Wednesday, March 13, 2013

We can't wait for clean water

I think it was that photograph that did it. Tinderbox, Craig Timberg's masterly work on the HIV/AIDS epidemic in Southern Africa was, as you might expect from such a subject, a book with a lot of very, very sad stories; however, there was only one that actually brought tears to my eyes. It was the story of Chandipiwa Mavundu who lost her baby Kabelo at age eight months. The book showed a picture of Mavundu standing in front of her Botswana home, holding a photograph of herself and Kabelo--the only photograph of him she owned. I'm trying to imagine what it must be like to be left with only a single battered snapshot of the baby you knew and loved and played with for eight months. How she must treasure that picture.

But Kabelo's death was not caused by AIDS; it was caused by a waterborne diarrheal disease. The water made Kabelo sick because Mavundu had been advised by her healthcare providers to bottle-feed him, to protect him from the HIV that lurked in her milk. Mavundu had no idea that the WHO were now recommending that HIV-positive mothers in developing countries breastfeed because the risks of bottle-feeding in such circumstances outweighed the risks of HIV.

I'm repeating this story here as a kind of "Lest we forget."On this blog, I quite often write posts that attempt to puncture what I consider to be bad science or misconceptions that overstate the benefits or importance of breastfeeding. As a result, it can be easy to lose sight of the fact that not all benefits claimed for breastfeeding are urban legends or exaggerations. Sometimes they are both real and life-saving.

What's the real killer--the formula or the dirty water?
In the last month or so, there's been a lot of coverage on the dangers of bottle-feeding in resource-poor settings, including the Guardian's discussion of the appalling behavior of formula manufacturers in Indonesia, and Save The Children's "Superfood" report, a 75-page paeon to the life-saving potential of "optimal breastfeeding" (early initiation and exclusive-for-six-months) in developing countries. It called for a number of strong measures to support breastfeeding, including obligatory WHO Code-compliance by formula manufacturers and stern-sounding warnings about the dangers of bottle-feeding on formula tins--even in developed countries. Needless to say, all this resulted in some lively discussion, including commenters on the Fearless Formula Feeder's Facebook page and a fierce debate on Mumsnet on whether the site should support STC's initiative as an official Mumsnet campaign.

Both breastfeeders and formula feeders alike on these sites expressed near-universal disgust at the tactics of Nestle, Danone and others in developing countries, and supported tougher measures against them (I couldn't agree more). Some posters, however, also expressed a bit of (understandable) annoyance at certain aspects of the "Superfood" report, which was perceived as having gone a bit too far in eulogizing breastfeeding and in failing to make adequate distinctions between the benefits of breastfeeding in poor countries and in rich countries. I'd broadly agree with this too (Suzanne at the The Fearless Formula Formula, by the way, has done a better job of setting out some of the "issues" than I could). And one point brought up by several commenters was "Look, what's the real killer here--the formula or the dirty water?"

Just going back to Kabelo for a moment: Kabelo's death probably could have been avoided had he been breastfed, sure. Yet there is no suggestion that there was anything lethal about the formula powder provided by Botswana's government. Kabelo's bottles only became deadly once the powder was mixed with contaminated water. Perhaps--and this is a commonly heard argument when this topic is discussed--rather than focusing our efforts so much on promoting breastfeeding in developing countries, we should be shifting our resources towards cleaner water instead--something that the "Superfood" report doesn't even mention? On the face of it, this seems like a very reasonable argument. After all, increasing breastfeeding would only benefit babies--what about other age groups? What's going to happen to those breastfed babies once they're weaned and exposed to dirty water anyway? Surely focusing on breastfeeding and ignoring the sanitation problem is merely delaying all these deaths, not preventing them. And making sanitation the key would help women in poor countries who have to formula feed--because they don't make enough milk or because they work as cleaners or shop assistants or maids (rather than as subsistence farmers).

Not a superfood.... but an impressive logistical system
Now, getting clean piped water and sewerage system into developing countries is a worthwhile endeavor, to say the least. No, not worthwhile--crucial and life-saving. NGOs and aid agencies think so too; indeed, many of these organizations devote their efforts to nothing else. But getting clean water and sanitation into developing countries is a long, slow, upward struggle. Many countries will not get there within our lifetimes. Meanwhile, we have babies dying from contaminated bottle-feeding right now. We need to be practical.

I don't believe breastmilk is "superfood." I mean, I find the very word "superfood" pretty risible--perhaps because I associate it with those Daily Mail articles touting one food after another (wheatgrass, quinoa, coconut oil, flax seeds, you name it) as the One True Elixir that, when consumed, will prevent cancer, cure acne, raise the value of your house by 15% or more etc., etc. However, I am impressed by the logistics of I like to call the "breast-to-mouth delivery system." This is, when all is said and done, a system in which the milk (with or without magical properties) is provided clean, without the need to be poured into a container or to sit at room temperature, and where the supply is not going to get watered down or stopped altogether because hubby decided to buy a transistor radio or a bottle of whisky instead. Even if it turns out that breastmilk itself has zero immunological properties and is in practical terms no different to formula coming out of a boob--well, a low-tech, readily available system that churns out clean formula correctly made-up and served in a germ-free container is in itself not to be sneezed at.

Plumbing is not a silver bullet either
As Timberg describes in Tinderbox, Mavundu's homeland of Botswana is no war-torn hellhole, but a peaceful and fairly prosperous African country which has never been at war, and which has decent infrastructure and governance and a very large middle class. So even after the WHO shifted policies towards recommending exclusive breastfeeding for HIV-positive mothers in poor countries, Botswana's government decided to keep going with its policy of telling such women to bottle-feed, confident that its networks of piped water, roads and electricity would keep formula feeding safe. 

Unfortunately for Kabelo and other babies like him, it turned out a bit of plumbing is not enough to ensure safe bottle-feeding. Flooding caused bacteria from underground latrines to leach into the piped water supply. Around 20-30% of the bottle-fed babies (but very few of the breastfed ones) in affected areas died in the outbreak, the fallout of which shook Botswana's confidence in its formula-feeding program. This kind of thing seriously calls into question the idea that we can make formula feeding safe by just getting a bit of simple infrastructure in. If even Botswana with all its advantages cannot really manage safe formula feeding when all's said and done, that doesn't bode well for the rest of the Bottom Billion.

Now, I have spent a fair amount of time in several Bottom Billion countries (Cambodia, remote bits of China/Central Asia and bush country in Papua New Guinea) because pre-baby I used to travel a lot. And I'll tell you what: it makes me bloody scared even to think about trying to prepare a baby's bottles in these sorts of environments. It's not just the lack of piped water. It's the difficulty of securing reliable supplies of formula in remote areas. The poor literacy and difficulty in understanding preparation instructions. The way everything gets dirty, constantly. The way there are flies and insects everywhere, and food and drink goes bad at unbelievable speed (no fridge-freezers here). The way in which men tend to commandeer family resources, and things that mothers and babies need tend to get "forgotten about" when the blokes want to buy alcohol and cigarettes. I wouldn't even want to bottle-feed a baby in most of China, where most people have piped water.

Babies (especially in the newborn phase) tend to snack on bottles, get bored, leave half the contents, then wail for another feed an hour later. But formula has to be thrown away within an hour of preparation to avoid dangerous multiplication of bacteria. Even formula feeders in developed coutnries--for whom baby milk represents only a small fraction of their spending--get frustrated at the amount of formula they end up throwing down the sink. Now imagine you're a poor family for whom formula represents a big, big hole in the family budget. How likely is that half-finished bottle to get thrown out after one hour... or two hours... or longer? Now imagine a kitchen with flies buzzing around and a bottle that wasn't properly sterilized in the first place. You're looking at a lethal health crisis in the making. Even when the water itself was reasonably clean to start with.

Delaying deaths and zero-sum games
The breastfeeding thing and the clean-water thing are not (or should not be) a zero-sum game. Just taking Save The Children as an example once again: if I thought that STC were using its breastfeeding-advocacy stance as an excuse to cut back on its development work in the domains of water and sanitation, I'd be pretty pissed off too. However, looking at the STC website I see no evidence that this is the case--STC has a long and distinguished history of sanitation work and there's no sign that this is changing. There's no discussion of clean water in the "Superfood" report because it's not the subject of that particular report.

And I don't think encouraging breastfeeding in dirty-water regions will just delay the wave of child deaths by a year or two. Deaths of kids under five are not distributed evenly across the five-year period; 43% of child deaths under the age of five take place during the neonatal period. Being confronted with contaminated water is a health risk for human beings at any age, but a toddler or preschooler has a much greater chance of surviving such risks than a newborn does. In terms of "lives saved per $1,000 spent," I would argue that increasing breastfeeding in poor countries therefore offers very substantial bang for your buck.

Not a superfood, but...
Breastmilk may not be a superfood, but it does appear to have some useful and proven immunological properties, such as the way certain compounds work to reduce the risks of diarrhoea and pneumonia. Sorry, but even I accept this as fact (and I'm really, really far from being a magical-thinking lactofanatic). So does Joan Wolf, author of Is Breast Best, by the way; she states that "Breast-feeding’s advantages are most plausible in reducing gastrointestinal infection... Research has shown how antimicrobial proteins in mothers’ milk, specifically secretory IgA and lactoferrin, act as protective agents in the gut." Significantly, breastfeeding in resource-poor environments also dramatically lowers a baby's risk of developing pneumonia--a non-waterborne disease--and breastfed infants in poor countries who do get pneumonia tend to suffer from it for shorter periods of time.

Now, I would say that a baby can manage pretty comfortably without IgA/lactoferrin action in a developed environment where there are few life-threatening infections (the PROBIT study--the nearest thing we have to a randomized control study of breastfeeding in a developed country--found no breastfeeding advantage for pneumonia; there was an advantage for gastro episodes, but such illnesses are seldom really dangerous in developed countries). But in a sewage-infested slum or swampy stilt village, baby needs all the help he or she can get. The size of the disease burden in poor parts of the world needs to be fully appreciated. I remember how when I was traveling, I could count on one "fairly serious illness" for every time I visited a Bottom Billion country--dysentery (with heavy bloodloss) from Xinjiang, a massive, weeping tropical sore on my leg that lasted for months and gave me a high fever from Papua New Guinea... I could go on.

Let's not throw the breastmilk out with the dirty drinking water
I started this blog with the aim of questioning some of the myths and misunderstandings about infant feeding that float around the internet. In fact, a number of skeptical and science-based parenting blogs, websites and individual voices have been questioning some of the excesses of the breastfeeding advocacy movement in recent years. This is an important trend. Nevertheless, we need to be careful that we don't fall into the trap of assuming that because some of the claims made about breastmilk/breastfeeding are bullshit, this necessarily means that any claims made about breastmilk/breastfeeding must be bullshit.

And breastfeeding enthusiasts also need to be more aware of their own responsibility in this process. I don't agree with everything The Skeptical OB says, but I think she had a point when she discussed in "Lactivism and reefer madness" how overblown claims by breastfeeding advocates can fuel cynicism and backlashes as people start getting cross and disbelieving everything lactivists say. I'm pretty sure the Save The Children report would have attracted more wholehearted support (including Mumsnet-campaign backing) and fewer "Yes, but..."-type reactions if it had not included demands for harsh warnings on formula tins in developed countries (which was absolutely guaranteed to piss formula feeders off--seriously, did nobody at STC think about this?), had distinguished more carefully between breastfeeding benefits in rich and poor countries and had refrained from using silly words like "superfood" and "silver bullet."

Evidence-based infant feeding politics is an area where it is incredibly difficult to get the balance right. I know this because I've rewritten this post about twenty times over the last week. It's difficult because: when we find data that indicates that "Breastfeeding is no better than formula feeding for XYZ" we have to try and present it in a way that doesn't undermine systemic support for breastfeeders or make it sound like breastfeeding mothers are wasting their time; when the evidence suggests "Breastfeeding is superior than formula feeding for XYZ," we then have to try and discuss this in a way that doesn't upset bottle-feeders. We have to try and support measures that keep babies in poor countries safe, without throwing rich-world formula feeders under the bus. We have to be skeptical without turning into bristly reactionaries. It's hard to get all this right. As always, keeping our eyes firmly focused on the data is a good start.


  1. Thanks for this post -- I think you got the balance exactly right in discussing these difficult issues. It's heartbreaking that the only options available to moms like Chandipiwa Mavundu are between which potentially-deadly virus or bacteria would be better to risk putting in their baby's stomach, and in a perfect world we could fix the underlying poverty and sanitation and infrastructure issues enough to make formula a safe, affordable option for moms in her situation. But I would agree that that's a long way off, and that it's important to do whatever else can be done in the meantime.

  2. "Choosing between a virus and a bacteria"--that's a nice succinct way of putting it. Something I didn't mention in the post (but should have) is that dismissing any claims made by lactivists which turn out later to be well founded is something I've done so many times myself. I was very skeptical of the whole "breastmilk can be left out at room temperature longer than formula" until I looked at the data and found it was true (albeit with some caveats).

  3. Were there any children affected who were above formula age? Clean water isn't just important for babies, but all young children. Perhaps part of the money for antiretrovirals for these moms could be for safe supplies of formula as well, and maybe resources to boil water for the formula (even here I can find a lot of advice for moms to boil the water for bottles).
    Breastfeeding when HIV+ seems like russian roulette-- and I'm sure some of those moms have breastfeeding issues in addition to their HIV status as well.

  4. Hi Manixter. There's a more detailed discussion of the problems in Botswana in 2005-2006 here It appears that there WERE cases of the diarrhoea among older children, but that it was concentrated among the very young: "Most (96%) of the children were under 2 years of age, median age 9 months."

    Breastfeeding with HIV definitely IS a Russian roulette, which is why I'd never recommend it to anyone who has access to safe formula feeding facilities. I'm going to post on HIV/breastfeeding in more detail next month, but the figures I've seen suggests that the risk of infecting the child is about 1 in 7 if mum is not getting any ARVs but exclusively breastfeeds (if she mix-feeds, the figure is higher), while in the most optimal case scenario--exclusively breastfeeding, proper ARV regime--there is still a 1-in-136 or so chance of infection by six months.

    Those are alarming odds in a developed-country context, but the problem is that the risks of formula feeding in poor/remote regions are greater still. As I talked about a little in the post, it's not just about the quality of the water used in the bottles but the poor hygiene in these environments in general and the difficulty of procuring reliable supplies of formula. As the link discusses, only about half the Botswana babies were getting adequate amounts of formula, and about half were growing poorly even before the outbreak. So there are some real structural difficulties with safe FFing even when the water IS safe. It's sad that mothers in these regions have to make such tough choices, but I fear that we need to be practical and recommend the "least dangerous" option...

  5. I know that refrigeration can be a problem in these areas too but what I'm wondering is how much extra it would be to provide the government with ready to feed formula? I know they use in cases of disasters when water is questionable. It could be worth a try to maybe offer to Mothers RTF formula if she wants it or possibly to provide a ration of water with the ration of formula.

  6. Lizza: I think RTF is definitely the way to go in developing-country situations where breastfeeding is not possible--it is indeed used in disaster zones these days as being the safest option. That said... I don't know of any research on the subject, but I would imagine that even RTF is less safe than breastfeeding in resource-poor areas, because the formula will still spoil quickly in the bottle, can be contaminated by the bottle itself, and does not contain the components found in breast milk that can lower the risk of gastroenteritis and other problems. Then there is the cost and the logistics involved: considering how hard it is even to obtain coverage with things like measles vaccines (where only a couple of doses are required to produce lifelong immunity), I just can't imagine poor countries being able to ensure the sort of infrastructure necessary to keep RTF refrigerated in large amounts and ensure that mothers constantly have 24/7 access to all they need.

    But, yes, in situations where a mother in a poor country cannot breastfeed for physical or practical reasons, trying to ensure a supply of RTF where possible is without doubt the best solution.

  7. If they use the nursettes it eliminates refrigeration and bottle contamination. Providing a 2 oz serving per bottle while it may take longer to feed would eliminate a lot of the wasted formula since even most newborns will take over an ounce. They use them even in the NICU through feeding tubes because they are basically sterile.
    In the story above it said that she was getting from the government and I know that South Africa had a very similar program which was very successful on getting free formula to HIV positive women. Usually you can find a company with excess stock to donate formula to NGOs for distribution.
    Obviously there is a need to concentrate on HIV positive women and in some areas hepatitis B because even with anti-retroviral drugs or other treatments the transmission rate is not zero by a long shot.
    I'm a student of public health and have had to kids who couldn't be breastfed so I've spent a lot of time trying to work on providing and supplying formula in all needed situations.

  8. See, here's the problem--if a woman requires an NGO to distribute the formula to her, that to me is a signal that her circumstances may be too rough to allow safe formula feeding.

    In countries like South Africa there are plenty of middle-class HIV+ women (every African country where we have data has higher HIV rates among relatively wealthy people than among the poor); but these women are able to purchase their own formula. I'm just going by my own experiences of poor and remote countries--transportation links are just terrible, and you cannot rely on reliable supplies of anything at all, and nursettes of RTD need to be delivered in large numbers every single day to every single mother using them, without fail---otherwise babies will wind up being given cow's milk, improvised concoctions and other things. In the story I quoted above, the mother in question frequently found her local stores had no formula available and was forced to give her baby watered cow's milk or flour and water mixtures. And that was in Botswana, which is quite a well organized and developed sub-Saharan African country.

    So I'd be skeptical about how reliable distribution schemes would be in the long term, although they might be possible in some circumstances, like dense urban areas. In addition, if only limited amounts of RTF are available, I'd prefer to see them prioritized towards mothers in poor countries who can't breastfeed or need to supplement-for example, because they work outside the home.

    Re: Hep B: what is the situation there regarding breastfeeding? Hep B is the Cinderella of public health; it gets almost no attention compared to HIV, probably because the groups of people who tend to get is are almost exclusively heavily stigmatized groups....

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