News article

Ethical Conflicts Delay the National Breastfeeding Awareness Campaign

January 3, 2004

On December 4, 2003 The New York Times ran an article by Melody Petersen, “Breastfeeding Ads Delayed by a Dispute Over Content.” The article brought to light a serious ethical conflict of interest between the formula industry and several entities which promote public health, including the American Academy of Pediatrics and the Department of Health and Human Services. National Public Radio reported on December 26 that Christina Pearson, of the Office on Women’s Health from DHHS, says that the ads are now being revised, and won’t comment on when they will be released. The Massachusetts Breastfeeding Coalition takes a strong stand against the pervasive influence of the formula industry over this public health campaign.

The promotion of breastfeeding on a nationwide scale has been called for since the 1984 Surgeon General’s Workshop on Breastfeeding and Human Lactation. The Office on Women’s Health, an agency within the federal Department of Health and Human Services answered that call with a $40 million ad campaign designed to help mothers choose breastfeeding who would not normally have done so. The ads were carefully crafted through the expertise of the Ad Council, a nonprofit expert on risk-based social marketing campaigns designed to change behavior. Input for the ads was gathered from the USDA’s Breastfeeding Promotion Consortium, the US Breastfeeding Committee and 36 focus groups representing the general public.

The campaign reframes the issue of infant feeding in terms of the risks associated with not breastfeeding, as opposed to the more traditional messages which only tout the “benefits” of breastfeeding. The Ad Council reached its conclusion to frame the ads this way after its research found that many women think breastfeeding is like supplementing a “standard diet” with vitamins. The traditional “benefits of breastfeeding” messages thus ignore the copious scientific evidence showing a greater risk for a wide variety of illnesses in children who were not breastfed. Many of these illness are chronic or have life-long health effects, such as type 1 diabetes and inflammatory bowel disease.

In the early fall of 2003, the infant formula manufacturers became aware of the nature of the campaign and began their own campaign to neutralize the impact that these ads would have on the sale of their products. The Ad Council had sent out a print ad about diabetes and breastfeeding to thousands of public service announcement directors in early November, and had posted it on its website, yet clearly the formula companies had access to all the ads even before this, probably in October. Companies and their crisis management firms contacted the Secretary of Health and Human Services, Tommy Thompson, the senate majority leader Bill Frist, the chair of the Health Committee Senator Lamar Alexander, and the heads of numerous federal agencies such as the FDA, CDC, and NIH to complain that the ads were negative and would hurt their business.

Representatives from the formula industry also attended the national convention of the American Academy of Pediatrics in New Orleans, held October 31-November 4. They met with several leaders of the AAP, including its newly installed president, Dr. Carden Johnston. Dr. Johnston openly admitted that the formula representatives showed him many of the ads at the convention — itself of ethical concern because the AAP leaders had not previously seen the ads, and in fact, Dr. Johnston was admittedly unaware of the campaign. In other words, somehow, the formula industry had access to the DHHS ads before the leadership of the American Academy of Pediatrics. At the convention, the formula industry representatives brought their objections to the “negative” tone of the ads to the attention of the AAP leadership. Of note, the formula industry gives heavily to the AAP, and the New York Times estimates that one formula maker, Ross, gave over $500,000 to the AAP’s 2001 budget. The pharmaceutical industry, which owns several of the formula makers, also gives heavily to the Ad Council. Formula manufacturing is estimated to be a $3 billion a year industry in the US alone.

On November 6, shortly after his meeting with the formula industry representatives, the new president of the American Academy of Pediatrics, Dr. Carden Johnston, sent a letter to the Secretary of the Department of Health and Human Services, officially expressing AAP’s concern over the “negative approach” taken by the agency’s National Breastfeeding Awareness Campaign. News of this letter was not even publicly known until late November.

Dr. Johnston sent his letter to Secretary Thompson without consulting AAP’s own Section on Breastfeeding, an 800-member strong group of physicians with expertise in this area. The chair of this committee, Dr. Lawrence Gartner, subsequently sent a letter to Secretary Thompson disagreeing with Dr. Johnston, and urging that the ad campaign be released in its current form. In a letter to fellow pediatricians, he states, “There is every reason to believe that [the infant formula industry] are pulling out all the stops to get this ad campaign buried, or, at least, modified to be less effective .. . This entire affair is a very serious matter, which raises many questions about the leadership of the AAP and the influence of the formula industry on AAP activities.”

Dr. Johnston’s letter set off a cascade of action by breastfeeding advocates. In mid November, the chair of the US Breastfeeding Committee, Amy Spangler, briefed national breastfeeding leadership on the recent events. In a widely circulated email, she said that “[a] meeting was held with the directors of the CDC, NIH, and DHHS. Members of the CDC and NIH reviewed the science of the six conditions highlighted in the ads and determined that the relative risk statements should be removed from the ads and that those ads highlighting conditions wherein the science is either new or inconsistent be removed, ie, leukemia and diabetes.” The decision of the CDC and NIH is puzzling, because, when the ads were developed, a technical advisory group of researchers and breastfeeding experts had reviewed hundreds of published articles to assign the risk data to six diseases and conditions affected by not breastfeeding: diabetes, leukemia, obesity, ear infections, diarrhea, and respiratory infections like asthma and pneumonia.The references used in the risk assignments are publicly available and were stringently reviewed at the time.

One possible explanation for this decision may be the financial influence of the formula industry. According to reporter Katie Allison Granju, “several sources within the Ad Council” said that Mead Johnson, a maker of formula, threatened “to pull its millions” from the Ad Council’s budget if the references to specific risk numbers were not removed from the ads. The Ad Council relies heavily on funding by pharmaceutical companies which also produce infant formula. According to Granju, the Ad Council declined to comment on this report, and instead referred all inquires to Christina Pearson at the Office on Women’s Health, who says her agency can neither confirm nor deny this alleged incident. Granju wrote an extensively researched article posted on hipmama.com, in which Dr. Johnston described in detail his contact with the formula representatives at the AAP convention.

In around mid-December, the Office on Women’s Health issued its official reasons why the print ads on leukemia and diabetes aren’t running. According to OWH,the official reason the print ad involving diabetes is not running is because they believe that women will not know the difference between type 1 and type 2 diabetes [type 1 is also known as juvenile onset diabetes, or insulin-dependent diabetes]. According to OWH, the official reason the leukemia ads are not running is that pediatricians are generally unaware of the literature on leukemia and breastfeeding, and the numbers of the children affected by leukemia are small. According to the US Breastfeeding Committee, DHHS removed the relative risk statments because “numbers always invite controversy,” even though the expert committee who put these numbers together was “very conservative in their recommendations.” However, it is known the the formula industry approached DHHS and pressured DHHS to remove the risk numbers because they reportedly feared that consumer concern would decrease sales. It is important to emphasize that the science behind the ads has NOT been discredited.

One of the original ads is available for viewing, but only to limited audiences, so it is difficult to comment on all the pulled ads. The Massachusetts Breastfeeding Coalition notes that the AAP Section on Breastfeeding, in its 1997 position statement on breastfeeding, mentioned a “possible protective effect” of breastfeeding against lymphoma and of type 1 diabetes. Subsequent data have since emerged strengthening the evidence linking absence of breastfeeding to an increased risk of type 1 diabetes. In addition, there is now substantial data linking not breastfeeding to increased risk of all types of maternal breast cancer, from the large multinational study published in the Lancet in July 2002.

After this scandal became public, a massive letter-writing campaign began.This campaign, driven by breastfeeding advocates, was large enough to shut down Tommy Thompson’s email.

The Massachusetts Breastfeeding Coalition agrees with the Ad Council’s approach to the campaign, and respects the Ad Council’s expertise in the field of public service advertising. Previous ads about the “benefits of breastfeeding” have not been effective in convincing parents to breastfeed exclusively, and the US continues to fall short of the breastfeeding goals set by the federal government. The “benefits” type of campaign does a disservice to public health by framing infant feeding as a life style choice, rather than a health issue. We do not,for example, persuade people to wear seatbelts by saying they are “even safer” than wearing no seatbelt, or that using a car seat is “even safer” than holding an infant on one’s lap, or that quitting smoking is “even healthier” than not smoking. Nor is there any concern about inducing guilt in people who smoke, or don’t wear seatbelts or use carseats.

We are disturbed that the financial interests of the formula industry have significant influence over the health interests of women and children. We do not feel the formula industry should have any say in the National Breastfeeding Awareness Campaign, as this creates an obvious ethical conflict of interest, pitting private financial gain against public health. The public has a right to receive complete information that has not been suppressed, neutralized or censored to meet the approval of formula manufacturers.