Dear all:

I'd thought I'd share a bit of history in the formula wars.  The formula
companies used to dismiss the mortality rates from the use of formula that
were detected in developing countries on the basis of the quality of the
research.  Anyone has conducted research will know that there are a lot of
constraints and those constraints become even more difficult when operating
in developing countries.  They would then point to studies done in
developed countries, usually with sample sizes that were too small to
detect differences in mortality as proof that the research done in
developing countries was wrong. My dissertation advisor did a study
called "Mother's Milk and Sewage" with an enormous data base in Malaysia
that was much stronger than some of the previous work.  It definitely
showed a higher mortality rates among formula fed infants EVEN WHEN
ADEQUATE SANITATION, ADEQUATE WATER QUANTITY AND ADEQUATE WATER QUALITY
were available.  So, this blows the argument that if you fix water and
sanitation you'll fix the problem of formula feeding.

At the same time, it also showed that the difference in mortality between
formula fed and breastfed infants was greater in situations with poor
sanitation and poor access to water.  But the important part from a public
health perspective of this information and subsequent articles in the water
and sanitation literature, is that you need the breastfeeding AND you need
the sanitation and water.  The order of priority in terms of infant
mortality is as follows:

1) breastfeeding (above all the others)
2) latrines
3) an adequate quantity of water
4) an adequate quality of water

And the best of all is to have all four together.  I don't know how many
times I have read proposals that start with boiling water without doing
anything for breastfeeding, toilets or enough water.  Women are walking
long distances to get the water and THEN with the precious little water
they have some idiot who hasn't ever worked as hard as these women thinks
they should spend precious fuel boiling it on top of everything else.
Meanwhile, they have no toilets and walk miles to get the water.

Now that I'm done ranting.  I think that some of these articles are very
important in the discussions for HIV because there are a lot of programs
proposed to improve "sanitation" so that the formula companies can come in
an dump their products.

I actually read a proposal from someone who worked for a big HMO in the US,
and then transferred that model to an Eastern European country, and then
brought the model to Uganda.  The SOLE intervention that this person
proposed was to have HIV testing of these women so that they could get
formula.  He had NO CLUE that these women would be stoned to death.  He had
nothing in there to preserve breastfeeding among other women.  There were
no interventions to prevent transmission during delivery.  I was so pissed
off that I wrote a fourteen page critique despite the fact I was only
supposed to write a 2 page response.  I have a suspicion that this might be
the reason I was never asked to review these proposals again.

The argument that the WHO/UNICEF recommendations are only for "poor" kids
is even dumber than the argument that if you improve infant and child
mortality rates in developing countries they will just have more kids.  And
I hear these comments all the time.  At least now, I don't have to spend
time at fund-raising events where everyone is spending more money gorging
themselves at the event than ever gets to the programs themselves, and on
top of it having to carefully explain that "no, if kids survive, parents
actually don't have as many kids" and "no, actually, kids in this country
have exactly the same nutritional needs as kids in those countries - there
is nothing really biologically different about them" and "well, yes it may
be nicer to know that your $5000 gave 10,000 kids a vitamin A capsule and
would save the lives of about 667 of them ---- temporarily until they
needed another one, but actually working with the Ministry of Health to set
up their own program would mean that you wouldn't have to keep giving the
$5000 forever because they might be able to improve the amount of vitamin A-
rich foods available and you wouldnt' need the capsules."

Wow- the poor vs. rich kids really hit a nerve didn't it!

Sorry for the long rant.

Susan Burger (who previously worked in international development for about
20 years)

I learned patience the hard way, watching kids die of xerophthalmia in
refugee camps in 1986 in Niger and being told by all the food dispensing
organizations that they couldn't give vitamin A because the kids were
starving.  Meanwhile, the food was revving up their metabolisms enough that
the underlying vitamin A deficiency became worse and they died quicked.  It
took another 14 years, but they did eventually get it and xeropthalmia was
almost completely wiped out.  So keep up the good fight for breastfeeding.
Time and patience win out in the end.

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