From the bottle to the grave: realizing a human right to breastfeeding through global health policy.

• Author: Meier, Benjamin Mason

1. BREASTFEEDING AS PUBLIC HEALTH A. Maternal and Child Health, Development, and Survival B. Breast Milk Substitutes, Disease, and Death C. Formula Industry Marketing and National Regulation. II. EVOLUTION OF GLOBAL HEALTH POLICY TO REGULATE BREAST MILK SUBSTITUTES A. Global Response to an Individual Harm B. UN Specialized Agencies and the Development of the International Code of Marketing of Breast-Milk Substitutes C. Post-Code Advances in Global Breastfeeding Policy III. A HUMAN RIGHT TO BREASTFEEDING A. Breastfeeding, Capability, and the Right to Health B. A New Rights-Holder for a New Right C. Duty-Bearers in a Globalized and Interconnected World IV. A RIGHTS-BASED APPROACH TO GLOBAL BREASTFEEDING POLICY A. Intersectoral Policy Development Through Global Health Partnerships B. WHO & International Legal Regulation C. Policy Reform Through Human Rights Treaty Monitoring Bodies V. CONCLUSION With millions dying each year from a lack of optimal feeding in the developing world, breastfeeding--the optimal form of infant and young child feeding--holds the potential to save more lives than any other public health intervention. Yet despite this unrivaled lifesaving potential, achievable at a comparatively minimal cost, international law has been unable to develop the global policies necessary to ensure the protection, promotion, and support of breastfeeding. As international law has faltered, human rights advocacy has been conspicuously absent in debates on this pressing public health issue.

   Although human rights scholarship has acknowledged public health as integral to the human right to health, it has rarely analyzed global breastfeeding policy. This dearth of breastfeeding scholarship transcends human fights specialties, with leading elaborations of health rights, (1) reproductive rights, (2) women's rights, (3) and children's rights (4) refraining from any significant discussion on this simple and obvious public health strategy for health promotion. In the absence of a scholarly foundation for human fights in breastfeeding policy, international law has wavered in addressing the global public health harms of breast milk substitute use in the developing world. (5) Analyzing the shortcomings of international law in addressing this pervasive threat from commercial infant formulas, this Article seeks to incorporate breastfeeding protection, promotion, and support pursuant to the international legal obligations of the human right to health, advancing these legal obligations through a rights-based approach to global breastfeeding policy.

   This Article outlines a theoretical framework for a human fight to breastfeeding, laying the normative foundation to propose an institutional framework for rights-based global breastfeeding policy. Beginning with the public health harms stemming from a global failure to realize optimal infant feeding, Part I reviews research on breastfeeding's benefits, highlighting the dangers of breast milk substitutes in the developing world and the actions of formula corporations to subvert national health policy. In moving from these national efforts to international law, Part II traces the evolution of global health policy in responding to the marketing of breast milk substitutes and in promoting breastfeeding practice in accordance with public health standards. Given the limited success of these global breastfeeding policies, Part III envisions a human right to breastfeeding, delineating the fights-holders and duty-bearers of such a right in a globalized world. To operationalize this rights-based approach to breastfeeding, Part IV proposes global health policy partnerships to develop international legal mechanisms through which states might translate a right to breastfeeding into global breastfeeding policy reflective of the public health harms of breast milk substitutes in the developing world.

1. BREASTFEEDING AS PUBLIC HEALTH

   Breastfeeding is the keystone supporting the successful continuation of a healthy intergenerational life-cycle, preventing infectious disease, facilitating birth spacing, and reducing chronic disease. However, many families use commercial infant formula, imperiling these health benefits to maternal, infant, and child health. Through aggressive marketing in an increasingly deregulated market, formula manufacturers have created a multi-billion dollar industry worldwide, pushing their product far beyond their original markets and causing irreversible health harms, especially in the developing world. Given consistent evidence of poor health outcomes from breast milk substitutes (even under optimal environmental conditions, but with deadly consequences under suboptimal conditions), breastfeeding advocates have long sought to promote exclusive breastfeeding as a universal norm, to be overridden only when medically necessary.

   This Part provides background on the public health benefits of breastfeeding and reviews the inherent and consequential dangers associated with undermining breastfeeding through the promotion of infant formula. Breastfeeding has been shown to have a positive, pervasive role in public health--across maternal health and child health, across health promotion and disease prevention, across communicable disease and chronic disease--with breast milk substitutes undercutting these multifaceted benefits. Due to exploitative dependencies on formula and deadly consequences from their use, breast milk substitutes are particularly dangerous in the developing world, where poor sanitation, malnutrition, and poverty conspire to cause the death of millions. Analyzing how social norms regarding breastfeeding are influenced by the marketing methods of transnational infant formula and baby food corporations, this Pan concludes that national health policy responses remain woefully inadequate to address formula marketing and to protect, promote, and support breastfeeding.

   1. Maternal and Child Health, Development, and Survival

      Analytic reviews have repeatedly revealed the enormous impact of breastfeeding on global child health, nutrition, development, and survival. With nearly nine million child deaths each year--primarily in low-income countries, with half in Sub-Saharan Africa (6)--this understanding has drawn attention to the substantial morbidity and mortality burdens attributed to suboptimal breastfeeding conditions: 1.4 million deaths and 43.5 million disability-adjusted life-years (DALYs) annually. (7) This infant death toll is largely attributable to infectious diseases, including diarrhea, pneumonia, measles, malaria, and HIV/AIDS, all of which can be reduced by optimal breastfeeding. These analyses conclude that exclusive breastfeeding for the first six months of life, with continued breastfeeding for at least one year, is the single intervention that could save the largest number of children's lives globally, preventing fifteen percent of child deaths and overcoming health setbacks from preterm and low birth weight deliveries. (8) Therefore, the World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, with continued age-appropriate breastfeeding in both developed and developing countries. (9)

      Evolutionarily honed to provide all the nutrients necessary for the survival, growth, and protection of the baby, (10) human milk is a living tissue, with breastfeeding continuing the biological "dyad" established in utero between the infant and mother and providing optimal nutrition for the development and growth of the child, (11) Human milk contains all of the nutrients critical to infant growth--a unique balance of proteins, carbohydrates, water, antibodies, hormones, micronutrients, and macronutrients--with the balance of these components adjusting during each feeding and over the course of lactation to provide the most appropriate nutritional content to the infant. (12) Even when the mother's nutrition is poor, the components and caloric content of her milk is not significantly changed, (13) with breastfeeding continuing to provide optimal infant nutrition despite adverse maternal conditions. (14)

      As a means of providing nutrition while protecting health, breastfeeding supplies irreplaceable immunological benefits and protections to the immunologically fragile newborn through the protective factors of human milk. (15) Numerous studies demonstrate the impact of breastfeeding on reducing the risk of ear infections, non-specific gastroenteritis, and severe lower respiratory tract infections. (16) Breastfeeding provides this anti-infective protection--through the production of oligosaccharides, interferon (which has been found to fight viruses), immunoglobulin A, lactoferrin, lysosyme and other enzymes, as well as living cells--and promotes the production of lactobacilli and other helpful bacteria in infant intestines, which protects against the growth of a variety of disease causing organisms. (17)

      In addition to breastfeeding's well-understood impact on early growth and child survival, recent studies have shed light on breastfeeding's significant impact on long-term growth and development. (18) Compounding the harms of under-nutrition and disease, recent data suggest a correlation between shorter breastfeeding duration and increased risk of obesity in childhood and later life. (19) Further, premature breastfeeding cessation reduces an infant's defense against atopic dermatitis, asthma, type 1 and 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis. (20)

      Supporting health and growth, breastfeeding also facilitates neural development and increased cognitive development. After controlling for genetic, socioeconomic, behavioral, and environmental factors, breastfed children score significantly higher than formula-fed children on a variety of intelligence tests (e.g., IQ scores and academic grades) throughout childhood, with these benefits enhanced by increased breastfeeding...