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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