This is good news. The Minister of Health in SA has started an important process to get South Africa breast feeding again, to save lives.

My colleague Mark Richards and I have published the following article in South Africa’s Sunday Independent newspaper on the subject (Dateline – 4th September 2011). It is not available online  so we are putting it here:

Investing in the breast

Tony Westwood and Mark Richards

Last week, the Minister of Health, the Honourable Dr Aaron Motsoaledi, hosted a widely representative consultative meeting on breastfeeding in South Africa. With his support, the meeting issued the Tshwane declaration of Support for Breast Feeding in South Africa. This declaration set out many reasons why breast feeding must be supported at a very fundamental level in this country, even in an era of HIV. These included its role in preventing infant deaths and promoting the health of children, and the new evidence that the risk of transmission of HIV through breastfeeding can now be brought down to very low levels through the use of anti-retroviral drugs.

We humbly submit that the drafters of the Tshwane declaration have missed an important perspective on the reasons that South Africa should rapidly bring breast feeding back into the mainstream: Breast feeding makes economic sense for the country.

While we do not suggest that the drafters of the declaration and the Minister do not know this, this fact deserves to be highlighted. We contend that, if our thinking is bound by warm notions of child survival and ‘bonding’ as ‘nice’ things that breastfeeding encourages, we need to think again. Breastfeeding is for ‘real men’, captains of industry, political leaders and economists, male and female. A re-branding of breastfeeding must take place if the declaration is to bring breastfeeding to the centre of the policy agenda in South Africa.

Here we set out the hard-headed and hard-nosed reasons why South Africa must take this opportunity to ‘Invest in the Breast’.

There is global consensus that, to get the best out of the breast, six months of exclusive breastfeeding is required: no water, no formula, no solids: just the goodness of breast milk. Benefits accrue the longer any breastfeeding is sustained beyond six months. With this approach, one gets optimal body growth (not too much and not too little, both of which are bad for the child’s health in later life as we will describe), optimal brain growth and function (breast-fed babies are brighter), and protection from many serious infections (such as diarrhoea).

What does not breastfeeding cost? How much would society gain if breastfeeding were the norm?

In an industrialised country, formula feeding costs about R25/day which would seem to be a small amount. However, formula milk costs don’t quite follow the Big Mac Index and, in poorer countries such as South Africa, the proportion of a family income spent on formula can be beyond a third of household income if appropriate volumes and concentrations are used. This does not include the cost of bottles, water, sterilising fluid and energy used in safe formula feeding. Safe formula feeding is simply beyond the means of a significant proportion of South African families.

The savings that breastfeeding brings mount up from the time the baby is born. They include health benefits not only to the baby during early life, but also to that baby as an adult and to the mother who did the breastfeeding. In addition, the economic benefits of being healthier accrue beyond the narrow world of health care.

Starting with the smallest babies, there is strong evidence that, for preterm babies, sickness and death is avoided by the use of breast milk. In particular, the risks of contracting necrotising enterocolitis, a potentially lethal and costly form of intestinal infection, are significantly reduced by using breast milk rather than preterm formula milks. With low birth weight rates reaching 20% in parts of South Africa, South Africa would do well to get breast milk, maternal or donated, to every tiny baby in its nurseries.

Diarrhoeal diseases lead the cause of childhood death statistics in all of South Africa’s provinces. They are also responsible for a large proportion of visits to doctors and admissions to hospital. Studies at the start of this Millennium have shown that about 40% of all infant deaths and health service costs caused by diarrhoea can be removed when exclusive breastfeeding is practised. In Botswana, that government’s well intentioned attempt to protect children from contracting HIV from breast milk by providing formula resulted in increased overall death rates in infants due to diarrhoea-related diseases. Some of South Africa’s dismal record on child mortality can be laid at the same door. We are thus afforded an opportunity for a rapid change of direction in our embarrassing infant mortality rate.

A common consequence of diarrhoeal illness is malnutrition. Combine episodes of diarrhoea with the economic impossibility of sustaining safe formula feeding in much of South Africa and we have a recipe for death, disability, lengthy hospital stays and blighted opportunities. A large majority of these financial and human capital costs from malnutrition in South Africa are preventable with breastfeeding.

Early health service savings are also to be found in the prevention of respiratory infections, the commonest reason for attendance at health facilities in early childhood and a big user of health rands in this country. Ear infections, a very common childhood malady, are reduced by an impressive 50% by breastfeeding.

In the USA, the simple cost savings of these illnesses have been demonstrated to be about R2000-R3000 per child for the average family. Talk of freebies! Dr Motsoaledi’s cabinet colleagues for Planning and Finance should be rubbing their hands in glee.

And now we have something for the Ministers of Education: on balance, breast fed babies do better on developmental scores than those who are formula fed. In South Africa, where inadequate early brain growth associated with under-nutrition in poorer communities where formula feeding and its infectious consequences are common, there can be little doubt that more breastfeeding will improve school pass rates, making school graduates more employable. We hope the Minister of Labour is listening.

What about the breast fed baby as an adult? Studies looking at these issues from many perspectives show that breastfeeding, probably through optimising early growth, sets the scene for protection of the adult who was breast fed against obesity (22% reduction), diabetes (39% reduction), heart attacks (16% reduction), and some common cancers. The health rand and human savings from promoting breastfeeding for South Africa in its demographic transition are likely to be immense. Further savings are to be found in breastfeeding-related reductions in asthma, eczema and inflammatory bowel diseases.

It is not only the child whose health costs are reduced by breastfeeding. The mother (and therefore her family and society) stands to be saved from the consequences of anaemia from blood loss after birth, and an unwanted next pregnancy due to a delayed return to fertility. She will return to her pre-pregnancy weight sooner. Later in life, women who breast feed suffer fewer hip fractures from osteoporosis, and have less breast and ovarian cancer. To get a feel for the cost savings produced by breastfeeding, the average cost of breast cancer therapy is at least R50,000. How aware are we that there is a significant cost saving to be gained by increasing the frequency and duration of breastfeeding among South African women?

Investing in breastfeeding is also good for the planet. Formula milk means cows needing feeds, fertilisers, trucks and factories. It leaves millions of left over tins, methane and carbon dioxide, degraded land for pasture and deforestation for soya plantations. And consider the environmental cost of using firewood, hydrocarbons or electricity to sterilise water for the safe preparation of formula milk. We offer breastfeeding to the Minister for Environmental Affairs as another link in the chain of living gently in South Africa’s fragile ecosystems.

What are the costs of breastfeeding? It takes more time to formula feed so breastfeeding wins this efficiency argument. The nutritional cost to a breastfeeding mother is about 500 Calories a day. This is a peanut butter sandwich and a banana – well within the means of most South African families. Another cost on this side of the equation is loss of income for the mother. Wherever this cost has been calculated, the savings to the family in terms of visits to the doctor etc. that we have described outweigh it by a considerable margin.

The Minister of Finance may be concerned about loss of tax revenue from the formula manufacturers. He need not worry; the balance is still in breastfeeding’s favour. Data is hard to come by for South Africa, but in the USA the overall cost saving for ideal breastfeeding rates is estimated to be $13.1 billion. Tellingly, the global market value of the formula milk industry comes in below this at $7.9 billion.

There is a cost attached to promoting breastfeeding, but again, in health rand terms, it pales in the face of the costs of not promoting breastfeeding.

There are medical cases where formula feeding is required, as the Tshwane declaration sets out. A woman has a right to choose how to feed her child. But we believe that South Africans from grassroots to government must grasp the opportunity for a complete shift in thinking and actions afforded by the new impetus being led by Dr Motsoaledi and ‘Invest in the Breast’.

Westwood and Richards are Child Health Specialists in the Western Cape