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preface to the third edition
I wish I were not writing this preface. There should be no need for this book. In a world beset by overwhelming problems, here is a resolvable issue. Twenty years ago when I was writing the first edition, more than three thousand babies were dying every day from infections triggered by lack of breastfeeding and by the use of bottles, artificial milks and other risky products. This is still happening.In the first and second editions I described the pressures on women, on health workers and on governments. I wrote about the culture of artificial feeding and the collusion between the baby food companies and the medical, nutritional and healthcare establishments. They have all promoted products and practices which have contributed to the suffering, illness and death of millions of babies and often their mothers too. This is still happening.This third edition is necessary because some things have changed. Scientific research has revealed more amazing facts about breastfeeding. It is now known that even in a rich country, a millionaire’s baby who is artificially fed is less healthy than the exclusively breastfed baby of the most disadvantaged mother. Long term health problems such as high blood pressure and diabetes are influenced by how babies are fed, and breastfeeding women reduce their own risk of breast cancer. Better understanding of women’s bodies shows how adaptable they are and what a resilient process breastfeeding is when it is not sabotaged from the start. Knowledge serves no purpose if it is not spread around. As the poor get poorer and the rich get richer, an entrenched ignorance is kept in place through a culture created and maintained by commercial interests. This new edition shows how the baby food and bottle companies use ever more aggressive promotion. Challenged by the new evidence, they work harder and pour more resources into more sophisticated marketing strategies; they manipulate the media, influence governments’ policies and infiltrate the very agencies that are supposed to protect health.Those who work to combat these influences have become more skilled, but progress is undermined by widespread misinformation and lack of awareness. I am so impressed by the talents of groups who struggle for human welfare: the women who support each other, the campaigners and those health workers who strive to cure their colleagues of the nonsense they learn from outdated training and text books and misleading promotional information. This book is not written for mothers, but for everyone; man or woman, parent or childless, old or young, because this issue concerns us all. I have added some facts and updated others, but the main theme remains unchanged. I hope that this will be my last preface and that this book will become merely the record of a tragically foolish phase in human history.
chapter 1 why breastfeeding is political
“From politics it was an easy step to silence.” Jane Austen, Northanger Abbey, 1818
If a multinational company developed a product that was a nutritionally balanced and delicious food, a wonder drug that both prevented and treated disease, cost almost nothing to produce and could be delivered in quantities controlled by consumers’ needs, the announcement of this find would send its shares rocketing to the top of the stock market. The scientists who developed the product would win prizes and the wealth and influence of everyone involved would increase dramatically. Women have been producing such a miraculous substance, breastmilk, since the beginning of human existence, yet they form the least wealthy and the least powerful half of humanity. As subjects of research, breastfeeding and breastmilk have attracted much attention during recent decades, yet as academic careers thrive on discoveries1 of how breastfeeding works and what breastmilk contains, women and their babies are still prevented from fulfilling this unique relationship. As knowledge about breastfeeding increases, so do global sales of artificial milks and feeding bottles. This may surprise those who live where breastfeeding is still part of the culture or where well-educated women have access to support, information and their babies. There are policy documents, promotional initiatives and media attention in many countries. However, all over the world women are impeded from protecting their own and their babies’ health, and often survival, because of factors beyond their control.Why, after about a million years of survival, has one of the principal evolutionary characteristics by which we identify ourselves as mammals become so damaged? Have women been freed from a time-wasting biological tyranny to lead nobler, more fulfilling and more equal lives? In this book I examine the political reasons for a situation which has a profound effect on the whole world from the major economic effects of squandering a natural resource to the individual misery of a sick child or an unhappy woman.Why is it that whether we were breastfed ourselves, or breastfeed our own children, depends on our social and economic position? How is it that in many societies, 100% of poor, undernourished women all breastfeed easily, while in others, groups of privileged, well-nourished women believe they cannot? Why is the right to breastfeed fought for so vehemently by some women and rejected so forcefully by others, often according to their class, education or society? And why, if women participate in the modern economic structures which are claimed to be for the benefit of us all, must the breastfeeding relationship be curtailed and restricted? For many women, what could be a simple compromise becomes an agonising decision.
power and sex
‘Politics’ does not only refer to economic and territorial power structures, it also means sexual politics. The fact of women’s separate biological capacities has been used as a pretext for excluding women from the centres of power. But even as women’s reproductive functions come to be controlled, both by themselves and others, in general there is little change in predominant male control. At the family level men still have a strong influence over women’s decisions about their bodies. Despite some real progress and several notable exceptions, most major organisations, whether governments, big business or international bodies of experts, are dominated by men. Sometimes, the very men who have discovered the excellence of breastfeeding and recommend it wholeheartedly, will object if employees bring their babies to work. They do little to establish facilities in the workplace or advocate the financial benefits and flexible schedules needed for women who must, or choose to, participate in the wage-earning world. In most of the industrialised world, and increasingly in the so-called ‘developing’ world, a woman working in a paid job must not flaunt any signs of lactation. If her breasts are functioning she must discreetly withdraw to feed her baby or express her milk. Is this because to suckle a baby in daily public life is too disturbing a sight for some colleagues? Do both men and women feel shocked, dis-approving or even disgusted? Away from the workplace these same workers might pay to watch a woman expose her breasts for the sexual stimulation of strangers. They might pay more for food served by bare-breasted women. Though any part of a woman’s body can be a focus of eroticism, our era is the first in recorded history where the breast has become a public fetish for male sexual stimulation, while its primary function has diminished on a vast scale. Perhaps the only parallel is the phenomenon of foot-binding in China, when the primary use of a part of the body was sacrificed to serve the cult of a sexual fetishism which celebrated female helplessness.In the 20th century, women were presented with an illusion of liberation through the artificial feeding of babies, only to find their breasts appropriated by men and popular culture. This continues in the 21st century. This has been expressed both privately, when men pressure their sexual partners not to breastfeed, and publicly through pornography and the mass marketing of products and information. Certainly in the dominant culture of the USA, regarding breasts as an ordinary part of the human body seems impossible. When entertainer Janet Jackson’s breast popped out at the televised Super Bowl game in Los Angeles, USA, in 2004, it was as though her breast had a life separate from the rest of her. “That was the most disgusting thing I have ever seen at a sports spectacle,” said a baseball coach. Viewers could applaud her sexualised dancing, hip movements and song lyrics about passion and desire, all commonplace themes in popular entertainment, but a breast really freaked them out. Why? Viewers, who watch TV series and films with violence and killing essential to their storylines, could not cope with the sight of a breast. Just a few hundred years ago, most human societies found breast exposure in everyday life unremarkable. What has happened to us? There is still a fundamental racism in attitudes to public breastfeeding. Intrusive cameras turn the lens on hungry women who, during disasters, keep their babies alive with this precious fluid and closeness. As long as the woman is black and devastated, programme makers include the scene, but if a well-dressed, white woman breastfeeds her baby, the camera shot is often edited out.
It is not a coincidence that the decline of breastfeeding accelerated as the predominantly male medical profession took over the management of childbirth and infant feeding. Nor was it chance that led to the expansion of the baby milk industry during the late 19th and early 20th centuries when improved techniques and mechanisation of milk-processing led to cows’ milk surpluses. When a manufacturer has an excess product his business instinct is to find a way to market it. The development of artificial baby milk has been a marketing success story, not least in the skill with which the competing product has been destroyed. Women are not paid for producing or delivering breastmilk, nor for caring for young humans in this special way. Those who market artificial baby milk, bottles, teats and the essential cleaning materials benefit financially from keeping breastfeeding in check. There is no equivalent vested interest group to protect breastfeeding and it is destroyed for the same reason that forests are destroyed – for immediate profit.In our modern world, status and often self-esteem come from a person’s role in the structures of wealth creation. If a woman joins the modern industrialised economy she must be seen to be like a man and it is taken for granted that she must adapt to this norm, not that social and economic organisation must adapt to all human beings. Women have had to prove (as it happens very successfully) that they are ‘as good as’ men, but men do not yet have to show that they are as good as women. To gain recognition, striving women must be as tough and competitive as men. New management theories extol women’s special skills, but merely for their usefulness in making business more profitable, not because they are good in their own right.
who is left holding the baby?
Women, whatever their nationality or class, still take major responsibility for the care of babies and children. Even in Scandinavia, where legislation and tax-incentives encourage fathers to do more, for the most part mothers remain the principal carers. In most of the world women who have children and who work in the wage economy are expected to delegate and organise the care of their babies, so they can function in a world designed by and for men. In most cases another woman takes on the task and is often underpaid and separated from her own children, or, in the case of relatives, is unpaid. The few men who care for their own or others’ children are a minority, perhaps because of the low pay and status. In this struggle for economic and sexual justice a baby’s needs are often neglected and, during this crucial phase of physical and emotional development, many are damaged for ever.
The global value of baby food sales is projected to reach US$20.2 billion annually of which around two thirds will come from infant formula sales. In 2007 the US infant formula market was estimated at US$3.9 billion. Europe is currently the leading market and sales may reach US$2.1 billion by 2010.3 Just one British bottle and teat company which exports all over the world had a £90 million annual turnover.4 Doctors, scientists and nutritionists may be investors and beneficiaries of the industry. A doctor who invents a new artificial milk may get a royalty on each batch sold. Those who support breastfeeding and see a conflict of interest in industry links will rarely get as rich as those who have close ties with a powerful company. Our current economic structure does not encourage the promotion of products or systems which provide long-term benefit and do not make rapid financial profits. As with so many of the biological solutions to the ecological devastation of the planet, the money makers would not benefit immediately if we adopted them, though in the long term the world and all society would be wealthier.Modern medicine is a wonderful thing and has made life more comfortable and longer for many. Who would want to be without vaccines, modern surgery and anaesthesia? Doctors and manu-facturers are not, and mostly have not been, evil individuals consciously planning to appropriate the power of women, though their cultural attitudes to women may have distorted their judgment. Many doctors have been faced with problems of failing lactation or with women not wanting to breastfeed their babies. Because of their own ignorance and misunderstanding they believed artificial feeding to be the answer.One sad fact of the 20th century was that the more contact mothers had with health workers, the less they breastfed.5 Industrial society is founded on technological solutions and indifference to the costs of primary extraction; it is often easier, and more lucrative, to work out a stopgap way of alleviating a problem than to discover why it occurred in the first place. Now that researchers have revealed the risks of not breastfeeding, there is no excuse for the medical and commercial promoters of substitute milks to continue their practices, but many are so caught up in the whirlwind of career progress and profit-seeking that they seem unable to stop to review the damage they do.There has been a curious doublethink among those scientists and manufacturers whose interests lie in the production of breastmilk substitutes. On the one hand there is eagerness to claim that artificially fed babies are just as healthy as breastfed ones and that the choice of feeding method is an equal one; on the other there is the claim to imitate human milk, and to use it as the gold standard to sell the commercial product.There is still much to find out about breastmilk and breastfeeding and the more research is done the more fascinating and miraculous the process seems. Much research is financed by the baby food industry. There is probably no other manufacturing industry which gains so much free access to the rival product. Drug companies are obsessive about patenting, but all over the world women have unwittingly given away their unique nutrient and medical product to the very people who want to replace it. If society were organised so that the true baby milk manufacturers, women, earned the rewards they deserve for their production, the baby food industry would dwindle and much of the poverty that causes infant disease and death would disappear. Helping and supporting women to breastfeed would save more children’s lives than any other public health preventive intervention, more even than immunisation, or improved water and sanitation.
product makers or philanthropists?
Much as they urge us to think otherwise, the infant feeding product companies are not philanthropic organisations, but competitive commercial enterprises. It is in their interests that women find it difficult to breastfeed. Classical economic theory tells us that the invisible hand of the market leads only to the manufacture of products that people need. If this is so, then why do these companies invest millions in promotion to persuade us to use more of their products? These methods are necessary because to sell substantial quantities they must impede the production of the rival product. People may notice the blatant shout of public advertising, but they may be unaware of more subtle tactics. For example, in the 20th century, US-based company Abbott-Ross provided free design-planning for hospitals:
“The purpose here is to impose a design that literally builds bottle-feeding into the facility by physically separating mother and infant to make bottle-feeding more convenient than breastfeeding for the hospital staff. . . . A single investment in such architectural services can create new sales opportunities for the entire life span of the building.”
A company could gain both prestige as a benefactor and create customers, all through a single strategy. These marketing activities are excellent investments because all parents have one thing in common: whether poor or rich they want their children to live and to be healthy. If a woman’s breastfeeding has been sabotaged and she sees artificial milk as the means of her child’s survival, she will sacrifice everything to buy it. In most of the world this purchase costs more than half the household income and will impoverish the rest of the family. The more that feeding bottles and artificial milk become acceptable and ‘normal’ in any society, the more stable are the manufacturers’ incomes. Breastmilk substitutes can be useful, life-saving products, just as artificial insulin can save the lives of diabetics, but no honest doctor could advocate the use of insulin unless it were strictly necessary. If a breastmilk substitute is needed, allowing commercial pressure to influence the choice of product is a betrayal of good medical practice, demeaning to the practitioner and a risk to the baby.
the right to choice
The infant feeding issue is often represented as one of individual choice between two parallel methods, ‘the breast or the bottle’. Neither the products nor the method are equal and the true cost to society and the individual is seldom mentioned or measured. Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored. The skilfully managed promotion and public relations of the baby food industry blur and distort the facts, for health workers as much as parents. Informed choice is the mantra of western society and is seen as a right, but few parents are fully informed. In much of the world the choice between breastfeeding and artificial milk is a choice between infant health and sickness, and too often between life and death. Much of the medical profession strives to be neutral and to ignore the integration of commercial interests with medical issues. The infant feeding industry provides products, research grants, health information, gifts and sponsorship for conferences: all the activities believed to be essential for progress. When a company donates expensive medical equipment or funds research, the recipients become beholden. That is why the donors invest in these activities. In 1981 the International Code of Marketing of Breastmilk Substitutes was adopted at the World Health Assembly (WHA) in Geneva. Yet every manufacturer of infant feeding products flouts its provisions, including promoting these products in regions where artificial feeding means playing Russian roulette with a baby’s life. Until the 1990s, even health workers dismissive of breastfeeding in rich societies acknowledged that it was essential in conditions of poverty. But then the Human Immunodeficiency Virus (HIV) became established and there was evidence that breastfeeding could transmit the virus in some cases. Breastfeeding advocates were horrified and there was panic, denial and confusion. At the time there were no drugs to treat HIV infection and it was impossible to predict which babies were most at risk. International health organisations struggled to work out policies to protect women and babies and instead created a muddle, mainly because the widening differences between rich and poor in the world led to contradictory messages. Even as compelling evidence emerged showing that breastfeeding was important for rich babies too, the idea was mooted that poor women could ‘choose’ to feed their babies artificially. The results were tragic as I will explain in Chapter 8.
the widening gap between rich and poor
By the start of this century, in many countries emerging primary healthcare systems had been nipped in the bud by the pincers of ‘structural adjustment’. This was the recipe for progress which the international finance bodies, such as the International Monetary Fund (IMF), imposed on poor countries during the 1980s. The message to government leaders was: ‘make your people pay for their health and education out of their own pockets and your country will become prosperous; ignore our advice at your peril because we hold the financial reins.’ The poor countries were pressured to reform their economies according to a policy which came to be called the ‘Washington Consensus’. They had to restrict public spending on public health and education and to open their markets. Ironically, most rich nations had originally invested public spending in health and education as the bedrock for their long-term development. Those same financial institutions did not pressure poor governments to restrict the promotion of products (often imported with scarce foreign currency) which undermined health and drained their economies. Whose interests were they serving? There is now a growing distortion of world food availability and distribution, in part due to these policies. The fact that the powerful men in Washington never counted the most valuable food of all as of economic importance has contributed to the hunger and health crises that many humans are enduring today.Women have a unique power through breastfeeding to maintain health, life and finite resources. Many might resist this suggestion because it is associated with the oppression of women by limiting them to supposedly traditional roles. When the powerful deny the practice and influence of this activity, and women who do it are kept apart, it is no wonder that confusion reigns. In a shrinking world where the consumption of finite resources and environmental degradation are reaching a breaking point, here is an unacknowledged resource. Until power structures change so that women are recognised and rewarded, gain full access to the means of economic independence and take a real part in decision-making, another natural product remains undervalued and discarded. Just as people have come to realise that forests are not simply a source of firewood or obstacles to the development of land, so economic planners need to learn that human beings are part of the ecosystem and that something as unnoticed as breastfeeding contributes to a saner management of the earth’s resources.
© Gabrielle Palmer 2009