In Botswana, Step to Cut AIDS Proves a Formula for Disaster

By Craig Timberg
Washington Post Foreign Service
Monday, July 23, 2007

NKANGE, Botswana -- Doctors noticed two troubling things about the limp, sunken-eyed children who flooded pediatric wards across Botswana during the rainy season in early 2006: They were dying from diarrhea, a malady that is rarely fatal here. And few of their mothers were breast-feeding, a practice once all but universal.

After the outbreak was over and at least 532 children had died -- 20 times the usual toll for diarrhea -- a team of U.S. investigators solved the terrible riddle.

A decade-long, global push to provide infant formula to mothers with the AIDS virus had backfired in Botswana, leaving children more vulnerable to other, more immediately lethal diseases, the U.S. team found after investigating the outbreak at the request of Botswana's government.

The findings joined a growing body of research suggesting that supplying formula to mothers with HIV -- an effort led by global health groups such as UNICEF -- has cost at least as many lives as it has saved. The nutrition and antibodies that breast milk provide are so crucial to young children that they outweigh the small risk of transmitting HIV, which researchers calculate at about 1 percent per month of breast-feeding.

"Everyone who has tried formula feeding . . . found that those who formula feed for the first six months really have problems," Hoosen Coovadia, a University of KwaZulu-Natal pediatrician and author of a recent study on formula feeding, said from Durban, South Africa. "They get diarrhea. They get pneumonia. They get malnutrition. And they die."

That's what happened in Nkange, a tiny village on the sandy northern edge of the Kalahari Desert. In a cluster of several dozen homes here, eight children under 2 died during the four-month-long diarrhea outbreak, according to interviews with families. Only two had ever been breast-fed, and only one was being breast-fed at the time of the outbreak.

Chandapiwa Mavundu, 28, a mother of three who has HIV, said she never breast-fed her son, Kabelo, because government nurses warned her not to.

When he died at 8 months, after two months of withering diarrhea and vomiting, she could not muster the strength for the long walk to the graveyard. Instead, Mavundu stayed behind, she said, weeping amid the thatch-roofed huts and the dust and the goats as a hastily assembled parade of relatives carried her son's shrunken body away in a tiny, cream-colored coffin.

"That was the only boy child I had," said Mavundu, who has sad, wide-set eyes and long braids that dangle past her shoulders. "I loved him very much."

The medical records kept by Mavundu and other families here echoed the finding of the U.S. investigators: Government clinics often ran out of cans of formula, forcing parents and grandparents to buy cow's milk or feed their children with diluted porridge or even flour and water.

Many of the babies had recurrent sicknesses and registered steep drops in their growth patterns during their final months. When the diarrhea struck, it was severe, prolonged and difficult for even doctors to cure. One child survived diarrhea only to die soon after from pneumonia, another disease that breast-feeding helps prevent.

"Since I was a girl, I can't remember a time when we lost so many kids," said Ntselang Swimbo, 66, whose 9-month-old grandson died during the outbreak. "Once a kid got diarrhea, you knew the chance of surviving was almost zero."

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