Thursday, July 26, 2007

Did you all see the coverage of the Botswana commercial formula-induced diarrhea disaster? a year after the event?

A formula-induced diarrhea disaster has been recognized by the international press - more than a year after it happened.

But the positive aspect is that it has been noticed and reported by the Washington Post.

It is interesting that most of the respondent emails sent to the post mention that it is "not the formula but the water". The article notes that breastfed babies were 1/50th as likely to suffer from this when compared to formula-fed. Dear friends: It may have been the water that concentrated the bacteria, but it was breastfeeding that saved the lives.

Thanks to Craig Timberg and the editors of the Washington Post for publishing this article.

However, why did they choose to blame UNICEF, and applaud CDC in relationship to the event? Yes, it was a CDC person who found the epidemic, but CDC also was encouraging - and may still be - countries to provide formula to all HIV+ moms. UNICEF, on the other hand, as noted in the article, discouraged this activity following the pilot tests, mentioned in the article as "programs" of provision. Botswana is an independent nation, and has every right and responsibility to make its own health decision, but this decision was against the advice of UN agencies, especially UNICEF.

I felt obliged to post the following:

Dear Mr. Timberg and Editors:

As the last Senior Advisor for Infant and Young Child Feeding at UNICEF HQ, from 2001-2005, I believe that it is quite important to note that UNICEF was not supportive of the provision of free formula to HIV+ women during these years. UNICEF supports government policies, attempts to help governments achieve well-informed health and other programming, and encourages World Health Organization (WHO) health policies.

In the 1990s, UNICEF did initiate some formula studies; these were pilot studies to assess whether or not it was safe to supply formula in these endemic settings where other infectious diseases kill many children, and where breastfeeding is the major defense available against them. UNICEF concluded by 2001 that it was not safe, nor feasible, in many settings in developing countries. These basic findings were accepted by 9 UN agencies, who then, following a global conference on the issue held at a meeting of the World Alliance for Breastfeeding Action, published a booklet "HIV and Infant Feeding: Framework for Priority Action." This booklet outlined the importance of establishing support for exclusive breastfeeding, reconfirming the Code of Marketing that advises against free supply of formula, and calling for increased counseling to ensure that each woman, HIV+ or not, was properly advised concerning infant feeding in the context of her own setting.

The Government of Botswana made a very difficult choice, and chose to follow the advice of others, including the respected US Center for Disease Control and Prevention and certain other US experts instead - not the advice of UNICEF HQ and other UN organizations. Botswana is not alone in this decision; virtually all countries in Central and South America and the Caribbean have made the same choice: to provide free formula for all children of HIV+ mothers, without fully taking into account the possible impact of the loss of the breastfeeding protection against other diseases. The support provided by UNICEF in Botswana was for the government-made decision, and UNICEF support Botswana's efforts to ensure a fair bidding process.

UNICEF has consistently supported WHO guidance that formula should be used to prevent vertical transmission only where it is affordable, feasible, acceptable, sustainable and safe. Clearly, it was not safe in these conditions. In fact, formula provision is not safe in at least some parts of most countries around the world; anywhere where ambient levels of infectious disease are high, or where the recognition of the importance of exclusive breastfeeding can be appropriately balanced against the risks.

I believe in mothers and their desire to do what is best for their children. The call to accept a free supply of an expensive commodity, especially where resources are limited, is very hard to resist. If donors were truly determined to offer a choice, they should be providing the mothers who choose to breastfeed support for exclusive breastfeeding as well as other commodites of an equivalent cost - perhaps other foods to feed herself and her family.


Miriam H. Labbok, MD, MPH
Professor of the Practice of Public Health
Director, Center for Infant and Young Child Feeding and Care
Department of Maternal and Child Health
School of Public Health, CB#7445
The University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7445
The Center for Infant and Young Child Feeding and Care in the School of Public Health at UNC-Chapel Hill was established January 2006 and exists to further statewide, national and global understanding and support for the mother/child dyad as key to the achievement of optimal infant and young child feeding and associated reproductive health.

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