Starting when the UN agencies changed their policy on HIV and infant feeding in 1997, HIV displaced baby food companies as the greatest threat to breastfeeding. There are spillover effects of all kinds, the worst being destruction of the natural, positive attitude toward breastfeeding that existed throughout Africa until this time. Now everyone says “breast is best, BUT…”
The right to “informed choice” was the basis on which the UN changed its policy, but unlike all other human rights, this one is not universal. For HIV+ women in Northern countries and even in some transitional economies, the photo above illustrates how they might feel if they let the authorities know they were planning to breast feed.
The situation was not much better in Cape Town, South Africa in 2002 when I gave this speech. I witnessed colleagues there sobbing after visiting mothers with severely malnourished old infants only 2-3 weeks old because they were forbidden from teaching HIV+ mothers to relactate, even when bottle feeding was clearly not working.
I assume that all of you know the basics on the issue of mother to child transmission (MTCT) of HIV through breastfeeding. Several studies have found a wide range of MTCT for women who practice mixed feeding, the most common form of feeding here in Africa with most reviews placing the average level of transmission through breast milk at about 15% of previously uninfected babies when neither mother nor baby receive any receiving antiretroviral (ARV) drug treatment. It may be lower for women who breastfeed for a very short time and higher for those who breast-feed for a very long time. For women who themselves are infected with HIV and thus go through the primary infection while breastfeeding, or for those actually suffering from AIDS, the risk may increase to about 30% (1).
Only one reasonably well-done prospective study, done in the Durban area by Coutsoudis et al (2), has examined transmission rates in babies who appeared to be exclusively breastfed, and they also found very low rates of transmission through breast milk. Smith and Kuhn have reviewed several mechanisms that may explain this (3). Thus, based on the best information currently available, it would appear that infants born to HIV-infected mothers either need to be fed exclusively with breast milk or exclusively with replacement feeding.
Types of replacement feeding
There is very little experience with any type of replacement feeding except infant formula. In theory, however, mothers who are committed to breastfeeding could be helped to learn to express their milk and treat it using the Pretoria pasteurization method, basically simply immersing the breast milk in boiling water, which apparently can deactivate the virus (4).
This method could be extremely valuable for women who choose to exclusively breastfeed and then relatively gradually stop breastfeeding altogether after six months, the period recommended by WHO, and when infants appear to be ready accept solid foods (5). As new foods are introduced at that age, breast milk could be heat treated, and then gradually as the baby accepts these changes, other milks and solid foods could replace breastfeeding at a relatively lower risk to infant health. The idea that breastfeeding could otherwise simply be stopped suddenly as early as four months is risky. I know of little directly relevant research, but what exists suggests that this will likely lead to severe consequences for mother and baby, including malnutrition (6).
Indeed, we have been assuming that mixed feeding after six months of exclusive breastfeeding (EBF) transmits HIV to the same extent as mixed feeding from birth, but this may not be the case. Some of the mechanisms likely to make exclusive breastfeeding safer for infants born to HIV+ mothers are likely to act only during the early weeks of life (3). However, it is conceivable that after six months of exclusive breastfeeding the infant gut is so robust and stable that as long as solid food introduction is hygienic, low rates of additional MTCT will occur. In any case, teaching good hygiene regarding solid food introduction is important. Indeed, like teaching EBF, it will have beneficial side effects. In contrast, teaching exclusive artificial feeding will have harmful side effects-something I will return to later.
Risk factors
Risk factors for higher rates of transmission include oral thrush in the baby and mastitis or anything likely to lead to bleeding from the nipples. Some studies suggest that transmission rates are particularly high early in infancy, but because infant HIV status cannot be accurately determined at birth, we cannot yet distinguish between transmission that takes place in early infancy or during labor. It is even possible that early breastfeeding reduces the latter.
It is important to remind ourselves that we are talking about relative risks. For a baby born to an HIV-infected mother, there are many unavoidable risks, particularly that of becoming an orphan. We must avoid policy-making predicated on some kind of illusion that all risk can be avoided. For example, I believe that in rural areas of Africa, wet nursing by a woman in a low risk group, particularly if she can be tested for HIV before the baby is born, is a reasonable public health approach. We must help the wet nurse to reduce such risks as the small chance that she will be infected by the baby by informing her how to avoid nipple damage and to watch for infant oral thrush-rather than insisting that wet nursing will not work based on the unavoidability of risk. For mothers who already have AIDS when the baby is born, I believe wet nursing is the best alternative, since this mother will then be more likely to adopt the baby when the mother dies.
Clearly rates of MTCT will be lower when mothers or babies receive ARV treatment. Short, simple regimens of monotherapy have been associated with a reduction of 50% in postnatal transmission among non-breastfeeding populations and up to 40% in breastfeeding populations (7). Continuing with the nevirapine with the infant may cut breastfeeding transmission to very low levels indeed, especially if EBF is practiced. Trials are ongoing to examine this question, particularly toxicity of the drug.
Exclusive breastfeeding
EBF is rare in South Africa, as in most of the world. It is a new concept. That breast-fed babies need no water even when the weather is hot, was first discovered in the mid-1970s (8), confirmed under extreme environmental conditions by several researchers during the 1980s (9), (10), and defined officially by WHO only about a decade ago (11). Thus there has been very little time to learn about its effects on infant health and how to promote it. So far, it seems to be much more protective against infant disease than mixed feeding (12) and also more effective in preventing short birth spaces (13), an important though neglected goal in working with HIV-infected mothers. Thus an increased rate of EBF will probably reduce MTCT in the majority of HIV- infected women who do not know their status, and improve maternal and child health in other ways.
But is it possible to achieve a society in which virtually all women give nothing but breast-milk to their babies? Not in places such as the USA, where poor women are offered subsidized formula through the Women, Infants and Children (WIC) program, and where there is no nationally mandated paid maternity leave (though Clinton mandated unpaid leave and some states are beginning to provide payment for it). In others, for example Sweden, about 70% of the babies receive virtually nothing else but breast milk during the first 4 months of life, and most of those who do not receive only small amounts of water or a rare bottle of formula (14). Swedes have set up their society so as to prioritize human values rather than materialistic ones, and accept lower incomes in return for, among other things, giving mothers and babies universal low-cost access to health care and giving parents access to well over a year of paid leave for each baby.
The major constraints to EBF now in most countries are actually not external, but “ideational.” Because the health professions have never paid attention to it, early feeding practices are riddled with traditional beliefs all over the world, including the use of water to prevent constipation, sugar and gripe water to reduce infant crying, and herbs to treat and prevent diseases and attacks by evil spirits. Thus the promotion of EBF must give highest priority to working with older women, who are the major arbiters of infant feeding patterns, to see if respectful education can make them open to trying this new approach. I found in Bangladesh that it was possible to get them to understand something as complex as renal solute load. When braver women tried it, other women in the village watched, and when they saw that babies who did not receive traditional prelacteal feeds were healthier, everyone adopted EBF in many villages. Thus promoting EBF may be like promoting a new type of hybrid seeds: farmers watch and see how well it goes for early adopters, before adopting it themselves.
The second important constraint to EBF is related to breastfeeding management. Basic training for virtually all health workers in virtually all countries is woefully inadequate in this respect. They need to know how proper latching on and positioning of the baby take place and how to help mothers to breast-feed properly and to deal with infant crying and with the perceived insufficient milk syndrome in other ways besides giving supplements.
From what I hear, the new South Africa has begun to improve social policies, even though implementing them is taking time. I hope a longer paid maternity leave, including the ratification of the new International Labour Organization Maternity Protection Convention 183, will be given serious consideration. Parents need time with their babies to exclusively breastfeed and for many other reasons.
EBF should be promoted universally at national level. If instead EBF is only promoted within efforts to prevent mother to child transmission of HIV (PMTCT), there is a risk that it becomes stigmatized. For example, if virtually everyone gives prelacteal feeds and mothers who receive voluntary testing and counseling are convinced not to do so, pretty soon not giving prelacteal feeds will raise suspicions about the mother’s HIV status.
Spillover
“Spillover,” refers to ways in which the new UN policy on HIV and breastfeeding may be implemented that encourage artificial feeding among HIV- mothers or those who do not know their status. When an estimate of this effect was included in MTCT simulations, the overall impact of infant feeding counseling that leads to artificial feeding turned out to be negative in a low-middle income country like South Africa (15).
We know that milk companies are quietly doing what they can to exploit the HIV tragedy to increase their sales. We also know that there are many PMCTC projects that are contravening the UN guidelines by actively promoting formula instead of providing mothers with information and advice and supporting what the mothers choose. But even beyond such more visible infractions, I believe spillover has been real, pervasive, and doing serious harm that will escalate unless we start paying more attention to it. To understand what I mean by spillover and why I think it has had so much impact, I will begin by seemingly digressing a bit.
The HIV threat to exclusive breastfeeding
Caldwell (16) recently pointed out that the carnage being caused by HIV/AIDS in the worst affected African countries was similar to that caused by war. In response to the threat of war, governments are always able to mobilize remarkable resources. If they did not, one would expect a strong reaction from the citizenry, even to the level of riotous rebellion. The goal of his paper, which will be sent by email to those who leave their email addresses, was to reflect on possible reasons why neither this level of resource mobilization nor the expected grassroots reaction was occurring in Africa. My reason for citing him is in an effort to understand why the international reaction to this human disaster has been to risk doing even more harm by damaging breastfeeding.
The emergency-like atmosphere surrounding this deadly HIV epidemic has led to an understandable willingness to ease up on the usual strict demands for following scientific protocol in how research is done, how it is interpreted, and how it is used in policy making. This alone would probably not be so harmful, but I believe in this case it has done great harm and threatens to do much more because this weakening of the usual scientific brake on rapid dissemination of new technologies is combined with commercial and political pressures in favor of artificial feeding.
In the field of public health and probably many others, most disciplines and areas of expertise feel neglected and under-funded, and, unless they relate to problems important to middle and upper class adult men, they probably are. HIV, nutrition and breastfeeding all come under that category, although HIV is proving threatening enough to the personal health and wealth of powerful people in a country like South Africa that the availability of funding for solving the problem will gradually continue increasing.
From a health point of view, breastfeeding should be equally important in both rich and poor areas. While its disruption causes different problems in poor and rich areas, these problems are of relatively high public health importance in each. However, countries that espouse more free-market approaches to capitalism such as the USA and Switzerland tend not to provide the kinds of support domestically that women need to breastfeed and do not consider breastfeeding to be politically important. The US government not only purchases more weapons than the nine next largest military budgets in the world combined, it is also by far the largest purchaser of infant formula in the world through its WIC program. Scandinavian countries on the other hand have achieved nearly universal EBF and thus no longer consider it of domestic concern.
Pediatricians and other health professionals with virtually no training on breastfeeding, simply assume that there is nothing more known than the little they know. Thus, among the kinds of people who decide how money is going to be spent to fight HIV in the world, it is hardly surprising that breastfeeding has simply not been a matter of concern. HIV research and policy-making have taken place without the involvement of much breastfeeding expertise, and thus have tended to misunderstand how breastfeeding works and accorded it low status and importance.
The change in UN agency policy on breastfeeding and HIV
The results of the Thai short-course AZT study (17) became widely known in 1997. It was assumed, with virtually no research basis, that because the babies in that study were not breast-fed, that the $50 per mother that could now be invested in reducing mother to child transmission (MTCT) would be wasted if the mothers were “allowed” to breast-feed. Simultaneously, the existing UN policy on HIV and breastfeeding (18) was being considered to be a hindrance to progress in PMTCT. This policy stated that in settings where the primary causes of infant deaths are infectious diseases and malnutrition, breastfeeding should remain the standard advice to pregnant women.
This policy was changed in 1997 to say that HIV+ women everywhere should make an informed choice on how to feed their babies.
While people should in theory always be able to make informed choices, informed choice is not taken to extremes in public health policy-making. We do not inform people that iodized salt can lead to iodine-induced thyrotoxicosis and even death, as has been documented in Zimbabwe (19). We do not inform women of the possible side-effects of immunization and politely give each mother an opportunity to weight the benefits and risks and give informed consent before we vaccinate their children. Nor do I suggest we do those things. What I do suggest is that in places where nearly all women are too poor to formula feed safely, there was no need to disrupt breastfeeding by presenting worrying information to the mother that she could do nothing about without actually increasing the risk of her baby dying.
At the World Health Assembly in May 2001, a subtle change was made to how this new UN policy was to be implemented. It more clearly spelled out that the health worker is to advise the mother-as is commonly done for other health-related matters.
Lack of information on MTCT through breastfeeding in Africa
Thus what should have been done during the past 15 years was to establish a research basis for providing health workers with the information they need to decide which types of advice to give to mothers living in various settings or at various levels of poverty. As most of you know, not only are we lacking in this kind of research information, we still have no data on the relative risk of not breastfeeding in any African context. The reason for this in the past was understandable: few if any poor African women do not breastfeed their babies. Researchers could not locate any substantial numbers of living babies who had not been breast fed in low-income African settings, so there was nothing to study (20). All we can do is extrapolate from data obtained in countries like Brazil, Malaysia and Pakistan where some relatively poor mothers may have lacked the kind of cultural support breastfeeding has enjoyed in Africa. Such studies now urgently need to be done, taking advantage of the fact that PMTCT programs all over the continent are leading to increasing numbers of cases of infants who are artificially fed from birth. So far, as far as I know, even research agencies like the Elisabeth Glaser Pediatric Foundation are only examining whether breastfeeding avoidance leads to reduced HIV transmission, not whether it leads to increased morbidity and mortality.
How implementation of the new UN policy is harming breastfeeding in Africa
The Thai study and the UN change in policy unleashed an anti-breastfeeding orientation in what I will loosely call the “HIV community.” Like all vertically oriented disease experts, HIV experts and activists were relatively uninterested and lacking in knowledge about other diseases. Abstracts I have seen from presentations at HIV meetings called on ministries of health to end breastfeeding promotion efforts because these were assumed to explain the poor success PMTCT efforts were having in convincing HIV+ mothers not to breastfeed.
As you know, nowhere in the UN guidelines (21) does it say that ANY mothers should be convinced to artificially feed their babies. This is a common misinterpretation, especially in this province. Health workers should give balanced advice, and then respect and support the mother’s right to make a decision. In Khayalitsha, one of the better organized high-density urban areas in South Africa, health workers did not warn mothers about the risks of not breastfeeding (22). Indeed, this was not done either in other countries that have run MTCT pilot projects longer than South Africa has (23). Not giving balanced warnings about risks on both sides (that is, not assisting mothers to do a risk assessment) or failure to show respect for her decision will do harm on many fronts. At the very least, it will drive breastfeeding underground. When studies begin to look at postnatal MTCT rates among mothers who supposedly accepted exclusive artificial feeding, I suspect a shock is in store.
While the HIV community may feel frustrated at its inability to attract funds from the powers that be and to make the necessary social changes, it certainly is a giant compared to the small and even more powerless “breastfeeding community.” Breastfeeding activism has also been an anathema to the business world, particularly the International Code of Marketing of Breast-milk Substitutes, since this was the first and still is the most powerful example of restriction of the free market. Whether intentional or not, the business and HIV communities joined forces to pressure governments into stopping their support for breastfeeding. I saw this very clearly in the late nineties when I discussed the issue among policy makers in a few countries. In Pretoria three years ago I was told that AIDS people had informed the government with “clinical certainty” what they should do, and that government officials were afraid of getting sued if they “allowed” HIV-positive women to breastfeed. Meanwhile I was told with a blameful wag of a finger, “you breastfeeding people are only whispering.”
UN agencies warned already several years ago that their breastfeeding staff no longer could work on general breastfeeding issues, because all their time was monopolized in dealing with the repercussions of the new policy. Nothing changed and UN work on breastfeeding simply died out. Governments all over Africa also began to waver in their support for breastfeeding. The Baby Friendly Hospital Initiative nearly collapsed. UNICEF’s regional office in Africa commissioned a qualitative study in four countries, Uganda, Kenya, Botswana and Namibia, which confirmed that this decline in support for breastfeeding had happened (23). These unfortunate changes were not inevitable. For example, Latham and Kisanga (23) found that Namibia was something of an exception. Policy makers there had decided that the scientific data were inadequate to justify changing national breastfeeding policy or even to initiate any pilot trials until they saw what happened in other countries.
The Breastfeeding and Complementary Feeding Working Group within the UN coordinating agency for nutrition, ACC/SCN, stated “The SCN should call upon all UN agencies to actively promote exclusive breastfeeding in all populations, and to report on the balance of attention given to this as compared to attention given to prevention of HIV transmission through breastfeeding.”
Role of the infant formula industry
In Peru a few years ago, the vice minister of health told me that it was too late to talk with him about this issue-his mind was made up based on the arguments presented to him by the local Nestle representative two years earlier. He asked me to consider the possibility that Nestle was not the evil entity that we “breastfeeding fanatics” made it out to be, but was actually doing its best to improve infant health.
Personally, I don’t think Nestle is evil at all. I think it is just going about its socially approved business of earning money. What IS evil is the growing political-economic ideology saying that the “market” must be free from interference from socially motivated limitations on its activities such as the International Code.
Despite the important limitations the Code places on how the baby food and bottle industries promote their products, the industries have many ways of marketing that cannot be controlled this way. A good example is the new Nestle Nutrition Institute in South Africa. In its website it originally stated, “The long term goal is to improve nutrition in southern and east Africa, in particular nutrition used in the HIV vertical transmission programme through infant formula,” according to Ferdinand Haschke, Nestle’s director of nutrition for southern and eastern Africa.
Private companies’ goal is to earn profit. This is appropriate and socially approved. My pension funds are to a large extent invested in stocks. I would not be pleased when I retire to learn that there would be no pension for me because the companies involved had earned no profit; I would not be consoled to learn that they HAD succeeded in improving infant health-that was not their role in society! The true explanation for Nestle spending money on infant health is and has to be that this will in the long run lead to increased profits. Shareholders would rightly call its leadership to task otherwise. Buying the reputations of leading South African scientists and getting headlines for charitable work follows a well-proven approach with long-term payoffs (24).
Many years ago, in a low-income West Indian country named St. Vincent, I studied how baby food industry promotional activities affect infant feeding practices (25). Women who had been exposed to and recalled infant food advertising started bottle feeding sooner, holding many other factors constant. Though many used those same brands, others did not, presumably influenced simply to believe that bottle-feeding per se was good. The two other clear evidence of influence I could document involved the health professions, as follows: (1) I asked women what would happen if a baby received breast milk and nothing else for five months. The majority said that would be good for the baby. Like mothers here, none of them actually practiced EBF, so I asked why. The most common response was that they could not afford it. They pointed to the Nestle brochure they had received at the clinic that said you must eat 3000 calories of expensive food to make good breast milk. One mother said the nurse told her she must drink milk to make milk, “So I just give her the milk directly.” (2) On a map of households interviewed, I noticed that the five women who used Fernleaf milk powder all lived near each other in a corner of one town. I returned to ask them why they used it and was amazed that all gave the same response. On their way to a plantation where they worked, they passed by a small nutrition rehabilitation center. They had looked in the window and noticed that the nuns were using Fernleaf. When I asked them why they thought the nuns used it, their unanimous reply was: “They were using it to show us how we should feed our babies.”
Don’t underestimate the power of official endorsement of any baby food. Young women with babies are not confident in the value of their own breast-milk and even if you even have a pen with a brand name on it in the pocket of your white coat, you may be conveying a message that you did not intend to convey (26). Imagine the potential power of the government itself buying and distributing a particular brand of formula.
Use of non-generic formula in South Africa
Meanwhile, open government use of Pelargon in South Africa, in contravention of the UN model of generic use of infant formula, has offered Nestle a public relations windfall. The marketing possibilities in the leading country in a continent with both the highest fertility rates and the lowest rates of formula use should be clear. Until the International Baby Food Action Network and the World Alliance for Breastfeeding Action publicized it internationally, Nestle claimed that Pelargon “killed bacteria from contaminated water.” In the original press article on the Institute, this sentence was followed by: “The formula was now available in southern and eastern Africa,’ according to Haschke.” Clearly, Nestle intended to use the HIV issue to increase sales of Pelargon among others as well. However, this may have been shortsighted, as Pelargon is now at risk of being associated with HIV and thus stigmatized. If Nestle marketing research reveals that this is happening, you will see a sudden reversal in industry opposition to this UN approach to reduce presumptive spillover effects.
Why not provide free infant formula?
I would like to close by discussing what is wrong with giving free infant formula to HIV+ women who choose to use it. To quote Browning’s famous love poem, “let me count the ways”:
1. In a country with enormous unmet health and other social needs, why is free formula being provided with no needs-based targeting? If the health worker judges that a woman can safely use the formula, is she not in most cases also able to afford to buy it? If she cannot afford it, where is the evidence that she can use it safely? This point is made clearly in the just-released report from South Africa’s Health Systems Trust: “Interim Findings on the National PMTCT Pilot Sites.” My remaining points focus on poor women, since the absurdity of a poor country providing free formula to women who can afford to buy it needs no further comment.
2. As Goga et al (27) point out, even for poor people, the cost of formula is so high that is hard to imagine that it is a wise use of scarce health sector resources.
3. Is one really giving an HIV+ woman an informed choice in how to feed her baby when we offer her some 500-1200 rand worth of commodities only if she chooses formula feeding? If she chooses breastfeeding, she is offered nothing but the opportunity to risk nutritional depletion in the face of a deadly disease that causes malnutrition and that we are usually not offering to treat. If the powers that be do not feel they can afford ARV treatment for AIDS victims, at least let them offer women who choose breastfeeding food commodities of equal value to the formula to shore up their own nutritional status. Even if all the food does not go for feeding the woman, like free formula is it in effect an income transfer that may free up money budgeted for family food that can be used to buy simple medicine and other needs she may have. Then there is hope that women can make an informed choice. If the government cannot afford that cost, then they should stop offering free formula. Indeed, UNICEF headquarters has now decided that it can no longer justify doing so and intends to begin soon to phase out its funding for infant formula. Any such decision must of course be taken in accordance with the International Code that states that any baby given free formula must be continued on such free formula for as long as that baby needs it. This leads me to my third point.
4. Where is the evidence that six months of formula is going to save any baby’s life? By giving free formula to a poor mother, one takes responsibility for a baby’s feeding. Are health workers adequately trained to do the very difficult training required to assist mothers in artificially feeding a baby from birth? Even if (1) depots or health centers where the formula is to be obtained are close to the mother’s home and never run out (as they have done in other countries); (2) formula is mixed properly and used safely; (3) the health care services are adequate to deal effectively with the substantial and expensive additional infant morbidity that will result (even in industrialized countries (28)); and (4) mothers always come to get the formula (which they have often not done in other African countries’ MTCT pilot projects), what will happen when the baby reaches six months of age and there is no longer either breast milk or formula available? I just visited the PMTCT pilot site in rural Rietvlei in Eastern Cape, and the health personnel there wait only with confusion and heavy hearts as their first cases approach this age.
5. Where did the idea come from that a mother will wake up several times each night a to formula feed her baby? (With breast-fed babies, the mother is barely disturbed in her sleep by the baby at her side who takes the breast at times when their synchronized sleep cycles are in light sleep.) How will she then find some way to light her hut, to make up a bottle of formula-or a cup if she was willing to spend a longer time feeding it-and then go back to sleep for a few hours until the procedure repeats itself? The mother may have only one bottle and a rusty balding bottle brush, cook over a wood fire, have no refrigeration, and believe that both under-nutrition and infant infection are more likely to be due to invisible spirits playing with the child rather than invisible germs. Where did the idea come from that artificial feeding could take place under conditions that do not encourage dangerous levels of bacterial contamination?
6. In reality I suspect that there will in most cases not be any dramatic tragedy occurring at six months of age, because most women are likely to have maintained some supply of breast milk which will increase when the free formula ends. Night feeds and feeds in public will from the beginning take place from the breast in most scenarios. In countries where free formula distribution has been going on for longer than it has here, the proportion of free tins actually obtained by mothers is usually small. No matter what “decision” mothers make, often under duress, in VCT sessions, real life intervenes and exclusive formula feeding among low-income mothers in Africa at least, is little more than a dream in the eyes of big-city HIV policy makers. In that case, if women are going to provide HIV-infected breast-milk to their babies anyway, who besides Nestle will have benefited from this brave new South African policy?
7. Will free formula lead to great spill-over effects and more formula use among women who are HIV- or do not know their HIV status? This can even occur indirectly. Already there have been reports that government funds that previously went to breastfeeding promotion now go to MCTC activities. Indeed, there is currently no nationally designated breastfeeding coordinator in the Department of Health.
References
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16. Caldwell JC. Rethinking the African AIDS Epidemic. Canberra: Australian National University; 1999.
17. Shaffer N, Chuachoowong R, Mock PA, Bhadrakom C, Siriwasin W, Young NL, et al. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Lancet 1999;353(9155):773-780.
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19. Todd CH, Allain T, Gomo ZA, Hasler JA, Ndiweni M, Oken E, et al. Increase in thyrotoxicosis associated with iodine supplements in Zimbabwe. Lancet 1995;346(8989):1563-1564.
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21. UNAIDS, UNICEF, WHO. HIV and Infant Feeding, Guidelines for decision-makers. Geneva: UNAIDS; 1998 June. Report No.: WHO/FRH/NUT/CHD/98.1.
22. Chopra M, Piwoz E, Sengwana J, Schaay N, Dunnett L, Sanders D. The effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa. in press 2002.
23. Latham MC, Kisanga P. Current status of protection, support and promotion of breastfeeding in four African countries. Nairobi: UNICEF Eastern and Southern Africa Regional Office; 2000.
24. Richter J. Holding Corporations Accountable, corporate conduct, international codes, and citizen action. London: Zed Books; 2001.
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26. Jelliffe DB. Commerciogenic malnutrition. Nutrition Reviews 1972;30:199-205.
27. Goga AE, Coutsoudis A, Rollins N, Coovadia HM. Free formula milk for infants of HIV infected women: blessing or curse? in press 2002.
28. Scariati PD, Grummer-Strawn LM, Fein SB, Yip R. Risk of diarrhea related to iron content of infant formula: lack of evidence to support the use of low-iron formula as a supplement for breastfed infants. Pediatrics 1997;99(3):e2.
This unpublished paper is edited slightly from a public lecture I gave UNIVERSITY OF THE WESTERN CAPE SCHOOL OF PUBLIC HEALTH in South Africa on March 4, 2002.
