posted August 31, 2007 11:01 AM         

Updated: 8:55 a.m. ET Aug. 31, 2007
In an attempt to raise the nation's historically low rate of breast-feeding, federal health officials commissioned an attention-grabbing advertising campaign a few years ago to convince mothers that their babies faced real health risks if they did not breast-feed. It featured striking photos of insulin syringes and asthma inhalers topped with rubber nipples.

Plans to run these blunt ads infuriated the politically powerful infant formula industry, which hired a former chairman of the Republican National Committee and a former top regulatory official to lobby the Health and Human Services Department. Not long afterward, department political appointees toned down the campaign.

The ads ran instead with more friendly images of dandelions and cherry-topped ice cream scoops, to dramatize how breast-feeding could help avert respiratory problems and obesity. In a February 2004 letter, the lobbyists told then-HHS Secretary Tommy G. Thompson they were "grateful" for his staff's intervention to stop health officials from "scaring expectant mothers into breast-feeding," and asked for help in scaling back more of the ads.

The formula industry's intervention -- which did not block the ads but helped change their content -- is being scrutinized by Congress in the wake of last month's testimony by former surgeon general Richard H. Carmona that the Bush administration repeatedly allowed political considerations to interfere with his efforts to promote public health.

Rep. Henry A. Waxman's Committee on Oversight and Government Reform is investigating allegations from former officials that Carmona was blocked from participating in the breast-feeding advocacy effort and that those designing the ad campaign were overruled by superiors at the formula industry's insistence.

Political interference?
"This is a credible allegation of political interference that might have had serious public health consequences," said Waxman, a California Democrat.

The milder campaign HHS eventually used had no discernible impact on the nation's breast-feeding rate, which lags behind the rate in many European countries.

Some senior HHS officials involved in the deliberations over the ad campaign defended the outcome, saying the final ads raised the profile of breast-feeding while following the scientific evidence available then -- which they say did not fully support the claims of the original ad campaign.

But other current and former HHS officials say the muting of the ads was not the only episode in which HHS missed a chance to try to raise the breast-feeding rate. In April, according to officials and documents, the department chose not to promote a comprehensive analysis by its own Agency for Healthcare Research and Quality (AHRQ) of multiple studies on breast-feeding, which generally found it was associated with fewer ear and gastrointestinal infections, as well as lower rates of diabetes, leukemia, obesity, asthma and sudden infant death syndrome.

The report did not assert a direct cause and effect, because doing so would require studies in which some women are told not to breast-feed their infants -- a request considered unethical, given the obvious health benefits of the practice.

A top HHS official said that at the time, Suzanne Haynes, an epidemiologist and senior science adviser for the department's Office on Women's Health, argued strongly in favor of promoting the new conclusions in the media and among medical professionals. But her office, which commissioned the report, was specifically instructed by political appointees not to disseminate a news release.

'No media outreach'
Wanda K. Jones, director of the women's health office, said agency media officials have "all been hammering me" about getting Haynes to stop trying to draw attention to the AHRQ report. HHS press officer Rebecca Ayer emphatically told Haynes and others in mid-July that there should be "no media outreach to anyone" on that topic, current and former officials said.
http://www.msnbc.msn.com/id/20523460/

posted August 31, 2007 06:56 PM         

So many children with so little immunities.
I have three of my own and am greatful to have been able to breast feed each of them.

So many woman are still clueless to the advantages though. Because of Corporations like the above these women are often misinformed.

Thank you for sharing this article. I hope to see in the future some backbone from our government and media as well!

posted August 31, 2007 09:00 PM         

Breast-Milk Substitutes

What is the International Code?

Big corporations are the winners in today's world, with earnings far beyond many countries' gross national products, let alone government budgets. One of the most advanced tools so far developed in regulating the behavior of private enterprise is the International Code of Marketing of Breastmilk Substitutes. It was passed by the World Health Assembly (WHA) in 1981 with the USA, due to Ronald Reagan’s personal intervention, casting the only dissenting vote. Some 20 countries have implemented it as law and dozens of others have implemented part of it as law or all of it as a voluntary measure. This can be taken as a sign of how seriously threats to breastfeeding have been taken in world policy-making bodies and by governments.

The Code covers breast milk substitutes, bottles and teats. For all these products, the Code stipulates the following:

there should be no advertising direct to the public,
no free samples to mothers,
no promotion of these products in health care facilities,
no company “mothercraft” nurses to advise mothers,
no gifts or personal samples to health workers,
no words or pictures idealizing artificial feeding, including pictures of infants, on product labels,
information to health workers should be scientific and factual,
all information on artificial feeding should explain its costs and hazards and the benefits of breastfeeding,
unsuitable products like sweetened condensed milk should not be promoted for use with babies, and
all products should be of high quality and take into account the climate and storage conditions of the country where used.

The consumer advertising that we are most aware of includes the use of mass media, billboards, and pamphlets but it is complemented by other types of promotion such as baby contests, temporary price reductions, and point of purchase promotion (an attractive display, lots of shelf space devoted to it, and labels idealizing the product). In the past, some companies used so-called mother-craft personnel, often some of the best-qualified nurses. They were hired to visit clinics and even homes, supposedly to teach mothers how to better care for their babies, though in fact they were promoting the companies baby foods and other products. Where implemented according to the text in the International Code, national codes will eliminate all these marketing techniques. The Code even disallows the use of bonuses to the salesmen based on volume of sales, though this would be difficult to monitor.
Yet the International Code has from the beginning been a somewhat weak and compromised “minimum measure” suggested to governments who must decide exactly what actions are needed within their particular situation to implement it. While nearly all countries have some relevant regulations or legislation, very few have developed the kind of broad and strong safety net that I believe is required to protect breastfeeding.

In Sweden the first voluntary agreement came in 1964 between the baby food industry and its paid consultants, a group of pediatric professors. (One can question the ethics of this kind of arrangement as well. These professors received monthly payments from the companies in return for loyalty—-and occasional they are called upon for professional inputs.) This code forbad direct advertising to the public and the distribution of free samples, but allowed other marketing practices such as the distribution of simple printed materials regarding follow-up formula and other baby foods directly to mothers when their infants reached three months of age. This practice was continued even after the passage of a more formal, though still voluntary Code in 1982. Apparently, some pediatricians in Sweden considered it “unreasonable” not to allow consumer advertising of cereal-based follow on formula from six months of age. In fact, however, the industry respected only the original three-month limit. In theory a new voluntary Swedish code now covers the period up to one year after birth, and the possibility of making it a law is being discussed. (The problem is that it would require a change in the national constitution, as it would restrict free speech.)

The Code was complemented by additional WHA resolutions

A WHO team published a paper in early February of this year on the relationship between artificial feeding and infant mortality. They found it impossible to estimate in the three African countries for which they had data because virtually every living child was breastfed well into the second year of life. The creation of demand for infant formula or baby feeding bottles in such cultures is deeply unethical behavior. Some may have difficulty accepting such a moralistic or judgmental way of looking at what one could call “business as usual.” But consider the similarity between company personnel who give insecure new mothers free samples of infant formula at delivery and narcotics salesmen who give free samples to children at a school. Both are knowingly creating dependency on something they want to sell once that dependency is created. The narcotics salesman is even likely to be more direct and honest about what is going on when he says, “First one’s free!” In both cases wealth is a likely outcome for one party and serious ill health or death for the other. The one who suffers in both cases is a child.

The Code banned free samples but allowed “free supplies” of infant formula. This was intended to allow companies to provide as much formula to a given baby “who needed it” for as long as that baby needed it, as a charitable gesture to orphanages, for example. But companies simply stamped the word “supplies” on all the free samples they gave to hospitals and the carnage continued. The UN decided to hold a meeting in December 1985 to define who needed breast-milk substitutes. Because the persons involved would no longer be directly affected by it, I can tell you that the late Jim Grant, former head of UNICEF and on of those who took the initiative to the Innocenti Meeting in 1990, received a personal threat from an employee of Ronald Reagan’s State Department that if the meeting even discussed marketing issues (rather than the physiological question of who needed breast milk substitutes), the United States would withdraw its support to UNICEF.

Reagan’s administration worked actively against the Code. A right wing think tank published a newsletter reporting for them on what activists were doing and whether WHO staff were working actively on the code. This appears to have been the basis on which the US government decided to meet its semiannual budgetary obligations.

The Swedish International Development Cooperation Agency, Sida, had heard about the threat to UNICEF and came up with an idea for bypassing industry and Reagan government surveillance of the various actors at the WHA. They contracted a Swedish professor who was able to attend without being a formal member of a delegation. He contacted one delegate he knew, the minister of health of Nigeria, who had written an article years before showing the harm done by infant food advertising. Together they drafted the text for a new resolution calling for an end to the use of free ore even subsidized supplies. It went through, thus closing the loophole in the Code.

Afterwards, industry newsletters reported to the Reagan Administration that they had no idea whose initiative this was. They knew it did not come from the baby food activists, and that WHO staff had been unable to stop it. The industry described this as a bigger blow to their marketing efforts than the Code’s ban on advertising. Another WHA resolution in 1994 was required to close a loophole in this one, stating that free supplies were not to be offered or accepted anywhere within in the health system, not just at maternity wards.

The Code works because activists focus public attention on violations

Given how much more deeply the mass media penetrate developing countries today than when the Code was passed nearly two decades ago, we might not have much breastfeeding left if it were not for the public relations damage companies feared if they continued with business as usual. This is always the reason for the companies not pursuing business as usual, not ethical concerns or concerns about whatever small fines or other measures might be taken against them if they break the code, even in the countries where it is law. Activist organizations, under the IBFAN network have effectively spread awareness of unethical company behavior. They and the donor agencies that have supported them over the years, mainly in Holland and Scandinavia, may have in this way saved more human lives, by preventing the decline of breastfeeding in poor countries, than even vaccination has saved.

What the companies do to evade the Code

Is the problem solved now? The answer to this is complex. On the one hand, in most of the developing world, at least the big international companies no longer heavily promote directly to mothers products strictly defined as covered by the Code. They now spend their promotional budgets in other ways, for example in convincing us all that there is no problem any more and we should put our attention into more important things. But behind the scenes these companies have just as much incentive to promote these products as they ever did, indeed a desperate need to find ways to expand their markets in the face on increasing breastfeeding rates and falling birth rates in many major markets.

To make themselves look like good corporate citizens in an increasingly well-informed world, many companies have indeed accepted that infant formula sales will remain low. Instead they focus their efforts on so-called “follow-up formulas,” the marketing of which is not restricted in many places. They are also constantly developing new products and new marketing strategies designed to by-pass national and international marketing regulations. In some countries, the promotion of “special” or “medically indicated” formulas like soy formula is not regulated the same way, and sales of these products have soared.

Also, the consumer advertising we are all familiar with is only a small proportion of what is involved in product promotion. The major pillar is and always has been “cooperation” with the health professionals.

Company marketing to the health professions

Since its birth in the 19th century, the baby food industry has utilized medical testimonials to give its products “a veneer of `scientific` and medical respectability.” In its early years, artificial feeding was thought to demand complicated calculations of ingredients, and this made mothers dependent on physicians. By about 1910, “patented” products could instead be used by mothers directly by following directions on the label. This was considered “physically unhealthy for the infant and economically harmful to the physician.”

Some companies soon began realizing that they stood to gain by utilizing physicians` skills both in better product development and in more profitable marketing. By 1932 the American Medical Association Committee on foods demanded that, to obtain its “seal of approval,” companies stop advertising to the public since “every infant...should be under the supervision of a physician who is experienced and skilled in the care and feeding of infants.”

This was not only the first voluntary “Code of Marketing,” it was to be followed by the first case of effective sanctions against a company that did not comply. Horlicks Malted Milk, because it continued to advertise to the public, was denied access to promotion through medical media such as journals and eventually stopped selling its product in the USA. Soon thereafter, the baby food industry began to support scientific meetings and to provide “open support of infant nutritional research.” Since then, grants are given for research and fellowships, and pediatric associations and medical students are wined and dined on luxury cruises, with scientific lunch-time seminars added to be avoid tax liability. Do companies’ boards of directors approve expenses like this for charitable reasons or are they aware, as the late Dr. Derrick Jelliffe warned, that such “manipulation by assistance” pays dividends in the long run?

Industry messages in their advertising to the health professions have been remarkably similar since 1910: “Our product keeps getting better and now contains component X, making it almost the same as to breast milk.” It is amazing that it never seems to occur to health professionals that the industry is thus indirectly admitting that their products must have been pretty inferior before component X was added. And that the process just keeps going on and on. So the industry itself, each time it says “NOW our product is similar to breast milk” is proving that it was lying last time it said that!

Every mother who starts artificial feeding is doing a little experiment on her baby. Neither she nor the doctor can know in advance how her baby will respond, especially during the early weeks of life. What is the best way to overcome her hesitation or fear? Number one, the doctor has to endorse the product. Health professionals are of course rarely willing to do this directly. But equally rarely are they aware that companies dupe them into doing so indirectly, “endorsement by association” as Dr. Jelliffe called it. The pen in the shirt, the notebook in the hand, the growth chart, all may bear the name of a company that conveys a clear message to the mother, whether or not the health professional intends it to.

Companies lobby governments and the United Nations

Another, less apparent component of a marketing strategy is direct lobbying to governments, mainly to keep down the cost of doing business. Governments are urged to reduce regulations, trade barriers, customs and taxes. Since the officials involved know nothing about health, it often proves a simple matter to convince them that commercial baby foods are a sort of “welfare product” that should be treated differently from other commodities. The most extreme cases of such misguided policies are countries such as Sri Lanka which subsidizes infant formula across the board and the USA which provides it to poor mothers. Some countries in Latin America have long provided milk powder to mothers of young infants, but in recent years this is at least put off until the infant reaches six months of age.

Lobbying also takes place in international fora such as United Nations conferences and scientific meetings. It is naive to assume that companies passively await scientific findings and alter their marketing accordingly. Rather they do everything in their power to fund research and spread awareness of research that supports their positions, influencing the scientific community in directions that benefit them. Especially important for them is extending the age range during which health workers believe their products are useful-—particularly the low end of the range. (If babies do not need solid foods until six months of age when they are physiologically more ready for it, maybe mothers will decide they don’t need to buy commercial baby foods at all!) This may be why they fight so hard to maintain the outdated recommendation that exclusive breastfeeding should end at 4-6 months (probably well aware that many uninformed pediatricians assume that early supplementation has a positive effect and advise it from three months, “just to be sure”). This flies in the face of the only two randomized controlled studies that have been done and a WHO-published state of the art review last year, all of which point to “about six months” as the proper time to start adding foods. The WHO Department of Nutrition for Health and Development that has always been responsible for the Code (and thus subject to intense industry lobbying), still supports this recommendation as well.

Is the Code relevant in Europe?

The big companies have good contacts with governments in countries they define as “developed” and have lobbied relatively successfully to ensure weak, preferably voluntary, national codes and a weak EU code. A historical fluke is probably the main explanation for their getting away with this.

Until the 1990s, very little research in industrialized countries examined the relationship between infant feeding and health utilizing proper definitions for breastfeeding. Infants in one group received breast milk and in another did not, but even very young infants in the breast-fed groups received supplements other than breast milk, as is nearly universal all over the world. (Not until the 1980s was it discovered that breast-fed babies do not need additional water and not until 1990 was this incorporated into a widely publicized set of definitions for breastfeeding.)

But most researchers still do not know about or apply these. For example, not until August 7, 1999 was a paper by Coutsoudis et al. on HIV transmission published utilizing proper definitions of breastfeeding and several have been published since then that did not use correct definitions. In contrast to other studies on babies whose mucous membranes may have been damaged by various unnecessary supplements, Coutsoudis et al found no evidence that HIV was transmitted through the milk of HIV-infected mothers if they breast-fed exclusively the entire time from birth until three months of age. This has been followed up on and still holds true at 15 months of life.

We simply do not know the effect of all these supplements on the immature infant gut. But increasingly in recent years studies are finding associations between acute infections such as otitis media and urinary tract infections and exclusive breastfeeding, even in industrialized countries. There are also a few pioneers such as Dr. Pisacane here in Italy that are even finding relationships between various chronic diseases and breastfeeding.

Anyone attempting to promote stronger codes (or even breastfeeding per se) in Europe or North America is likely to be met with scornful pronouncements that artificial feeding does not kill babies here like it does in developing countries. What ignorance and arrogance lies behind these words! In the UK alone, Lucas and coworkers estimated that 200 deaths a year of premature infants from only one rare disease, necrotizing enterocolitis, would be prevented with optimal breastfeeding.

It must be admitted that more research is needed before we are aware of the potential health costs of artificial feeding, even among educated populations in hygienic settings. But if the public and decision-makers were aware of even what we know already, there might be greater interest in protecting breastfeeding and in giving mothers the substantial support and reduced work burden they need to practice it exclusively through the first six months of life.

Threats to the Code

Equally behind the scenes, and more sinister, is the lobbying these companies and those who act on their behalf are quietly doing, through the World Trade Organization for example, to obliterate the code and return to the days when this kind of “interference in the flow of free trade” was non-existent.

Neither governments nor the international community of concerned scientists and health workers has been able to devote enough resources to the protection of breastfeeding to compete with the private industry. After all, no code or law can reduce how much resources they allocate to marketing, including promotion, public relations and advertising, only place certain limits on how those funds may be used.

Thus the challenges that lie ahead for the Code are:

How to avoid being classified as an unfair trade restraint and, in the current climate of trade liberalization, done away with.

How, when it is adopted at national level, its measures can be monitored and enforced on a routine basis rather than as a periodic donor-funded NGO activity.

How, like the market it regulates, the Code (and national adaptations of it) can evolve over time.

How breastfeeding can be protected against the other marketing ploys described above, particularly corruption of the medical professions.

Ted Greiner, PhD

This paper is a talk given at the international meeting “Allattamento e Politiche per l’Infanzia Dieci Anni dopo la ‘Dichiarazione degli Innocenti,’” at the famous Innocenti Center (where the original Innocenti meeting took place) in Florence, Italy on March 16, 2000. It uses some pieces of the earlier paper on this site called “The Infant Food Industry: Why and How it Promotes its Products.”

posted August 31, 2007 09:29 PM         

I have also been part of the WIC program [Americas #1 educator for Women, Infants, and Children] off and on for 15 years or so.
In the WIC program; coupons for absolutely free formula are given to participants.
The formula varies by locality (generally Enfimil) but is in fact free.

Hmm?... Talk about making America's choice for them! Although the benefits of breastfeeding are lightly discussed, most if not all representatives of WIC will promote or encourage formula use as at least a suppliment.

What does this say...

posted September 01, 2007 11:44 AM         

November 3rd, 2003 was a big day for Alabama emergency room pediatrician, Dr. Carden Johnston. On that date last month, he was installed as the new President of the 66,000 member American Academy of Pediatrics (AAP) at the prestigious organization's annual meeting in New Orleans. It was also the date that he sparked what has emerged as a major ethical controversy by inadvertently pulling back the curtains on the powerful influence that a particular corporate interest appears to have in shaping AAP policy and action.

"I have to admit that I never imagined that my presidency would start off with such a bang," Dr. Johnston says, acknowledging the debate now taking place within his organization.

At issue is a letter dated November 3rd that Dr. Johnston sent to Secretary of the Department of Health and Human Services (DHHS), Tommy G. Thompson, officially expressing the AAP's concern over the "negative approach" of the federal agency's soon-to-be-released, pro-breastfeeding advertising campaign. What Dr. Johnston didn't mention in his letter, however, was that he had developed this sudden and seemingly urgent interest in this issue not via a last minute clinical review of the scientific literature, or even after consulting with the AAP's own recognized lactation science experts.

In fact, his concern came immediately after aggressive, personal lobbying by representatives of one of the AAP's biggest financial contributors, the $3 billion U.S. infant formula industry. Within days of a New Orleans meeting with worried formula industry reps, Johnston hurled the considerable credibility and persuasive impact of the esteemed American Academy of Pediatrics into an explicit effort to stifle the most ambitious initiative ever undertaken to promote breastfeeding in the United States.

"Some of us within the AAP have long suspected that the infant formula companies had this sort of direct access to AAP leadership," explains Dr. Lawrence Gartner, a founding member of the Academy of Breastfeeding Medicine and chairman of the AAP's Professional Section on Breastfeeding. "Dr. Johnston's actions have revealed the extent of this influence more clearly than anything else I've seen. Many doctors within the AAP are very disturbed by this."

Reflecting the strong opinions of a number of AAP members interviewed in the past week, Dr. Jay Gordon, a pediatrician and best-selling author of several parenting books, says that his opinion on the AAP leadership's actions in this matter go beyond "disturbed."

Dr. Gordon reports that, that in his view, the AAP leadership has "weakened and emasculated (the ads) to suit the manufacturers of formula," and "as a result of their craven disregard for America's babies and families, more infants will get sick and die each year. I wish that this greedy, immoral, reprehensible act could be met with criminal charges," explains Gordon.

The ad campaign currently inspiring such passion among the nation's pediatric health care providers is funded within the DHHS Office on Women's Health (OWH), and has been in the works since 2000. Officially dubbed the "National Breastfeeding Awareness Campaign," the creative end of the OWH project has been handled by Raleigh, North Carolina advertising agency McKinney+Silver, while the entire project is overseen by The Ad Council, the private, non-profit organization that produces, distributes, and promotes public service campaigns on behalf of charitable organizations and government agencies.

In 2002, DHHS described the upcoming breastfeeding initiative as a three-year, multimedia social marketing blitz worth as much as $40 million in advertising dollars. It is alleged by a variety of organizations representing lactation consultants, physicians, nurses, midwives, and public health activists that the AAP's last-minute appeal to DHHS prevented the much-anticipated campaign launch from taking place as scheduled this month. Additionally, it appears that representatives of the infant formula industry - with the benefit of prematurely leaked information about the specifics of the ad campaign - have been quietly lobbying federal and Ad Council officials to change the ads' content and tone.

According to the AAP's own Breastfeeding Section, at least one thousand new scientific and medical papers on topics related to breast and bottle feeding have been published in just the past four years. Taken as a whole, this mounting body of research reveals dramatically different health outcomes for populations of breast and formula-fed babies, even when controlling for socioeconomic and other factors. The new ad campaign was designed to reflect this research and to catapult the issue of breastfeeding into the same category of public health concerns as smoking, carseat use, childhood vaccinations, and SIDS prevention.

While critics of Dr. Johnston's action strongly disagree that the tone of the DHHS ads is "negative," they concede that the new campaign does offer a fundamentally different way of looking at the breast-bottle issue. They hasten to add, however, that this new approach was completely intentional. According to those medical professionals who played a role in creating the actual content of the new campaign, the ads utilize a market-oriented and evidence-based approach to the issue, relying for the first time on the proven communications strategies that have successfully impacted other public health behaviors in recent years.

According to those who have viewed them, the ads feature catchy slogans meant to become memorable such as "Breastfeed: It's too important not to," and "Babies are born to be breastfed." Some of the ads also use humor to make their points, including TV spots showing a pregnant woman participating in roller derby and riding a mechanical bull. These absurdist images are used to make the point that, just as no woman would take those sorts of risks while pregnant, mothers of infants should avoid the quantifiable risks to their babies' health that come with not breastfeeding.

"As I understood it, this was to be the first national advertising campaign that focused on the risks of not breastfeeding as opposed to the benefits of choosing to breastfeed," explains Dr. Audrey Naylor, a San Diego pediatrician and Executive Director of Wellstart International, as well as a member of the AAP's Breastfeeding Professional Section, and a past consultant to the World Health Organization on infant nutrition issues. "This would definitely mark a significant change in the way this issue would be presented to the general public. It's a change to promote breastfeeding as a public health issue rather than simply as a personal parenting choice."

The area of the website of The Ad Council devoted to a brief discussion of the planned DHHS breastfeeding campaign offers a glimpse into this very different, market-oriented way of viewing the issue of breast vs. bottle, stating that, "Babies who are not exclusively breastfed for at least 6 months will be more likely to contract asthma, allergies, and cancer." In previous breastfeeding promotion campaigns, this statement would have certainly read "Babies who are breastfed will be less likely to contract asthma, allergies, and cancer."

In a presentation sponsored by the Breastfeeding Task Force of Greater Los Angeles on the planned campaign, McKinney+Silver was quoted as seeking to move from creating awareness to creating conversion with the ads.

"Shift the language from 'If you breastfeed, your baby will be healthier,' to 'If you don't breastfeed, your baby will be more prone to...," noted McKinney+Silver in describing the campaign's approach. The presentation went on to note that, while most American women seemed informed of the benefits of breastfeeding, few seemed aware of the potential consequences of not nursing their babies. "(There is) no perceived disadvantage if you don't breastfeed. Many think breastfeeding is like supplementing a 'standard diet' with vitamins. Formula, by default, is credited with the status of being 'the standard.'"

In much of the rest of the world, ads for infant formula directed at consumers are verboten in much the same way that television ads for cigarettes and liquor are no longer acceptable in the United States. This global aversion to infant formula advertising is due to the widespread adoption by governments and private industries outside the United States of the World Health Organization's Code on the Marketing of Breastmilk Substitutes - known as the WHO Code.

In this country, however, there is only minimal adherance to the WHO Code by public or private entities and as a result, advertisements for different brands of infant formula are a ubiquitous part of the U.S. media landscape.

In years past, various individual government agencies, hospitals, and private organizations such as La Leche League International have attempted to counter the advertising sledgehammer wielded by the well-heeled infant formula industry via a patchwork of relatively low-budget, smaller-scale ads focusing on the "the benefits of breastfeeding." However, the DHHS breastfeeding campaign to which the AAP leadership has now objected was to be the first national effort to utilize high-end, commercial-quality production values to position the "breast is best" public health message to go head-to-head with even the slickest Madison Avenue-produced infant formula ads.

Clearly, this was not a campaign that was going to play well with the infant formula industry, which has until now managed to create a uniquely advantageous situation in which it has positioned itself as the primary spokesman for its chief competitor in the marketplace, breastfeeding. And this new message is assuredly not the one they want projected into public consciousness.

"Ironically, infant formula companies in this country can honestly say they spend more on what they call 'breastfeeding education' than any other single entity," explains Amy Spangler, a nurse and lactation consultant who currently chairs the United States Breastfeeding Committee, an umbrella consortia of health care organizations interested in breastfeeding that was intimately involved in developing the new DHHS campaign. "They also underwrite much of the research into infant feeding issues. The pay-off for them is that they then get to manipulate the message, which is always "Breastfeeding is best, but... There is always a 'but,' and breastfeeding is suggested as a type of 'bonus feature' for parenting rather than the norm."

According to a number of sources within the medical community who were included in meetings during the planning process for the breastfeeding campaign, DHHS officials repeatedly stressed to participants that the specific messages of the ads -- which were clearly shaping up to be potentially controversial -- needed to be "embargoed" until their official release.

Amy Spangler attended several meetings with DHHS and OWH officials to discuss the Breastfeeding Awareness Campaign and she says that federal and Ad Council officials encouraged participants to avoid speaking publicly about the content of the planned ads before their release.

"It was never said specifically that the need for keeping the ads under wraps until release was due to anything having to do with infant formula companies, but I think we would have been naïve to assume that this was not one of the reasons why," explains Spangler.

Despite the warnings, however, the infant formula industry did apparently gain access to much of the content of the ads, allowing them to begin an intensive and targeted lobbying effort against their release. DHHS officials are reluctant to discuss the circumstances surrounding the premature leak of the ads, saying only that "a small amount" of information about the campaign was accidentally released on The Ad Council website at some point in November. Hipmama.com has learned, however, that DHHS and Ad Council officials voluntarily met with formula industry representatives at several points during the fall, even as pro-breastfeeding stakeholders were being instructed by the same officials to keep mum in order to preserve the integrity of the ad campaign's message.

Additionally, most or all of the actual ads were shown to dozens of attendees at a North Carolina medical conference in October, something that Office on Women's Health spokesperson Christina Pearson says the agency didn't authorize or even know about until after the event.

According to a variety of sources, members of Congress began hearing complaints about the pending ad campaign from infant formula manufacturers as early as the first week of October, but it was at the AAP convention in November that the industry was able to aim what is arguably the biggest weapon in its lobbying arsenal --the clout of the American Academy of Pediatrics - directly at the the breastfeeding campaign.

"The reason why the infant formula industry is so successful is because they have managed to manipulate health care providers into providing them with a cloak of credibility," explains Amy Spangler. "The bottom line here is that the president of (an infant formula company) doesn't have to send a letter directly to a federal official when he can get the President of the American Academy of Pediatrics to do it for him."

Public health advocates and many individual physicians, nurses, midwives, and lactation consultants have long criticized the cozy financial ties between infant formula manufacturers and major medical organizations such as the AAP, the American Medical Association, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology. The infant formula industry -- part of the larger pharmaceutical industry lobby -- is also recognized as one of the most effective and powerful lobbies on Capitol Hill.

Critics of this relationship between baby doctors and formula makers note that because the U.S. infant formula industry -- with sales of $3 billion annually -- clearly has a commercial interest in impacting parents' infant feeding choices, the industry should not play any role in crafting public health messages relating to the industry's clear competitor in the marketplace, breastfeeding.

"It is simply not appropriate for these companies to have a say in how publicly-funded health education campaigns present breastfeeding issues," argues Marsha Walker, RN, IBCLC, and Executive Director of the National Alliance for Breastfeeding Advocacy (NABA), a non-profit group promoting breastfeeding. "It would be like inviting a cigarette manufacturer to have a say in the message of a government sponsored anti-smoking campaign."

OWH spokesperson Christina Pearson disagrees, however, insisting that DHHS has made it clear all along that the agency wanted to hear from "all sides" on the issue.

While it may be reasonably asked what "sides" exist when speaking of a public health campaign promoting a free or low-cost, healthy alternative over another, expensive and less healthy alternative, the AAP leadership decided that their organization was going to take sides. In a phone interview with Hipmama.com on December 3rd, AAP President Dr. Johnston readily admitted that he was approached by representatives of infant formula companies during the annual AAP convention in the first week of November, and asked to attend a "private," "not on the agenda" meeting to discuss some concerns that the industry had with the planned DHHS breastfeeding campaign. He says that he and the three other members of the American Academy of Pediatrics Executive Committee, Dr. Joe Sanders, Dr. Carol Berkowitz, and Dr. E. Stephen Edwards, immediate past president of the AAP, met for approximately 45 minutes with "two or three" representatives of Ross Products "and maybe one other company" to hear their concerns.

"This was the first I had heard about this planned breastfeeding promotion campaign," says Dr. Johnston. "Sad, but true. I didn't know it was in development until after these folks told us about it."

Dr. Johnston's account of his interest in and knowledge of the DHHS ad campaign differs from the version reported in the December 4th edition of the New York Times. In a story entitled "Breastfeeding Ads Delayed In Dispute Over Content," reporter Melody Peterson writes that Dr. Johnston and Dr. Sanders "...said that they had decided to send their letter before (infant formula company) executives expressed their concerns at the Academy's national conference, held last month in New Orleans."

In his interview with Hipmama.com, Dr. Johnston said that he became alarmed at the tone and message of the ads after viewing samples shown to him by the infant formula company reps in New Orleans.

"They showed us more than ten but fewer than twenty printouts of something that looked like ads. It was my impression these were copies of some of the ads," says Dr. Johnston. "A lot of the ads looked fine to me, but I shared their concerns about the negative approach overall. It worried me, as it did them, that parents whose kids got cancer or grew up dumb might feel guilty if they did not breastfeed."

Dr. Johnston says that he did not find it inappropriate or even remarkable that a commercial interest would have advance advertising copy from a planned multi-million dollar federal public health campaign designed to convince Americans to buy less of their products.

"I never asked them where they got this stuff," says Dr. Johnston. "I just had the feeling that their relationships within Health and Human Services were better than ours at the Academy. I was actually embarrassed that this was the first time I was being made aware of the problems with this advertising campaign. Of course, they have to be concerned about issues that impact their shareholders."

Dr. Carol Berkowitz, who will become AAP President in 2004-2005, confirms that she also attended this meeting, however in a phone interview on December 3rd, she told Hipmama.com that the meeting was noted on her personal conference schedule when she arrived in New Orleans.

"The meeting was on my own schedule that they handed me when I arrived," says Dr. Berkowitz. "I assumed it had been set up in advance at AAP headquarters. I saw nothing remarkable about it; I attended many such meetings while I was there and I've been friends with many infant formula representatives for years."

Dr. Berkowitz says that she too was concerned about the tone of the ads based on what formula industry representatives told her when she met with them at the AAP Convention.

"At the end of the meeting, Dr. Edwards asked what they wanted us to do and they told us that they had just wanted to make us aware of the situation, " remembers Berkowitz.

Apparently, the AAP leadership's freshly heightened awareness led to almost immediate action on behalf on the formula industry. In a letter dated November 3rd -- while the AAP convention was still underway in New Orleans and on the very same day he was installed as President -- Dr. Johnston signed off on a strongly worded statement to DHHS objecting to the ostensibly still-under-wraps breastfeeding advertising campaign, based solely on what he had been shown and told by infant formula company lobbyists.

In the letter, Johnston notes that it has "come to his attention" that an ad campaign is about to be launched, and that he formed his opinions "after reviewing the Web Page of The Ad Council." He does not mention that his concern was, in fact, prompted by a private meeting he had just concluded with representatives from the infant formula industry. Dr. Johnston told Hipmama.com that, despite the wording in his letter to Secretary Thompson, he is not certain that he personally viewed The Ad Council webpage before signing the letter, and that he didn't actually draft the letter himself; staff at AAP offices near Chicago did. But he says that he was comfortable signing his name to it.

"I felt that we needed to send a letter immediately because the people we met with told me that these ads were about to be released," explains Dr. Johnston. "They conveyed a sense of urgency to me and I shared their concerns. I thought many of our members would be disturbed if these ads were released in that format. I felt we needed to act."

Meanwhile, members of the U.S. Breastfeeding Committee and other medical professionals with an interest in the DHHS advertising campaign had no idea that the new President of the AAP had taken such an action. Within a week of the AAP convention, however, sympathetic sources within DHHS began contacting interested medical professionals around the country and quietly reporting that "something was up" with the breastfeeding campaign.

"We started hearing from people that the infant formula companies had begun an intense lobbying campaign against the ads within DHHS and other government offices, including Senator Bill Frist's," says Marsha Walker of NABA. "They were saying that they were unhappy with ads that told of consequences of not breastfeeding as opposed to stating the benefits."

By mid-November, Dr. Lawrence Gartner had been alerted by a DHHS staffer to the existence of the Johnston letter sent on behalf of the AAP. Gartner says that he was very disturbed that the AAP's own Breastfeeding Section had not been consulted or even notified about the contents of Dr. Johnston's letter to Secretary Thompson, even though he and his colleagues in the AAP's Breastfeeding Section had also attended the AAP Convention earlier in the month. After investigating the matter, Dr. Gartner felt compelled to send his own letters to Secretary Thompson, as well as to other AAP members.

In his letter to fellow pediatricians across the country, Dr. Gartner wrote that, "There is every reason to believe that (the infant formula companies) are pulling out all the stops to get this ad campaign buried, or, at least, modified to be less effective... This entire affair is a very serious matter, which raises many questions about the leadership of the AAP and the influence of the formula industry on AAP activities."

Mardi K. Mountford, Executive Director of the the International Formula Council, a trade group representing the interests of infant formula manufacturers takes issue with Dr. Gartner's assertion that her industry is seeking to discredit or delay the DHHS campaign.

"We strongly encourage mothers to breastfeed if they can, but we don't believe that women need to be subjected to scare tactics like the ones that are in these ads," explains Mountford. "Our only interest in reviewing the scientific claims in the ads is that they be accurate so that parents have the information they need to make their own decisions about what's best for their families"

Mountford's remarks highlight something that public health advocates have long noted; namely, that the infant formula industry's tactics in lobbying against initiatives such as FDA regulation of their product, standardization of ingredients in their product, and now, the DHHS breastfeeding campaign are remarkably similar to the strategies employed by tobacco companies in the early years of the anti-smoking public health movement.

According to PRWatch.org, the tobacco industry created what eventually became known as the Council for Tobacco Research (CTR) in 1953, claiming that the organization's mission was to "find out whether smoking was dangerous...'" During the 1980s, internal CTR memos revealed that " the CTR actually worked at "promoting cigarettes and protecting them from these and other attacks," by "creating doubt about the health charge without actually denying it, and advocating the public's right to smoke, without actually urging them to take up the practice." Just as the infant formula industry currently pays for much of the research into breastfeeding in the U.S, for many years the CTR funded most research into tobacco health issues and attempted to insert itself as a "concerned" corporate citizen into the government's earliest anti-smoking campaigns.

While Dr. Johnston's letter to DHHS referred only to a "negative tone" in the ads, infant formula industry lobbyists had been contacting DHHS and Ad Council officials since Spring, 2003 and insisting that the specific scientific research upon which some of the language of the ads were based was faulty. OWH spokesperson Christina Pearson confirms that the infant formula industry raised these concerns with DHHS officials, and concedes that the ads have now been modified to remove references to specific statistics that quantify the higher risks for certain diseases. However, she says that this change was in no way the result of pressure from the infant formula industry.

Several sources within the Ad Council, which relies heavily on funding by pharmaceutical companies that also produce infant formula - such as Mead Johnson - claim otherwise. They say that Mead Johnson threatened to pull its millions from The Ad Council's budget if the references to specific risk numbers were not removed from the ads. The Ad Council declined to comment on this report, instead referring all inquiries to Christina Pearson at OWH, who says her agency can neither confirm or deny this alleged incident.

According to Dr. Gartner, the industry's complaints about a "negative" tone in the ads, as well as its questioning of the science behind the campaign are just red herrings designed to delay and water down the campaign for as long as possible.

"As far as a negative tone goes, most successful public health campaigns rely heavily on making the public aware of negative consequences of certain behaviors. While it may be a new way to approach breastfeeding promotion, it's a common advertising device." says Dr. Gartner. "We don't tell parents about the 'benefits' of carseats. We tell them that studies indicate that if they do not use a carseat, their baby has a greater risk for being injured or killed in an accident. And telling them this has worked. Thousands of lives are saved every year because this message works."

Dr. Johnston admits that he now regrets not having discussed the letter he sent to Secretary Thompson with his own "breastfeeding experts" within the AAP, including Dr. Gartner. But notification is as far as it should have gone, says Johnson. He stands by his concerns about the ad campaign.

"I rely on the breastfeeding experts to help me learn more about breastfeeding issues, but some of the science behind these breastfeeding claims is shaky. It's just not solid yet, and you know how some of these breastfeeding enthusiasts can lack objectivity," noted Dr. Johnston.

When asked whether this lack of scientific objectivity he has observed extends to members of the AAP breastfeeding section, he replied "some, not all."

Dr. Gartner says that he finds Dr. Johnston's statement about objectivity among the physicians in the AAP's Breastfeeding Section "outrageous."

"I've read thousands of scientific papers on breastfeeding and formula feeding in just the past few years and so have my colleagues in the Breastfeeding Section within the AAP," notes Dr. Gartner. "I challenge Dr. Johnston to discuss the hard science behind this issue with me any time. I would welcome the opportunity. Frankly, I do not believe he is qualified to comment on the research because I doubt he's read much of it except -- it appears -- possibly what the infant formula companies have shown him."

According to many lactation consultants and physicians who have played a consulting role in crafting the DHHS ad campaign, an earlier release date offered by DHHS officials was to be in October, 2003, to correspond with World Breastfeeding Week. That date came and went and participants were next told that the date for the campaign's official roll-out would December 3rd, to correspond with a meeting of breastfeeding and infant health experts that was scheduled to take place in Washington. In its December 4th edition, the New York Times cited an Ad Council newsletter that named a December, 2003 release date for the campaign.

Christina Pearson of OWH disputes the claim that there has ever been a true release date set for the ads and emphatically denies that any changes have been made to the campaign's message as a result of pressure from the AAP or infant formula industry representatives.

"The campaign is still on the drawing board and as far as we are concerned it has never come off the drawing board," explains Pearson. "Anyone who thought we were about to release the ads was simply mistaken. We will continue our review of the message and the content until everyone feels comfortable that we have it right."