Lobby Tones Down Fed Breastfeeding Campaign

Marc Kaufman and Christopher Lee
Washington Post Science Writers
Friday, August 31, 2007; 12:00 PM

Washington Post science reporters Marc Kaufman and Christopher Lee were online Friday, Aug. 31, at Noon ET to discuss how the infant formula industry successfully lobbied the Health and Human Services Department to tone down ads warning mothers of the health risks faced by babies who aren't breast-fed.

Read the story: HHS Toned Down Breast-Feeding Ads ( Post, Aug. 31)

The transcript follows.


Christopher Lee: Welcome, everyone. Thanks for joining us for a chat about the fate of the Department of Health and Human Services' breast-feeding awareness campaign from a few years ago. It taps into broader concerns about the mixing of politics and public health in Washington, a subject that is under investigation by at least two congressional committees. While in some respects the HHS campaign broke new ground -- it was rare for the federal government to sponsor such an effort at all -- there is ample evidence that the infant formula industry had considerable influence over the content of the ads that ran. People who defend the changes argue that some of the science behind the more in-your-face ads was questionable. Breast-feeding advocates say that's not the case, and the real motivation for changing the ads was to protect a politically powerful industry. We're interested in hearing what you think. Let's begin.


Toronto: Firstly, I want to thank the authors for their excellent article. It is infuriating that formula makers would be equally unethical as tobacco companies, holding the bottom line above the best interests of the people -- and in this case, the welfare of newborn infants. Perhaps we need warning labels on all formula just as on cigarette packs -- "Warning: Feeding this formula to your infant instead of breastfeeding is associated with increased rates of asthma, diabetes, and weaker immune system."

Marc Kaufman: I understand your concern, but have to disagree that formula should be in the same category as tobacco. There are women who have real and difficult problems with breast-feeding, and enriched formula undeniably helps them and their babies. There also are women who chose formula for their own personal reasons, and I don't quarrel with those decisions. We found this story to be interesting and important because some HHS officials were working with real creativity to highlight the risks of not breast-feeding, and their efforts were often stymied. It seems to me that the breast-feeding campaign was trying to educate women -- to give them information that would allow them to make informed choices -- and that seems important to me.

All this said, the issue of formula advertising is a tricky one. It is widespread here, but banned or regulated in many other nations.


Connecticut: How about we focus on the underlying causes of low numbers of breast-feeding women -- things like no paid maternity leave, difficulty finding affordable quality child care close to work, and the limited nature of the current Family and Medical Leave Act law?

Marc Kaufman: Good point, and from what I understand, this is the next emphasis of the breast-feeding group within the Office on Women's Health. American workplace policies are not nearly as generous to young mothers as in most European countries, and that has a definite effect on the breast-feeding rate. That said, the group with the lowest breast-feeding rate in the U.S. is unemployed mothers, according to the Ross Mother's Survey. I'm sure this involves the availability of formula through the federal Women, Infant and Children program, but it also raises interesting questions about the social and advertising messages that mothers receive.


Washington: Throughout the nuances and developments in this story I really have to ask -- what business does the government have telling a woman what she should do with her breasts? I support public health efforts, but there's a difference between educating people and telling them what to do. Thank you.

Christopher Lee: Hi, interesting question. One of the fascinating things we learned in reporting this story was that a wide range of people and groups had concerns with the campaign, including the National Organization for Women. We've been told that some of those concerns were resolved, but clearly some people -- women in particular -- were turned off by the notion of a government-funded effort that strongly recommended that parents feed their children in a specific way. As we've noted, some women have difficulty breast-feeding, and there were concerns about making them feel "guilty" for not doing so. And breast-feeding is a special challenge for working women, given that many workplaces -- not to mention full-time job responsibilities -- do not make it easy for women to breast-feed. On the other hand, there is clear evidence that breast-feeding is best for the health of the baby. Even the formula companies acknowledge that. Shouldn't the government make people aware of that?


Washington: Are the Department of Health and Human Services officials mentioned in your story still working for the government?

Christopher Lee: Some are gone, some are still there. Kevin Keane, once a top HHS spokesman, is now an executive with the American Beverage Association. Cristina Beato, the former acting assistant secretary of health, is now a top official at the Pan American Health Organization. And Gina Ciagne, a former public affairs official at HHS, now works for a breastfeeding lotion company. But Christina Pearson remains a top public affairs person at HHS, Wanda Jones is still the head of the Office on Women's Health, and Suzanne Haynes still works in the Office on Women's Health too.


Bethesda, Md.: In reading your article closely it seems that there was a lot of controversy and that maybe the Office of Women's Health was pushing bad science. Were any objective authorities or scientists brought in to evaluate?

Marc Kaufman: This is an important and complex question. When the HHS breast-feeding team was putting together its initial, hard-hitting campaign, it had a team of scientists/doctors from the Centers for Disease Control and Prevention, National Institutes of Health, and some breast-feeding promotion groups to review the science and give advice. One of those people said that all group members had to agree that science supported the campaign before a particular ad or language in an ad was used.

Some of the decisions made by this group were later overturned by more senior NIH, CDC and HHS officials -- who said that the science did not support the assertion that breast-feeding protects against diseases such as childhood leukemia and diabetes, as well as asthma and obesity. I'm not a scientist and so have a layman's perspective rather than a professional one, and it is this: The initial campaign probably pushed the envelope in some areas, but also uncovered important studies that had been ignored before (especially involving childhood leukemia).

The Office on Women's Health asked an evidence-based research arm of HHS to look into the science and they finished their report this spring. The conclusions are not simple, but they did support the general finding of increased disease risk for infants who are not breast-fed (and for mothers who do not breast-feed). The quality of the studies was mixed, however, and the reviewers emphasized that an association between breast-feeding and lower disease rates does not mean there is necessarily a cause-and-effect.

In short, the science is evolving and quite interesting -- quite settled for some diseases but less so for others.


Dayton, Ohio: A February 2006 GAO report, " Some Strategies Used to Market Infant Formula May Discourage Breastfeeding" (.pdf file) is pertinent. This argument isn't about mothers' choices -- it's about marketing a product that imperfectly competes with a woman's biological processes. One conclusion of the GAO report: "While the health community and formula companies agree that breastfeeding is best, advertising of formula is widespread and increasing. Studies have shown that some infant formula marketing, particularly hospital discharge packs, may discourage breastfeeding."

Marc Kaufman: Yes, the GAO found that infant formula advertising increased significantly during the years that the HHS breast-feeding campaign was in progress. I suspect that played a role in the fact that breast-feeding rates remain static, and according to the Ross Mothers Survey actually are falling.


Los Angeles: Thank you for the in-depth, accurate report. The formula industry is powerful and the health and well-being of families suffer. What can be done to support Dr. Suzanne Haynes in her efforts to communicate the Agency for Healthcare Research and Quality report information? Her office commissioned this important research; the results are startling. Very few people even know about it.

Christopher Lee: One nice thing about the Internet is it really opens up information to everyone. Those interested in the Agency for Healthcare Research and Quality's recent report on breast-feeding should be able to find it here.


Interesting...: Isn't the party running our country the "family values" party? Don't they advocate stay-at-home moms and such? So, how is it, that breast-feeding, something that is natural and "the way God intended" is not something they would support? Riddle me that, Batman.

Marc Kaufman: A doubtlessly partisan but nonetheless interesting comment. It seems to speak to some of the divisions within the Republican Party -- especially between social conservatives (many of whom actively support breast-feeding) and the economic conservatives (who support an unfettered market and generally support the efforts of companies to sell their products). In this case, the industry lobbied hard and, in some ways, prevailed.


Houghton, Mich.: It seems to me that formula companies have dominated the discussion about infant feeding for far too long. I've had two children, each in a different hospital, and I was offered formula coupons, samples and swag (free diaper bags) both times. The diaper bags from Enfamil (which were stuffed with formula samples) were supposedly promoting breast-feeding because they came with ice packs. I don't understand it either.

Why are hospitals obligated to pass out formula if mothers don't ask for it? Why do formula companies get upset if hospitals don't give out samples as a matter of course? Because they want to capitalize on how difficult breast-feeding is at first (and it can be very hard and quite painful) to convince mothers that formula is just as good. It's not! It's sufficient (I, and most in my generation were formula-fed, and we really did turn out fine) but it's not as good. Breast-feeding benefits mother and baby, and I see no reason why that message should be sugar-coated to appease the pharmaceutical lobby.

Christopher Lee: Some areas are beginning to curtail the influence of the formula industry in hospitals. This month, for instance, the New York City public hospital system said it no longer would include free baby-formula samples in the gift bags it provides to new mothers. Britain and many other countries already ban giving out formula to mothers in hospital, and the World Health Organization has called for an end to the practice.


Atlanta: The question of breast-feeding vs. formula has been around since the advent of formula and will be around as long as there are mommies and babies. It's important to note, whether you're a supporter of breast-feeding or a staunch advocate of the right of formula companies to sell their product, that millions of babies have been born, raised, grown, lived full and rewarding lives and then died a natural death having been fed formula. Personally I can't understand why anyone would go through the hassle of formula feeding when they have a free renewable source of food for their baby, but it's a free country. As for the lobbyists, well, unless it's proven they did something illegal and not just distasteful, again, it's a free country.

Christopher Lee: One perspective. Thanks for writing in.


Fairfax, Va.: Thanks for the very interesting story. It doesn't surprise me that the formula industry tried to exert pressure on HHS. It is surprising to me that the agency would fold so easily. I think the industry was able to make their case because there are a lot of concerns about offending women. I've breast-fed all three of my children for 12 months to 20 months. Whenever that comes up in conversation with non-breast-feeding girlfriends, the conversation stops cold. It's as if even mentioning my breast-feeding offends them. Why do you think we have to handle this issue with such kid gloves?

Marc Kaufman: Having written a number of stories about breast-feeding over the years, I know what you mean about the subject sometimes being a conversation stopper. I have to assume the reason is that mothers have complex reasons for breast-feeding or not, and they all want to believe they are doing well by their infants. Mothers have to juggle so many pressures these days that I'm certainly not here to judge any for their decisions. (Hey, I was bottle-fed back in the '50s, when my mother and others were told that making the nursery into a "laboratory" was best for their babies, and I seem to be okay. )

What I find to be questionable is the advertising by formula companies that ever-so-subtly suggests that breast-feeding may turn out to be more difficult than mothers expect. Months of breast-feeding do require a prolonged commitment, and advocates complain that the formula companies (which are actually pharmaceutical companies) work to undermine that.


Bethesda, Md.: As you say: "The quality of the studies was mixed, however, and the reviewers emphasized that an association between breastfeeding and lower disease rates does not mean there is necessarily a cause-and-effect." So how could you, and HHS, justify a campaign that scares and misleads women and families based upon "mixed" studies?

Marc Kaufman: Here's the dilemma: Soft-focus breast-feeding campaigns generally don't work. Many have been tried, and the effects are limited. The initial hard-edge HHS campaign went out to focus groups and came back with a clear signal that it would change women's breast-feeding behavior -- making more of them give up formula.

That initial campaign included not only some arresting images, but also statistics saying that not breast-feeding decreased the likelihood of ear infections, for instance, by a very large percent. The same for childhood leukemia, diabetes and other diseases and conditions. Was the science as strong for those? Probably not -- but rather than throwing out the hard-hitting approach, why not modify or tweak it so any concerns about the science would be addressed. And as I mentioned before, a team of science advisers did support the initial campaign, and the higher-ups got involved only after the formula companies complained and began their lobbying.

Also, regarding the science, we found it interesting that former surgeon general David Satcher told us that different administrations look at, and interpret, science differently depending on their political points of view.


Princeton, N.J.: It seems to me that the main thing the original ads did was to try to change the conversation: To treat breast-feeding as the norm, and to suggest that formula increases certain risks, when the pro-breast-feeding awareness campaigns usually treat formula as the default and say that breast-feeding "decreases" certain risks. Other advertising and public service announcements try to "scare" people into doing the right thing for their health, and I don't see what made this one different.

Christopher Lee: There are two schools of thought about this. One argues, as you do, that one way to change behavior is to dramatically present the risks associated with the behavior. We see it with images of crumpled cars in anti-drunk driving campaigns and scarred lungs in anti-smoking campaigns. In this case, the goal, using some pretty stark ads initially, was to raise awareness not merely of the health benefits of breast-feeding but of the health risks of not breast-feeding.

The other school argues that drunk driving is clearly unacceptable behavior and smoking is dangerous and has well-known health consequences, and that encouraging people not to do either is a no-brainer. Breast-feeding vs. formula feeding is a much more complicated question, they say, and a "scare" campaign may do more harm than good by demonizing parents who either cannot breast-feed or choose not to.


Washington: Do you know if changes to make Women, Infants and Children Program more breast-feeding-friendly were discussed as part of this campaign? I don't deny that low-income moms can have good reasons to choose/need formula, just like their wealthier counterparts, but I know that in some states WIC pays for formula but does not provide extra food aid to breast-feeding moms. Given how much formula WIC buys, I suspect that the industry lobbyists are heavily involved in WIC policy-making as well.

Marc Kaufman: I do not think that this campaign focused on WIC in particular. I know that WIC came under pressure some years ago to provide more breast-feeding information and counseling, and I believe it does in some states. But the bottom line is that about half of the formula used in the United States is provided through the WIC program.


Arlington, Va.: I am currently nursing my 5-month-old, but had I seen the adverts I think I would have been more likely to be put off from nursing than otherwise. I already feel that as a new mother too many people have felt a need to give me input on the breast-feeding issue. I must have been told this at least 50 times. Even complete strangers, for some reason, feel a need to tell you that it is better for the baby. And I am nursing, and am at least spared lectures from the same strangers on this issue. I think that any additional guilt would have been counterproductive. A better advert would have been "do you know how many miles you'd have to run to use up the same number of calories as a day of breast feeding?" That being said, obviously it is bad for our democracy when funding can alter the message given by federal authorities.

Christopher Lee: Interesting perspective, thanks for writing in. Some of the advocates of the campaign argue that the formula industry engages in huge marketing and advertising campaigns, so something like the breast-feeding awareness campaign was a relatively small effort to balance things out. Of course, the impact they were hoping for was to encourage women to breast-feed, and you say it would have had the opposite effect on you.


Washington: For the woman who said don't tell me what to do with my breasts, I would like to respond by saying: Public health officials have science based recommendations about many body parts -- mammograms of our breasts, pap smears, prostate exams, colonoscopies, etc. They are not telling you what to do, they are advising you on how to keep yourself and your baby healthy. This is a positive message about your breasts -- if you breast-feed, you are much less likely to get breast cancer and ovarian cancer. It is always your choice, but an informed choice is the best choice.

Christopher Lee: Another perspective -- thanks for writing in.


Olney, Md.: Where can we go to find the AHRQ report, and can you give a summary of some of the risks noted in that report? Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries

Marc Kaufman: In short, the AHRQ report found that breast-feeding was associated with decreases in some short-term diseases (upper-respiratory infections, gastrointestinal problems) as well as some long-term conditions, such as diabetes and asthma. But because the studies it analyzed were not randomized, placebo-controlled studies -- the kind needed to get a drug approved by the FDA -- the authors said they could not say the association definitely was a cause-and-effect relationship. Those kind of "gold standard" tests probably never will be done, however, because it would be considered unethical to tell one group of women not to breast-feed.


Tysons Corner, Va.: To build on Satcher's comments, isn't it true that even scientists sometimes disagree on the science? Not just about breast-feeding, but just about everything?

Marc Kaufman: Absolutely so. And in this case, there were indeed very different views of the science.


Washington: Thanks for your great coverage. This article highlights an important problem -- the influence of industry on public health campaigns. Companies that make money from health care products shouldn't be able to water-down public heath messages. They're protecting corporate profits at the expense of people's health. Hopefully this article will spur investigations that will lead to change for the better.

Marc Kaufman: Several House and Senate committees have said they will take up this general issue, which was raised quite dramatically last months by former surgeon general Richard Carmona. He testified that for political reasons, he often was kept from saying and doing what he felt was best for public health.


In defense: I think it's horrifying that a trade group with a vested interest was able to affect a government decision. Oh, wait -- I forgot, it happens all the time. Actually, I do think the formula people were out of line -- but I think the original ads were also out of line, so perhaps it's as well that someone actually did say so. My younger brother, who is now 17, has Type 1 diabetes. He was diagnosed two years ago. Anyone with a 17-year-old probably can imagine how difficult it is to get him to comply with his treatment plan and how much my parents worry about his health now and in the future.

There are nine kids in my family. With the exception of my diabetic brother, we were all breast-fed to about a year old. But when my brother was less than two months old, my mother was hospitalized for more than a week for a gangrenous ovary. She was running a fever over 103 for that entire time. She spent much of it unconscious. By the time she was treated, awake, and lucid, her milk had stopped. My brother drank formula. She carries a huge burden of guilt about my brother's diabetes -- I have found her crying about it. She thinks it's because he wasn't breast-fed.

Look, parents need to know how important breast-feeding is. I think ads that make the point with ice cream cones and flowers are perfectly appropriate. I think doctors ought to hit harder to emphasize it, particularly with the new moms who seem unaware of the possible health problems associated with not breastfeeding. But there are a lot of women whose decisions were made (or whose decisions were made for them by circumstances) years ago, and there are more of them than there are of nursing mothers. Does the government really need to imply that they've poisoned their kids with their parenting decisions? Frankly, I think we can live without that. Sometimes the choices are between bad and worse, and they are hard enough without breast-feeding ads that look like they're talking about prenatal crack cocaine use.

Marc Kaufman: Thanks for your posting. One aspect of the story that I frequently find myself returning to is this: If some officials thought the initial hard-hitting ads went too far, then why not tweak them rather than killing them? We know that edgy, strongly-framed ads work and soft-focus ones generally do not.


Washington: Mr. Kaufman, it's true that some women have problems with breast -eeding. Then why did the infant formula lobby help ban Domperidone, a prescription drug which aids in lactation? This drug is successfully used in Canada and other foreign countries to help mothers produce milk.

Marc Kaufman: Afraid I don't know about this issue, but it certainly sounds interesting.


Germantown, Md.: What about promoting the full range of infant feeding options? I recently returned to work after the birth of my daughter and I continue to breast-feed by way of using a breast pump at work. I knew that option was available to me and I am fortunate to have the resources to purchase the necessary equipment, however I did not see or receive any encouragement to follow that path. I'd like to see a public health campaign that promotes alternatives and gives information about how to balance breast-feeding, pumping, and formula feeding.

Christopher Lee: We've heard from several people on all sides of this issue that there is a real need for a campaign that focuses not just on the health benefits of breast-feeding but also on the many logistical obstacles mothers face, especially working mothers, and what they can do to cope with them.


Alexandria, Va.: Please deal with this issue: The pro-breast-feeding cult in this country has frightened doctors, parents, and apparently, the media. My child, born seven months ago, needed plenty of supplemental formula -- in addition to breast-feeding -- to fight off jaundice. The information we received from the doctors and nurses was inadequate at best. Please consider scrutinizing thisklatchl clatch of operatives who are just as "political," if not more so, than the formula makers. Either way, parents are not getting all the information they need, as this battle rages.

Marc Kaufman: Clearly, some mothers are put off by messages urging them to breast-feed, and just as clearly nobody should be made to breast-feed if they don't want to. What the breast-feeding advocates say is that the formula industry spends millions on subtle advertising to convince women they may or will need formula at some point. They see their efforts, and the goal of the HHS campaign, as to briefly compete with the formula industry in terms of getting their message out.


Washington: I imagine a part of the low rates of breastfeeding has to do with the stigma here of women breastfeeding in public. Perhaps an ad campaign celebrating breast-feeding with depictions of women doing it in public places would be an effective way of encourage a more tolerant (and even a positive) culture of breast-feeding. The reduction of stigma and growth of positive associations with breast-feeding would made it easier for the other messages about health benefits to make it though these mazes of conflicting interests.

Marc Kaufman: Good point. While discreet breast-feeding in public is welcomed in many areas, it remains virtually taboo in others. That strikes me as very unfortunate.


Washington: Thank you for publicizing this outrageous politicization of public health. While you mentioned that the WHO recommends exclusive breast-feeding for the first six months of life, it is important to note that WHO recommends continued breast-feeding through the first two years of life, and beyond. The precise guidelines for complementary feeding (solids and breast milk) can be found in this report (.pdf file).

Marc Kaufman: Thanks.


Richmond, Va.: I believe that the formula industry has every right to advertise their product honestly. However, I also believe that HHS should be able to advertise their "product" just as aggressively. Who in the formula industry would allow an outsider -- and competitor even -- to come in and dictate their advertising campaign? Short of proving dishonesty in advertising, HHS should have gone forward with their campaign.

Marc Kaufman: Interesting point.


Washington: This isn't specifically about the campaign, but about the breast-feeding stats -- I suspect that much of the correlation between breast-feeding and healthier kids is also tied to demographics like income level. Have there been studies of breast milk vs. formula within the same communities (i.e. middle-class, lower-class, etc.)? To me, that would be far more telling.

Marc Kaufman: I don't know if studies exactly like the ones you mention have been done, but I do believe it is beyond scientific doubt that breast-feeding increases health outcomes. That has been confirmed by the World Health Organization, relevant American health organizations and by the formula companies themselves.


Christopher Lee: Thanks for a fascinating discussion. You all had much more interesting things to say than we did. Time is about up, so we're going to shut the chat down now. Thanks to everyone for participating. We'll keep following these issues, which are not going away any time soon.


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