I sent a response to the British Medical Journal (which they published!)
regarding their article about the Wall Street Journals blatant bias regarding
sending "free" formula to third world countries. A Dr. Ted Greiner,
PhD,Section for International Maternal and Child Health
Department of Women's and Children's Health, Uppsala University Academic
Hospital
Sweden and I have been corresponding on topic and he has given me
permission to post to Lactnet some of his thoughts on the matter.
Dear Denny,
I completely agree with you. Earlier today I had formulated my ideas on
this
issue for a friend and paste them in below.
Happy New Year!
Ted
1. EBF plus a cheap and seemingly relatively effective dose of
neverapine
leads to a very low if still not well known risk of MTCT.
Thsu probably it does
not make sense to suggest avoidance of breastfeeding except in
population
groups with IMRs under, say 25-30/1000 live births. In addition to
this
IMR/poverty criterion, no one should be advised to artificially feed who
is
living in an isolated area where access to continuous supplies of
infant
formula and good health care cannot be guaranteed.
UNAIDS et al protect themselves by saying they do not advise anything,
just
provide information for the mother to make an informed decision. But
Pam
Morrison points out that Africans have never before been given choices
by
their health care workers. So talking with them about artificial feeding
may
sound to them like advice--or at best confuses them. Also she points
out
that the African health care system cannot afford to give private
counselling about anything. So messages are often given to whole
groups,
greatly increasing the risk of a "spillover" effect among those of
unknown
or negative HIV status.
Some "establishment" HIV people are saying that in countries with high
HIV
prevalence maybe this does not matter so much, since many of them have
HIV
and probably should avoid breastfeeding. Some are even saying that BF
should
be avoided among anyone in a risk group. (Which could mean everything
from
being thin to having a philandering husband--so which women in Africa
are
then to be identified as not at risk?!)
2. Artificial feeding leads to huge risks of death from other things
but
these risks are completely undefined in Africa. From other countries,
data
suggest that the risks decrease exponentially with age. Thus the idea
has
been raised of EBF for the first months when that risk is high and then
when
solids start (assuming--which I suspect may be incorrect--that this
"mixed"
feeding then puts babies at increased risk of MTCT) stopping the
breastfeeding abruptly (unrealistic as far as we know) or heat
treating
expressed breast milk (we don't know how willing and able women would be
to
do this). I'd like to see more studies that look at this to see if,
after
several months of EBF and some hygiene training, HIV+ women may be able
to
continue breastfeeding with solids and rates of MTCT will probably
continue
to be low. One problem is that so many people have it in their head that
the
risk has to be zero before any approach is of interest.
3. For babies who already have HIV at birth, breastfeeding will extend
the
length of their lives, but so far we have no test to determine HIV status
at
birth. Thus the right to life of babies born infected is being
totally
ignored in preference to the assumed protection of some babies uninfected
at
birth. The latter group is thought to be about half the size of the
former.
4. The whole thing is a storm in a teacup in a way because voluntary
couselling and testing is not and will not be available among African
women
too poor to artificially feed safely, nor do many if not most of them
want
it. As you probably know, it is routine in some countries now for
pregnant
women. I have not seen much discussion about how "vountary" this is
in
reality.
Among pregnant HIV+ women in Africa, I would assume the less than 5%,
perhaps less than 1%, know it before the baby is born. Almost
inevitably
they find out only when the baby starts showing signs of having AIDS. In
any
case the numbers who can be counselled during pregnancy are very
small
compared to the numbers who are HIV+ and do not know it and whose
babies
would REALLY benefit from EBF, both to reduce risk of MTCT and for
other
reasons. UNAIDS and co. are totally uninterested in this way of looking
at
the issue. A WHO staff running a list serve was even unwilling to share
that
idea with the others on the list serve.
5. Yet routine breastfeeding promotion, including the BFHI, has greatly
slowed down in Africa due to misunderstanding of the issue and possible its
exploitation by the infant food industry. UNICEF has recently fielded a
study on this in four African countries, a report on which will hopefully
be
available soon.
6. Pilot tests can and do find HIV+ pregnant women in several African
countries and give them counselling and/or free formula. But what happens
to
those babies? The HIV research community presented a lot of lessons
learned
in Durban from the pilot tests regarding drugs, but nothing on the fate
of
the artificially fed babies. Shame on the West. We would NEVER accept
this
kind of experimentation with untested approaches on our babies with no
one
revealing after such a long time what the results are. Once the results
are
known (and I do not frankly trust the honesty of some of the establish HIV
researchers to
reveal it if they have even bothered to find out), then whole thing
will
probably have to stop for ethical reasons. But UNAIDS does not want it
to
stop, do they? Because this horribly expensive and culturally
inappropriate
approach can reduce HIV transmission. That babies die of diarrhea is
not
their headache.
If this were a rational non-racist world, this would be a much bigger
scandal than the blood bank scandal in France. UNAIDS people and
researchers
involved would be tried and sentenced to jail if juries found that they
had
intentionally suppressed information on this. Either they ARE doing so;
or
they are really dumb; or they simply don't care. It makes me ill. And it
just keeps going on.
--- Denny Rice, RN, IBCLC
--- Dallas, Texas
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