Letters to the Editor

A reaction to George Kent's feature article in SCN News No. 18, p89...

RISKS TRUMP RIGHTS IN UNPROTECTED MINORS

The Human Rights & Nutrition feature "Tested in Court: The Right to Breastfeed" by Professor George Kent in SCN News No 18 brought immediately to mind the words of the plaintiff ballad from the musical, Jesus Christ Superstar, sung by the Mary Magdalene character in the song "I Don't Know How to Love Him. "By humanizing "The Savior" with her refrain, "... he's just a man, and I've known so many men before ... he's just one more," she shocked society of thirty years ago with what was considered tantamount to blasphemy. In many parallel ways, the advent of the Human Immunodeficiency Virus (HIV) has brought human milk into the sights of human frailty. The poignant and sensitive article in SCN News No 17, p17, on AIDS by Dr. Jean Humphrey, on the dilemma of vertical transmission of HIV by breastfeeding Zimbabwean women, pointed out the tarnish on the sacred halo that has surrounded "nature's perfect food for the infant." Although perfectly adapted to the nutritional needs of the newborn, human milk is not perfectly isolated from becoming a vector of harmful agents, and it is, after all, just a food. Throughout history, deaths related to contaminated foods and beverages, spoiled foods, and even intentionally poisoned fare, have been a leading cause of mortality. The chapters on "food-borne illnesses" swell the textbooks of medicine and public health. Pork can transmit trichinosis. Ground-grown vegetables can transmit cysticercosis. Cow milk can transmit bovine tuberculosis and brucellosis. Jack-in-the-Box hamburger's can transmit lethal stains of Escherichia coli. The examples are legion. Joining these ranks, since 1981, has been human milk and its transmission of lethal viral infections.

What about the merits of Prof. Kent's case? If one is to be known by the company he keeps, the readers of this periodical are unlikely to be impressed by the company George Kent sports in the courts. David Rasnick's alternative theories about the etiology of AIDS run into the now irrefutable scientific reality that HIV really does fulfil Koch's Postulates for the causation of the syndrome. And, to the extent that Roberto Giraldo's critique concerns the uncertainty of HIV diagnostic tests, a battery of approaches exists for reducing the uncertainty, vanishing to near-zero. With respect to the judicial precedents, HIV-seropositive persons have been found culpable of willfully attempting to infect others through their bites, through rape, or by using their own blood as a weapon. The Oregon judge in Kent's parable followed both the law, and sound judicial judgement in the domain of the unprotected minor. If parents were to announce their intention willfully to expose their infant to any other HIV-bearing human fluids (blood, saliva, semen), the authorities would certainly take notice, followed by swift action. If parents were to announce their intention to place a lethal organism in the food of a child, the justice system would be obliged to intervene and enjoin. The halo has been tarnished; human milk can become, at the same time, an HIV-bearing human fluid and an infected food.

HIV, moreover, is not the only noxious substance or agent that can be transmitted to a child through mother's milk either knowingly or inadvertently, Hepatitides viruses can be also transmitted vertically. Mothers who have suffered radiation accidents might bear harmful levels of strontium-90 in their milk. Mothers undergoing chemotherapy to save their own lives might endanger that of their infants by passing the antimetabolite through the milk. Prior maternal exposures to excessive heavy metals, pesticide or toxins might present milk levels making it unfit for the infants' consumption. Unfortunately, technology's capacity to insult our environment portends more and increasing assaults on the safety and quality of human milk with noxious substances. Returning to the judicial court, and that of public opinion, knowingly exposing an infant to this litany of damaging and legal hazards could only be justified when (1) the vehicle is human milk and (2) all of the other feeding options are worse.

Unfortunately, in getting the discussion back to the pressing and relevant life-and-death public-health issues raised by Jean Humphrey, we have had to pass across the gauntlet ineptly cast down by Kent, He has framed the discussion in the context of competing rights, centered around the mother's right cum obligation to breastfeed and the infant's right to be breastfed. The Oregon, U.S. court framed the discussion in the context of competing risks. Where the rubber meets road of soaring HIV seropositivity in Africa, and now Southeast Asia, the issue boils down to rights versus risks. Informed choice for an HIV-positive mother involves a child who, if he or she survives the precarious challenges of infant diet, is sadly destined to become an orphan anyway, Rasnick's denial notwithstanding. The mother must be told of the finite risk of vertical transmission of the viral infection to the child from consuming her milk; such an infection would carry the child away in a matter of years. And she must be instructed in the alternative to feeding the infant at the breast, whereby the nutritional inadequacy and unacceptable hygienic and microbiological condition of the water for home-concocted formula might shorten the life of the child to an even greater extent than the progression to infantile AIDS. This is the stark choice facing the poor African or Asian mother. Mrs. Tyson's personal lot was not much better, but her options for artificially feeding her son were vastly superior. The right to life for newborn infants will only be addressed and enhanced in HIV-endemic populations when safe and accessible alternatives to infected breast-milk provide a legitimate choice, and a way out of the now, doubly-lethal, dilemma.

NOEL W. SOLOMONS, MD, Center for Studies of Sensory Impairment, Aging and Metabolism, Guatemala City

CESSIAM, PO Box 02-5339, Section 3163/Guatemala, Miami, FL 33102-5339 USA; tel/fax: ++502 473 3942; email cessiam@tikal.net.gt

Reply from George Kent...

SOLOMONS' WISDOM?

I appreciate Noel Solomons' response to my article in SCN News No. 18 on the trial of an Oregon mother who was prevented from breastfeeding because she was diagnosed as HIV-positive. I would like to take the opportunity to clarify the argument.

(1) I accept that the HIV diagnosis "has brought human milk into the sights of human frailty". Breastmilk can be contaminated.

(2) The argument about the company that I keep is irrelevant.

(3) It is true that people diagnosed as HIV-positive have been found guilty of willfully attempting to infect others. In the Oregon case, there was no such allegation. This argument is irrelevant.

(4) The suggestion that the mother was trying to "place a lethal organism in the food of a child" is grossly exaggerated. While I can accept that there is some level of risk associated with breastfeeding by a woman diagnosed as HIV-positive, there is no clear published evidence to show that such breastfeeding is a virtual death sentence. In the Oregon case, the state was not able to demonstrate clear evidence that a high percentage of breastfed infants of mothers diagnosed as HIV-positive would die early.

(5) I agree that there are several "noxious substances" that can be transmitted from mother to infant through breastfeeding. However, there is a difference between demonstrating the possibility of transmission and demonstrating that there is a high likelihood of negative health outcomes. Many of the studies fail to explore actual health outcomes.

6) Solomons said I framed the discussion in terms of competing rights of the mother and the child. Actually, I framed it as a question of government coercion vs. patient decision-making based on informed consent. It is not the government's task to regularly minimize the risks to which we expose ourselves or our children. Many more children die in automobile crashes than die from being breastfed by mothers diagnosed as HIV-positive, but governments do not prevent us from putting our children into cars. These are judgments that parents are expected to make.

7) I agreed that there are exceptional cases in which the state may override this principle of patients themselves making the final decisions regarding their care, on the basis of informed consent. However, I also argued that the conditions required to justify such an exception were not met in this case. I said:

The published scientific evidence was not adequate to justify the State's presumption that breastfeeding by a woman diagnosed as HIV-positive (but otherwise asymptomatic) would be subjecting that child to excessive risk by breast-feeding.

(8) Like the court in Oregon, Solomons conveniently ignores my point that "United Nations agencies and the United States government had repeatedly reaffirmed the principle that HIV-positive women should not be coerced." Following long and hard study of the issues, policy analysts at these levels have concluded that the treatment of women diagnosed as HIV-positive should be based on their informed consent. The court in Oregon was not willing to hear about this.

(9) I stand by my argument: "If there is a failure of informed consent, there is an obligation on the part of government and health care workers to provide better information. Resort to coercion is not the appropriate remedy."

(10) Rather than promote the assumption that infants breastfed by mothers diagnosed as HIV-positive are almost certain to die as a result, Solomons could help to clarify matters for all concerned by helping to develop good scientific data on the actual risks involved.

I appreciate Noel Solomons' provocative argument because it provides an opportunity for setting out the concerns more clearly.

George Kent, University of Hawaii, November 4,1999

Professor & Chair, Dept of Political Science, University of Hawai'i, Honolulu, Hawai'i 96822-2281 USA; tel 808 956 7536; fax 808 956 6877; internet http://www2.hawaii.edu/~kent email kent@hawaii.edu

The Oregon Case - Clouding the Issue of Alternative Infant Feeding Methods for Mothers with HIV

The trial of the Oregon mother who was prevented from breastfeeding because she was diagnosed as HIV positive, which led to the article by George Kent in SCN News No. 18, and the responses here by Noel Solomons and by George Kent, raise interesting human rights arguments. But the issues raised in this debate are dwarfed beside the enormous problem of HIV in millions of poor pregnant women living in developing countries. Discussion of the Oregon case should not be allowed to mask the uncomfortable situation in which we have to make health recommendations that differ, depending on whether mothers are affluent, or are poor, and living in developing countries. Affluent women everywhere in countries of the north or south, who are HIV positive, would generally be advised not to breastfeed their infants, but that choice for many poor women in developing countries is not advisable. There is a danger that the arguments about rights of affluent women to make a free choice may cloud the important difficult decisions for poor mothers in Africa. All this may unwittingly lead to a "spill-over effect" reducing breastfeeding rates, even in non-infected mothers.

Currently the majority of pregnant women who are HIV positive are poor and live in Sub-Saharan Africa. A tiny minority of them have conditions necessary for adequate and safe formula feeding. Most live in poverty: many have poor access to education, decent health care, safe water, good hygiene, fuel and secure supplies of breastmilk substitutes. Fortunately recent evidence (see p6) suggests that exclusive breastfeeding greatly reduces the already low risk of HIV transmission through breastmilk, at least in the first three months. The use of the relatively cheap oral drug nevirapine (AIDS 1999 Mar 11;13(4):479-86) may also reduce risks of transmission of HIV to the baby.

In the end, women should have access to HIV testing, and then make infant feeding decisions based on risk assessment. If they decide not to breastfeed normally, then the alternatives need to be considered. Formula feeding may not be the best option. Alternatives include a shorter duration of breastfeeding, with emphasis on exclusive breastfeeding; heat treatment of the mother's own expressed breastmilk to kill the virus; donations of breastmilk by non-infected mothers; milk banking, or possibly wet nursing; and use of modified animal milks. Research on alternative methods of infant feeding for infants of HIV positive mothers is urgently needed.

Michael C. Latham, Professor of International Nutrition, Cornell University
Savage Hall, Ithaca NY 14583 USA; tel: 607 255 3041; fax 607 255 1033;
email mcl6@cornell.edu

Dear all,

...I would like to ask all of you if you can point me to any good published research that has shown that perhaps 90 out of 100 infants who were EXCLUSIVELY FORMULA FED from the day of birth in circumstances common for poor families in Africa were well nourished, healthy and alive at 6 months of age. Circumstances would include: no running, nor safe potable water; no latrine or decent sanitation; insecure income and supplies of formula; illiteracy; no refrigerator; no turn-on stove, and fuel shortages; poor access to decent health care; inadequate light in the house from about 20:00 to 5:00 to allow proper mixing of formula.

Figures from Pakistan showing an odds ratio for infant mortality in the first month of life associated with not breastfeeding of over 21 (one death in infants breastfed to 21 deaths in infants not breastfed) make me believe that it is well nigh impossible to provide exclusive safe breastmilk substitutes to children from poor underprivileged families. But if you can lead me to some published studies that contradict this view, I would be most grateful...

Michael C Latham, Professor of International Nutrition
Savage Hall, Cornell University, Ithaca NY 14853 USA; tel 607 255 3041; fax 607 255-1033; email mcl6@cornell.edu