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

"Sometimes it was there," she recalled. "Sometimes it was not there."

A Shifting Consensus

The government later blamed hitches in its contracting system for the formula shortages. But supply was not the only problem uncovered by the investigators from the U.S. Centers for Disease Control and Prevention, which announced its findings at a scientific conference in Los Angeles in February.

Testing of government water pipes in 26 villages in northeastern Botswana found contamination in every one, apparently caused by flooding during the heavy rainy season. Tests of the stools of sick babies also found dangerous waterborne pathogens such as cryptosporidium and an especially virulent strain of E. coli.

Investigators determined that it was mainly the babies who were not breast-fed who got sick from the dirty water. Among a group of infants at one hospital, those admitted for diarrhea were 50 times more likely to be fed formula or cow's milk than those admitted for other ailments. Cow's milk is more difficult for babies to digest and lacks the antibodies found in breast milk.

In one village the team visited, 30 percent of the formula-fed babies had died; none of those being breast-fed had.

The report also reflected the shifting scientific consensus on breast-feeding. In the years since Botswana began its formula-feeding program, studies have increasingly shown that the risk of HIV transmission comes mainly from the combination of breast milk and other foods, such as formula and solids, that damage the lining of a baby's intestines, inviting infection.

In one study in Botswana, breast-fed babies contracted HIV at a slightly higher rate than those fed with formula, but formula-fed babies were more likely to die. By the time the children in the study reached 18 months, similar numbers from both groups were alive and free of HIV.

Putting a mother on an effective combination of antiretroviral drugs, which are widely available in Botswana and some other African nations, also dramatically cuts the risk of transmission through breast-feeding -- likely to less than 2 percent, Coovadia said.

"You can protect kids, and you can give them the benefits of breast-feeding," he said.

UNICEF, after distributing 365,000 packs of formula in eight African countries -- and providing training and technical assistance to the program in Botswana -- began phasing out its infant-feeding programs in 2002.

UNICEF officials also participated in an October 2006 conference that issued new guidelines reemphasizing the importance of breast-feeding and warning that formula can be dangerous in all but the most developed, reliably sanitary settings.

"There are very few places where those conditions exist," Alan Court, director of programs for UNICEF, said in an interview from New York.