exchange? Not much.

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  Scientific Breakthroughs or Breakdowns?

  Doubt is our product, since it is the best means of competing with the “body of fact” that exists in the minds of the general public.

  —FROM A 1969 MEMO WRITTEN BY A TOBACCO INDUSTRY EXECUTIVE

  If you’re like me, you have at least one friend in your social circle who is always quoting some new scientific study to defend their latest diet, exercise routine, parenting style, or something else. You can barely get through the morning news or the home page of your favorite Web site without learning about a recent study proclaiming some new health benefit or disputing a previously identified one. A reliance on scientific research is now deeply embedded in American culture, and we are simply infatuated with scientific innovation. In a 2015 survey by the Pew Research Center, 79 percent of those surveyed said that science has made life easier for most people, while just 15 percent said that it has made life more difficult. Meanwhile, parents are increasingly relying on science to help guide their decision making about everything from nutrition and vaccinations to social development and preventive health measures. Yet when parents turn to science for evidence that infant formula is inferior, they find a confusing landscape of information that has been muddled by faux science, questionable funding sources, inconsistent research methodologies, outdated protocols, and the media’s hunger for the next provocative “breakthrough” headline. This search for science is another byproduct of the structural and economic forces that undermine breastfeeding. When breastfeeding is extremely difficult because of the structural barriers, parents feel that the preponderance of scientific evidence that breastfeeding is superior must be indisputable to justify the time, effort, and potential shaming involved. With that in mind, the infant formula companies have a vested interest in keeping the scientific landscape muddled by industry-sponsored studies and questionable protocols that lead to sensational anti-breastfeeding headlines. In the end, science is yet another source of unclear information for mothers, letting them down.

  Meanwhile, the process of science is far less linear than the media’s coverage suggests, and the media often gives no account of the trials and errors that actually occur along the way. This creates unrealistic expectations that the scientific community is good at self-policing and that science always gets it right, without providing the tools to decipher the good science from the bad. That, in turn, perpetuates the illusion that the scientific body of evidence proving that breastfed babies are healthier is conflicting and inconclusive, when all of it is not. There is strong science,
weak science, and junk science on both sides of the issues. In the end, a scientific conclusion is like a prosecutor’s indictment; it’s really the beginning of a long process. After an indictment, we expect a prosecutor to provide detailed and consistent evidence that must stand up to a jury of peers, who should be able to take as much time as they need to review it. Science is similar, but in science a community of peer reviewers are simply assessing the evidence to see if it is sufficient to accept the claim. But this does not make it fact. There are always uncertainties in science, because science is a process of discovery. The good news is that the uncertainty keeps scientists questioning and propels the science forward. The bad news is people are generally looking to science for cold, hard facts—which are really hard to find.

  The Internet certainly has not helped. The Internet was meant to lead to the great democratization of information—the opportunity for billions of people to reclaim control of expertise from the elitist clutches of research institutes, universities, consultancies, big corporations, and the mainstream press. This was supposed to raise the quality, usefulness, and relevance of expert advice; instead, we find bad information masquerading as fact everywhere. We find faux science looking and sounding exactly like the real thing.