Political Pressure Sidelined HHS Efforts to Increase US Breastfeeding Rates
NOTE: The following is one of a series of case studies produced by the Union of Concerned Scientists' Scientific Integrity Program between 2004 and 2010 to document the abuses highlighted in our 2004 report, Scientific Integrity in Policy Making.
The Department of Health and Human Services (HHS), bowing to political pressures, restricted important public health messages from reaching Americans on two occasions. In 2007, media outreach regarding the release of a comprehensive scientific report highlighting the health benefits of breastfeeding was blocked by HHS political appointees. Previously, in 2004, lobbying efforts by the infant formula industry persuaded HHS to soften pro-breastfeeding messages in a nationwide advertising campaign designed to increase rates of U.S. breastfeeding mothers.
In 1998, looking to increase the low rates of U.S. breastfeeding mothers, then-Surgeon General David Satcher requested that HHS develop a scientific evidence-based plan of action. This report, "Blueprint for Action on Breastfeeding," was released in October 2000 and includes a set of recommendations to meet 2010 goals of increasing the percentages of U.S. mothers that initiate breastfeeding to 75%, and those that continue to breastfeed at 6 and 12 months postpartum to 50% and 25%, respectively.1
2004 rates of breastfeeding mothers in the U.S. are reported at 73.8% of mothers initiating breastfeeding, 41.5% continuing for 6 months, and 20.9% continuing for 12 months.2 The U.S. rate of initiating breastfeeding lags behind many European nations, where as many as 98% of mothers initiate breastfeeding.3
To address the educational recommendations in the HHS Blueprint4, in 2007, the HHS Office on Women's Health (OWH) commissioned a report from the HHS Agency for Healthcare Research and Quality (AHRQ) that reviewed published scientific studies evaluating the short and long-term benefits of breastfeeding on the health of the child and mother in developed countries. This comprehensive, peer-reviewed report was written with guidance from experts in the breastfeeding field and ultimately highlighted breastfeeding as a public health issue.
The report showed breastfeeding to be linked with substantial health benefits for the infant, including reductions in common infections, the likelihood of developing type 1 and type 2 diabetes, childhood leukemia, asthma, sudden infant death syndrome (SIDS), and obesity. The report also found substantial benefits for the mother, including the reduction in developing type 2 diabetes, breast and ovarian cancers, and lowered risk of postpartum depression.5
Unfortunately, intervention by political appointees at HHS prevented these public health messages from receiving any coverage by the news media. While Suzanne Haynes, a senior science adviser for the OWH, had reportedly "argued strongly" to promote these important findings within the medical community and the public, the agency press office reported that they were "specifically instructed by political appointees not to disseminate a news release." Further, HHS director of communications, Rebecca Ayer, reportedly instructed Haynes and others that there should be "no media outreach to anyone" on the topic of this report.6
The 2007 assault on the free communication of public health science was not the first instance of political interference in this arena. The HHS Blueprint recommended educating the public about the health benefits of breastfeeding through advertising campaigns and public service announcements (PSAs).7 In 2004, an advertising campaign to promote breastfeeding was significantly altered in response to pressure from the Infant Formula Council (IFC).
The OWH had partnered with the Advertising Council, leaders in producing generations of highly influential PSAs, and experts on breastfeeding to develop scientifically based and effective pro-breastfeeding messages and to deliver these PSAs nationwide.8 The original PSAs contained hard-hitting messages portraying the health risks of not breastfeeding a child. Images in the original print ads included asthma inhalers and insulin bottles topped with rubber nipples to depict health consequences (increased risk of developing asthma and diabetes, respectively) of bottle feeding and not breastfeeding a child.9
Catching wind of the tone of the proposed PSAs, the IFC began to apply their pressure. The IFC enlisted the then-president of the American Academy of Pediatrics (AAP), Dr. Carden Johnston, to write a letter to then-HHS secretary Tommy G. Thompson, in November 2003 expressing his concern about the tone of the ads.10
Yet, many of the 800 members of AAP's Section on Breastfeeding did not share Dr. Johnston's assessment of the ads. Dr. Lawrence Gartner, the chair of the AAP Section on Breastfeeding Executive Committee, defended the science and the strategy behind the ads in a letter to Thompson in November 2003. Dr. Gartner stated, "... it is essential that the message point out the risks of not breastfeeding" and continued, "We know from those who have participated in the preparation of the Breastfeeding PSA materials that every word and claim made in these [PSAs] has been reviewed by multiple scientists and validated by published research from respected medical journals."11
To further influence HHS, in February 2004, a letter written on behalf of the IFC by two former high-level government officials was sent to Thompson, indicating that the IFC disapproved of the allegedly distorted, and fear and guilt-provoking pro-breastfeeding messages, and strongly encouraged HHS to change the approach of the ads.12
Despite multiple efforts from expert scientists in the field, the messages portrayed in the original breastfeeding PSAs were substantially toned down prior to their release.13 The released print ads took the opposite approach from what was recommended by the Advertising Council and results from focus group studies. The revised ads depicted the benefits of breastfeeding—rather than the risks of not breastfeeding—and contained images of dandelions,14 otoscopes15 (medical instruments used to examine the ear), and ice cream,16 to portray the reduction in the likelihood of developing childhood respiratory and ear infections, and obesity, respectively.
Gina Ciagne, the breastfeeding awareness campaign's public affairs specialist, was reported saying, "We were ready to go with our risk-based campaign – making breastfeeding a real public health issue – when the formula companies learned about it and came in to complain. Before long, we were told we had to water things down..."17 A secondary letter to Thompson on behalf of the IFC in April 2004 thanked HHS officials for meeting with some of their members and ultimately altering the ads.18
1. HHS Blueprint for Action on Breastfeeding, U.S.Department of Health and Human Services, Office of Women’s Health, accessed 17 July 2008.
2. U.S. Department of Health and Human Services Centers for Disease Control and Prevention, “Data and Statistics: Breastfeeding Practices – Results from the 2004 National Immunization Survey,” accessed 25 July 25, 2008.
3. The WHO Global Data Bank on Breastfeeding and Complementary Feeding: 1999 Portugal national survey data, 1999 Sweden national survey data, 1997 Norway national survey data.
4. HHS Blueprint.
5. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J, Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290-02-0022). AHRQ Publication No. 07-E007, Rockville, MD: Agency for Healthcare Research and Quality, April 2007, accessed 17 July 2008.
6. Kaufman, Mark, and Lee, Christopher, “HHS toned Down Breast-Feeding Ads: Formula Industry Urged Softer Campaign,” Washington Post, 31 Aug 2007.
7. HHS Blueprint.
8. HHS Press Release, 4 June 2004, “Public Service Campaign to Promote Breastfeeding Awareness Launched,” accessed 17 July 2008.
9. Kaufman and Lee, supplemental images.
10. Kaufman and Lee.
11. Gartner, Lawrence, Letter to Tommy Thompson, 18 Nov 2003.
12. Yeutter, Clayton, Letter to Tommy Thompson, 17 Feb 2004.
13. Kaufman and Lee.
14. National Breastfeeding Campaign Materials, Dandelion Print Ad.
15. National Breastfeeding Campaign Materials, Otoscopes Print Ad.
16. National Breastfeeding Campaign Materials, Ice Cream Print Ad.
17. Kaufman and Lee.
18. Yeutter, Clayton, Letter to Tommy Thompson, 21 Apr 2004.