THE PROBLEM WITH BREASTFEEDING
A personal reflection

Interview with author James Akre

Q. Why did you write your book and what is your intended audience?
A. I didn’t set out to write a convince-you text where breastfeeding as such is concerned. If, in the light of the compelling evidence that’s readily available elsewhere, readers don’t already fully subscribe to breastfeeding’s universal importance, it’s unlikely that they will be won over by delving here. On the other hand, for readers who already accept this fundamental truth, I hope that my reflection will contribute in two ways: by providing them with a different, or at least a less common, view of breastfeeding’s cross-cultural commonalities and differences; and by suggesting what we might do, individually and together, to move things forward. Thus, rather than attempting to draw up an all-inclusive list of my intended audience, it makes more sense simply to say: everyone but non-subscribers.

Q. Can you explain what you mean when you say that it’s not really mothers who breastfeed after all?
A. Essentially, what I’m saying is that it’s not just women who breastfeed, but entire cultures and societies that do – or variously don’t. In other words, cultures and societies as a whole are responsible for producing and sustaining the complex value system that results in more or less breastfeeding by the mothers and children in their midst. I base this observation on a single universal constant across time and geography: With only the rarest of exceptions, all mothers love their children and want what is best for them. And translating this love into “best” feeding behavior is invariably a culturally determined value. Thus, our best hope of seeing more mothers and children breastfeeding longer lies in transforming the society in which they are born, reared, come of age, beget, birth and nurture.
We often talk about the role choice plays in our lives, which is understandable given how fond we are of describing our behavior in terms of rational decision-making. But where child-feeding mode is concerned – to breastfeed or not – do we “choose” whether to breastfeed based on carefully worked out criteria? In the main, I think not. We respond the way we have learned to respond, which is why I insist that if we want to change a society’s predominant artificial-feeding mode we need to change society in all its structural complexity and not just focus on one or two contributing factors in isolation.

Q. In your view, what is the single most significant barrier to increasing breastfeeding prevalence and duration?
A. Where breastfeeding remains undervalued and under-practiced, the primary barrier to more and longer breastfeeding is society-wide ignorance both of human milk’s unique, species-specific properties and of the inescapable implications for the health of all people throughout the life course. Moreover, this ignorance is as much a sign as it is a source of the disrespect for the biological norm for feeding the young of our species that contributes so effectively to ensuring a continuation of already low rates of breastfeeding prevalence and duration. Every other barrier to breastfeeding – from individual attitudes and how they are formed, to non-supportive health services, to the multiple unhelpful ways society is often structured – can be traced directly to this cross-cutting core ignorance. And thus, to return breastfeeding to the realm of the ho-hum ordinary – which is how I define my goal for society – we also need a society-wide shift in awareness and attitude.

Q. Why do you say that “breast is not best”?
A. I believe that by adopting this perspective we avoid implying that artificial feeding is the norm and that breastfeeding is somehow better than the norm. On the contrary, anything else is a deviation from the norm. Breastfeeding should be normal, routine, commonplace, and, as I have just said, even ho-hum ordinary.

Q. Okay, breast is normal. But surely infant formula is second-best isn’t it?
A. No, the second-best feeding option is obviously other breast milk, for example expressed milk from a child’s own mother or milk from another mother in good health, whether directly from the breast or a human-milk bank. And if there is no breast milk, infant formula, which we should never forget began as a crisis commodity for emergency use only, is the least-bad alternative.
To put this alimentary aberration into perspective, consider routine use of infant formula as the feeding equivalent of emergency devices on airplanes – for example overhead oxygen masks and under-the-seat life jackets – suddenly transformed into everyday must-have fashion accessories. Infant formula pitched as somehow suitable for routine non-emergency use is immediately denatured, thereby forfeiting its only claim to legitimacy – as a life-sustaining crisis commodity.
But no matter how appropriate infant formula might be when infants are denied access to breast milk, feeding an inert pediatric fast-food based on the milk of an alien species remains a deviation from the biological norm for the young of our species. I invite you to reflect on this not-so-rhetorical question: At what point should society begin to regard a routine deviation from the biological norm as deviant behavior?

Q. What do you mean when you refer to “deconstructing infant formula”?
A. Essentially, this means removing infant formula from its totally inappropriate nutritional pedestal; shifting the collective perception of infant formula from the best alternative to breast milk to the least-bad alternative to breast milk; and showing why normalized artificial feeding is nutritional mediocrity at best and what the true costs are to the individual across the entire life course, and to society as a whole. Removing this inert pediatric fast-food from the kitchen pantry and returning it to where it got its start – in the medicine cabinet for emergency use only – requires a society-wide shift in popular, health-professional and political thinking. Deconstructing infant formula is one of the most important tasks at hand. Indeed, it is a pre-condition to moving to the next plateau of improved awareness, society-wide change, and greater prevalence and duration of breastfeeding. 2
Infant formula will sustain life in a pinch, and thank goodness this is so. But from a nutritional and developmental standpoint, not everyone has understood just how hugely inferior it is to breast milk, with negative implications for both children and their mothers – and thus the whole population – across the entire life course. The idealized view of normalized infant-formula feeding that manufacturers are so adept at portraying – and, regrettably, so many consumers, health professionals and politicians are inclined to accept – doesn’t allow for even a hint of this disenchanting reality. Finally, routine non-emergency formula feeding ends up being perceived across society and culture as a perfectly legitimate, albeit second-best, source of nourishment for children instead of the vastly inferior ersatz pretender that it is.

Q. Would you say that mothers have a duty to breastfeed their children?
A. Not really. Instead, I see it as a joint right. Since both mothers and children breastfeed, by defining the breastfeeding twosome in terms of a child’s right and a mother’s duty, we would be painting ourselves into a very tight corner. Whose right is it then and how do we satisfy it for the one without infringing on the right of the other? Is it possible to tiptoe between the horns of a dilemma in a way that fully respects the individuality, integrity and rights of both parties? Well, I think we can begin by deliberately walking away from this pseudo dilemma. We don’t need to butt our heads against a false conundrum; as some are presently defining it, this indeed becomes a zero-sum game, which inevitably produces only one winner and one loser every time. In fact, breastfeeding is a win-win alliance – children and mothers whose health and welfare are simultaneously and mutually fostered, reinforced and protected, immediately and across the entire life course, thereby rewarding not only mothers and children but the entire society.

Q. Are we witnessing a breastfeeding revolution?
A. While we still have a long way to go, my sense is that we’re well into what I prefer to call a breastfeeding counterrevolution since we’re talking about a return to our species’ nurturing and nutritional roots. Compelling scientific and epidemiological evidence is available and being reinforced daily. We also have considerable experience with strategic thinking about what motivates populations to adopt health-enhancing behavior. But we need to move promptly – by restructuring society and culture, by bridging the gap between science and policy, and by using policy as a tool for improving public health – to consolidate, expand and transform this knowledge into action that will take breastfeeding to the next plateau of significantly changed behavior.
I liken the situation to what we’ve experienced in other key areas of public health, for example the relatively rapid, radical and increasingly global shift, first in attitudes and then in behavior, toward using car seat belts and away from using tobacco products. And no matter how reasonable, even obvious, these changes appear in retrospect, I also know that both have had to drag in their path of change many of the kicking-and-screaming unconvinced.
The highest hurdles to more and longer breastfeeding are not scientific or epidemiological; they are primarily political, sociocultural, economic and organizational. It’s time to move more aggressively on all four fronts. And as we do, I urge readers to recall the singular advantage that we have over anyone who would still dare to promote a routine deviation from the biological norm for the young of our species. Embracing breastfeeding automatically places us on the right side of history!

Q. But what about infant-formula manufacturers; don’t they share a big part of the blame for the low prevalence and duration of breastfeeding?
A. It is indisputable that the processed-food industry is actively engaged in creating, structuring, consolidating and expanding a market that is favorable to infant formula for that is what commercial interests of every type do the world over. But please, let’s not forget that commercial interests don’t operate in a vacuum. Battling formula manufacturers can be an exciting, even adrenaline-pumping, way to focus our energy. Unless demand gets its due, however, fighting supply is pitifully inadequate. Worse, it can be misleading and even counterproductive in terms of achieving what I believe should be our common goal – more and longer breastfeeding – and our common objective – entire societies that are geared to supporting the biological norm for the young of our species. Attempts to micromanage the activities and actions of formula producers, distributors and retailers is a dubious investment of scare resources in the absence of a simultaneous focus on increasing awareness not just among mothers and health professionals but the entire society.
More to the point, however, a prescription for change in feeding behavior that focuses primarily on commercial interests and is filtered through a regulatory prism is also doomed to failure. Instead of more and longer breastfeeding, consistent with elementary principles of the economics of scarcity – and failing a change in values and expectations – pressure of this type results mainly in making artificial feeding still more expensive by acting like a surcharge on an airline ticket to cover rising fuel prices. Simply put, doing business in a restricted market is more expensive, and inevitably it’s the consumer who pays the difference.
The most efficient and effective way to reduce the supply of infant formula is to reduce the demand for infant formula; and the most efficient and effective way to reduce demand for infant formula is to increase demand for breast milk. But when I say “efficient and effective”, please don’t conclude that I’m implying “spontaneous and trouble-free”. In the complex social environments in which we live, I recognize that often it’s a very hard struggle indeed – one mother and one child at a time.
Commercial interests have refined to an art form the variety and subtlety of the “information” on infant feeding they provide health professionals and the general public alike. However, all manage to convey a single simple idea: Not only is it all right to substitute for breast milk; in fact, it doesn’t really matter one way or the other provided that we buy a good product, our water is clean, we wash our hands and we follow mixing instructions.
It may sound frustratingly circular, but experience also shows this: We are unlikely to see adequate measures widely adopted to protect, promote and support breastfeeding until society and its leaders first embrace the proposition that routinely feeding a breast-milk substitute represents a significant deviation from the biological norm for the young of our species that carries with it serious consequences throughout the life course.

Q. In that case, do you see any role at all for the infant-formula industry?
A. Yes, I think the industry has a place at the table, albeit a narrowly defined ad hoc one, in the same way that manufacturers of emergency equipment – for example air bags, oxygen masks, life vests and inflatable rafts – have places at tables around which also sit hospitals, airlines, aircraft and automobile manufacturers, accident prevention bureaus and consumer organizations. I’m not naively suggesting that the infant-food industry, as presently self-
perceived, will voluntarily assume such a narrowly defined and Spartan straight-back chair in favor of its currently coveted cushy one; just that, if this is indeed the seat we want the industry to occupy, it’s up to us to effect the downward product-demand shift – through significantly more and longer breastfeeding – that will make industry only too glad to grab it out of sheer enlightened self-interest. But as with gradually changing society-wide attitudes toward tobacco and seat-belt use in recent decades, we’re not going to see this downward shift in product demand happen overnight, or at all, except by altering the way society as a whole views artificial feeding and its life-long negative consequences.

Q. Isn’t one of breast milk’s biggest advantages the fact that it’s free?
A. Not at all. There are some truly outrageous claims regularly made about the value of breast milk or, more accurately, the absence of value. One of the most infuriating is that breast milk is somehow free. While we occasionally speak about the money breastfeeding saves, we mostly ignore what breastfeeding costs. Breast milk is most assuredly not free. In fact, I would start by describing it as priceless, even as breastfeeding itself has at least three price tags directly attached: a mother’s time (which far too many people erroneously consider to be “on the house”); the energy cost of producing milk (up to 500 kcal a day that need to come from somewhere); and the opportunity cost.
You’ll have no difficulty recognizing the first two tags, which are an altogether spectacular bargain when you consider the payback in terms of lifelong benefits for children, mothers and thus the entire society. But the third may not be so familiar; “opportunity cost” is one of the basic concepts in economics that refers to the cost of a decision based on what must be given up – for example mothers who are forced to choose between staying at home with their children and returning to paid employment outside the home to meet their families’ financial needs. As we all know from personal experience, there really is no such thing as a free lunch.
Unfortunately, the true cumulative costs of artificial feeding and the savings that accrue from a greater prevalence and duration of breastfeeding remain hidden from the majority of observers. Meanwhile, many persist in the delusion that breast milk is somehow free and that large-scale normalized artificial feeding is without significant economic consequences. Perhaps you’ve heard the popular slogan: A mind is a terrible thing to waste. Let me ask you this then: What would you say are the implications of more or less breastfeeding for the world’s 136 million or so new minds every single year?
Q. How do you see the way forward in terms of achieving what you describe as your goal for society – returning breastfeeding to the realm of the ho-hum ordinary?
A. Perhaps the ultimate irony here is that there can be no universal approach to our universal food and feeding system, which are forever mediated by culture and society. In the process of trying to re-think the problem with breastfeeding, I nevertheless feel that some useful conclusions can be drawn to speed things up a little – and possibly a lot. What do we want Planet Breastfeeding to look like in 2016, 2026, or 2056 when the world’s premier mother-to-mother support group, La Leche League International, celebrates its one hundredth anniversary?
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Human breasts, and the incomparable nurturing and nourishment they provide, help define who and what we are as a species. They also contribute to establishing a species-specific kinship system, both horizontally with the rest of today’s human family, and vertically as much with all who have come before us as with all who will come after us. Acting consistently with the biological imperative for feeding the young of our species is thus a universal act of allegiance as much to ourselves as to all our children. But even as we continue to think and act locally in the manner most suitable for us as individuals, we need also to think and act globally as constituents of a grand coalition, as members of what I have imagined as the International Breastfeeding Support Collective: people the world over who are interconnected by a common goal – more and longer breastfeeding – and a common objective – entire societies that are geared to supporting the biological norm for nurturing and nourishing the young of our species.

Q. How would you like to conclude this interview?
A. Taking a long look at history, I sometimes have the impression that few topics have been as thoroughly obscured by unsound information, contradictory beliefs and illogical thinking as child feeding. Yet I don’t think it would be excessively boastful if I were to affirm that we are collectively becoming ever more knowledgeable ... about our ignorance. The key messages are clearer now: that during the early years the nurturing role of mothers is central to children’s healthy physical, intellectual and emotional development; and that babies are indeed born to be breastfed. Neither nurturing nor nourishing naturally can be entirely safely substituted; the best we can hope to accomplish is to minimize the inherent risks.
I’ll put it this way. In light of 200 million or so years of mammalian evolution, we’re finally beginning to see routine recourse to the paltry pay-off of a century and a half of laboratory fiddling for what it really is: monumental short-sighted scientific hubris. Whether growing awareness of our ignorance and the hard-won scientific facts accompanying it will be enough to influence political and economic events, and thereby markedly improve global society’s child-feeding practices, remains to be seen. Attempts to derive social policy from biological concepts are not risk-free. Yet, as we have learned – both in terms of the benefits of breastfeeding and the risks of artificial feeding – the alternative conjures up a truly appalling vision of nurturing and nutritional mediocrity for children, mothers and society as a whole.
I consider myself an optimist by nature and this surely extends to breastfeeding, whether protecting it where it’s still the norm or promoting it where it’s not. And I remain convinced that, as the traditional civil rights anthem affirms, we shall indeed overcome – one day. It’s mainly a question of how quickly the International Breastfeeding Support Collective can move the counterrevolution forward. I’m not so foolhardy to assume that I have the answer; but in my book I’ve tried to stimulate thinking about how we might at least formulate the most relevant questions while reconfiguring, and candidly considering, the real problem with breastfeeding.