Larry Gartner MD gave me permission to share his letter with you all:

August 29, 2002

Dr. Joe Sanders, Executive Director
Dr. Louis Cooper, President
American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098

Dear Joe and Lou,

    I am writing this letter as Chair of the Executive Committee of the
Section on Breastfeeding.  This letter has benefited from significant input
from a number of members of the Executive Committee and Committee Chairs of
the Section.  Since the present version of the letter has not been formally
reviewed and approved by the Section leadership group, it should not be
construed as representing all of their views.  I have copied the letter to
the leadership team of the Section and to a number of other concerned
individuals both within and outside the American Academy of Pediatrics.  They
may wish to write to you in support of this letter or to provide additional
or different views of their own.  In the course of collecting information
about the matter discussed below I have also talked with Ms. Rebecca Johnson,
the executive at Ross Products Division of Abbott Laboratories responsible
for professional relations.  Her comments and agreements are included in this
letter.

The Executive Committee members and Committee Chairs of the Section on
Breastfeeding of the American Academy of Pediatrics have deep concern with
the manner in which the marketing of the recently published book New Mother's
Guide to Breastfeeding was handled by the Academy leadership.  We are
specifically concerned that sale of copies of the book to Ross Laboratories
included permission for them to have a modified cover which contained a bold
imprint of  "Ross Pediatrics" and their product logo.  This imprint gives the
reader of the book the distinct impression that the book was sponsored by an
infant formula manufacturer and may contain material which is favorable to
the commercial interests of the company.  More specifically, the potential
reader may have the unfortunate impression that the book will not contain the
full scientific and clinical facts about breastfeeding and lactation that a
book from the AAP should contain.  In short, it devalues an excellent and
important book.  We who were involved in the writing and editing of the book
know that Ross Laboratories was never involved in any way with the
preparation of the book.  Dr. Joan Meek, the Editor, and the members of the
Breastfeeding Section and others in the AAP who reviewed and edited the
chapters are responsible for all of the content.

The book is for sale to anyone who wishes to buy it either through the AAP,
from Bantam Books, or from other book distributors or stores.
If we had been consulted we would have advised that the cover not be altered
and that Ross Products attach a cover slip or folder with the book that
indicated that it is a "gift from Ross" and that "the book and all of its
contents are a product of the American Academy of Pediatrics."

We are concerned both with the decision that was made and with the
administrative process that allowed this decision to be made without any
consultation with the Editor of the book, Dr. Meek, or with members of the
Executive Committee or staff of the Section on Breastfeeding.

    It is our understanding that Ross Products Division purchased 330,000
copies of the book.  Becky Johnson has informed me that Ross has not yet
determined how these copies will be distributed, whether only via health
professionals (e.g. physicians, lactation consultants, nurses, dieticians)
for them to distribute to mothers or by including the book in the discharge
gift pack that is made available to hospitals.  With the present format of
the modified cover, we would hope that no further copies be distributed to
anyone until the problem is resolved.

    Following my discussion of the problem with Becky Johnson, she had
discussions with the marketing people at Ross.  Ross has agreed to print a
cover label to obliterate the current printed image and replace it with a
statement that the book is a "Gift from Ross Pediatrics" without the logo.
They have also agreed to attach a disclaimer that would clearly state that
the book and its contents are entirely a product of the American Academy of
Pediatrics.  The wording of the disclaimer would be discussed by Ross with
AAP leadership.  This agreement solves the immediate problem of the existing
330,000 copies of the book owned by Ross Products Division.  We strongly urge
AAP executive leadership to counsel Ross Products that even after re-labeling
they not be distributed in the discharge gift packs since the 1997 AAP policy
statement on Breastfeeding and the Use of Human Milk cites "commercial
promotion of infant formula through distribution of hospital discharge packs"
as an "obstacle to the initiation and continuation of breastfeeding."
Associating a publication of the American Academy of Pediatrics with
discharge packs is clearly unacceptable and a violation of our own published
principles.  In addition, distribution of the book in the gift pack in
association with distribution of formula samples and formula marketing
materials may be a violation of the WHO International Code of Marketing of
Breastmilk Substitutes.  The AAP has endorsed "the stated aim" of the WHO
Marketing Code and should recognize the importance of ethical marketing of
infant formula.

    This book was a labor of love for Dr. Joan Meek, who did a marvelous job
of editing a superb, accurate and important parent education book.  The
members of the Section on Breastfeeding Executive Committee and Committee
Chairs carefully reviewed and edited chapters of the book because we felt
that it was a valuable and important contribution to public education in the
field.  We had no reason to think that this book would be distributed in any
manner other than the traditional sale of the book through the AAP bookstore,
at meetings, and through commercial and non-commercial book vendors.  Linkage
of the book with a formula manufacturer was something we never considered
could happen. The unfortunate decision has brought undeserved public
condemnation to Dr. Meek and to the leadership of the Section on
Breastfeeding.
The avenues for marketing this AAP publication have been diminished because
it will be seen to have been tainted by association with a formula
manufacturer.  Even though the text of the book is unaltered and contains
every point we wanted to make, some potential purchasers will shy away from
it or think that it does not contain valid information.  Appropriate
consultation with the editor and the Section Executive Committee would have
resulted in creative approaches to achieve wide distribution and sales
without compromising the image of the Academy and the value of the book.

    Of greater concern to us is the harm that may come to the image of the
American Academy of Pediatrics as a strong advocate of breastfeeding.  We in
the Section have always taken the position that the AAP was one of the most
effective supporters of breastfeeding.  We still believe that is the case,
but many of our members and a large number of non-members will see this as
evidence that the Academy has sold itself to the highest bidder at the
expense of our breastfeeding effort.

    What is most troubling to those of us in the Section on Breastfeeding and
to those who worked so diligently on this book is that there was never any
attempt or consideration of contacting Dr. Meek or the Section leadership to
ask how we felt about this "opportunity" or how we thought it might "sell"
out on the street.  We knew nothing of this arrangement with Ross
Laboratories until someone thrust a copy of the Ross version of the book in
our face and accused us of selling out.  Others of us found out when we read
the first of many hundreds of letters sent on e-mail protesting this action
by the Academy. You have seen and read these letters.  Why were we not
consulted on this matter?  It is, after all, a book that was prepared by Dr.
Meek and members of the section.  Did it not occur to anyone in marketing or
the AAP Executive Group that it might be good marketing procedure to
determine how the consumers and members of the Academy might view this
decision?    A simple cover slip that stated that the book was a gift from
Ross Laboratories might have worked and would not have implied that the book
was a Ross product.

We have been told that there is an Academy and general "industry" guideline
that allows a sponsoring company to place their logo and the name of one
product on the cover of a book.  While there may be some circumstances in
which this is acceptable, this is not one of them.  This is a highly
sensitive area.  An arms length relationship with formula manufacturers must
always be observed.  It was for that reason that the WHO code was created and
has been so widely accepted world-wide.  Perhaps this incident should be
taken in a positive light as an indication that the Academy needs to
re-examine its policies and operational procedures regarding infant formula
marketing and its relationship to the manufacturers of infant formula. It is
our understanding that this is, in fact, not the first time that there has
been outspoken protest by AAP members about the commercialization of
educational products by the AAP.  Apparently other AAP Committees have voiced
their objection to the placement of commercial names and products on their
books.

We are in the process of  writing two new educational products on
breastfeeding: The Breastfeeding Handbook for Physicians (edited by Dr.
Richard Schanler with associate editors and writers from AAP and ACOG) and
the Speakers Kit on Breastfeeding Promotion and Management (written by Dr.
Joan Meek with editing by several members of the Breastfeeding Section
leadership).  These two editors and all of us now have considerable concern
and fear that these products may also be marketed in the same way,
potentially corrupting their value and usefulness.  We need to have absolute
assurance that these products will be marketed in more appropriate ways and
only after full consultation with the authors and editors, as well as with
Section leadership.

It has been brought to our attention that members of the staff associated
with the Section on Breastfeeding have counseled staff from the AAP
Development Office to avoid potential conflicts in seeking financial backing
for projects because of the WHO marketing code and the sensitivities of
section members and others in the Academy.  Unfortunately, the AAP Marketing
Department was not similarly advised.

    We request that the American Academy of Pediatrics executive leadership
and Board of Directors undertake the following efforts 1) to repair the
damage that has been done by this inappropriate marketing decision and 2) to
avoid future unfortunate decisions:

1.  Accept and support the offer by Ross Products Division to modify the
books they currently own and assure that an appropriate disclaimer
accompanies the distribution of all of these books now in their possession.
2.  Support the recommendation that the books currently in the possession of
Ross not be placed in the discharge gift packs and be distributed only
through health professionals.
3.  Vigorously market the New Mother's Guide to Breastfeeding through the AAP
and Bantam Books and other traditional book vendors, both commercial and
not-for-profit (e.g. La Leche League International)
4.  Develop a strong policy to assure that commercial names, products and
logos are never placed on any educational and promotional materials of the
American Academy of Pediatrics.
5.  We urge that the AAP executive leadership and the Board of Directors
review AAP policies on marketing and relationships with commercial
enterprises, especially formula and baby food manufacturers.
6.  We suggest that the Bioethics Committee of the AAP or a specially
appointed committee develop recommendations to address consumer advertising.

7.  Institute procedures which would insure that every section, committee, or
task force involved in a project be fully consulted before any decisions are
made on any product or recommendation, especially involving marketing,
emanating from that group.
8.  Offer an apology to Dr. Meek.

    This letter is being copied to our Section membership and to others who
have expressed their concern over this matter.  I ask that copies of this
letter also be distributed to the members of the AAP Board of Directors, to
the AAP Executive Committee and to other AAP leadership.

            Sincerely,



Lawrence M. Gartner, M.D., FAAP
Chair of the Executive Committee
Section on Breastfeeding
American Academy of Pediatrics

Cc: Dr. Joan Meek
       Section on Breastfeeding Leadership Group


Nancy E. Wight MD, FAAP, IBCLC
Attending Neonatologist,
Children's Hospital and Sharp Mary Birch Hospital for Women
Medical Director, Sharp HealthCare Lactation Service
San Diego, CA, USA

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