Our Own Devices: How Technology Remakes Humanity

by Edward Tenner

  While artificial feeding methods had been folk practice for centuries, even millennia, scientific replacements for mother’s milk were a nineteenth-century innovation. Early modern urban elites used some expedients we would find bizarre: only two of Mozart’s six children, all fed mainly sugar water, survived beyond their third year. The cow and goat milk sometimes previously used as a substitute or supplement was too thick and alkaline. In 1741, the London physician Sir Hans Sloane established that at the Foundling Hospital, 53 percent of infants receiving animal milk or cereal mixtures died, as opposed to 19 percent of those with wet nurses. American nineteenth-century doctors documented that the milk of sick cows could transmit not only throat infections but life-threatening diseases like typhoid and tuberculosis. They warned about the deficiences of “swill milk” from cows consuming brewery slops. In late-nineteenth-century London, milk still might be adulterated with as much as 25 percent water. As railroad supply lines and chemical knowledge grew, preservatives—including truly dangerous ones like hydrogen peroxide—were marketed openly; by one estimate, they were used by half the dairy trade.14

  Even as some manufacturers were producing dubious additives, more idealistic chemists were finding new ways to detect them. And still others had an even more ambitious and, it seemed, noble goal: developing scientifically optimal foods for infants. The problems of artificial feeding, like other technological dilemmas, began with the best of motives. In England’s industrial cities, malnutrition of mothers and the feeding practices of untrained women who cared for infants during the working day had raised the mortality rate of young children as high as 55.4 percent in 1858. In the 1860s, chemists began to develop foods with patented or secret formulas that “humanized” cow’s milk to make it suitable for human infants. Baron Justus von Liebig (1803–1873), a founder of nineteenth-century chemical research, education, and industry, and one of Europe’s most influential scientists, tried to help his nanny’s granddaughter, who was unable to nurse her own children. Earlier in the century, the family would have brought a wet nurse to live in, but the middle class was beginning to avoid what it perceived as a potential source of malnutrition and, linked with malnutrition in their minds, bad moral influence. Liebig developed an infant feed consisting of ten parts of cow’s milk with one part each of wheat flour and malt flour, and a supplement of potassium bicarbonate. Liebig claimed that it offered nutrients in twice the concentration available in human milk, and that infants would thus need less of it. Unfortunately, his ratios were indirectly based on the methodologically flawed studies of a Berlin chemist named J. F. Simon. As a result the formula was too high in carbohydrates and had dangerously low levels of vitamin C, of other vitamins, and of amino acids.15

  Liebig was an outstanding predecessor of today’s academic scientist-entrepreneurs, not only a preeminent chemist but an esteemed mentor and the master of a flourishing professional network. He promoted his preparation vigorously in the popular science press, solicited testimonials, and licensed an English company that soon was producing a dried form with pea flour to be mixed with cow’s milk. Meanwhile, a self-taught Texan inventor, Gail Borden, had turned from meal biscuits to milk after observing children die, apparently of malnutrition, on an ocean voyage. (He adapted a spherical copper vacuum condenser used by Shakers for condensing fruit juice.)16

  Despite medical reports of the food’s inadequacy and mixed responses from consumers, Liebig’s prestige allowed him to maintain his claims for the superior nutritional value and digestive qualities of his product. At least one supporter wrote that because its composition had been scientifically shown to have “the very same ingredients” as human milk, “I cannot understand why they should be unable to digest Liebig’s Food.” It went on sale in the United States in 1869, advertised with the slogan “No More Wet Nurses!” Other entrepreneurs had already realized the product’s economic potential—Liebig’s Food sold for a dollar a bottle in New York at a time when that sum represented many workers’ daily pay—and competition grew. In Switzerland, with its large dairy industry, the American diplomat Charles Page and his brother formed the Anglo-Swiss Condensed Milk Company in 1866 to use Gail Borden’s 1856 patent for the production of condensed milk. The following year a Swiss merchant named Henri Nestlé developed an infant preparation that allegedly had saved the life of a baby that had refused all other food. It consisted of “good Swiss milk” and bread, “cooked after a new method of my invention” and marketed in tin packages, to be mixed with water. The market proved spectacular, and in 1873 Nestlé was selling half a million boxes annually in Europe and in North and South America. Meanwhile, an English chemist named Gustav Mellin developed a variation of Liebig’s Food to which cow’s milk as well as water were to be added. In the United States, the Borden Company was promoting its own Eagle Brand, and the pharmaceutical industry began to take notice of the potential market when Smith Kline & French bought the rights to a product called Albumenized Food. The manufacturers appealed to doctors and lay consumers alike. Some, like Nestlé, promoted the safety of using only (preferably boiled) water; others, like the makers of Mellin’s Food, sought medical support for mixing their product with raw milk. Doctors could not agree on the optimum treatment.17

  Between 1890 and World War I, some physicians tried to place substitute infant feeding on a scientific basis free from the manufacturers’ commercialism. The leader of this movement, Thomas Morgan Rotch of Harvard Medical School, sought not merely an acceptable substitute for breast milk, but scientifically optimal nutrition for each child that could reduce the still-high rate of infant mortality. Using analyses by the Philadelphia physician A. V. Meigs, a significant advance on Liebig’s work, he developed a series of tables instructing mothers on the preparation of a formula containing precisely correct proportions of fat, sugar, and proteins, to be compounded by the mother from milk, milk sugar, cream, and lime-water (a solution of calcium hydroxide in water). To avoid contaminated milk products, Rotch worked with scientific dairies to produce certified milk products with newly developed hygienic procedures. Other doctors in France, Great Britain, and the United States helped establish “depots” where pure milk could be provided under medical supervision. Contamination of commercial cow’s milk nevertheless remained widespread through the 1920s, if British and American evidence is typical. Critics of the formula industry argue that even the best-managed programs did not contribute to the decline of infant mortality that commenced around 1905, but they did establish a disturbing and continuing link between medical clinics and artificial milk distribution.18

  The complexity of Rotch’s “percentage method,” which turned the household into a small-scale chemical laboratory, led to its abandonment after 1915. (It had been influential mainly in the northeastern United States.) In its place, a new pattern of infant nutrition appeared: the marketing of infant formula to be administered under pediatricians’ supervision. For these rising specialists, and for family practitioners, scientifically managed feeding was a medical crusade. While some authors present the medicalization of life as the imposition of professional judgment on an intimidated laity, the reality was more complex. Many doctors as well as mothers affirmed the superiority of breast milk. But older networks of support for nursing mothers encountering difficulties were declining in the early twentieth century. On the other hand, at least before about 1875, lay men and women were enthusiastic about the authority and capabilities of scientific medicine. Medicalization may have introduced new prejudices and errors, but it was not simply imposed by legislation. Women themselves turned, whenever possible, from the craft knowledge of midwives to the care of obstetricians for safer and less painful delivery. They believed in the movement called “scientific motherhood” as much as the physicians did. The technologies of bottle, nipple, and formula likewise appeared to mothers and physicians alike as a more modern replacement for the techniques of breast-feeding that had been transmitted informally. With hospital delivery (rising from 20 percent to 80 perce
nt of American births between 1920 and 1950), artificial feeding was institutionalized. To prevent infection, hospitals limited the frequency and duration of contacts between mother and infant. Babies regularly received supplementary feedings, and were bottle-fed at night to let mothers sleep.19

  GLOBALIZERS OF THE BOTTLE AND THEIR FOES

  Confidence in science and aggressive marketing by manufacturers were not the only reasons for the success of infant formula. Beginning in the 1920s, the breast was sexualized in a way that made public feeding potentially more sensitive than it had formerly been. Bottle-feeding was associated with scientific motherhood and at the same time with freedom from domesticity. Some bourgeois European circles also welcomed bottle-feeding as a step against prolonged oral gratification and for the development of good habits. The result was a steady increase, though with many national and regional variations, in the proportion of bottle-fed infants between World War I and the 1960s. In one American study of 1958, 63 percent of infants returning home from the hospital were already consuming only formula, and 21 percent were fed only breast milk. Few employers accommodated working mothers who had nursing infants, but even in the Sweden of the 1960s, where new mothers remaining at home with their infants received 90 percent of their professional salaries, bottle-feeding prevailed. A revival of breast-feeding among middle- and upper-class women in North America and Europe began in the 1970s and remains a strong force, but it has delayed bottle-feeding rather than replaced it as a routine of upbringing.20

  In Europe and North America, the health effects of infant formula are still debated. In the great age of expansion of bottle-feeding from 1890 to 1950, infant mortality also dropped markedly—from 140 to fewer than 40 deaths per 1,000 live births in New York City, for example. Reduction of digestive and respiratory ailments, notably diarrhea and pneumonia, was especially pronounced. In Sweden, an even more pronounced decline in mortality had begun in the late eighteenth century and continued through the nineteenth and early twentieth. In neither the United States nor Sweden did the trend appear to be affected by the spread of bottle-feeding or by the Depression of the 1930s. All this suggests that in affluent countries, formula-feeding was indeed a good alternative to the wet nursing that had been practiced so widely in early modern Europe.21

  The great unintended consequence of artificial feeding has arisen not in the industrial countries but in the developing world. Especially since the late nineteenth century, North American and European farmers have produced abundant milk. Breeding and animal nutrition alone have raised the annual yield of a dairy cow from about 1,500 liters in the early nineteenth century to 6,500 liters—and for some breeds as much as 10,000 liters—today. Pasteurization has been commercialized since the 1890s, refrigerated trains have drastically reduced spoilage on the way to market or processing, and global beef imports have allowed more European farmers to specialize in dairying.

  Meanwhile, the growth of cities and market economies in Asia and Africa made processed infant formula a valuable export. In these markets, infant formula remains costly for all but a small segment of families. The formula producers applied with great success the scientific appeals that had been effective in the West. Infant formula was also promoted as a sign of modernity and education; elites adopted it as a mark of their political and economic authority. In the rest of the population it was most influential in cities, where rapid migration and women’s industrial labor helped disrupt the transmission of breast-feeding techniques. Urban slum life and disease can also interfere with lactation. And even low-income women came to share the privileged classes’ view of infant formula as a progressive and scientific alternative to breast-feeding, and the Westernized taboo on the public display of breasts. Advertising linked formula with infant health as well as with prosperity and modernity. Intentionally or not, it persuaded many mothers who could have established lactation successfully that they suffered from “insufficient milk” syndrome. In some countries, “milk nurses” receiving sales commissions, some of them with real nursing credentials and all easily confused with hospital staff, promoted manufacturers’ products to new mothers in hospitals. Inadvertently, distribution of millions of pounds of powdered milk for starving babies by the United Nations Children’s Fund (UNICEF) and other agencies in the 1960s helped legitimize substitute food in new markets. What helped the sick would surely benefit the well.22

  The result instead was malnutrition and death. The first prominent crusader against formula-feeding in the Third World, the pediatrician Dr. Cicely Williams, had promoted condensed milk in combating kwashiorkor, a severe protein-calorie deficiency disease, in Africa. But in 1939, Dr. Williams, then working in Singapore, was disturbed by the consequences of feeding infants sweetened condensed milk. In those days the product was not supplemented with vitamins D and A, so it had contributed to many cases of rickets and blindness. Speaking on “Milk and Murder” to the Singapore Rotary Club, Williams accused the producers of callous neglect of infant life in the interest of profit.

  Well-meaning agencies as well as commercial interests could work against breast-feeding. Two leading pediatric public health specialists, Derrick and Patrice Jelliffe, call the distribution of powdered milk by feeding programs in the 1940s and 1950s a “nutritional tragedy.” In the absence of health education programs, the product encouraged a shift to bottle-feeding. The commercial distribution of formula, far from reducing the rate of nutritional deficiences, increased them seriously. Bottle-fed babies gain weight more slowly than breast-fed ones, and are more likely to suffer from bacterial and viral infections and parasites in their second year. Marasmus—a form of severe growth failure closely connected with the lack of high-calorie foods—is linked with bottle-feeding. Dilution of cow’s milk formulas to reduce costs is a special risk factor for marasmus in many poorer countries. Since mother’s milk may be the only safe liquid in many regions and feeding bottles may be impossible to keep clean without refrigeration or sanitary storage areas, formula-feeding also promotes infections, especially diarrheal diseases that inhibit appetite and lead to malnutrition and more illness. Meanwhile, the bottle-fed infant receives none of the protective substances in mother’s milk. In seven villages in the Punjab studied in the 1950s, mortality among infants bottle-fed from birth was fully 95 percent during the first eleven months, compared with 12 percent among infants breast-fed from birth.23

  United Nations—sponsored efforts to encourage industry regulation faltered. In the 1970s, social activists armed with the damaging statistics and with Derrick Jelliffe’s identification of “commerciogenic malnutrition” in Jamaica began to urge restrictions on the marketing of infant formula in the developing world. A boycott of Nestlé, begun by religious groups and others, was resolved with a vote of the World Health Organization’s (WHo’s) World Health Assembly in 1981 establishing a UNICEF code restricting advertising and the distribution of samples and intended to put proprietary formulas under strict medical supervision. Manufacturers’ literature now extolled the virtues of mother’s milk while encouraging an early transition to bottle-feeding. But activists, believing formula manufacturers were trying to circumvent the UNICEF code despite several amendments designed to close loopholes, renewed the boycott in 1988.24

  HEALTH IN THE BALANCE?

  In the First World, infant formula raises different but equally interesting issues. Like the WHO, the American Academy of Pediatrics (AAP) strongly supports breast-feeding. In a 1997 policy statement it declared that “breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant.” But the cohort born at the peak of formula-feeding, from 1946 to 1952, comprises the babies who started the boom, and they flourished, as the science writer Natalie Angier and others have reminded breast-feeding advocates. Yet whatever their present health—could they not be even healthier?—they did not necessarily have an easy time as babies. Breast milk is an elaborate package of chemicals developed over millions of years of primate evoluti
on to promote the newborn’s development and build up its defenses against infection. Some of its constituent molecules keep microbes from spreading from the digestive tract into the body’s tissues; others reduce the availability of vitamins and minerals (especially iron) that disease-causing bacteria need; and still others help the work of immune cells and kill bacteria directly by attacking their cell walls. And a variety of white blood cells helps the infant produce antibodies and attack microbes directly. A pediatrician recalls how easily incorrect preparation of bottles by hospital formula rooms could caramelize the sugar and precipitate diarrhea. In fact, many infections are more common in bottle-fed infants deprived of the protective antibodies unique to mother’s milk. Even now, pediatric researchers estimate that 250 to 300 infants die each year from diarrheal infections as a result of bottle-feeding; another 500 to 600 die from respiratory diseases. Middle ear infections, more frequent among formula-fed children, have been treatable with antibiotics, but the high price of therapy has included the rise of resistant strains of bacteria.25

  Even more important and less well known is how formula-feeding affects the long-term welfare of both infants and mothers. Whether to breast-feed or bottle-feed has always been a cultural as well as a biological decision. Mothers who choose one or the other method may well feed their children differently after weaning, give them more or less encouragement in school. They may be more or less affluent than other parents, and their children may have different peers and experiences. Bottle-fed infants are also more likely to be given pacifiers, which in turn differ in design and in their effects on the development of the mouth.