Global, Government, Public Health

US is evidence outlier on breastfeeding

July 11, 2018

Note: This post includes special comments from Ginger Sall, humanitarian, advocate, member of our School’s Advisory Council and board member for multiple organizations.

Stunning US policy shifts

Our inboxes are overflowing with digital outrage about the U.S. government’s latest actions on breastfeeding.

There is a huge body of high-quality, peer-reviewed, credible evidence for the benefits of breastfeeding. Reports from the Surgeon General, including the last one in 2011, evidence reviews by the Agency for Health Research and Quality and thousands of peer-reviewed journal articles confirm the value of sustained breastfeeding for the health of mothers and infants. Likewise, the literature also documents the potential harms of exclusive reliance on infant formula for babies.

On July 8, The New York Times published an article that shocked many in the public health community and well beyond it. Laura Magaña, PhD, president and chief executive officer of the Association of Schools and Programs of Public Health (ASPPH), wrote to members:

 The article details heavy-handed efforts by the U.S. to block a resolution supporting breastfeeding during the recent World Health Assembly meeting. Although the resolution eventually was adopted, the U.S. efforts, apparently done to placate formula manufacturers, involved threatening foreign and military aid to the original sponsor, Ecuador.

The resolution called on governments to “protect, promote and support breastfeeding and to strive to limit the inaccurate or misleading marketing of breast milk substitutes.”

In a letter to U.S. Department of Health and Human Services Secretary Alex Azar, ASPPH leaders highlighted decades of research documenting the benefits of breastfeeding for mothers and babies and the risks associated with formula, especially exclusive formula use.

The 2011 Surgeon General’s Report from the agency Azar now leads concluded: “One of the most highly effective preventive measures a mother can take to protect the health of her infant and herself is to breastfeed.” The Surgeon General’s Call to Action also said, “… it is critical that we take action across the country to support breastfeeding.”

ASPPH leaders called upon Secretary Azar to “take the ethical step of standing up for the health of mothers and babies across the U.S. and around the world. They need your leadership and your stalwart defense of evidence and their health far more than industry needs your help marketing its products.” I echo that!

If breastfeeding were a miracle drug…

Breastfeeding has so many benefits for mothers and children that it’s simply staggering. It even helps in preventing some cancers. If breastfeeding were a miracle drug that had the same benefits as breastfeeding, consumers, companies, non-government organizations and government agencies would be all over it. There would be an IPO. It would be touted on CNN, talk shows and every other channel and medium.

Yet, breastfeeding has not been monetized as have infant formulas, which have been packaged, promoted and purveyed around the world. I believe that the administration’s apparent new position isn’t about the health of mothers, babies and children or the public’s health. It is about profits. It reminds me of big tobacco’s fight against the American Cancer Society in the 1960s and 1970s, and the sugar and beverage industries condemning experts who advocate for soda taxes as a strategy to fight the worldwide obesity epidemic.

Perhaps, the free market is the wrong approach for infant feeding

Free-market approaches don’t apply in many areas of health and the environment, including, perhaps, breastfeeding. Although more information about health is available now than ever before, thanks to the internet, consumers don’t have comprehensive knowledge about many topics related to their health care and can’t get it.

That’s especially true for many vulnerable women seeking information and unbiased advice about breastfeeding. Industry representatives have unfair access to decision makers in hospitals (e.g., chief medical and financial officers and those who make purchasing decisions), many other venues and the West Wing.

Monday, I had an email conversation with Ginger Sall, one of the smartest, most astute people I know, a member of our School’s Advisory Council and director of the Sall Family Foundation, which she and her husband, John, created. They care deeply about equity, health and the environment. Ginger has been a global advocate and architect for breastfeeding and related policies. She summed up the issues well (and gave me permission to share her comments).

Companies are marketing to vulnerable families willing to sacrifice for the sake of their children — in settings where breast milk does not have a corresponding advertising budget (e.g., television, radio, direct postal and electronic mail, retail points of sale, pharmacies that profit from the sale of substitutes). Because of this uneven playing field, the conditions for market-based solutions are not met; hence, the need for these “code of marketing” interventions. Imagine the heartbreak and rage of a family to find they have spent precious resources on inferior products when feeding and supporting the mother to breastfeed was the optimal and best course — with resources left over to feed other family members or to send them to school.

 When children are mentally and/or physically stunted because of suboptimal nutrition in the first 36 months, the rest of the family and all of society suffer from the missed mental/physical potential, added health care burden and reduced economic choices because money is spent on something that is not needed and not optimal.

 Dr. Alison Stuebe, distinguished scholar in infant and young child feeding, associate professor of maternal and child health in the Gillings School and associate professor of obstetrics and gynecology in the School of Medicine at UNC-Chapel Hill, is president-elect of the Academy of Breastfeeding Medicine. Dr. Stuebe gave a specific example that showed the impact of industry in a post she wrote for the Breastfeeding Medicine blog.

The formula industry has long recognized that rising breastfeeding rates are a threat to their financial bottom line. In his Q1 2016 earnings call with shareholders, Mead Johnson CEO Peter Kasper Jakobsen said: On a positive note, we believe the strengthening labor market and workforce participation rates have caused a rise in breastfeeding rates to level off over the last four months or so. [italics added]

Read all of Dr. Stuebe’s blog post here.

I’m not anti-industry. I am pro-science and pro-evidence. Evidence is accumulated over time. It’s built upon the edifice of careful research. The evidence is clear about the benefits of breastfeeding and the potential harms of exclusive formula use. Carl Sagan said it well:

What counts is not what sounds plausible, not what we would like to believe, not what one or two witnesses claim, but only what is supported by hard evidence rigorously and skeptically examined. Extraordinary claims require extraordinary evidence.

I am for women, babies and families. Their voices do not get equal time to industry’s voice. Too often, their interests are not best served when it comes to infant feeding. As Ginger Sall, Alison Stuebe and our ASPPH leaders articulated, infant formula and other companies have unfair access to power and undue influence. One of these days, payment for our neglect will come due in the form of deaths, diseases and ill health that could have been averted, and the very real costs associated with care delayed and denied.

That’s a tragedy, a preventable tragedy. Honestly, we should be ashamed.

The views expressed in this blog are Barbara Rimer’s alone and do not represent the views and policies of The University of North Carolina or the Gillings School.


michele forman


Unfortunately the U.S. government's position on breast feeding has a long history of not supporting the evidence base. In the early 1980's the U.S. stood against the WHO Code for infant feeding in contrast with most other countries. The WHO Code passed that reduced the ability to give out formula and bottles after delivery and to advertise on radio and other media about infant formulas. SO history repeats itself.

Vinay Kumar


Well said Vivek

Vivek Soni


that's a great information about what people think about breastfeeding. Thanks for this Useful Info.

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The views expressed in this blog are Barbara Rimer’s alone and do not represent the views and policies of The University of North Carolina or the Gillings School.