Intercepted Letter

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Intercepted Letter BREAST IS BEST Dear Christopher, Now that you are to be a fully fledged paediatrician, let me first of all applaud your desire to do some research for the first time in your life. I support your hunch that breast-feeding is both a worthy and a productive topic. You ask for my views and experience as an experimental pathologist, and here they are. Everyone knows that "breast is best", at least where babies are concerned. But the topic looks like becoming as much a matter for polemics and lobbying as for the cool assessment of any evidence there may be. My own view, for the record, is that breast is indeed best (for babies); but that we will lose the baby with the bathwater if we are not a little more convincing about it. It is a matter for regret that, though paediatricians are almost unanimously and passionately in favour of the breast, their influence is negligible or even negative. I

wonder why? The usual general proposition is. that the human breast "was meant" to feed the human baby, and that, if it "fails", the best substitute is a product designed to mimic the human material. This proposition is incontrovertible, even though there is very little evidence for it. It is a "fact of life". The medical profession-in England at least-has always had an ambivalent attitude to the scientific, evidential method. Thus a conviction which is poorly supported by proper evidence will be adhered to very strongly if it is something that "Nature intended"; but doctors will ignore that Nature may well have intended the high infant mortality of a generation and more ago; and did she really intend that children should be given killed viruses through a needle or on a sugar lump, or extracts of various moulds? The scientific, evidential method of reasoning is rejected in practically every clinical circumstance unless it shows some sign of being adducible in favour of an emotionally held fact of life; just as a clinical measurement or investigation will often only be accepted if it accords with the predetermined clinical impression. When either of these coincide, a tremendous air of pseudoscientific learning is often assumed, the most bogus logic is resorted to, and statistics of the kind which will prove anything are embraced. The main clinical sin remains the old one of misread-. ing the word casual as causal. Thus the current increase in our consumption of Cypriot or Egyptian potatoes is casually related to the present spate of ingrowing toenails. This is not so very far removed from the recent wave of conviction that neural-tube defects were due to potato’blight, for which there was never very much real evidence. The difference between the two examples-the MESSERT, DR. QUAGLIERI: REFERENCES—continued 9. MacKenzie, G. J., Taylor, S. H., McDonald, A. H., Donald, K. W. Lancet, DR.

1964, 1, 1342. 10. Szam, I. Münch. med. Wschr. 1972, 114, 594. 11. Cropp, G. J., Manning, G. W. Circulation. 1960, 22, 25. 12. Keszler, H., Oppelt, A., Sliz, K., Vyska, K. Acta anœsthes. scand. 1968, suppl. 29, p. 61. 61.

first of which is manifestly absurd-is that in the second we all have a desperate, emotional thirst for some sort of solution for a terrible human problem, together with a greater or lesser degree of guilt that our much-trumpeted cleverness still awaits its reward. Cot deaths are a similar case. The need for a solution is so emotionally pressing that an intense search is in progress for any casual relationship with them-such as bottle feedingand it is but a short, predictable step that the mind’s typewriter will slip, and casual will become causal. It is perfectly true, of course, that the solution to many problems has begun with the observation of a casual relationship. But we conveniently forget those which are unproductive, or even frankly misleading. For example the casual observation of cholesterol crystals in plaques of atheroma has led to a quarter-century of research based on the supposed causal relationship between the two. Probably the only people to have derived any benefit from this have been the researchers themselves who were kept in a job, and certain sections of the food industry. The chances are that even the high serum-cholesterol of the atheromatous is unrelated to the cholesterol in the plaque and that neither has any more causal relationship to atheroma than cold weather has to Christmas. Articles for the promotion of breast-feeding would often make wonderful set-pieces for courses in the medical abuses of logic, even though they are almost certainly correct in their general conclusions. Let us examine the usual list of conditions incriminating artificial

feeding. Infections.-The immunological properties of colostrum are well-known, and there is sound evidence that colostrum should be ingested by the baby because it confers immunity. Farmers have known this longer than doctors. However, there can be little evidence that breast-feeding beyond the first few days will add very much in this respect, the clutching-to-the-bosom of recent scientific discoveries related to immunoglobulin content of breast milk notwithstanding. In another example, the prevalence of gastroenteritis in bottle-fed babies accords best with the proposition that it is less easy for underprivileged mothers, lacking in hygienic facilities, education, and motivation, to feed uninfected artificial milk to their babies than to breastfeed them cleanly. If bottle feeding had been shown to be would

have

highly advantageous

in other respects,

been surrounded by

public clamour for the relief of underpri-

a

we

now

vileged, working-class conditions rather than for these mothers to breast-feed their babies. It might even now be the better of the two solutions. Dirty homes, however breast-fed their children, will continue to generate more than their share of childhood infections.

Hypocalcaemia.-Infant convulsions, perhaps significantly, are

yet another potentially serious condition about which doc-

so that the ratio of demand for available information is very high indeed, and the hypocalcaemia of bottle-fed infants will not lack its adherents for the argument.

tors are a

desperately puzzled,

solution

to

Hypernatrcemia.-Here supporters of breast-feeding are on surer ground, though it is alarmist and probably quite unjustified to associate hypematnemia causally with brain damage, the relationship being in great measure casual and far from diIn any case it is not the modern artificial feed which is the culprit but the manner in which the mother makes it up. So why blame the feed? rect.

Obesity.-The best doctors have heard of the recent doubts about the supposed dangers of infant obesity, leading allegedlY to middle-aged obesity and its related lethal hazards-as in-

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teresting a hoax perpetrated by the ptediatric profession on itself as any to be found. This does not prevent them from addmgit to the list of dangers of the bottle. This they do somewhat unscrupulously, usually with the personal convenience of having backed all the runners by mentioning the hypothesis and at the same time exhibiting awareness of its weaknesses. Cou’s milk allergy undoubtedly exists, but along with other allergies is hard to quantify and is a good standby diagnosis outside the major centres of interest in the subject for any puzzling episode of apparent digestive upset in a baby.

Secrotising enterocolitis.-It is not fair to add this highly fatal and distressing condition of unknown aetiology to the argument. Doctors are extremely worried that they personally are the cause of it on special-care baby units, and it is characteristic of human nature, but not excusable, for them to wish to add it to the ragbag of sins attributable to an outside source like artificial feeding. Cot death.-As has been said, there are as many theories of its setiotogy as there are people searching for them and, although several look mildly promising, the area is best described as one of total ignorance. An association with bottle feeding may indeed be meaningful, just as is the association of geographical latitude with multiple sclerosis (see below). But no more so.

Atopic diseases, ulcerative colitis, coronary vascular and multiple sclerosis.-Here is another collection of

disease,

serious,

yet puzzling diseases. It is quite reasonable for doctors to feel very ignorant and even very guilty that they have no explanation for them. But it is quite unreasonable for them to lash out at any target in the vicinity, such as artificial feeding, to account for them and save their personal bacon. For example,

Round the World

remarkable fact about multiple sclerosis is its gradually increasing incidence the further North the population. It is not a matter of climate, since distance from the equator has nothing to do with it. Thus it is very uncommon in South Africa, and very common in Scotland and Scandinavia. Is it therefore wicked, or unnatural, to live in northern latitudes? I can see no justification whatever-indeed one might say it is seriously irresponsible-to add these diseases to the ragbag just because sporadic papers have appeared "suggesting" their relationship to bottle feeding. Further, it is downright bad doctoring as well as lacking in ordinary humanity to threaten mothers with them as a penalty for not feeding their babies themselves, as seems to be so often suggested. a

prominent recent article its author came to three conclusions: (1) breast-feeding should be more strongly In

a

advocated than in the past for

MOUNTING DISCONTENT

THE soaring cost of medical care in the U.S. is producing further resentment’and dissatisfaction among the public: a reaction that is being exploited by certain Congressmen whose chances for reelection in November are somewhat uncertain. The American Medical Association and other medical organisations blame the increased costs on expensive therapeutic advances, such as renal dialysis and coronary-artery bypass surgery, but the argument carries no great weight. Congress and the news media keep asking why the U.S. spends 7S%-8% of its gross national product on health care-a gross national product which, per head, exceeds that of all other countries-and yet lags behind many Western European nations in life expectancy and infant mortality. Fortunately, for the U.S. medical profession, most Congressmen have not heard of Ivan Illich, and, even granting the possibility that they had, it is likely they would ignore him as a left-wing revolutionary propagandist. Nevertheless, his writings sustain the suspicions of those who believe that the responsibility for the high cost of health care in the U.S. can, for the most part, be placed squarely on the shoulders of the medical profession. Permitting, and sometimes encouraging, multiplication of costly facilities (such as intensive-care units and linear acceinterceding for the construction of new hospitals

lerators),

only S0%-60% occupied, promoting

unproven medical rituals, perpetuating unbalanced training programmes (so that until two or three years ago, most teaching hospitals produced more neurosurgeons than general prac-

uuoners), reacting sharply to any form of Government control r

planning, suffused with good

intentions but

two

weeks and

Yours, Daddy

ship, the medical profession has become the whipping-boy of the politician. It has been estimated that the cost of bypass op-

United States

are

least

the diet before the age of 4 months should be discouraged. I cannot find anything in these conclusions to disagree with, although my backing for them would be largely for reasons of the emotional and behavioural bonding of mother and baby. I "believe" this to be important with all the tenacious attachment which might be expected of a doctor for a "fact of life". I am surprised that few writers on the subject mention it much. With best wishes to Sue on the impending arrival of my first grandchild. I wonder if she will feed him.

erations for coronary-artery disease will reach$1 billion (American billion 1 000 000 000) this year-and this for an operation whose benefits are unproven. A further$15 billion or so is spent on the "the annual physical" or what Time magazine renamed "the annual rip-off." For years the A.M.A. and the American Cancer Society have been advising the public to "go get yourself a check-up," yet the president-elect of the A.M.A. and its immediate past-president, interviewed recently by a Time reporter, came out against routine physicals. At about the same time as the Time article, a relatively objective piece in a Sunday magazine section of the New York Times examined the evidence that routine health check-ups are beneficial and found it unconvincing. A series of 50 000 routine sigmoidoscopies in asymptomatic but at-risk patients gave a yield of bowel neoplasms of around 25. The A.M.A.’s change of heart may be related to the fact that if a Democrat is elected President in November, some form of National Health Insurance is probable and the A.M.A. wishes to keep the costs within bounds. The Federal Government’s solutions have so far been unpromising. About two years ago, Professional Standards Review Organisations (P.S.R.O.S) came into existence. The purpose of P.S.R.O.S is to limit unnecessary admissions to hospital and to cut down on long stays. Each hospital admission is now reviewed within 24 hours to see whether it is necessary, and the investigations carried out and treatment given are scrutinised for conformity to the "regional norm." The net effect of P.S.R.O.S so far seems to have been the hiring of new clerical and administrative staff, more bureaucratic form-filling for physicians, and an extra$25-$45 on the bill of every patient who is discharged from hospital. P.S.R.o.s have not been shown to improve medical care or to lessen substantially the number of hospital admissions-but perhaps it is a little early. All of which, it seems, makes National Health Insurance inevitable: the question is when and in what form. =

which, once opened,

at

preferably four months; (2) when breast feeding is not possible one of the new low-solute milks should be recommended; (3) the introduction of solid foods into

lacking leader-