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 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 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 is the
author of "Attachment Parenting: Instinctive Care for Your
Baby and Young Child" and her essays can be viewed on her
website at Loco
Parentis.
©2004 drjaygordon.com
All rights reserved by author.
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