By Melissa Bartick, MD, MS
Chair, Massachusetts Breastfeeding Coalition

February, 2007 — In Massachusetts, getting hospitals to stop marketing baby formula became a battle of words fought in the press and in the corridors of the State House. In February 2006, then-Governor Mitt Romney directed our state’s Public Health Council to rescind the country’s first state regulation to ban hospital distribution of formula company discharge bags. Romney, his spokesman, and other opponents of the ban argued that women should be “free to choose” how they feed their babies, and that women should not be “forced” to breastfeed.

Freedom of choice is a concept that is frequently raised by proponents of baby formula, as well as by manufacturers of other unhealthy products, such as fast food, soft drinks, and tobacco. These corporations like to say that healthy choices are the individual’s personal responsibility. They minimize the effect their marketing has on consumer behavior, despite the fact that they spend huge sums of money to get people to purchase their unhealthy products. Because companies cannot admit that they want to get people to buy as much of their unhealthy product as possible, the best they can do is to describe their marketing efforts as a way “simply to educate” the public about their products. By emphasizing “freedom,” “choice” and “individual responsibility,” they tap into classic American values.

The strategy is effective, in part because consumers do not want to admit that they are vulnerable to the effects of advertising, even though, clearly, those vast sums spent on marketing are not for nothing. One Romney staffer even told us, “Women are too smart for that.” She turned unethical marketing on its head by praising women’s “intelligence,” even though effects of marketing often play on a consumer’s emotional vulnerabilities, which has nothing to do with intelligence.

During the formula marketing debate in Massachusetts, Romney received letters in support of the marketing ban from the CDC, the president of the American Public Health Association, and the state chapters of the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, the Massachusetts Public Health Association among others. Despite knowing of all this support for the ban, the governor’s spokesman repeatedly characterized proponents of the ban as “a small but vocal group” of “liberal” activists, and not the mainstream. So, how did we respond? We learned a lot of lessons in language.

Reframe, don’t react:

One of the biggest lessons we learned was that we needed to reframe the argument, rather than react to our opponents’ charges. When you reframe the argument, you are in control of the message you give; when you respond directly to their charges, they are in control of your message.

For example, countering “women are smart” with “women are vulnerable” is a no-win argument. Similarly, countering “freedom of choice” with assurances that we support choice deprives us of many more powerful arguments. It also deflates our message by turning it into just part of our opponent’s message.

Ultimately, we learned that the best response was to avoid using the word “choice” at all. In fact, it helped to listen carefully to the language used by our opponents, and then avoid repeating it altogether. There are many ways to frame the bag issue more effectively. Here are some of them:

Unethical marketing and the badness of Big Pharma:
Many people do not realize that the name-brands advertised on most formula bags are owned by two pharmaceutical giants: Abbott Labs (Ross/Similac) and Bristol-Myers Squibb (Mead Johnson/Enfamil). We knew that there was a growing movement against the unethical marketing techniques employed by the pharmaceutical industry. To build on that momentum, we reframed the discussion:

“Why are hospitals marketing baby formula?” The very question makes a powerful statement.

“Hospitals should market health and nothing else.”

“The only way to sell more formula is to sell less breastfeeding.”

“Formula companies aren’t giving away freebies just to be nice; they’re doing it to build profits.”

“We would never tolerate the idea of giving out coupons for Big Macs on the cardiac unit.”

“People, not profits.”

We also had a graphic of the bags on our website, accompanied by the phrase, “Compliments of Big Drug Companies.”

Once we framed the issue as drug company marketing, and not “feeding choice,” we were in control of the discussion.

Do you want to be used?

“You went to nursing school (or medical school) to take care of patients, not to peddle baby formula.”

We found that hospital staff bristle at the idea of being manipulated by the formula industry. Health professionals shudder when they hear the quote from a Ross training manual that was cited in a Texas court case:

“Never underestimate the importance of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra salesperson.” (Abbott Labs v. Segura, 1995)

Nobody wants to be “sold and serviced.”

Help women follow medical recommendations:
Research shows that when breastfeeding moms get commercial bags, they are more likely to start using formula. The effect is so powerful that it persists even if formula is not in the bag. The result? Women who get bags will be less likely to breastfeed exclusively for the first 6 months, which is the recommendation of all major medical groups. Since health care providers are expected to practice evidence-based medicine, there’s no way for an educated provider to support giving out the bags.

Many people also do not realize that research shows that breastfeeding information provided by formula companies is associated with lower breastfeeding rates than when it comes from a non-commercial source. Having a breastfeeding book or pamphlet in the bag does not actually help breastfeeding mothers.

This data was especially powerful when talking to individual women who argued, “I got a bag, and I liked it, and I still breastfed.”

We countered, “It’s great that you succeeded in spite of the bags. But in carefully designed studies of large groups of new mothers, the bags interfere with breastfeeding.”

“Evidence-based medicine shows that the bags hurt our patients.”

“The bags undermine the advice we give our patients. How can we tell them breastfeed exclusively for 6 months, then hand them a formula bag?”

“We want to support mothers so they can succeed in following medical recommendations.”

The bags advertise only pricey name-brands:
Our opponents often argued that taking the bags away from indigent mothers will hurt them financially. In fact, the bags encourage all parents to spend more money, an average of $700 more a year above store brands.

We found that reporters did not seem to care about the price differential, but women cared deeply. When we exhibited at the American Baby Faire in the spring of 2006, the only thing that grabbed people’s attention as they made a beeline for the Enfamil exhibit was our sign that said, “This free bag costs $700.” Before we put that sign up, people just walked on by.

“The bags aren’t free.”

“This free bag costs you $700.”

In the CDC Guide to Breastfeeding Interventions, it’s noted that the women most susceptible to the effects of the bags are those who are most vulnerable: non-white women, primiparas, and those with illness or complications. Indeed, the bags increase health disparities, not close them.

Breastfeeding is normal:
In 1996, Diane Wiessinger published her seminal treatise, “Watch Your Language,” in the Journal of Human Lactation. She persuasively argues that we should not talk about the “benefits of breastfeeding,” because that implies that formula is normal and breastfeeding is just something “extra.” The American Academy of Family Physicians and the American Academy of Pediatrics both note that breastfeeding is the norm against which all other feeding methods must be compared in terms of health outcomes.

Instead of talking about the “benefits of breastfeeding,” talk about the risks of not breastfeeding.

Instead of breastfeeding “preventing” breast cancer, we should note that breast cancer risk increases with shorter durations of breastfeeding. Instead of “preventing” obesity, we need to talk about “increased risk” with shorter durations of breastfeeding.

Weissinger notes that even the formula industry describes breastfeeding as “optimal” “special,” all of which paints breastfeeding as an unattainable ideal. The undercurrent to this language is that most people just want to settle for “regular” and are not interested in going the extra mile for something “optimal” “ideal” or “special.” As Weissinger notes, “special” requires extra effort.

Breastfeeding is a public health challenge:

The human cost of not breastfeeding can be enormous. The financial costs of the excess disease burden can be eye-opening.

Cite the risks of not breastfeeding, both to mothers and to children, both for acute illnesses and chronic illnesses. When you factor in such big-ticket items as maternal breast cancer and childhood obesity, and the costs become too great to ignore.

The AAP notes that lack of breastfeeding costs the US about $3.6 billion a year in excess health care costs. Other research notes that mothers who aren’t breastfeeding have much higher absenteeism from work.

When citing health risks, include specific statistics rather than just general language about risk. By itself, saying “there are risks of not breastfeeding” may be interpreted as a value judgement. By contrast, saying “babies who are formula-fed have double the risk of diarrhea” sounds informative and scientific.

When the National Breastfeeding Awareness Campaign spoke of the risks of not breastfeeding, critics charged that this language was upsetting to many women. In fact, the original campaign contained statistics about specific health risks, but they were all eliminated following pressure from the formula industry, thereby weakening the campaign and leading to charges that it made women feel guilty. We can take a cue from the formula industry here: the numbers are powerful—use them whenever you can.

Reframe guilt as anger or grief:
Women face countless barriers inhibiting them from following medical recommendations to breastfeed. With the rise of formula, we’ve lost the idea that breastfeeding is normal, and with it, we’ve lost the expertise of grandmothers, aunts, doctors, and nurses. Our society does not readily tolerate breastfeeding in public, and employers too often make it difficult for moms to continue breastfeeding. When women fail at breastfeeding, they often grieve the loss of this precious opportunity. Too often they blame themselves, rather voicing their anger at the myriad roadblocks they face in contemporary American society.

People are often concerned with inducing feelings of “guilt” in women who choose not to breastfeed, or who fail at doing so. But, as Linda Smith of the US Breastfeeding Committee asks, “how much of this guilt is really anger or grief” that women were not supported? Indeed, people feel guilt when they blame themselves for their failings. When a woman recognizes how others have failed her and her baby, she doesn’t feel guilty – she feels angry. Rather than talking about guilt, we need to talk about supporting new mothers so that every mother can breastfeed.

Stand up for mothers and children:
Mitt Romney went so far as to fire one-third of the state’s Public Health Council just before the final vote on the bags, to ensure that women keep getting these marketing message.

The Boston Globe ran a story about Romney’s last minute firings on May 20, 2006. In it, I was quoted as saying, “I think the governor is clearly illustrating that he is more interested in protecting the pharmaceutical industry than in standing up for the children and mothers of Massachusetts.”

What’s your opponent’s real agenda?

Why did Romney go to such extreme measures to make sure women got their bags? We will never know for sure, but 10 days after he quashed the ban in May 2006, he proudly announced a $660 million deal with Bristol-Myers Squibb, the nation’s largest formula maker, to build a pharmaceutical plant in Massachusetts. Such a deal conveniently allows Romney to boast that he “brought jobs to Massachusetts” during his bid for the White House. The plant may bring jobs, but it will bring them at the expense of the 80,000 children born each year in Massachusetts, and at the expense of their mothers, whose commitment to breastfeed their infants continues to be undermined to protect the interests of Big Pharma .

Summary:
Reframe, don’t react. Don’t use your opponent’s language. Cite the research that giving out bags runs counter to evidence-based practices, and remind people that exclusive breastfeeding for six months is the medical recommendation. Breastfeeding is a serious public health challenge. We cannot allow ourselves, as a society, to be manipulated by big corporations that put profits before of the health of mothers and children.