This is a transcript of the Gastropod episode, The Milk of Life, first released on June 21, 2022. It is provided as a courtesy and may contain errors.

NEWS ANNOUNCER: The out of stock rate for baby formula in the US was more than 40% at the beginning of the month.

ASHLEY LANE: My sister picked me up some in Arvada yesterday, my dad up in Thornton the other day.

NEWS ANNOUNCER: Ashley Lane in Colorado is one of the many moms struggling to find the formula her infant son needs.

CHRISTINA DEMAURICE: The worsening baby formula shortage has become every parent’s worst nightmare. Searching high and low only to find empty store shelves.

MOM: I bottle feed. And you can, I can not find it anywhere. I have to go all the way to Springfield to get her formula. It’s scary.

NICOLA TWILLEY: Unless you have been living under a rock, you’ve undoubtedly heard that getting hold of formula milk to feed your baby in the US right now is way harder than scoring tickets to a Billie Eilish concert. It was already 40 percent out of stock in March, and then it went up to 70 percent out of stock by early June.

CYNTHIA GRABER: This is in part because one company at one factory makes a full quarter of all the infant formula in the US. In February, the plant was shut down because of contamination issues there that had led to the death of as many as nine babies, according to the most recent information.

CARLA CEVASCO: And so that plant is now starting to start production again, but it will be months before they are up to full production. And in the meantime, millions of people around the United States, millions of families are being affected by this really dramatic shortage in infant formula.

TWILLEY: For the young and helpless segment of the population that relies on formula, this is a food crisis, and we at Gastropod are on it — that’s right, you are listening to Gastropod, the podcast that looks at food through the lens of science and history. I’m Nicola Twilley.

GRABER: And I’m Cynthia Graber, and this crisis made us curious. How did we get here? What is formula actually—why do so many parents rely on it to feed their babies, and why do so few companies make it?

TWILLEY: And on our way down the rabbit hole, we also wondered: what happened to babies before formula was invented? And what’s so different about human milk compared to other species, like cows?

GRABER: This episode we’re telling the story of human milk, human milk substitutes, how we got to the crisis today, and where we should go next.

TWILLEY: This episode is made possible in part by the Burroughs Wellcome Fund, in support of our coverage of biomedical research, and by the Alfred P. Sloan Foundation for the Public Understanding of Science, Technology and Economics. Gastropod is part of the Vox Media Podcast Network, in partnership with Eater.

PRE ROLL 1

GRABER: Cecilia Tomori is the director of global public health and community health at the Johns Hopkins School of Nursing. She loves to write about and talk about and promote breast milk.

CECILIA TOMORI: It’s a particular secretion that has been around for millions of years, that actually predates mammals.

TOMORI: It’s both a food. And also what sometimes we call a medicine because it has immunological properties and anti microbial properties. It’s also a form of hydration.

TWILLEY: It’s the Swiss Army knife of beverages! And it is produced and dispensed exclusively by mammary glands. Lawrence Weaver is a pediatrician who wrote White Blood: A History of Human Milk, and he says these mammary glands were probably originally sweat glands that adapted to produce a special anti microbial coating for eggs.

TWILLEY: But then, once these animals stopped producing eggs and switched mostly to placentas, they started secreting a magical white liquid instead.

WEAVER: Human milk or breast milk is really modified blood.

GRABER: Lawrence says that humans have in our blood all the nutrients we need to keep us alive and give us energy and defend ourselves against infections — basically blood is what helps all of us, including mothers, live a healthy life.

WEAVER: And in order to set up the baby to do the same thing, she produces a distillate or a modified version of her blood. Which is actually human milk. It’s in many respects, like blood, but it doesn’t contain the red blood cells.

WEAVER: And it has many of the same properties. And that’s one of the reasons I call my book White Blood, because this is what the ancients in the ancient Greece and Rome, and so on, regarded milk as. And they were entirely right.

TWILLEY: Of course humans are not the only species that make this white blood. That cow’s milk I put in my tea? Also white blood.

GRABER: But we mammals, we don’t all have the same white blood. For instance, seals are born in the Arctic and they need lots and lots of fat to stay warm, so seal milk has ten times more fat than ours does. Lawrence says that tiny tree shrews, which grow super fast, their milk has eight times more protein than ours does.

TWILLEY: Each species’ milk isn’t just tailored to the baby’s needs, it’s also tailored to the mothers’ lifestyle.

TOMORI: A rabbit may put their infants in a burrow and therefore the milk is adapted so that the baby does not have to be fed in a particularly frequent way.

TOMORI: Whereas primates are really different from that and they evolved a carry strategy so that they are in close contact with their infants.

TOMORI: So that means that the milk of humans is pretty dilute. It reflects that strategy and that reflects the frequent feeding both during the day and during the night.

GRABER: So human milk is pretty dilute because we feed our babies frequently, but the ingredients are also really particular to what a human baby needs.

WEAVER: Well, the ingredients list would probably run to over a thousand different chemicals. Different sorts of protein and different sorts of carbohydrate, different sorts of fat and so on.

TWILLEY: Lots and lots of fats, in fact — a full half of the calories in human milk come from what scientists call PUFAs, long-chain polyunsaturated fatty acids. And that’s because we have big brains.

WEAVER: The brain is about 60% fat. It’s a great sort of lump of fat made up of millions and millions of neurons.

WEAVER: And every one of these neurons or these nerve cells has a membrane around it to contain its contents. And those membranes are made of what are called polyunsaturated fatty acids.

WEAVER: And they are very unique to the human baby, they’ve got unpronounceable names like do-casa-hexanoic acid. And arachadonic acid and so on.

GRABER: Breast milk also contains all sorts of hormones and antibodies to protect against infections and digestive enzymes that help the baby’s gut break down all that fat. The ingredient list goes on and on.

TOMORI: Some of the things in breast milk also feed other microorganisms. And so there’s also a microbiome that human milk cultivates in the gut of the infant.

TWILLEY: That’s right, human milk also contains sugars that humans actually can’t digest — they’re specifically for microbes! Drink!

GRABER: Yep, breast milk helps feed the microbes that are colonizing an infant’s gut to become the gut microbiome. Amazing. But also amazing, the ingredients in breast milk change over time.

WEAVER: The milk early on immediately after birth is often called colostrum. And this is loaded with what are called immunoglobulins, antibodies.

WEAVER: They’re sometimes described as antiseptic paint. They line the guts and to a certain extent, the respiratory tract and act as a barrier against infection.

TWILLEY: After those first few days, human milk becomes fattier and richer in protein and the levels of antibodies go down a little and from then on it stays relatively stable — but not completely.

GRABER: Because the milk doesn’t just change over the course of a few months, it also changes over the course of a single feeding.

WEAVER: As the feed goes on, the fatty content gradually increases. And then that acts as a sort of satiety signal turning off the baby’s hunger as it were, or appetite.

TWILLEY: We could go on, but basically, it’s amazing.

WEAVER: Human milk is a, an extraordinary living substance containing everything that the newborn baby needs. Not just as food, but to help it adapt to life outside the womb, to protect itself from infections, to regulate its growth.

GRABER: But just because something is amazing doesn’t mean that it’s always available.

CEVASCO: There have always been babies who have not been able to have breast milk for various reasons.

CEVASCO: In the past one in 20 women could have died in childbirth. And so there might — mom, you know, might not have been around period.

TWILLEY: This is Carla Cevasco, she’s a food historian at Rutgers University and she is working on a book about feeding infants and children in early America. And she said, even if the mother didn’t die, sometimes breastfeeding still wasn’t an option.

CEVASCO: Impoverished women or enslaved women have always needed to return to work soon after birth.

CEVASCO: And then breastfeeding is, is hard for a lot of people. It’s a lot of time. It’s physically very demanding. In the past, issues like cracked nipples or mastitis could actually be deadly because you know, there weren’t antibiotics.

CEVASCO: And that’s, before we get into things on the infant side. You know, being born premature, having a cleft palate or other reasons for having trouble latching.

CEVASCO: And then that’s before we get to people, you know, like adoptive parents or people who have always, you know, people have always needed some sort of breast milk substitute throughout history.

GRABER: And for a lot of those babies who couldn’t have their mother’s breast milk, this was a death sentence. In his book, Lawrence says that in a hospital in Dublin, the director in the late 17, early 1800s wrote that for babies who weren’t nursed by their moms, 99 percent of them died.

TWILLEY: That was a particularly shocking statistic, but it’s not a complete outlier — for most of history, babies who couldn’t be breast fed by their mothers didn’t do so well.

GRABER: But there were some options. One of those is a wet nurse.

WEAVER: Babies might be brought up by a wet nurse. Michelangelo is said to have been brought up by a wet nurse. Mohammed is said to have been brought up by a wet nurse.

TWILLEY: Wet nurse is the old school name for a woman that breastfeeds a baby that is not her own.

GRABER: This is possible because of another amazing thing about breast milk, and it’s that mammary glands will produce more if more is demanded of them. Like if there are two babies nursing instead of one, the woman’s glands can produce double the milk.

CEVASCO: Before the 19th century, most, you know, married women were spending decades of their lives bearing children or nursing.

CEVASCO: So there were a lot of lactating people around.

WEAVER: In Rome, for instance, a lot of well to do mothers chose to employ a wet nurse. And wet nurses were often slaves.

CEVASCO: So this was a choice option, when we’re looking at very wealthy populations. So people who could afford to hire a servant, or, you know, in places with slavery, you know, have an enslaved person breastfeed their children. That was a matter of choice for some people.

CEVASCO: And it was actually, for the nobility in Europe, there was pressure to produce a lot of heirs. And so, there’s a recognition that breastfeeding does have a contraceptive effect. It’s not foolproof, but.

CEVASCO: So the result was that there were husbands, there were wealthy husbands who had pushed their wives, you know, to give their babies to wet nurses so that they could get back to creating more heirs for the family.

TWILLEY: Like Carla says, oftentimes, wet nursing was a thing rich women could afford and poorer women did. But Lawrence says that in Paris in the 1700s, everyone hired wet nurses. The rich women did it because they could, and the poor women did it because they had jobs working in shops or as servants and seamstresses, and they couldn’t afford to take the time off.

WEAVER: And there was a organized market really, in human milk.

WEAVER: The baby went off to the wet nurse when it was about two or three weeks or so. And came back, if all was well, two years later, nappy trained, clean, walking, having been not just fed, but of course, brought up by the wet nurses.

WEAVER: And the whole economy of Paris and the villages around, was organized around this.

WEAVER: And the mothers could work freely in Paris. And Paris in this time was described by someone as a “city without babies.” Because all the babies were out in the villages around.

GRABER: For babies whose moms couldn’t feed them for whatever reason, like all those babies in Paris, wet nurses were a better option than nothing. But the babies didn’t always thrive.

TWILLEY: Because these women were poor and because wet nursing was a business, Lawrence said sometimes wet nurses cut corners.

WEAVER: If they’re taking on too many babies, they were what’s called hand feeding or dry feeding the babies. Ie, feeding them with things other than their own milk.

WEAVER: They were using various things to sedate the babies, to calm them down, which didn’t help and so on.

WEAVER: So there was a fair amount of what you might politely call bad practice, and it became described by the end of the end of the 19th century as baby farming.

GRABER: That said, it wasn’t all baby farming. Sometimes babies did thrive with wet nurses, and sometimes the whole set-up was just communities helping each other.

CEVASCO: Somebody who was having trouble nursing, in the days after birth could turn to neighbors or family members or friends, you know, other people who are likely to be nursing.

CEVASCO: And there were definitely babies who were, who were fed just that way in these sort of informal, you know, community relationships, as opposed to that paid or enslaved, you know, labor relationships that are happening among wealthier people.

TWILLEY: Wet nursed babies and babies fed by their own mothers were, obviously, consuming human milk. But like Lawrence said, there was also something called “dry feeding” — feeding babies with something other than human milk. And we are going to tell the story of breast milk alternatives after this break.

MIDROLL 1

GRABER: So let’s start with a story from Carla’s upcoming book.

CEVASCO: So one of the stories that I write about is this woman named Elizabeth Hanson who is taken captive. She was a mother of six and she had just had her sixth child two weeks prior, when she was taken captive by Wabanaki Raiders during Dumar’s War in 1724.

CEVASCO: So Hanson, you know, was not a new parent and she didn’t mention having trouble with breastfeeding before.

CEVASCO: But being taken captive, walking long distances, not having access to food and doing all this really close to postpartum, her milk dried up, and she was unable to feed her child.

CEVASCO: So in that situation, it was a Wabanaki woman who taught her how to make Wabanaki baby food, basically. To boil walnuts and water together with fine cornmeal. And this made a food that the baby was able to eat. And Hanson said that, you know, the baby thrived and looked well after eating this diet.

TWILLEY: For as long as there have been babies needing to be fed and unable for any number of reasons to be fed on human milk, there have been substitutes. Obviously, there’s the milk of other mammals — cow’s milk, sheep’s milk, even pig’s milk. None of those are the same as human milk — even without modern chemical analysis, people could tell cow’s milk was thinner and not as sweet as human milk. So they attempted to remedy that by adding some starch and sweeteners, some sugar or honey.

GRABER: Carla told us there were two official categories of what was called dry feeding in early modern Europe and the European colonies. These two infant foods were called pap and panada.

CEVASCO: So pap is milk and flour or bread crumbs, panada tends to add in broth into that mixture.

CEVASCO: And then the native American versions that you see of these things tend to be sort of nuts and corn, sometimes meat or broth in there as well.

TWILLEY: Once you’ve got your substitute, you’ve got another problem—the problem of how to get this pap or panada or whatever mush into the baby without your breast as delivery vehicle.

TWILLEY: Carla told us about pap boats, which were super shallow sort of dishes to help the food cool down before feeding the baby. But there were also bottles.

AMY BENTLEY: There are archeological findings that show types of bottles or gourds being possibly used for infant feeding. Nipples were a problem. So they were sometimes made of cork, made of a bladder, animal bladder, a glass tube.

GRABER: Amy Bentley has been on the show before, she’s a professor of food studies at New York University and author of the book Inventing Baby Food. We had her on before to talk about introducing babies to solid foods for our episode First Foods. But she also researched how infants were fed.

BENTLEY: There were a variety of types of delivery devices invented. Glass bottles were manufactured eventually and became the standard. And then, and then plastic with rubber nipples.

TWILLEY: So did any of those babies fed panada and pap in a gourd with a cork nipple actually make it?

CEVASCO: Sometimes they did. Sometimes they didn’t. We don’t have, like, the best demographic data from these time periods.

CEVASCO: But there was definitely an understanding that infants who were spoon-fed or for these alternative foods did die at higher rates than breastfed children.

GRABER: There are a few reasons why babies didn’t thrive on these substitutes. For one, for the first few months of a baby’s life, its gut isn’t actually able to digest any carbohydrates except for lactose. It can’t digest sucrose for instance, like in sugar or honey, it can’t digest proteins in cow’s milk without help.

WEAVER: The baby is incapable of making proper use of the milk that’s going into its gut, which will lead to malnutrition, but also lead to diarrhea because those nutrients are just coming out the other end.

TWILLEY: And then the substitute milk wasn’t necessarily clean, nor was the bottle it was served in.

WEAVER: These very easily got contaminated with bacteria. And they contributed to the diarrhea. So it’s a sort of mixture, malnutrition and diarrhea are interlinked. They go together as it were.

GRABER: But on the other hand, if you were a desperate parent who had no other way to feed your baby, you did what you could.

CEVASCO: Babies who aren’t getting breast milk can starve, right. People were turning to these alternative foods because they had no other choice.

CEVASCO: And they often did it knowing that there was a danger of illness or malnutrition in their children, but they did it because they had no other choice.

TWILLEY: So that was how babies were fed for most of human history—human milk, from their mum or someone else, or, in desperate situations, these dry feeding alternatives. But by the 1800s, with the rise of modern science in Europe, a few things happened at once.

TWILLEY: For one, people started measuring everything they could, and one of the things they started measuring was infant mortality. And the numbers were pretty shocking.

GRABER: This had European governments nervous, because a lot of them were heading out and colonizing the world and fighting with each other, and they needed a lot of bodies. Carla told us the British government made breast feeding a political priority.

CEVASCO: The British empire is gearing up to go invade the world. And there’s actually a big public health campaign to convince mothers to breastfeed their own babies because it’s seen as you know, a way of lowering the infant mortality rate and creating more British people. You know, more and more healthy British citizens to go out and take over the world.

TWILLEY: But, as always, there were some babies who couldn’t for whatever reason be breast fed. Fortunately, in the 1800s, Pasteur figured out germs and John Snow figured out the importance of clean water, and milk and water supplies got a lot cleaner.

BENTLEY: I mean once water supplies and milk supplies were safe, that took out a lot of the danger out of it.

GRABER: Cows milk plus some added ingredients still wasn’t a complete substitute for breast milk, as we mentioned. But luckily, modern chemistry had taken on the task.

BENTLEY: In the mid to late 1800s, you start to have scientists understand the chemical properties of food. And that included breast milk.

BENTLEY: You had some formulas that were commercially prepared, starting in Germany and England. These were called proprietary formulas. They claim to mimic the composition of breast milk in the way that they understood the components at that time, which were primarily carbohydrates and proteins and milk solids.

TWILLEY: Formula was literally a mathematical formula that contained the proportions of ingredients that you needed to combine to arrive at a human milk substitute. Which is why it’s called formula milk, still today.

BENTLEY: And so they would take some wheat, and they would take some cows milk and they would take some sugar to act as an extra carbohydrate and create formulas in the attempt to mimic the chemical composition of breast milk.

BENTLEY: Of course, there’s a lot more in breast milk than they were able to understand at the time.

GRABER: But nevertheless, they kept at it—scientists worked on refining these formulas, and companies in the late 1800s, early 1900s, they jumped right in to sell the new products.

TOMORI: And then really Nestle’s the one who formalizes it.

TOMORI: So while there are others who are making attempts, Nestle’s the one who kind of figures out how to… not just create something, but something that is very marketable.

WEAVER: It contained a cereal in it, which wasn’t much good for the newborn, but that became popular and advertised quite widely.

WEAVER: These adverts tended to start with a headline saying “no more wet nurses, this wonderful stuff will, you know, be just as good” and so on.

TWILLEY: For centuries, dry feeding had been seen as a distant third choice for feeding babies. Human milk, from the baby’s mother or from another woman, was seen by everyone as preferable. But with this new scientific formula, that started to change.

GRABER: Part of the reason that new scientific formula caught on so quickly was that the medical profession had started to specialize. Until this point, midwives had been assisting birthing itself and then they also helped new moms who needed assistance with breastfeeding.

GRABER: But in the 1800s male obstetricians started to take over that first stage, childbirth.

TOMORI: So once childbirth is controlled by the medical system, that also creates a market for infancy to be also controlled by medicine. And also creates a whole new market for what became pediatrics.

TWILLEY: This was also unsurprisingly a male field of expertise. And these men approached the question of feeding infants with the best of intentions and classic Enlightenment rationality.

TWILLEY: They started to do things like regularly weighing babies and measuring how much milk they were drinking and when, compared to how much they grew, and they came up with rules that turned feeding infants into what they saw as a science.

GRABER: And they positioned themselves as the ones to provide the best possible outcomes for babies.

BENTLEY: They had professional and scientific expertise, and therefore had more expertise about child-rearing and infant feeding than say, midwives did, or parents did. That parents may maybe shouldn’t trust their instincts, shouldn’t trust their, you know, folk remedies anymore, that we should listen to professionals.

GRABER: In the US, one of the key figures in this new professional field of pediatrics was a man named Emmet Holt, he was one of the fathers of modern pediatric science. He wrote basically THE manual in the US at the time called the Care and Feeding of Children. Cecilia told us that in theory, he seemed to be supportive of breastfeeding…

TOMORI: He had this whole quote about how, you know, breastfeeding is great. And then the other part is like, well, except for if you have these emotions. And then he essentially lists up every emotion that you could possibly have. And so then, you know, then it’s not good.

TOMORI: (Laughs) You know, so. He’s really, um. He’s really undermining that idea.

TWILLEY: This passage from Emmet Holt’s book is really, pretty ridiculous. He blames the quote failure of the modern mother as a nurse on quote “Uncontrolled emotions, grief, excitement, fright, passion,” which you know, does cover a lot of the bases.

GRABER: Dr. Holt claimed that basically any strong emotion a mother might have could, again, here’s a quote, “cause milk to disagree with the child. At times they may excite acute illness, and at other times may cause a sudden and complete disappearance of the milk.”

TWILLEY: Meanwhile, Dr. Holt’s own advice for how to breastfeed actually directly decreased a woman’s ability to produce milk. He had a rigorous schedule that he prescribed for feeding, with mothers told to let the baby quote “cry it out” in between.

TOMORI: So Emmet Holt advised that you don’t feed your baby very often and you don’t feed them at night at all.

TOMORI: And if you cut out feedings, then lactation doesn’t really work very well.

GRABER: Because once a baby doesn’t feed from a mother’s breast as frequently, the mom doesn’t produce as much milk. So basically, if women who were breastfeeding followed Dr. Holt’s advice, they wouldn’t have had enough milk to feed their baby.

TWILLEY: Fortunately, Cecilia told us, Dr. Holt also made and promoted his own formula. The perfect solution to a problem largely of his own making.

GRABER: Dr. Holt wasn’t alone in this, of course, the other new pediatricians followed his lead, and they promoted formula as well. And the companies started picking up on this new idea of science proving the need for formula, and they used it in their marketing.

TOMORI: One of those efforts was to, for example, commission scientific studies that were sponsored—paid for and commissioned by Nestle.

TOMORI: And they basically said, well, you know, breastfeeding is wonderful. It really is this ideal thing. But it’s so unreliable!

TOMORI: You know, it doesn’t really work and basically, it needs to be supplemented from a very early age or it just doesn’t really work, you know, like even in the very early stages.

TOMORI: So, you know, idealized and at the same time undermined is a very pivotal tactic.

TWILLEY: Another part of the undermining concerned the other traditional solution for a mother who wasn’t able to feed her own baby — a wet nurse. That system, as we’ve said, had its problems. And formula companies were not afraid to exploit those anxieties for their own benefit.

GRABER: One of those anxieties was this centuries-old idea that a wet nurse didn’t only give the baby milk, she also transmitted some of her own characteristics. We told you that Michelangelo was fed by a wet nurse, and he laid his success as a sculptor at her feet, because she was a stone mason’s wife.

TWILLEY: But because most wet nurses historically were usually poor and often also women of color, that potential for transmission could easily be portrayed — and often was — as a negative in racist advertising.

TOMORI: And, you know, there were these ideas about how wet nurses could potentially pollute the character of the infant, that they could transmit their, you know, poor characteristics.

TOMORI: Which are really like code for, you know, poverty and ethnic and racial minorities.

GRABER: So the medical profession was encouraging formula feeding, the companies were obviously marketing it big time. And then especially after World War II, there were a bunch of other cultural factors that had come into play, too. Amy says that for one, there were more women in the work force, and they found formula feeding useful.

BENTLEY: I mean, it’s convenient. It frees up a woman from being held to a regulated schedule, being always on demand, for their infant. So it provides some flexibility and freedom for a woman.

BENTLEY: But there’s also an emerging culture of the sexualization of women’s bodies, especially the breast.

BENTLEY: And so you get the world war II pinup girls. Rosalind Russell. We get Marilyn Monroe.

BENTLEY: And so that has an effect on breastfeeding in that breasts become sexual and less functional, I think. Less, mammary glands, like a cow, useful for feeding their infant and more sexual parts of a body for men’s pleasure for instance.

TWILLEY: Ah, the good old days where women existed solely for men’s pleasure. All of this together meant that by the 1950s, only one in four American newborns were breastfed at all for any length of time.

DOCTOR: Much of your baby’s health depends on his getting enough of the right kind of food. Your doctor will prescribe what is right for your baby’s needs.

GRABER: This is from a 1950s instructional video for new parents called Baby Goes Home, a guide to care and feeding.

DOCTOR: Since baby gets his food by sucking, it must be liquid food. That means a formula. The baby’s formula contains milk. This supplies protean for bodybuilding and growth.

DOCTOR: The formula also contains carbohydrates, such as dextramaltose, to supply more nourishment and to make baby’s food better balanced.

DOCTOR: The formula also contains water. This dilutes the milk to make it easier for baby to digest.

DOCTOR: So you see the formula is more than just milk.

TWILLEY: Incredibly, there is no mention of breast feeding at all. Formula was clearly best. After all, this was the era of better living through chemistry.

CEVASCO: So formula is marketed as something really modern and scientific. This is how a lot of baby boomers recall their parents approaching, you know, industrialized food in general.

CEVASCO: Why waste time chopping vegetables when you can have them out of this sleek, space age can, right?

CEVASCO: And so there’s a similar philosophy at work in pushing formula. As, you know, breastfeeding is hard, it’s getting in the way of your modern life. It takes all this time. Why would you want to do that?

CEVASCO: So that formula is marketed as this, you know, modern, clean, hygienic, scientific solution to the problem of feeding infants,

CEVASCO: And it’s the period of the industrialization of the food supply in the United States and in Europe, right? So it’s the moment when processed foods start to emerge.

CEVASCO: And it’s significant, I think, that one of the early processed foods that people want to make is infant food.

VOICEOVER: All babies are different. That’s why hospitals send more babies home on formulas made with Pet evaporated milk than on any other form of milk.

VOICEOVER: For a Pet milk formula is flexible. It can be adjusted exactly to each baby’s need.

BENTLEY: Hospitals, when a woman had a baby in the hospital, you always went home with a couple of cases of infant formula as part of your swag. (Laughs)

VOICEOVER: Your doctor prescribes the formula, the amount of water and Pet milk to use. And the kind and amount of sugar or syrup to add.

VOICEOVER: A Pet milk formula fits your baby’s needs as no ready-made formula ever can. It’s exactly right. For your special baby.

GRABER: Medicine, companies, culture—the result is, for decades, really only a small percentage of people in America gave breastfeeding a try. But then by the late 1960s, things started to change. That story, coming up after this break.

MIDROLL 2

TWILLEY: So, we’ve talked about this before, but in late 1960s early 1970s, there’s the rise of the hippie movement, and really a lot of social unrest and change.

GRABER: People were protesting the Vietnam War and watching Watergate unfold. News programs reported on the horribly unethical things companies were doing, like polluting rivers so intensely that the rivers caught fire…

BENTLEY: You see emerging distrust of corporations. A distrust of science, a distrust of government, disillusionment with government, with officials.

BENTLEY: There was the emerging consumer movement, Ralph Nader and center for science in the public interest, which started to advocate for the consumer.

BENTLEY: And this also applied to food and food for everyone, but also infant food. People started to look at the way infant food is manufactured. The way formula was manufactured.

BENTLEY: And so you have a rising consumer movement, a rising counterculture movement, that sees food as… the need to take food back from corporations to the emergence of natural foods.

BENTLEY: There’s also emerging scientific studies that are beginning to point to oh, maybe breastfeeding was better than these formulas. Maybe there’s benefits to breast milk that we didn’t really understand before.

BENTLEY: And so public health campaigns start to reverse the mid 20th century messaging and start to encourage breastfeeding more.

CEVASCO: So that the pendulum actually starts to swing again at the end of the 20th century away from, you know, this moment that’s the low ebb of breastfeeding towards an embrace of breastfeeding.

TWILLEY: But the formula companies have shareholders and they need to keep growing. And so when their market share dropped a little in the US, they started aggressively targeting new markets in the developing world, in countries like India and South Africa and Mexico.

TOMORI: So you have industry sponsored conferences and meetings.

TOMORI: You’ve got health professionals who are trained by the company. You even have groups of people who are pseudo health professionals. So, hiring what looks like nurses, but turn out to be industry representatives.

TOMORI: And so they’re going into maternity hospitals and aggressively promoting their products as a solution to malnutrition.

GRABER: They did things like helping fund the architecture for newborn care facilities and doling out excessive amounts of money to the medical profession.

GRABER: Nestle also apparently hired women dressed up like nurses to show up at new parents’ homes and explain how, sure, breastfeeding is great, but the baby really needed much more, and better to provide it with Nestle formula sooner rather than later to prevent any problems from occurring.

TWILLEY: Formula milk had an aura of Western modernity, and like in the West, governments and medical professionals endorsed it. And the companies’ own marketing was even more shameless if possible. And so women in the developing world started adopting this magical formula substance en masse.

GRABER: But just dropping in this Western model of relying primarily on formula? It didn’t work.

BENTLEY: Of course women couldn’t afford it or they would water it down and the water would be contaminated and it caused a lot of infant illness and death.

TWILLEY: Estimates of exactly how much death were hard to pin down, for obvious reasons — and they varied widely. One US AID doctor who was a big opponent of Nestle’s tactics in the developing world claimed that the company was responsible for a million babies dying every year from malnutrition and diarrhea. Other estimates were lower.

GRABER: In any case, it was bad, and it became a huge, huge scandal. It sparked a global boycott of Nestle, and in 1978 there was a Senate hearing on the marketing of formula in developing countries. Here’s Ted Kennedy introducing that hearing.

TED KENNEDY: Can a product which requires clean water, good sanitation, adequate family income and a literate parent to follow printed instructions be properly and safely used in areas where water is contaminated, sewage runs in the streets, poverty is severe, and illiteracy is high.

GRABER: And here he is cross-examining a Nestle rep.

KENNEDY: Would you agree with me that your product should not be used where there is impure water?

KENNEDY: Yes or no?

NESTLE PRESIDENT: Uh, we give all the instructions-

KENNEDY: Just, just answer it, what would you, what is your position?

NESTLE PRESIDENT: Of course not! But we cannot help with that.

TWILLEY: Oof. Eventually, this global outrage led to the development of the International Code of Marketing of Breastmilk Substitutes, which was adopted by the World Health Assembly. It’s supposed to protect against unethical marketing of the sort that Nestle was doing.

TOMORI: And when the code was proposed at the World Health Assembly in 1981, the United States voted against it.

GRABER: Have to protect the companies at all cost, nothing like capitalism. But okay, despite the US vote, the World Health Assembly adopted that, so, no more unethical marketing and promotion of formula, right?

TOMORI: You know, whenever we talk about this to students, you know, they’re like, oh yeah, you know, we kind of heard about something, you know, it was like the Nestle scandal and they’re like, well, this is done now. You know, it’s over.

TOMORI: And in fact, what happened was they just regrouped. And then figured out new ways to expand the market. And actually have been enormously successful at expanding their reach.

VERONICA MAK: So in Hong Kong, it is widely acceptable that the mother doesn’t want to breastfeed.

GRABER: Veronica Mak is a professor at Hong Kong University, and she wrote a book called Milk Craze: Body, Science, and Hope in China. She told us she did in fact breastfeed a decade ago, but it was so rare that she was memorable.

MAK: I am brave enough to feed in coffee shop, I have on my clothes to cover. Yeah.

MAK: But do you know that even nowaday my son after 10 years, the coffee shop, and parties can still remember, I’m the one who breastfeed.

MAK: So you can imagine how rare it is in Chinese society the woman breastfeeds.

TWILLEY: Veronica told us that there’s a variety of reasons why it has been so unusual for Hong Kong women to breastfeed, but part of it is cultural expectations. Hong Kong mothers are under all kinds of social pressure to get right back to their pre-birth working woman selves.

MAK: I still remember when I, after I give birth, there’s another very elegant lady next to me.

MAK: After she gave birth, she already talking to her Chinese medical doctor, asking him, okay, what kind of Chinese medicines she need to take in order to get her body slim.

MAK: So this kind of mentality that the woman needs to — back to sort of normal body shape. Doesn’t look like a mother, look like, yeah, a very young woman. And also work like normal.

MAK: Is a kind of, I would say that very highly capitalist city like Hong Kong that is very, for the woman, very appearance conscious. And body shape conscious.

TWILLEY: The other part of that capitalist, workaholic culture is that parenting in Hong Kong and increasingly mainland China can be hyper competitive, And that’s where the formula companies step in with their messaging, doing what they’ve always done — sowing doubt.

MAK: This is more like a kind of illusion that is very much created by the pharmaceutical company, making the woman feel uncomfortable or not have confidence in breastfeeding.

GRABER: Just like in the 60s and 70s before the Nestle boycott, the companies’ marketing makes women feel inadequate. They’re working hard, they’re exhausted, and they’re being told their milk isn’t sufficient—

MAK: So this is one of the most common reasons that the mothers, in addition to they want to give the best for the kids, they also doubt that, whether her milk is good enough.

TWILLEY: And, of course, formula companies help confirm that idea and then promote the benefits of their product. They hype all the omega-3s…

MAK: They do a lot of advertising, putting the young kids, that they can, after drinking the milk, they can have all that kind of nutritions.

MAK: Can, forming a sort of super brain for the baby. They advocate that they can good for the language, movement, intelligence, creativity, and even emotion.

MAK: So it’s quite strange. I don’t know why they can even put it under emotion.

TOMORI: Some of them will make claims about how it helps you sleep. That’s one of the other common ones. How it makes you less colicky, how it builds your brain.

TOMORI: A lot of these are claims that are being made, but they’re actually not supported by evidence.

TOMORI: But because the regulations, you know, are so loose and because they fought against those regulations, they can continue to make those claims. And they do.

GRABER: There’s little science behind most of these claims, obviously. And if we’re talking science, there’s more of the good brain fats in human breast milk than in formula milk. But this kind of marketing, even supposedly illegal unethical marketing, it works.

TWILLEY: In fact over the past 15 years, the global infant formula market is reported to have doubled in size. And it’s projected to double again over the next five.

GRABER: Today, in America, about 85 percent of women start to breastfeed after they give birth, but by six months, only about 25 percent are still breastfeeding exclusively. Honestly, the figures seem to be pretty similar to those in Hong Kong.

TWILLEY: What that means is a lot of parents rely on formula.

GRABER: But this does raise the question: sure, the companies’ marketing is over the top and unethical, but is feeding children formula really a problem?

TWILLEY: Okay, so there’s no doubt that formula milk today can’t mimic the way that a mother’s breast milk is so precisely tailored and changes according to her environment and the individual baby’s needs. Formula is a standardized product. It can’t change.

GRABER: And there’s a lot of data that says clearly that breast milk is ideal for a growing and developing baby, and if a parent can and wants to breastfeed, in the US, around the world, they should.

TWILLEY: In the developing world, which is where more than four fifths of children are born today, UNICEF has estimated that breastfeeding for at least six months could save something like 1.5 million babies’ lives every year — lives that are currently lost to malnutrition and diarrhea from bad sanitation and formula dilution.

GRABER: Cecilia says breastfeeding is clearly better also for the long-term health of babies everywhere. But frankly it’s hard to study those long-term benefits, because you can’t say, hey this group of people has to breastfeed, and the other one has to formula feed, that would be unethical.

TWILLEY: Which means it’s really hard to tease out what difference is made by breastfeeding, versus what difference is made by, say, the socio economic status of parents who choose to and are able to breastfeed.

TWILLEY: Some researchers have suggested that, when you look at the statistics, a lot of the benefits that seem to be associated with being breast fed are actually due to those kinds of socio economic advantages.

GRABER: But others, including Cecilia, point to studies that have been done that try to account for socioeconomic status and do still find differences. This is not easy to tease out long-term. What we do know is that modern formula can feed babies.

BENTLEY: Babies thrive on formula. Most American babies in the mid 20th century were formula fed. I was formula fed and I’m fine.

BENTLEY: So, it’s easy to get hung up on the nuances of breast milk and, and feeding habits of parents. I think the upshot is parents do the best they can under the circumstances that they have.

TWILLEY: Which brings us right back to our current crisis. Where, the circumstances are that a lot of parents rely on formula, and there isn’t enough on the shelves right now. Part of the reason for that is that globally, the formula milk industry is super consolidated.

GRABER: That is extremely true in America.

TOMORI: You know, the entire market is in the hands of, you know, four or five companies that are multinational.

TWILLEY: This consolidation has been exacerbated in the US sort of accidentally through the Special Supplemental Nutrition Program for Women Infants and Children, or WIC, as it’s usually known.

TOMORI: And it really is a formula subsidy program, sort of, in an unintentional way. So attempting to help people feed their babies, but essentially providing free formula.

GRABER: The way it works is that entire states request bids for their WIC contracts for all the free formula that WIC hands out. If a company wins that contract, the sales are so big that they basically have a monopoly in that state.

TOMORI: And essentially, that is how Abbott ended up consolidating their market so much is because they have so many of these exclusive contracts.

TWILLEY: Abbott is the company whose factory in Michigan was closed down because of contamination. That one factory made a quarter of all America’s formula. Hence the current crisis.

GRABER: So that’s how we got to this crisis, how we got to needing a lot of formula, and relying on a very small number of companies to provide it.

GRABER: When the crisis hit, though, there was a real backlash to the anxiety and panic that a lot of families expressed, basically saying that they were complaining unnecessarily. Just one famous example: the actress Bette Midler tweeted: “Try breastfeeding, it’s free, available, and on demand.”

BENTLEY: Well, it’s never free. There’s no such thing as a free lunch or bottle of breastmilk.

BENTLEY: You know, it requires the wherewithal, the confidence, the time, the space, the psychic space to breastfeed. The commitment. It does require commitment. And all of that is time or money or, support from family members and friends.

BENTLEY: And many women have that, but many women don’t.

TWILLEY: Also Bette, I hate to say it but once someone is using formula, they can’t easily go back to producing more milk, that’s basic biology.

GRABER: Another part of the backlash came from people honestly like someone in my family, she was born in the 40s, and she commented on Facebook that people should just make their own formula at home. She said that her mom probably did. Carla saw a lot of comments like that one.

CEVASCO: And I’m like, no, no, no, we don’t want to go back. Talk to, like —

CEVASCO: And just because people may have done okay on these kinds of foods in the past doesn’t mean that they pass muster for, you know, by our modern, you know, nutritional and medical standards today.

TWILLEY: For Carla, one big takeaway from this whole crisis is the government needs to step up and regulate the formula market, reducing the monopolies and diversifying the supply chain to make it more resilient against this kind of failure.

CEVASCO: That means that we need to recognize formula, not as, you know, a necessary evil or some sort of modern luxury, but just an essential part of, you know, the lives of millions of Americans.

CEVASCO: And that means constructing our policies and our supply chains accordingly. That we do not ever face this situation again, of people running short of the only food that they can feed their children.

GRABER: We asked Cecilia about this, and she agreed that the industry needs to be better regulated and that it shouldn’t be in the hands of only a few companies. But basically she didn’t think the solution to the problem was necessarily more formula, at least not in the long term.

TOMORI: Why not make this a call for enacting paid leave, which we desperately need, that everybody would benefit from regardless of how they feed their babies?

TOMORI: Why is it that we’re not even talking about human milk banking?

TOMORI: You know, we could have a milk bank in every city, multiple places, which is exactly what Brazil did.

TWILLEY: This idea — that rather than use formula, parents who can’t feed their child themselves could turn to a human milk bank, like a kind of modern version of wet nursing — that’s something we’ve saved to explore in our special supporters’ newsletter.

GRABER: But there’s also a lot that can be done to help families breastfeed. Cecilia mentioned better parental leave, there’s also easy access to lactation experts, maybe a mom needs medication that can promote her milk production.

TOMORI: When you look at it on a population level, what you can see is, you know, in communities that support breastfeeding, you have much higher success.

TOMORI: For example, the UK has really low breastfeeding rates over time. You know, and then you compare it to, like, Sweden next door. Like it’s not that people in the UK are somehow physiologically different.

TOMORI: One system works better than another. One has better support than another.

TWILLEY: It’s not actually that hard. Human milk is great for human babies, we can and should do a lot more to make human milk available for human babies, by supporting the people who produce it and finding ethical safe ways to share it.

TWILLEY: Also modern formula prepared in situations where sanitation is not an issue is also good for babies. In fact, it can be a life-saver, which means it should be regulated as the essential it is.

GRABER: As is clear from the current crisis, there are very real things we need to fix. But as we’re also seeing today, this question of what to feed your baby is fraught. And it always has been. And that leads to a whole lot of anxiety and unnecessary guilt.

GRABER: What’s the most important is to keep a baby alive and well however you do it.

TWILLEY: Thanks this episode to Carla Cevasco, Cecilia Tomori, Lawrence Weaver, Veronica Mak, and Amy Bentley, we have links to their research and books on our website, gastropod.com.

GRABER: And thanks of course to our wonderful producer Claudia Geib for all her help this epsiode.

TWILLEY: Thanks also to our dearly beloved former producer Sonja Swanson, who helped us *formulate* this episode a while back.

TWILLEY: Don’t forget to support the show at the $5 or $9 level to receive our extra special newsletter. Thanks to Sonja and Claudia, it will contain the curious underground market for breast milk among body builders, as well as Brazilian milk banking and some very odd looking early breast pumps.

GRABER: We’ll be back soon. ‘Til then!