November 3rd, 2003 was a big day for Alabama emergency room pediatrician, Dr. Carden Johnston. On that date last month, he was installed as the new President of the 66,000 member American Academy of Pediatrics (AAP) at the prestigious organization's annual meeting in New Orleans. It was also the date that he sparked what has emerged as a major ethical controversy by inadvertently pulling back the curtains on the powerful influence that a particular corporate interest appears to have in shaping AAP policy and action.
"I have to admit that I never imagined that my presidency would start off with such a bang," Dr. Johnston says, acknowledging the debate now taking place within his organization.
At issue is a letter dated November 3rd that Dr. Johnston sent to Secretary of the Department of Health and Human Services (DHHS), Tommy G. Thompson, officially expressing the AAP's concern over the "negative approach" of the federal agency's soon-to-be-released, pro-breastfeeding advertising campaign. What Dr. Johnston didn't mention in his letter, however, was that he had developed this sudden and seemingly urgent interest in this issue not via a last minute clinical review of the scientific literature, or even after consulting with the AAP's own recognized lactation science experts.
In fact, his concern came immediately after aggressive, personal lobbying by representatives of one of the AAP's biggest financial contributors, the $3 billion U.S. infant formula industry. Within days of a New Orleans meeting with worried formula industry reps, Johnston hurled the considerable credibility and persuasive impact of the esteemed American Academy of Pediatrics into an explicit effort to stifle the most ambitious initiative ever undertaken to promote breastfeeding in the United States.
"Some of us within the AAP have long suspected that the infant formula companies had this sort of direct access to AAP leadership," explains Dr. Lawrence Gartner, a founding member of the Academy of Breastfeeding Medicine and chairman of the AAP's Professional Section on Breastfeeding. "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."
Reflecting the strong opinions of a number of AAP members interviewed in the past week, Dr. Jay Gordon, a pediatrician and best-selling author of several parenting books, says that his opinion on the AAP leadership's actions in this matter go beyond "disturbed."
Dr. Gordon reports that, that in his view, the AAP leadership has "weakened and emasculated (the ads) to suit the manufacturers of formula," and "as a result of their craven disregard for America's babies and families, more infants will get sick and die each year. I wish that this greedy, immoral, reprehensible act could be met with criminal charges," explains Gordon.
The ad campaign currently inspiring such passion among the nation's pediatric health care providers is funded within the DHHS Office on Women's Health (OWH), and has been in the works since 2000. Officially dubbed the "National Breastfeeding Awareness Campaign," the creative end of the OWH project has been handled by Raleigh, North Carolina advertising agency McKinney+Silver, while the entire project is overseen by The Ad Council, the private, non-profit organization that produces, distributes, and promotes public service campaigns on behalf of charitable organizations and government agencies.
In 2002, DHHS described the upcoming breastfeeding initiative as a three-year, multimedia social marketing blitz worth as much as $40 million in advertising dollars. It is alleged by a variety of organizations representing lactation consultants, physicians, nurses, midwives, and public health activists that the AAP's last-minute appeal to DHHS prevented the much-anticipated campaign launch from taking place as scheduled this month. Additionally, it appears that representatives of the infant formula industry - with the benefit of prematurely leaked information about the specifics of the ad campaign - have been quietly lobbying federal and Ad Council officials to change the ads' content and tone.
According to the AAP's own Breastfeeding Section, at least one thousand new scientific and medical papers on topics related to breast and bottle feeding have been published in just the past four years. Taken as a whole, this mounting body of research reveals dramatically different health outcomes for populations of breast and formula-fed babies, even when controlling for socioeconomic and other factors. The new ad campaign was designed to reflect this research and to catapult the issue of breastfeeding into the same category of public health concerns as smoking, carseat use, childhood vaccinations, and SIDS prevention.
While critics of Dr. Johnston's action strongly disagree that the tone of the DHHS ads is "negative," they concede that the new campaign does offer a fundamentally different way of looking at the breast-bottle issue. They hasten to add, however, that this new approach was completely intentional. According to those medical professionals who played a role in creating the actual content of the new campaign, the ads utilize a market-oriented and evidence-based approach to the issue, relying for the first time on the proven communications strategies that have successfully impacted other public health behaviors in recent years.
According to those who have viewed them, the ads feature catchy slogans meant to become memorable such as "Breastfeed: It's too important not to," and "Babies are born to be breastfed." Some of the ads also use humor to make their points, including TV spots showing a pregnant woman participating in roller derby and riding a mechanical bull. These absurdist images are used to make the point that, just as no woman would take those sorts of risks while pregnant, mothers of infants should avoid the quantifiable risks to their babies' health that come with not breastfeeding.
"As I understood it, this was to be the first national advertising campaign that focused on the risks of not breastfeeding as opposed to the benefits of choosing to breastfeed," explains Dr. Audrey Naylor, a San Diego pediatrician and Executive Director of Wellstart International, as well as a member of the AAP's Breastfeeding Professional Section, and a past consultant to the World Health Organization on infant nutrition issues. "This would definitely mark a significant change in the way this issue would be presented to the general public. It's a change to promote breastfeeding as a public health issue rather than simply as a personal parenting choice."
The area of the website of The Ad Council devoted to a brief discussion of the planned DHHS breastfeeding campaign offers a glimpse into this very different, market-oriented way of viewing the issue of breast vs. bottle, stating that, "Babies who are not exclusively breastfed for at least 6 months will be more likely to contract asthma, allergies, and cancer." In previous breastfeeding promotion campaigns, this statement would have certainly read "Babies who are breastfed will be less likely to contract asthma, allergies, and cancer."
In a presentation sponsored by the Breastfeeding Task Force of Greater Los Angeles on the planned campaign, McKinney+Silver was quoted as seeking to move from creating awareness to creating conversion with the ads.
"Shift the language from 'If you breastfeed, your baby will be healthier,' to 'If you don't breastfeed, your baby will be more prone to...," noted McKinney+Silver in describing the campaign's approach. The presentation went on to note that, while most American women seemed informed of the benefits of breastfeeding, few seemed aware of the potential consequences of not nursing their babies. "(There is) no perceived disadvantage if you don't breastfeed. Many think breastfeeding is like supplementing a 'standard diet' with vitamins. Formula, by default, is credited with the status of being 'the standard.'"
In much of the rest of the world, ads for infant formula directed at consumers are verboten in much the same way that television ads for cigarettes and liquor are no longer acceptable in the United States. This global aversion to infant formula advertising is due to the widespread adoption by governments and private industries outside the United States of the World Health Organization's Code on the Marketing of Breastmilk Substitutes - known as the WHO Code.
In this country, however, there is only minimal adherance to the WHO Code by public or private entities and as a result, advertisements for different brands of infant formula are a ubiquitous part of the U.S. media landscape.
In years past, various individual government agencies, hospitals, and private organizations such as La Leche League International have attempted to counter the advertising sledgehammer wielded by the well-heeled infant formula industry via a patchwork of relatively low-budget, smaller-scale ads focusing on the "the benefits of breastfeeding." However, the DHHS breastfeeding campaign to which the AAP leadership has now objected was to be the first national effort to utilize high-end, commercial-quality production values to position the "breast is best" public health message to go head-to-head with even the slickest Madison Avenue-produced infant formula ads.
Clearly, this was not a campaign that was going to play well with the infant formula industry, which has until now managed to create a uniquely advantageous situation in which it has positioned itself as the primary spokesman for its chief competitor in the marketplace, breastfeeding. And this new message is assuredly not the one they want projected into public consciousness.
"Ironically, infant formula companies in this country can honestly say they spend more on what they call 'breastfeeding education' than any other single entity," explains Amy Spangler, a nurse and lactation consultant who currently chairs the United States Breastfeeding Committee, an umbrella consortia of health care organizations interested in breastfeeding that was intimately involved in developing the new DHHS campaign. "They also underwrite much of the research into infant feeding issues. The pay-off for them is that they then get to manipulate the message, which is always "Breastfeeding is best, but... There is always a 'but,' and breastfeeding is suggested as a type of 'bonus feature' for parenting rather than the norm."
According to a number of sources within the medical community who were included in meetings during the planning process for the breastfeeding campaign, DHHS officials repeatedly stressed to participants that the specific messages of the ads -- which were clearly shaping up to be potentially controversial -- needed to be "embargoed" until their official release.
Amy Spangler attended several meetings with DHHS and OWH officials to discuss the Breastfeeding Awareness Campaign and she says that federal and Ad Council officials encouraged participants to avoid speaking publicly about the content of the planned ads before their release.
"It was never said specifically that the need for keeping the ads under wraps until release was due to anything having to do with infant formula companies, but I think we would have been naïve to assume that this was not one of the reasons why," explains Spangler.
Despite the warnings, however, the infant formula industry did apparently gain access to much of the content of the ads, allowing them to begin an intensive and targeted lobbying effort against their release. DHHS officials are reluctant to discuss the circumstances surrounding the premature leak of the ads, saying only that "a small amount" of information about the campaign was accidentally released on The Ad Council website at some point in November. Hipmama.com has learned, however, that DHHS and Ad Council officials voluntarily met with formula industry representatives at several points during the fall, even as pro-breastfeeding stakeholders were being instructed by the same officials to keep mum in order to preserve the integrity of the ad campaign's message.
Additionally, most or all of the actual ads were shown to dozens of attendees at a North Carolina medical conference in October, something that Office on Women's Health spokesperson Christina Pearson says the agency didn't authorize or even know about until after the event.
According to a variety of sources, members of Congress began hearing complaints about the pending ad campaign from infant formula manufacturers as early as the first week of October, but it was at the AAP convention in November that the industry was able to aim what is arguably the biggest weapon in its lobbying arsenal --the clout of the American Academy of Pediatrics - directly at the the breastfeeding campaign.
"The reason why the infant formula industry is so successful is because they have managed to manipulate health care providers into providing them with a cloak of credibility," explains Amy Spangler. "The bottom line here is that the president of (an infant formula company) doesn't have to send a letter directly to a federal official when he can get the President of the American Academy of Pediatrics to do it for him."
Public health advocates and many individual physicians, nurses, midwives, and lactation consultants have long criticized the cozy financial ties between infant formula manufacturers and major medical organizations such as the AAP, the American Medical Association, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology. The infant formula industry -- part of the larger pharmaceutical industry lobby -- is also recognized as one of the most effective and powerful lobbies on Capitol Hill.
Critics of this relationship between baby doctors and formula makers note that because the U.S. infant formula industry -- with sales of $3 billion annually -- clearly has a commercial interest in impacting parents' infant feeding choices, the industry should not play any role in crafting public health messages relating to the industry's clear competitor in the marketplace, breastfeeding.
"It is simply not appropriate for these companies to have a say in how publicly-funded health education campaigns present breastfeeding issues," argues Marsha Walker, RN, IBCLC, and Executive Director of the National Alliance for Breastfeeding Advocacy (NABA), a non-profit group promoting breastfeeding. "It would be like inviting a cigarette manufacturer to have a say in the message of a government sponsored anti-smoking campaign."
OWH spokesperson Christina Pearson disagrees, however, insisting that DHHS has made it clear all along that the agency wanted to hear from "all sides" on the issue.
While it may be reasonably asked what "sides" exist when speaking of a public health campaign promoting a free or low-cost, healthy alternative over another, expensive and less healthy alternative, the AAP leadership decided that their organization was going to take sides. In a phone interview with Hipmama.com on December 3rd, AAP President Dr. Johnston readily admitted that he was approached by representatives of infant formula companies during the annual AAP convention in the first week of November, and asked to attend a "private," "not on the agenda" meeting to discuss some concerns that the industry had with the planned DHHS breastfeeding campaign. He says that he and the three other members of the American Academy of Pediatrics Executive Committee, Dr. Joe Sanders, Dr. Carol Berkowitz, and Dr. E. Stephen Edwards, immediate past president of the AAP, met for approximately 45 minutes with "two or three" representatives of Ross Products "and maybe one other company" to hear their concerns.
"This was the first I had heard about this planned breastfeeding promotion campaign," says Dr. Johnston. "Sad, but true. I didn't know it was in development until after these folks told us about it."
Dr. Johnston's account of his interest in and knowledge of the DHHS ad campaign differs from the version reported in the December 4th edition of the New York Times. In a story entitled "Breastfeeding Ads Delayed In Dispute Over Content," reporter Melody Peterson writes that Dr. Johnston and Dr. Sanders "...said that they had decided to send their letter before (infant formula company) executives expressed their concerns at the Academy's national conference, held last month in New Orleans."
In his interview with Hipmama.com, Dr. Johnston said that he became alarmed at the tone and message of the ads after viewing samples shown to him by the infant formula company reps in New Orleans.
"They showed us more than ten but fewer than twenty printouts of something that looked like ads. It was my impression these were copies of some of the ads," says Dr. Johnston. "A lot of the ads looked fine to me, but I shared their concerns about the negative approach overall. It worried me, as it did them, that parents whose kids got cancer or grew up dumb might feel guilty if they did not breastfeed."
Dr. Johnston says that he did not find it inappropriate or even remarkable that a commercial interest would have advance advertising copy from a planned multi-million dollar federal public health campaign designed to convince Americans to buy less of their products.
"I never asked them where they got this stuff," says Dr. Johnston. "I just had the feeling that their relationships within Health and Human Services were better than ours at the Academy. I was actually embarrassed that this was the first time I was being made aware of the problems with this advertising campaign. Of course, they have to be concerned about issues that impact their shareholders."
Dr. Carol Berkowitz, who will become AAP President in 2004-2005, confirms that she also attended this meeting, however in a phone interview on December 3rd, she told Hipmama.com that the meeting was noted on her personal conference schedule when she arrived in New Orleans.
"The meeting was on my own schedule that they handed me when I arrived," says Dr. Berkowitz. "I assumed it had been set up in advance at AAP headquarters. I saw nothing remarkable about it; I attended many such meetings while I was there and I've been friends with many infant formula representatives for years."
Dr. Berkowitz says that she too was concerned about the tone of the ads based on what formula industry representatives told her when she met with them at the AAP Convention.
"At the end of the meeting, Dr. Edwards asked what they wanted us to do and they told us that they had just wanted to make us aware of the situation, " remembers Berkowitz.
Apparently, the AAP leadership's freshly heightened awareness led to almost immediate action on behalf on the formula industry. In a letter dated November 3rd -- while the AAP convention was still underway in New Orleans and on the very same day he was installed as President -- Dr. Johnston signed off on a strongly worded statement to DHHS objecting to the ostensibly still-under-wraps breastfeeding advertising campaign, based solely on what he had been shown and told by infant formula company lobbyists.
In the letter, Johnston notes that it has "come to his attention" that an ad campaign is about to be launched, and that he formed his opinions "after reviewing the Web Page of The Ad Council." He does not mention that his concern was, in fact, prompted by a private meeting he had just concluded with representatives from the infant formula industry. Dr. Johnston told Hipmama.com that, despite the wording in his letter to Secretary Thompson, he is not certain that he personally viewed The Ad Council webpage before signing the letter, and that he didn't actually draft the letter himself; staff at AAP offices near Chicago did. But he says that he was comfortable signing his name to it.
"I felt that we needed to send a letter immediately because the people we met with told me that these ads were about to be released," explains Dr. Johnston. "They conveyed a sense of urgency to me and I shared their concerns. I thought many of our members would be disturbed if these ads were released in that format. I felt we needed to act."
Meanwhile, members of the U.S. Breastfeeding Committee and other medical professionals with an interest in the DHHS advertising campaign had no idea that the new President of the AAP had taken such an action. Within a week of the AAP convention, however, sympathetic sources within DHHS began contacting interested medical professionals around the country and quietly reporting that "something was up" with the breastfeeding campaign.
"We started hearing from people that the infant formula companies had begun an intense lobbying campaign against the ads within DHHS and other government offices, including Senator Bill Frist's," says Marsha Walker of NABA. "They were saying that they were unhappy with ads that told of consequences of not breastfeeding as opposed to stating the benefits."
By mid-November, Dr. Lawrence Gartner had been alerted by a DHHS staffer to the existence of the Johnston letter sent on behalf of the AAP. Gartner says that he was very disturbed that the AAP's own Breastfeeding Section had not been consulted or even notified about the contents of Dr. Johnston's letter to Secretary Thompson, even though he and his colleagues in the AAP's Breastfeeding Section had also attended the AAP Convention earlier in the month. After investigating the matter, Dr. Gartner felt compelled to send his own letters to Secretary Thompson, as well as to other AAP members.
In his letter to fellow pediatricians across the country, Dr. Gartner wrote that, "There is every reason to believe that (the infant formula companies) are pulling out all the stops to get this ad campaign buried, or, at least, modified to be less effective... This entire affair is a very serious matter, which raises many questions about the leadership of the AAP and the influence of the formula industry on AAP activities."
Mardi K. Mountford, Executive Director of the the International Formula Council, a trade group representing the interests of infant formula manufacturers takes issue with Dr. Gartner's assertion that her industry is seeking to discredit or delay the DHHS campaign.
"We strongly encourage mothers to breastfeed if they can, but we don't believe that women need to be subjected to scare tactics like the ones that are in these ads," explains Mountford. "Our only interest in reviewing the scientific claims in the ads is that they be accurate so that parents have the information they need to make their own decisions about what's best for their families"
Mountford's remarks highlight something that public health advocates have long noted; namely, that the infant formula industry's tactics in lobbying against initiatives such as FDA regulation of their product, standardization of ingredients in their product, and now, the DHHS breastfeeding campaign are remarkably similar to the strategies employed by tobacco companies in the early years of the anti-smoking public health movement.
According to PRWatch.org, the tobacco industry created what eventually became known as the Council for Tobacco Research (CTR) in 1953, claiming that the organization's mission was to "find out whether smoking was dangerous...'" During the 1980s, internal CTR memos revealed that " the CTR actually worked at "promoting cigarettes and protecting them from these and other attacks," by "creating doubt about the health charge without actually denying it, and advocating the public's right to smoke, without actually urging them to take up the practice." Just as the infant formula industry currently pays for much of the research into breastfeeding in the U.S, for many years the CTR funded most research into tobacco health issues and attempted to insert itself as a "concerned" corporate citizen into the government's earliest anti-smoking campaigns.
While Dr. Johnston's letter to DHHS referred only to a "negative tone" in the ads, infant formula industry lobbyists had been contacting DHHS and Ad Council officials since Spring, 2003 and insisting that the specific scientific research upon which some of the language of the ads were based was faulty. OWH spokesperson Christina Pearson confirms that the infant formula industry raised these concerns with DHHS officials, and concedes that the ads have now been modified to remove references to specific statistics that quantify the higher risks for certain diseases. However, she says that this change was in no way the result of pressure from the infant formula industry.
Several sources within the Ad Council, which relies heavily on funding by pharmaceutical companies that also produce infant formula - such as Mead Johnson - claim otherwise. They say that Mead Johnson threatened to pull its millions from The Ad Council's budget if the references to specific risk numbers were not removed from the ads. The Ad Council declined to comment on this report, instead referring all inquiries to Christina Pearson at OWH, who says her agency can neither confirm or deny this alleged incident.
According to Dr. Gartner, the industry's complaints about a "negative" tone in the ads, as well as its questioning of the science behind the campaign are just red herrings designed to delay and water down the campaign for as long as possible.
"As far as a negative tone goes, most successful public health campaigns rely heavily on making the public aware of negative consequences of certain behaviors. While it may be a new way to approach breastfeeding promotion, it's a common advertising device." says Dr. Gartner. "We don't tell parents about the 'benefits' of carseats. We tell them that studies indicate that if they do not use a carseat, their baby has a greater risk for being injured or killed in an accident. And telling them this has worked. Thousands of lives are saved every year because this message works."
Dr. Johnston admits that he now regrets not having discussed the letter he sent to Secretary Thompson with his own "breastfeeding experts" within the AAP, including Dr. Gartner. But notification is as far as it should have gone, says Johnson. He stands by his concerns about the ad campaign.
"I rely on the breastfeeding experts to help me learn more about breastfeeding issues, but some of the science behind these breastfeeding claims is shaky. It's just not solid yet, and you know how some of these breastfeeding enthusiasts can lack objectivity," noted Dr. Johnston.
When asked whether this lack of scientific objectivity he has observed extends to members of the AAP breastfeeding section, he replied "some, not all."
Dr. Gartner says that he finds Dr. Johnston's statement about objectivity among the physicians in the AAP's Breastfeeding Section "outrageous."
"I've read thousands of scientific papers on breastfeeding and formula feeding in just the past few years and so have my colleagues in the Breastfeeding Section within the AAP," notes Dr. Gartner. "I challenge Dr. Johnston to discuss the hard science behind this issue with me any time. I would welcome the opportunity. Frankly, I do not believe he is qualified to comment on the research because I doubt he's read much of it except -- it appears -- possibly what the infant formula companies have shown him."
According to many lactation consultants and physicians who have played a consulting role in crafting the DHHS ad campaign, an earlier release date offered by DHHS officials was to be in October, 2003, to correspond with World Breastfeeding Week. That date came and went and participants were next told that the date for the campaign's official roll-out would December 3rd, to correspond with a meeting of breastfeeding and infant health experts that was scheduled to take place in Washington. In its December 4th edition, the New York Times cited an Ad Council newsletter that named a December, 2003 release date for the campaign.
Christina Pearson of OWH disputes the claim that there has ever been a true release date set for the ads and emphatically denies that any changes have been made to the campaign's message as a result of pressure from the AAP or infant formula industry representatives.
"The campaign is still on the drawing board and as far as we are concerned it has never come off the drawing board," explains Pearson. "Anyone who thought we were about to release the ads was simply mistaken. We will continue our review of the message and the content until everyone feels comfortable that we have it right."
Katie Allison Granju lives in Knoxville and is the mother of three children. She is the author of Attachment Parenting (Simon and Schuster, 1999) and her website is www.locoparentis.blogspot.com. This article first appeared on HipMama.com. Used by permission of author.
