Cindy raises an excellent question about the photo of the Pakistani twins --
why is formula so deadly in this context, when we know lots of children
survive being raised on formula in the U.S.  There are many reasons that
contribute to the deadlieness of non-breastfeeding in cultural contexts
outside the U.S., including:

1.      Indeed it may not have been proprietary formula in that bottle.  It
may have been cows' milk, goats' milk, coffee whitener, coconut milk, or any
one of a number of substances that look white.

2.      The water used to mix it may have been contaminated with human or
non-human animal sewage, decaying food, bacteria, viruses, parasites, dirt,
pesticides and herbicides from agricultural runoff, etc.  Most people in the
world still do not have running water in their homes and even those who do
have running water may not have uncontaminated water.  Some people get their
water from rivers, streams, or ponds, where other people bathe and wash
clothes and dishes, and where non-human animals come to drink and then
defecate and urinate in the water, and where non-human animals and people's
bodies sometimes end up after they die.  Some people get their water from
wells that are near the pit latrine the family uses for a toilet.  Or the
water source may be clean, but the buckets used to carry the water and the
jars used to store the water may be contaminated.  Often there isn't enough
firewood or money to purchase firewood to afford to boil the water, and
people don't necessarily understand the importance of clean water.

3.      The bottle and nipples themselves are most likely not sterile.  They
may be rinsed out in water (see #2), but are not necessarily washed in hot
water with soap, and certainly are not sterilized by boiling in clean water.

4.      The bottle may be mixed up in the morning and then sit around in the
heat (up to 140 degrees Fahrenheit in Mali, where I worked, during the hot
season) for several hours before the child finishes all of it.  By the time
several hours has passed, the child is getting basically a bottle full of
bacteria.

5.      In Pakistan, as in much of the world outside modern industrial
countries, immunizations are not available, so children suffer from a
variety of diseases, including many that are not helped particularly by
breastfeeding -- such as malaria and measles.  High disease loads
contributes to the energy needs of the child, meaning that they need more
food, not less, than their industrial-country counterparts.

6.      In Pakistan, as in much of the world outside modern industrial
countries, antibiotics are not available, so simple bacterial infections,
such as those causing ear infections and pneumonia, are deadly.  Even a case
of the chicken pox provides multiple entry sites for bacteria to infect the
child's skin, leading to death.

7.      Intestinal parasites are much more prevalent, and contribute to
malabsorption of nutrients in the gut, bleeding from the gut, etc., again
increasing the child's nutrient need.

It is practically impossible for a woman living in a Third World country to
keep a child alive that has not been breastfed.  Chances are good, to, that
the little girl in the photograph was not taken to the doctor, and did not
have any of the family's financial resources "wasted" on medicines or
proprietary formula.  Sometimes if a mother has a son and then has a
daughter, the son will be allowed to continue nursing, while the daughter
will be put on the bottle (or smothered, or burned in a fire, or abandoned)
so that the son can continue to have access to the breast milk.  There are
also cases where the male children get any meat or fresh fruit or any sort
of special foods available to the family, while the girls are given rice or
millet only.

Katherine A. Dettwyler, Ph.D.
Associate Professor of Anthropology and Nutrition
Texas A&M University