Breast or Bust

Ever heard of a game called Russian Roulette? The premise involves loading one live round into an empty revolver. The barrel is then spun and the weapon pointed at the victim. In a standard revolver the statistical chance of being shot and potentially killed is 1 in 6. Our Health Minister, bless his fast food despising soul, recently decided to play his own version of this game with our nation and its HIV infected children. As of late August 2011 he unilaterally (in consultation with a number of his ‘yes’ men) decided to change South Africa’s breast feeding policy.

 

In essence the government no longer supplies formula milk to any patients accessing the public health system. Thus the only option available to mothers is to breast feed or purchase formula milk privately. This is a financially unsustainable option for the overwhelming majority. The finances are however better for government, who despite announcing the NHI which will purge R225 billion from taxpayers, will be saving in the order of R200 million per year with this move.

 

Of course the economics of Health are such that a short term saving today is often very costly in the long term. The evidence around adopting the approach taken by the Health Department is based on research which shows that infants who breast feed are generally healthier and have better immunity. Add to this the benefit of decreased cost to the state and associated costs to patients, and the decision seems to have merit. Furthermore formula feeding requires good sterilisation techniques to avoid gastrointestinal infections. This is particularly difficult because those in poor communities have been shown to battle with these techniques due to lack of resources.

 

As a direct result a common killer of young children is gastroenteritis. Much like when you have a bad case of food poisoning the time spent with your toilet bowl will drain you of fluid. In children and infants this is particularly dangerous because the progression to a lethal stage of dehydration can be far quicker with parents often failing to see the danger signs. In a country like Cuba where the socioeconomics are similar but the HIV prevalence is not, the choice is simple. If breast feeding offers so many advantages and formula feeding has an increased risk of gastrointestinal infections then the 1 +1 really is equal to 2.

 

However in South Africa we live within the environment of a colossal HIV pandemic. Once again the research here is quite clear. A mother who exclusively formula feeds has no chance of passing HIV onto her baby. A mother who exclusively breast feeds and together with her infant is on ARV’s has such a small chance of transmitting the virus that the risk is considered negligible. The problem is mixed feeding. Infants have a gastrointestinal lining which protects them from contracting HIV and other bugs in their gut. This lining only remains intact if the child is fed strictly one type of milk – breast or formula for not less than six months as recommended by the WHO. Mixing either of these or feeding the child additional cow’s milk, maize milk or any other foodstuff before 6 months will erode the lining destroying the protection. In addition to this there are several social factors to consider. Mothers are educated by health workers but family members with whom the child may be left are often exempt from this process. In addition South African culture means that mothers are likely to feed their children something other than just breast or formula before six months. Moreover working mothers only get 4 months of maternity leave, meaning that if they start breast feeding their children the child will have to be put onto solids or other milks before 6 months which will predispose them to either to gastrointestinal or HIV infection,  or both.

 

For all of these reasons up until recently many HIV positive mothers chose to formula feed. Now given no choice they will be forced to breast feed. At best in any town, city or province of this country 1 in 4 pregnant women is HIV positive. At worst the figure is 1 in 3. The direct result of this new policy, which has been instituted overnight, is a generation of babies born to HIV positive mothers being doomed to a potential death sentence.

 

Indeed much like in Russian Roulette our Health Minister has decided to load a revolver with a single round while pointing it directly at the head’s of our country’s children. We can only hope that his love of breasts helps him sleep better at night, for tomorrow and the day after may be spent digging graves just big enough to fit thousands of suckling infants.

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3 thoughts on “Breast or Bust

  1. Werner Weber says:

    It is frighting the decisions that are taken without consider the true impact. If what you say is true (I cannot judge I don’t have the medical expertise) then I see a very dark and bleak future for us.

  2. Rochelle says:

    Very ironic that I was studying this as I came across the article!! The government roll out of nevirapine will (in theory) prevent most of these children from contracting HIV but the flip side is that it will also cause the virus to mutate making this drug class ineffective. They have based their principle on the stats that show more children who were breastfed rather than formula fed will be alive after 5 years – as HIV takes longer to kill than gastroenteritis. This is very short sighted, but as you say financials play a big role. When they ask me to counsel the mother in the exam I will stick to what they say in the notes, but it doesn’t mean we all believe it.

  3. Adri says:

    I respectfully have to disagree with some of the statements you make in this post.

    I’m scared of making generalisations, and obviously a policy that doesn’t allow for exceptions based on individual circumstances is flawed.

    You rightfully point out that many HIV positive South African mums (I would even put my foot in it and say the majority) cannot afford to buy formula milk. In fact, they can hardly afford to feed themselves and the other children at home.
    In this lies the difficulty. No child (who is born HIV negative) should contract the virus postnatally from breastfeeding when free formula milk is available to all mothers who cannot afford it, yet children are infected. We have to stop and ask ourselves why this happens.
    Poverty is once again the answer. The mothers use the milk from the clinics to feed the adults and other children in the household who is starving and, for obvious reasons, cannot be breastfed. Thus we are putting the very infants we are trying to protect at risk of contracting HIV through mixed feeding.

    We cannot continue to do the same thing and expect different results. The socio-economic conditions in SA makes the current strategy ineffective, and a new policy was necessary.

    A study done at the National Hospital in Bloemfontein showed that with exclusive breastfeeding the chance of transmitting the virus to the infant is less than 2% as opposed to with mixed feeding where the risk is exponentially higher. In an ideal world the risk is unacceptable if it could be zero, but this is South Africa, not an ideal world.

    Personally I hope this strategy discourages the practice of mixed feeding. I have doubts as you rightly pointed out education is limited and often it is only the mom who is educated and with the pressure and old wives tales from family members mothers often ignore the education provided by health workers.

    Give the strategy a chance. I may be wrong but I don’t think the decision was taken simply to save money. If it was it is pretty short-sighted. The cost of providing adequate health care to a child sick and dying of AIDS for a year or two or five is certainly more expensive than providing milk to prevent mixed feeding.

    Monitor the situation. If it works, great. If it doesn’t a new plan of action is required, because providing the formula for free hasn’t been the answer either.

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