Breast Milk As Medicine And Virus: Modern Maternity And HIV/AIDS

January 15, 2010 at 5:56 pm

John & Penny Hubley, Wellcome Images, London Breast feeding: health promotion . In this urban slum in India, a poster on mother and child health and breast feeding is being tested. Ideally, health education programms should start with trials in small groups before wider implementation.  Second half 20th century

Commentary by Bernice L. Hausman, Ph.D., Professor, Department of English; coordinator of the undergraduate minor in Medicine and Society, Virginia Tech.

Biologically speaking, breastfeeding has always been a health-promoting practice of motherhood. Within modernity, breastfeeding has become a consciously health-promoting activity through a complex historical development that has rendered all forms of eating and nutrition as analogs to a healthy lifestyle. To single out breastfeeding may seem to ignore the ways in which many other foods have become medicalized in the last half century. After all, eating has long been the focus of health advocates and lifestyle politics in the United States. Yet what is specific to the figuration of breast milk as medicine concerns, at least in part, the fact that breast milk is the only food produced in the human body for human consumption, and it is produced almost exclusively by female humans.

Breast Milk as Medicine

Breastfeeding's contribution to health is imagined through the representation of breast milk as medicine. This figuration appears prominently in guidebooks for new mothers. La Leche League's The Womanly Art of Breastfeeding contains a short section in its first chapter where the reader learns that breastfeeding provides not only the "best possible infant food," but that it aids in contracting the uterus after birth, helps the development of the infant's jaw and facial structure, "safeguard[s]" the baby against the development of food allergies, "inhibit[s] the growth of harmful bacteria and viruses," contributes to a higher IQ for the baby, protects the mother from breast cancer, ovarian cancer, urinary tract infections, and osteoporosis, and contributes toward the sex education of older children. (1) In another example from a global publication on breastfeeding and HIV, colostrum is defined often as "the infant's first vaccine." (2) In yet another example, this one from a local breastsfeeding coalition newsletter, a neonatologist writes, "The benefits of breastfeeding in terms of species specificity, balanced, changing nutrients and enzymes, host resistance factors, immunologic protection, allergy protection and psychosocial development, make breastmilk [sic] the most important and cost effective substance we have in medicine today." (3).

I believe that these claims concerning the biological benefits of breastfeeding are true, by the way. The point here is to examine the unfolding of a story about breast milk as medicinal, not to question the biological truth-claims of such a story. In the short section of The Womanly Art of Breastfeeding cited above, the new or expectant mother learns to think of her body as producing a substance with effects that are defined and measured in medical terms. Almost all breastfeeding advocacy in the United States works on this model—medical benefits and measures of breastfeeding's "natural superiority" couched in language also suggesting the central closeness that emerges in the mother-infant breastfeeding relationship.

Cultures of Breastfeeding/Breastfeeding in Culture

In general, breastfeeding operates within cultures as a behavior promoting the core values, beliefs, and practices of that culture. For example, in The Afterlife Is Where We Come From, anthropologist Alma Gottlieb demonstrates that West African Beng culture treats infants very differently than conventional U.S. families, understanding infantile behavior to be essentially unpredictable and without a knowable cause. Scheduled feeding and sleeping is an unknown value and thus not sought after, even though mothers are often separated from infants of 2 months of age when they return to work in the fields. While some maternal infant feeding practices, like feeding newborns and young infants water before nursing, are rationalized as healthful, Beng conceptions of health are themselves mediated primarily by spiritual belief rather than by medicine as an institutionalized form of knowledge about the body. (4)

In heavily medicalized contexts like the United States, the "nature of infants" is understood to be biologically determined; infants fuss because of a physical or physiological need. Scheduling feedings corresponds to a belief about "normal infants" as cohering to cultural values; "good babies" are those who eat at specific times and sleep in predictable, lengthy units (especially at night). (5) All of these factors are presented in advice books as healthful because they are understood to be biologically appropriate for growing infants, yet it is not hard to discern that medical ideas provide a justificatory rationale for culturally specific practices and perspectives on infant behavior.

In addition, a discourse of mother-infant closeness is grafted onto the medical narrative of biological causation, bolstered by pseudo-scientific ideas of "bonding." (6) The loving relation of mother to baby is founded on the transfer of a medically pure substance in a gift exchange. (7) This gift of breast milk is also a gift of medicine itself. Breast milk is not just a nutrient with medicinal effects, like an "anti-oxidant" or vitamin, something that helps avoid allergies and disease, but a pharmacological substance, a product associated with medical research and industrial production.

Yet what makes breast milk special is that it comes from women's bodies-it is figured as food and medicine made by women. It is also part of a cultural debate—longstanding and largely displaced from explicit social recognition—about whether mothers can really succeed at mothering. Cultural messages about pure milk and the implication that breast milk itself is medicinal are bound up with presumptions about good mothering and the embodied purity of good mothers. (8)

Scientific Motherhood

Scientific motherhood, defined initially by Rima Apple in Mothers and Medicine and developed in her later book Perfect Motherhood, is the notion that maternal practices are best subjected to the authority of medicine and the (presumably male) physician. (9, 10) In the context of scientific motherhood as an ideology, maternal knowledge and traditional practices do not hold the same authority as the scientifically derived understanding of doctors; thus, individual mothers are taught to rely on the advice of expert professionals. The best mothers are those whose practices promote growth and development that can be defined and measured by medical personnel.

Currently, in the United States, breastfeeding is a practice in service to the ideology of scientific motherhood, and, at least discursively, breast milk is the product that leads to the medically defined "healthy development" of babies. "Good mothers" are also narrative effects of these practices, figured through their selfless labor in relation to their infants' health, their disciplined relation to their own body projects, and their attentiveness to the purity of their own bodies. Scientific motherhood is a white ethnoracial and middle-class construct, although it serves as a model for all women's behavior and many different groups of women subscribe to its values. Scientific motherhood has also transformed the disciplinary experience of being a maternal body. If, in the early part of the last century, mothers were encouraged to stop feeding coffee to their babies because coffee stunted the growth of infants and led to digestive problems, now we see in pregnancy and infant care guide books advice to mothers to eliminate or diminish their own consumption of coffee and caffeinated beverages in order that the caffeine not affect their fetus or nursing infant.

Barbara Duden has discussed this kind of thinking as the figuration of the maternal body as an ecosystem, and she argues that its overall effect is to disembody women. (11) What this development alerts us to is a perception of the female body itself as a danger to fetuses and infants, for what mother can keep herself clean enough to avoid the transfer of some noxious agent? We are all the repositories of the chemicals that permeate our environment. In another historical shift, in the 1970s and 80s the body of the mother was posed against the bottle as the source of goodness figured against poison. If the image was striking—as the Nestle boycott meant it to be—it was effective. Now, however, the body of the mother is not clearly the good ending to the story of how to keep babies healthy and alive; it is instead implicated in the illness narratives of her infant. And there is no limit to the purity that can be demanded.

Breast Milk as Virus

The advent of HIV/AIDS has made salient the viral possibilities of breastfeeding. The opposition medicine/virus operates to enhance medicine's authority over mothers. In its articulations in affluent countries, it contributes to maternal anxiety and concern over breastfeeding. In poor countries, where the majority of HIV-positive mothers live, uncertainties about the meaning of breast milk are intertwined with bleak outcomes for many infants and children.

Biomedical research itself is not uniform in its understanding of mother-to-child HIV transmission rates and optimal feeding protocols. The World Health Organization (WHO) has developed guidelines for infant feeding in the case of maternal HIV infection that emphasize maternal informed choice. The AFASS criteria—which define whether replacement feeding is ACCEPTABLE, FEASIBLE, AFFORDABLE, SUSTAINABLE, and SAFE—are supposed to be evaluated in each instance. If these criteria cannot be met, mothers are counseled to breastfeed exclusively during the first months of an infant's life. Yet scholars suggest that myriad factors interfere with the model of rational decision making imagined in these guidelines. Indeed, sometimes even the simple understanding that a mother's milk contains HIV will be enough to convince a woman not to breastfeed, regardless of her circumstances (12, 13).

"Informed choice" situates the mother in the middle of a scientific and social controversy, and then asks that she make a decision responsive to her material and social circumstances and an abstract understanding of biomedical risk. HIV-positive mothers are figured as modernized individuals whose success at mothering is a blend of rationality, choice, and options. It is my view that these guidelines implicitly imagine the privileged mothers of the global north as their exemplary ideals, mothers for whom "choice" is understood (however improperly) as a relatively free endeavor and whose choices are supported by the social, cultural, and medical infrastructure of their communities.

Choice, Breastfeeding, and Modern Motherhood

It is not that I would want to deny choice and the agency it relies on to (mostly impoverished) HIV-positive women. Rather, I'd like to suggest that we need to reorient the utopian views of good mothering that frame and constrain our perceptions of what mothers do and the choices they make. Mothers need to be understood as neither the repositories of pure nutrition nor the potentially infectious contaminators of the young, but as materially embedded subjects whose bodies are of this world as everyone's are. It is probably impossible to return to breastfeeding a set of meanings untouched by medicalization, but it is possible to construe its significance as not completely captured by medical narratives and understanding.

Medical narratives that frame good mothering as the result of rational choices made on the basis of biological imperatives ignore the social and cultural contexts of practice that exist for all mothers. The medical framing of breastfeeding has obscured for many of us the important cultural functions that nursing enacts, and thus makes it difficult to see how HIV-positive mothers are affected by multiple social determinants. It is not just that the affluence of the global north makes understanding the practices of impoverished mothers of the global south difficult; it is that we no longer believe that breastfeeding has any other meaning than to create (biomedically) better babies.

It is my view that the biomedical and public health struggles over how to advise HIV-positive mothers point us toward larger issues concerning the social meaning of mother's bodies and mother's practices. These are, in Anthony Giddens's words, some "consequences of modernity." (14) To offer women more than a strait-jacket of choice, we might begin with a revision of the stories told about breastfeeding, especially those that suture its meanings to medicine and normative expectations of maternity.

References
1. La Leche League International. The Womanly Art of Breastfeeding. 6th ed. Schaumburg, Ill.: La Leche League International, 1997, 6-7.
2. Linkages. Infant Feeding Options in the Context of HIV. Washington, DC: Academy for Educational Development, April 2004. Web. www.linkagesproject.org (accessed October 15, 2004).
3. Wight, Nancy E. "Breastfeeding in High Risk Populations: The Mom with Hepatitis." Breastfeeding Update (San Diego County Breastfeeding Coalition) 1, no. 4 (December 2001): 1, 4. Web. www.breastfeeding.org/newsletter/v1i4 (accessed March 8, 2004). Emphasis added.
4. Gottlieb, Alma. The Afterlife is Where We Come From: The Culture of Infancy in West Africa. Chicago: University of Chicago Press, 2004.
5. Millard, Ann V. "The Place of the Clock in Pediatric Advice: Rationales, Cultural Themes, and Impediments to Breastfeeding." Social Science and Medicine 31, no. 2 (1990): 211-21.
6. Eyer, Diane E. Mother-Infant Bonding: A Science Fiction. New Haven: Yale University Press, 1993.
7. Golden, Janet. A Social History of Wet Nursing in America: From Breast to Bottle. Cambridge History of Medicine. Cambridge, U.K.: Cambridge University Press, 1996.
8. Meyer, Dagmar Estermann, and Dora Lucia de Oliveira. "Breastfeeding Policies and the Production of Motherhood: A Historical-Cultural Approach." Nursing Inquiry 10, no. 1 (2003): 11-18.
9. Apple, Rima D. Mothers and Medicine: A Social History of Infant Feeding, 1890-1950. Wisconsin Publications in the History of Science and Medicine, no. 7. Madison: University of Wisconsin Press, 1987.
10. Apple, Rima D. Perfect Motherhood: Science and Childrearing in America. New Brunswick, NJ: Rutgers University Press, 2006.
11. Duden, Barbara. Disembodying Women: Perspectives on Pregnancy and the Unborn. Translated by Lee Hoinacki. Cambridge, MA: Harvard University Press, 1993.
12. Blystad, Astrid, and Karen Marie Moland. "Technologies of Hope? Motherhood, HIV, and Infant Feeding in Eastern Africa." Anthropology and Medicine 16.2 (August 2009): 105-18.
13. Moland, Karen Marie, and Astrid Blystad. "Counting on Mother's Love: The Global Politics of Prevention of Mother-to-Child Transmission of HIV in Eastern Africa." In Anthropology and Public Health: Bridging Differences in Culture and Society, Second Edition, edited by Robert A. Hahn and Marcia C. Inhorn, 447-79. New York: Oxford University Press, 2009.
14. Giddens, Anthony. The Consequences of Modernity. Stanford, CA: Stanford University Press, 1990.

The Healthcare Debate And Disability Studies

July 29, 2009 at 9:26 pm

Neil Leslie, Wellcome ImagesMedicine - diagnosis and treatment, Digital artwork/Computer graphic

Two related items in the Science Times section of Tuesday’s New York Times (July 26) drew my attention. One was Dr. Abigail Zuger’s book review of Normal at Any Cost by authors Susan Cohen and Christine Cosgrove and the other was an essay entitled "To Overhaul the System, ‘Health’ Needs Redefining," by Dr. H. Gilbert Welch. What these articles have in common is that both ask us to re-examine what is meant by "normal health." And both articles raise this issue in the context of current national discussions about runaway health care costs.

The book that Zuger reviews deals with "the medical industry’s quest to manipulate height" using growth hormone. Zuger notes that "the boundaries of ‘normal’ height are hazy, and the drug’s performance is measured only in averages." According to Zuger, the book’s authors deduce that every inch of growth gained by hormone treatment costs $50,000. As height is increasingly manipulated to satisfy social standards as well as pharmaceutical and medical profits, costs rise; of equal importance is the failure to promote social acceptance of a wide range of heights.

Gilbert Welch frames his argument more generally. The "medical-industrial complex" needs patients and so it defines health as "the absence of abnormality." Increasingly, the range of normal has been narrowed. But "more often than not, the value of treating . . . mild abnormalities is simply not known" and physicians in training "are increasingly confused about who is really sick and who is not."

Questions about the definition of normal, about who gets to define "normal," and about the medicalization of the body are at the core of disability studies scholarship. So it would seem that in the debate about health care funding and cost control, some of this scholarship needs to be injected. Policy wonks and legislators should be aware of this body of work. In the context of these two articles we could point them to the work of those who have addressed these issues for more than a decade. For example, Robert Aronowitz demonstrated in 1998 that disease definitions are influenced by the vested interests of physicians, researchers, and policy makers in the biomedical enterprise and are not immutable biological entities, disconnected from their cultural context (Making Sense of Illness: Science, Society, and Disease. Cambridge: Cambridge University Press, 1998, pp 11-14).

Lennard Davis discussed statistical norms: "When patients are treated they are not treated as individuals but as instantiations of norms. . . While normalcy requires that I appear in person as an individual before my health care giver, I am treated by reference to laboratory and statistically determined medical norms. A good deal of the energy of being alive becomes devoted to this imperative to conform physically." (Bending over Backwards: Disability, Dismodernism and Other Difficult Positions. New York: New York University Press, 2002, pp. 115-116).

Kathryn Pauly Morgan developed a medicalization model of pregnancy (conception, gestation, and birth) in North American culture. (Contested bodies, contested knowledges: Women, health, and the politics of medicalization. In S. Sherwin, ed., The Politics of Women’s Health: Exploring Agency and Autonomy. Philadelphia: Temple University Press, 1998, pp. 83-122.)

Susan Wendell outlined the social construction of abnormality and disability: "Disability is socially constructed through the failure or unwillingness to create ability among people who do not fit the physical and mental profile of ‘paradigm’ citizens." (The Rejected Body: Feminist Philosophical Reflections on Disability. New York and London: Routledge, 1996, p. 41).

Also relevant are "The Meaning of Normal" by Philip Davis and John Bradley in What’s Normal?A eds. Carol Donley and Sheryl Buckley (Kent, Ohio: Kent State University Press, 2000, pp. 7-16) and selections from The Tyranny of the Normal, eds. Carol Donley and Sheryl Buckley (Kent, Ohio: Kent State University Press, 1996)

And all of us should remember Paul Starr‘s important book, The Social Transformation of American Medicine, published in 1982.

Felice Aull

Summer Blogging: Traveller’s Joy

July 20, 2009 at 3:58 pm

Traveler's Joy

We are taking a break from our regular essay commentaries until September.A In the meantime, there will be occasional short postings, mostly by me (Felice Aull). This image of the plant, Traveller’s Joy, invokes this summer interlude — the pleasure of enjoying gardens, parks, nature (at least in the northern hemisphere) and of vacation traveling, but also the possibilities for intellectual travel, creative travel, and other explorations beyond familiar borders. Here are some thoughts to begin with.

We learned today that author, Frank McCourt, died on Sunday, July 19.A His memoir (creative nonfiction?), Angela’s Ashes, is one of the most compelling, absorbing, and entertaining books that I have ever read (and I read a lot). I was moved to annotate it for the Literature, Arts, and Medicine Database as soon as I finished reading it in 1996, and before it won The Pulitzer Prize and the National Book Critics Circle Award. In addition to being well-crafted and devastatingly sad, it was witty-a rare combination. But the book and its author pulled me into their orbit for additional reasons.

McCourt had taught for years at Stuyvesant High School, an intellectual rival of my own alma mater, the Bronx High School of Science, and located just a few blocks from where I live — until it moved to its present location near Battery Park City. Not only that, but somehow I found out that Frank McCourt LIVED a couple of blocks away from me, in a nondescript apartment building. I wanted to contact him to invite him to be a speaker in the Literature, Arts, and Medicine Speaker Series sponsored by NYU School of Medicine, where I taught and organized the series. He could speak, I thought, about deprivation and resilience, humor and illness, writing and the self, the human condition. Among the medical students and faculty he would be addressing were many who had graduated from Stuyvesant High School, and some who even remembered him as their teacher.

I don’t remember how-probably just by searching the phone book-but I found his telephone number. When I called, a pleasant woman answered the phone and said she would give him my message. I waited several weeks without hearing from him and phoned again. This time, there was an answering machine that gave out very little information. Apparently, the book had taken hold, publicity was churning out, and his life was no longer confined to East 18th St. His gain, and our loss. I never read the books he wrote after Angela’s Ashes — I didn’t want to spoil the pleasure that book had given me.