going to develop leukemia’ … those kinds of scare tactics were there,” Johnston explained to me on the rare sunny day that we met in Seattle, where he and his wife live part-time. “Now, if the data that something in infant formula might cause leukemia was solid, the Academy would have to find out what in the formula was causing leukemia and eliminate that, and meanwhile, encourage everyone to breast-feed … but the data was not that strong. And [the executive committee] needed to respond, because the Ad Council was working hard on this campaign and were likely to get something out pretty quickly. I signed a letter saying where the Academy was coming from; that the ads should be more positive than negative in promoting breastfeeding; and I think it’s a very good letter. … What we didn’t do, in retrospect, was to involve a lot of our breastfeeding advocates before we mailed it. We wouldn’t have had to change the letter, but they should have been notified and consulted.”
As for the claim that the formula companies were influencing the AAP, Johnston says that “the formula company was monitoring the website [so they] were able to show me what was on the website before the Office of Women’s Health pulled it down. So, is that influence or not?”
Certain members of Johnston’s own organization clearly believed that it was. Dr. Lawrence Gartner, head of the Breast-feeding Section of the AAP, spoke harshly about Johnston when interviewed for Granju’s article. “Some of us within the AAP have long suspected that the infant formula companies had this sort of direct access to AAP leadership. … Dr. Johnston’s actions have revealed the extent of this influence more clearly than anything else I’ve seen. Many doctors within the AAP are very disturbed by this.”24
Whether there really had been “many doctors” offended by the executive committee’s actions, or if it had merely been the vocal few that comprised the Breastfeeding Section, is likely a matter of interpretation. It’s tough to know where the majority of the AAP really stands, since you’d be hard pressed to find anything on the AAP website having to do with breastfeeding that hasn’t been written by the Breastfeeding Section. Johnston spent about twenty minutes trying to explain the role of a section to me; basically, it is “a group of individuals [within the AAP] who are enthusiastic about an issue.” The executive committee will then turn to the section when it needs to construct a policy on that specific issue; for example, the majority of information on infant feeding that gets filtered through to the public via the AAP website is written by the Section on Breastfeeding.25
I asked Johnston if those in the Breastfeeding Section were single-minded, and if this posed a problem for the rest of the organization; he told me I had it backward. “Those are who you want to have in there. If it’s child abuse, sexual abuse, if it’s immunizations, if it’s breastfeeding, if it’s safety, child passenger safety, ATV’s—you want the enthusiasts in there, leading. But I think that passion sometimes will distort interpretation of studies the same as it does for me when I’m doing child passenger safety studies”—child safety is Johnston’s field of interest, as a former emergency room doctor—“and I read a study, and I completely believe it. There may be some holes in it that I’m not seeing. … You know, you’ve got all this science, and then you have your personal biases and beliefs. Now, which one do you go with? I mean, this is emotionally correct. This is scientifically correct. Which one is stronger? When the science is hard, it’s not an issue. But we’re making statements before the science is that hard. So you’re using experts interpreting the best data that’s available.” (Which makes me wonder: The statements of the AAP are considered the word of God by most American parents. If the enthusiasts are the ones writing the policy, and being enthusiastic may alter one’s perception of the facts, are the rules we’ve been following based on little more than bias and zealotry?)
Johnston feels that it’s a pediatrician’s job to lay out the facts and encourage breastfeeding. But he also warns that when dealing with a mom “who’s had emotional problems before, or guilt or insecurity,” doctors should tread more carefully. “I think you would handle that a bit differently and let her ventilate some about how important she feels breastfeeding is, and about her family support system. … How much does she want to breast-feed? And then, support her decision. I think a pediatrician still can approach each parent, each situation differently.”
In practice, most pediatricians (at least the good ones) are probably taking this type of approach. I’ve heard rumors of a few rogue doctors in the Los Angeles area who won’t accept patients who aren’t breastfed, but on average, physicians seem to share Johnston’s moderate modus operandi. Several studies have been conducted examining pediatricians’ attitudes toward breastfeeding advocacy, and most conclude that pediatricians aren’t pushing breastfeeding as much as the AAP official policy suggests they should. In a 1999 survey of more than fifteen hundred fellows of the AAP, “only 37% recommended breastfeeding for 1 year … [and a] majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula-feeding are equally acceptable methods for feeding infants.”26 (Interestingly, the same study also found that physicians—presumably the female ones—who had themselves breastfed were “more informed and confident in their [breastfeeding] management abilities” and suggested that “educational programs also be targeted to professionals to effect changes in their personal behavior.” I wonder how female physicians would react to being told that what they do with their breasts is integral to the well-being of their patients. Or if the same type of approach were taken with the obesity epidemic, and the AAP sponsored weekly weigh-ins to ensure that its members were leading by example.) And while government and media support for breastfeeding has increased since 1999, and the AAP has issued stronger and stronger statements supporting the process in recent years, a study conducted in 2004 found that pediatrician support for breastfeeding had actually declined. Compared to a comparable study in 1995, pediatricians were “less likely to believe that the benefits of breast-feeding outweigh the difficulties or inconvenience … fewer believed that almost all mothers are able to breastfeed successfully … [and] more pediatricians reported reasons to recommend against breast-feeding.”27 Since the DHHS campaign fiasco occurred in 2003, I wonder if these changes reflected an underlying backlash against the extreme sentiments voiced in the campaign and throughout the resulting debates within the AAP.
Unfortunately, when doctors publicly speak out against the pressure to breastfeed, they risk their professional and personal reputations. After the birth of his first child, Dr. Barry Dworkin’s wife was having trouble breastfeeding. The Canadian family practitioner came home one evening and found his wife in tears because a lactation consultant she had called for advice had “essentially told her that she was endangering our child’s life because she was not breastfeeding properly, or breastfeeding enough, [that] supplementing was harmful to our baby.”
This personal experience, and hearing similar horror stories from his patients, led Dworkin to write a column for his local paper titled “The Hazards of Breastfeeding.” “In my practice, I observe many mothers equating breastfeeding to their competency to be good mothers. This narrowed perspective—the dependency upon one aspect of newborn care—can be damaging to the mother’s well-being,” he explains in the column, which appeared in a 2002 issue of the Ottawa Citizen.28 “Despite the best of intentions, women are bombarded with messages that lead them to believe if they stray from breastfeeding they are potentially harming their newborn child. … There must be a balanced approach to newborn feeding. If a mother is unable to breastfeed, and yes this does happen, she should not be made to feel that she is a failure. … Every woman should be encouraged to breastfeed but should not be subjected to judgment of her maternal skills in a punitive fashion.”
Within days of the column’s publication, Dworkin received piles of irate letters, which called him “uneducated, unethical, and unprofessional. … I had people who felt that anything that forestalled breastfeeding was a criminal offense writing me, telling me how irresponsible I was, and how terrible it was that I’m an assistant professor at a university, that I must be poisoning medical students’ minds with this kind of information.”29 It
