Formula for Failure

By: Clara JeffreyNewborns rustle in their clear, plastic cribs as the nurse makes her rounds. Among the squirming swaddles of mauve, rust and brown, it is difficult to distinguish sex or race, or one child from the next. A card in the crib of a day-old Latino boy reads, "Breast milk only please." The nurse drops a bottle of baby formula into his crib. She looks up, catches the eye of a visitor, and removes the formula.

"It's a good thing we were here," said Peg who runs the Chicago Breastfeeding Task Force at Cook County Hospital.

The children of many poor and minority women get their first meal from a bottle, despite studies showing that breast-feeding reduces infant mortality rates and childhood medical costs. The nation's three leading formula companies are pushing their products in hospitals, clinics, medical and nursing schools, and to the federal Women, Infants and Children program, according to an investigation by The Chicago Reporter.

The companies give free formula to hospitals, and provide gifts, grants, seminars and scholarships to doctors and nurses, the Reporter found. The free samples are "not intended to influence the method of feeding," wrote Holly D'Amour, a spokeswoman for Mead Johnson Pharmaceuticals, in response to the Reporter's questions. Rather, she said, they "provide information to mothers who are unable to breastfeed, choose not to do so, or need a supplement."

Adds Audrey Ashby, a spokeswoman for Wyeth-Ayerst Nutritional Inc.: "A woman doesn't make that decision in the hospital. She has nine months to think about it."

White women breast-feed at more than twice the rate of black women, according to Ross Laboratories, a formula company whose Mothers' Survey is used by industry analysts, the government and breast-feeding advocates.

"If minority women realized the devastation that is happening to their children because they are not breast-feeding they'd get angry. Angry no one bothers to tell them," said Angela Jacobi, a lactation consultant at Rush-Presbyterian-St. Luke's Medical Center on the near West Side.

Doctors get minimal training in breast-feeding, and nurses who try to promote the practice are often undermined by hospital policies, the Reporter found.

Government officials and health professionals blame low nursing rates on cultural and racial barriers. Yet studies show that intervention can significantly increase breast-feeding.

Miracle Milk
Over the last decade, fewer low-income women have breast-fed. Breast milk helps develop a baby's immune system, according to the American Academy of Pediatrics, which recommends exclusive breast-feeding for the first four months and supplemental nursing for one year. It also helps fight allergies, asthma and ear infections, and combats bacterial and intestinal disorders.

Advocates say the practice could help lower Chicago's high infant mortality rate, which in 1990 stood at 15.6 infant deaths for every 1,000 births. The rate was 23.1 among blacks and 8.9 among whites.

"Breast-feeding is the most cost-effective way to lower infant mortality," said nutritionist Erlinda Binghay, director of the Near North Health Service's WIC program. "Five hundred babies die each year in this country of diarrhea. Most could be avoided," she said.

Until the 1930s, when formulas made from cow's milk were improved, nearly all infants were breast-fed. But by 1959, only one in every four new mothers were nursing. Breast-feeding rates climbed in the 1970s and peaked at 62 percent in 1982. By 1991, the rate had fallen to 53.3 percent-25.8 percent among black women, according to the Ross survey.

"There is still this idea that lingers on from the '50s that science-formula-is better than nature-breast milk," said Mary Lofton, spokeswoman for La Leche League, an international nursing support group.

Formula companies give free supplies to hospitals, which in turn give them to mothers when they are discharged. A Reporter survey found that 33 of 34 Chicago-area hospitals use the "starter packs." Of those, 24 hospitals give supplies to all new mothers, four provide them on request and two give them only to bottle-feeding mothers. Three others provide the packs on occasion.

Free supplies encourage mothers to rely on formula at home, said Nicki Ward, a lactation consultant at Prentice Women's Hospital, a division of Northwestern Memorial. "It sits in the cabinet like a siren song that calls out to mothers as soon as something goes wrong," she said.

In a brief written statement, Ross said "our products are used and distributed in hospitals at the discretion of health care professionals."

And Mead Johnson's donations are "part of our business efforts, much like samples provided to physicians by pharmaceutical companies," D'Amour wrote.

Nineteen consultants at 28 hospitals said they would like to eliminate formula giveaways to breast-feeding mothers. But Dublin said, "We have to gain more support among the staff before we try that."

New mothers want the discharge packs, said Jacobi of Rush-Presbyterian-St. Luke's. "The families expect it, the nurses want to give it, we've completely enculturated this system. Delivery is the only procedure where a patient expects to be sent home with a grocery bag of goodies.

"Walk down any maternity ward in the country and you'll see dozens of incentive gifts-pencils, coffee cups, calendars, note pads. They bribe us with anything," she added.

But the benefits can be even more lucrative. Mead Johnson contributes to "capital campaigns to improve facilities, educational funds and support for research," D'Amour wrote. "The contributions are intended to enhance the quality of patient care and advance pediatric medicine," she said. The company would not provide details on specific grants.

Formula is "a good product when used appropriately," said Minda Lazarov, a former WIC administrator who now works with UNICEF. "I don't necessarily blame the formula companies for what they are doing. It's up to (health care workers) to refuse these free supplies," she said.

"Hospitals got suckered into this years ago," said Dr. Kathleen Auerbach, editor of the Journal of Human Lactation. "When you start receiving something for free, that you would otherwise need to pay a lot of money for, you are very grateful. That's how the hospitals have gotten hooked."

Prentice no longer gives formula to nursing mothers, but the hospital received an undisclosed donation to its Development Education Clinic from Mead Johnson as part of a new three-year, exclusive contract with the company.

As financial pressures increase, other hospitals will want to make such deals, Ward said. "It's a trade-off, they want the contract, so we have to say-'what will you give us?' If you are realistic, you need the money for a valuable service that the hospital is losing money on."

Formula companies have also given hospitals free architectural advice to help them expand or remodel. Ross Laboratories has offered such advice to Rush. "We have taken advantage of benefits they have provided," said Dr. Susan Monoghan, who oversees women's and children's services. "There is absolutely no quid pro quo."

Lactation consultants advocate "rooming-in," where the infants remain in their mothers' rooms and can be breast-fed "on demand," instead of on nurses' schedules.

The Reporter found that 29 of 36 hospitals have written plans to promote breastfeeding. Five do not, and two plan to establish policies. Four lactation consultants said their hospitals are not following their policies. Breast-feeding rates at suburban hospitals average around 70 percent, while some city hospitals have rates as low as 3 percent.

When Sharon Casillas enrolled in the WIC program eight years ago, her counselor explained that first she would get formula for her baby, then later, food. "I told her this was a breast-fed baby that wasn't going to get any formula. She looked at me and said, 'Don't you know you can be reported?' "

She wasn't sure what the counselor meant, but, "I shut up after that," said Casillas, who is now training to be a breast-feeding counselor.

WIC gives pregnant, breast-feeding and postpartum mothers coupons for milk, eggs, cereal, cheese and juice. WIC also provides iron-fortified formula and food to older children. And while WIC officials say they encourage women to breast-feed, last year the U.S. Department of Agriculture spent $1.15 billion on formula for the WIC program and $12.4 million to promote nursing.

WIC accounts for about 40 percent of the nation's formula sales, industry estimates show. Illinois, the fifth largest WIC provider, purchased $51.7 million in formula last year, but spent only $341,000 to promote breast-feeding, according to the federal agriculture department.

"We can hire peer counselors and work 10 times as hard, but having the federal government distribute formula sends a real strong message," Lazarov of UNICEF said. In 1991 the program could have saved $33 million if every WIC mother exclusively breast-fed for one month, she added.

Since 1991, WIC officials have required that state health agencies offer breast-feeding classes and prohibit them from displaying formula advertisements in their clinics.

"The slight increase in breast-feeding rates may be directly attributable to the changes in WIC over the last two years," Auerbach said.

Binghay of Near North Health Services said health agencies that promote breast-feeding can dramatically improve rates. Her sites in Cabrini-Green and Humboldt Park average more than 38 percent. At the Nutrition Education Center in West Town, where mothers nurse in a comfortable pastel room, the rate is 41 percent.

In 1991, 36.9 percent of WIC mothers breast-fed while still in the hospital, compared to 65.2 percent of mothers not in the program. Six months later, 9.8 percent of WIC mothers were still nursing, compared to 26.6 percent of non-participants, according to the Ross survey.

Breast-feeding rates at the Chicago health department's WIC clinics are three times lower than the city's privately run WIC sites, city records show.

Thomasine Johnson-Partlow, the city health department's WIC director, blames the low rates on budget constraints and demographics.

"We need money to do more," she said. "Certain ethnic groups don't feel breast-feeding is a method of feeding the baby. You have to educate them," she said.

Status Symbol
"I often see a black teenager who comes in expressing an interest in breast-feeding," said Cheryl Winker-Paras, a consultant at St. Joseph's Hospital on the North Side. "But you see very strongly that her mother is in charge, and she does not want her daughter to breast-feed."

Every new mother learns how to care for her baby from the examples around her, especially relatives.

"Mothers and mothers-in-law can be very detrimental," Winker- Paras said. "They had their babies in the '50s and '60s, when breast-feeding was at its lowest point. They were taught that formula is just as good, or better."

Income is a big influence, the Ross survey shows. In 1991, women of all races who earned at least $25,000 breast-fed at twice the rate of women earning less than $10,000.

The survey also showed that 59.2 percent of all white women breast-fed in 1991, compared to 25.8 percent of black women and 51.8 percent of Latinas.

In the past, doctors believed that African Americans rejected breast-feeding because slaves had been forced to nurse the children of their masters. But the biggest reason may be money, said Jeretha McKinley of the task force. Poor women cannot pay for Lamaze classes or parenting books, she said.

Latinas come from a breast-feeding culture. But nursing rates begin to decline when immigrants settle in the United States. By the third generation, Latinas breast-feed at the same rate as other women in their socio-economic class, McKinley said.

Asians, Poles and other immigrants use formula as a symbol of assimilation, Winker-Paras said. And Asian mothers believe breast-feeding is a sign of poverty. "They think rich Americans use formula," Lofton said.

"It's a middle-class status symbol to feed your baby formula," said Penny Roth, a nutritionist for the Illinois Department of Public Health.

By Example
At Altgeld Gardens on the far South Side, the March rain has turned the grounds of the low-rise housing project into a giant, oily puddle. The mud surrounds the dingy brown brick buildings, one of which houses a WIC clinic.

Inside, Loretta Hamilton is getting in people's faces.

"You have biased people ask what they know about breast-feeding and they'll tell you it hurts, am I right?" she asks the young women sitting in front of her. Both are about six months pregnant. One of the women, Deadra Howell, nods and whispers to a friend, "That's true. It hurt you, didn't it?"

Hamilton tells the women: "Even my grandma told me, 'Loretta you need to put something else in your baby,' but I didn't listen. For one year, I was exclusive, I didn't give him nothing but me. He never got sick 'til I stopped breast-feeding."

Hamilton is a peer counselor, and she leads by example. Poor and minority women can find it hard to accept advice from white health professionals. So women who have successfully breast-fed are recruited and trained to pass on their knowledge to others.

"Miss Hamilton helped me a lot. She calls me, I call her all the time," said Barbara Butler as she nurses 5-month-old Keia Carter. Butler said that none of her friends breast-feed.

La Leche League and the breast-feeding task force have trained Hamilton and more than 200 other peer counselors. Chicago health department WIC clinics do not pay peer counselors.

The counselors spend their days calling and visiting the women, giving them advice and encouragement.

"My life changed a lot," said Alicia Beltran, a staff peer counselor at the Community Nutrition Education Center. "I never worked before, I just stayed in my house and cleaned. But I have five kids. I breast-fed them all. I can talk to these ladies, relate to them."

Hamilton is making converts as she goes. "It encouraged me a lot-I didn't know anyone before who breast-fed," said Howell. Adds Hamilton, "Those moms will breast-feed. I'll be in touch. I'm not done with them yet."

Until 1986, all states paid full market price for formula. Since then, they have demanded a rebate for each can of formula purchased with WIC coupons. In 1992, the formula companies returned $750 million to the states, who used the money to serve an additional 1.2 million clients. But unless more money is spent to promote breast-feeding, the rebate system merely expands the market for formula companies, Lazarov said.

In January 1992, the Illinois health department awarded a three-year exclusive contract to Wyeth-Ayerst. The company pays Illinois $1.65 for each of the 22 million cans of formula WIC babies consume each year. Last year, Chicago VVIC clients bought $23.7 million in formula, of which $10.6 million was rebated.

Last June, the Federal Trade Commission charged Ross, Mead Johnson and Wyeth-Ayerst with keeping formula prices artificially high. Mead Johnson, with about 30 percent of the national market, and Wyeth-Ayerst, with 10 percent, were also charged with leaking closed bids they submitted to state agencies.

The companies settled the suit by giving the government 3.6 million pounds of formula, worth $25 million. Mead Johnson also paid $38.8 million to settle class action suits brought by retailers.

Ross, with about half the market, faces 37 anti-trust suits and five investigations brought by state agencies, individuals and retailers. Ross officials refused to comment.

The emphasis on formula feeding that began in the 1950s and 1960s continues to influence doctors and nurses, despite the recent recommendations of the American Academy of Pediatrics and the World Health Organization.

"We've got one doctor who still tells mothers that if they nurse for more than five minutes their nipples will fall off," said Nicki Ward, of Prentice.

Jacobi said that many doctors believe that "sore nipples and engorgement are to breast-feeding what labor is to delivery-that you can't breast-feed without pain. That's simply not true," she said.

A Reporter survey of Chicago's six medical schools found that students averaged less than one hour of lactation instruction in four years. Pediatric and obstetrics residents averaged only one hour of additional training. "Medical schools for the most part teach nothing about lactation," Auerbach said. "The only thing they learn about the breast is that it gets cancer."

Jacobi, who lectures at Rush Medical School, said no one showed up for her breast-feeding classes until she changed the focus to "how to market your practice toward women who want to breast-feed. Suddenly they all came-you have to wave the dollar sign," she said.

Making Progress
The Chicago Breastfeeding Task Force has raised the nursing rate at Cook County Hospital from 21 percent in 1988 to 37 percent in 1993, and has trained 150 peer counselors.

"We've begun to see some progress. But we have a long way to go. We need a lot more money going into the marketing of breast-feeding. Formula is marketed very effectively," Dublin said.

Dublin estimates that a breast-feeding program would cost a hospital $100,000 a year-to pay for two lactation consultants, training and supplies.

But doubts about breast-feeding persist, advocates say. And they hope that President Bill Clinton's pledge to increase the WIC budget will lead to a greater emphasis on nursing.

Auerbach recalls last year's visit by Vice President Dan Quayle to the Near North Winfield Moody clinic. His advance team told clinic staff to remove breast-feeding posters, because they were an unacceptable backdrop for Quayle's press conference.

"A young WIC mother, bless her heart, asked him if his mother breast-fed," Auerbach said. Quayle responded, "Of course not."

Interns Kendall Allen, J. J. Breazeale, Mikahla Beutler and Joanne Esters-Brown helped research this article.