The Dilemma
By Lida Lhotska
I was happy! I got a dream job, in 1994: to assist UNICEF’s work in protection, promotion and support of breastfeeding. Breastfeeding was a cornerstone of UNICEF strategy following the 1990 World Summit for Children and the entry into force of the Convention on the Rights of the Child with its overarching “best interest of the child” consideration.
Implementation and monitoring of the International Code of Marketing of Breastmilk Substitutes (WHO, 1981) were part of the deal as it was soundly understood that breastfeeding may be threatened by market forces seeking to place private profit above public health.
This course was charted, despite significant pressures from the powerful private sector lobby, already in the ‘80s by the late Mr. Grant. A quote from the influential Heritage Foundation illustrates these pressures: "These [multinational infant formula] firms have written their own industry codes and regulations which, in fact, predate the WHO code. Yet UNICEF, perhaps for political reasons, seems determined to castigate the industry". ..."If UNICEF continues to move in this direction, it will find itself compromised by the reflexive anti-Western rhetoric and anti-free market arguments that have undermined other U.N. agencies." [1]
As a newcomer, I had a lot to figure out. The impossible number of acronyms for one. Fortunately, I could count on full support of an outstanding team of colleagues: David Clark’s flawless legal work on the Code; the invaluable technical support by Helen Armstrong, Dora Gutierrez and Gay Palmer; and Joanne Csete’s guidance through interagency challenges saved me much trouble. I am still very grateful to them!
I was happy. What could be more positive and straightforward than working on policies and measures that help mothers to take care of their babies within a great team? We were making good progress and aiming for more. Then an ice-cold shower dropped on our heads: the HIV/AIDS pandemic.
The fact that some babies could contract HIV through breastfeeding became known in the mid-‘80s and led to one of the most painful dilemmas of public health ever and to excruciating moments for UNICEF’s work on breastfeeding.
In 1992, the first UN Consensus statement on HIV and breastfeeding was agreed. It noted the need to weigh the baby’s risk of HIV infection through breastfeeding against its risk of dying of other causes if denied breastfeeding. That still meant, for most of the countries in which UNICEF worked, full support for breastfeeding.
When, however, the first anti-retroviral treatment (ART) that could be used in Global South was announced in 1997, breastfeeding came to be overnight regarded as a dangerous thing to do. Why should HIV positive mothers run the risk of infecting they baby through breastmilk, after having successfully prevented infection of their child during pregnancy, thanks to the ART treatment?
With some WHO colleagues, we realized rapidly that something was wrong with the studies that showed the risk of HIV transmission through breastfeeding. They did not look at whether the babies were exclusively or only partially breastfed, with some other form of artificial or complementary food added!
This may seem very technical, but understanding it was crucial for the issue. Evidence suggested that exclusive breastfeeding was important for maturation of babies’ intestinal mucosa while early introduction of infant formula or of any other food might cause micro- bleeding of the gut. Such micro-bleeding was likely to facilitate the virus getting across the baby’s gut wall. The breastfeeding pattern, we realized, could be an important determining factor for HIV transmission. We urgently needed research to look into this closely before breastfeeding went down the drain!
Yet such research was hard to push for, especially since UNICEF seemed suddenly divided into two camps: those who argued UNICEF should start advocating infant formula and supplying it to HIV-affected countries, and the few of us who believed breastfeeding should not be discarded and called for good quality data to guide new policies.
To make the matters worse, the press caught the scent of this struggle. Even the Wall Street Journal bombarded the communication section and wanted to write a “balanced” article on the theme. The “13th floor” – Office of the Executive Director- kept asking questions for which there were no answers. UNICEF was caught in a public relations and press storm and our team was in its eye.
Baby food companies did not take long to express their interest to be “a part of the solution”. Bristol-Myers Squibb wrote on its website in 1999: "Mother-to-child transmission is a serious problem acknowledged by UNICEF and the WHO have lessened their strong support for breastfeeding in communities where the risk of HIV transmission through breastfeeding is high." The company also explained its views of 'educational' activities: "Education also increases the sales of HIV products by developing HIV marketplace… Although education requires longer-term investment, the returns will ultimately materialize…particularly given that most of this HIV market is untapped". [2]
In 1999, the data we hoped for came in as researchers in South Africa looked at the impact of breastfeeding patterns on HIV transmission and established that exclusive breastfeeding protected against the transmission of HIV. [3]
This gave an impetus for further policy development. In 2000, the UN recommendations were refined: When replacement feeding [4] is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers should be recommended. Otherwise, exclusive breastfeeding is recommended during the first months.
The HIV and breastfeeding dilemma does not end with this partial victory towards restoration of the rightful place of breastfeeding in UNICEF’s strategies to save children’s lives.
The 2016 WHO Recommendation took us a full circle: “Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence.”
Endnotes:
[1] Roger A. Brooks, UNICEF, beware—dangerous shoals ahead: backgrounder #287 http://www.heritage.org/Research/InternationalOrganizations/bg287.cfm Accessed 14.8.2008
[2] Bristol-Myers Squibb (1999) ‘AIDS background’, www.bms.com/public/aidba, accessed July 1999
[3] Coutsoudis A, Pillay K, Spooner E, Khun L, Coovadia HM for the South Africa Vitamin A Study Group. Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study, Lancet 1999; 354; 471-76
[4] A term coined for this particular context means giving an infant, who is not receiving any breastmilk, a nutritionally adequate diet until the age at which the child can be fully fed on family foods.
Comments
Post a Comment