Health Check: 'Aids has brought the makers of formula milk a marketing opportunity to die for'

It used to be so simple. Breast was best. No argument, no dispute, end of story. And when manufacturers of baby milk infant formula, such as Nestlé, started promoting their products in the developing world it provoked an outcry which reverberates today.

It used to be so simple. Breast was best. No argument, no dispute, end of story. And when manufacturers of baby milk infant formula, such as Nestlé, started promoting their products in the developing world it provoked an outcry which reverberates today.

A study published in The Lancet confirms 20 years of research showing that breast is best. Bottle feeding, research shows, may have led to the early deaths of thousands of children in the West. But the role of breast feeding in the developing world is even more important.

This month, the charity Breakthrough Breast Cancer turned down a £1m promotional deal with Nestlé because of qualms about its involvement in the baby milk trade. Nestlé has been the subject of a 20-year boycott over allegations that it has persistently breached the World Health Organisation code on promoting infant formula.

The snub prompted a pained response from Alastair Sykes, the chairman of Nestlé, who complained that a "small group of activists" had helped sink a "very significant contribution" to help women with breast cancer. "Where is their commitment to women's health?" he asked.

He got his answer last week, when the International Baby Food Action Network, which has campaigned since the 1970s, published its latest report detailing 2,000 violations of the baby-milk marketing code in 69 countries. Under the code, manufacturers are banned from promoting their products, and must say that breast is best.

The trouble is, it isn't any longer necessarily so. In the era of Aids, breast can be worst because of the risk that breast milk may transmit the virus. One in four pregnant women in South Africa is HIV-positive, with similar rates in other sub-Saharan African countries, and in up to 40 per cent of cases they will pass the virus on to children.

This transmission rate can be halved if mother and baby are treated with a single dose of the drug nevirapine at birth and breast feeding is avoided. So Aids has brought the infant formula manufacturers a marketing opportunity to die for - and they have milked it for all it is worth.

They accused the WHO and Unicef of putting babies at risk by restricting the availability of formula milk. Unicef eventually announced pilot projects where free formula was offered to HIV-positive mothers.

The problem was that one risk, of HIV transmission, was being exchanged for another, of diarrhoeal disease caused by contaminated water used to make up the formula for the baby's feed. The mother who gave her baby infant formula had to find clean water to mix it, and a clean bottle and teat to deliver it - no simple task in a shanty town or village.

Unicef abandoned its pilot project after early experience suggested that use of the formula was raising more problems than it was solving. Other charities have also revised their policy after a simple truth dawned: if a mother is so poor she needs infant formula to be donated free she is unlikely to be living in circumstances that will allow her to make it up safely.

Thus in Malawi, one of the poorest countries in Africa, doctors recommend HIV-positive mothers continue to breast feed because access to clean water is so limited the risks of formula feeding are too high. But in Botswana, a richer country, HIV-positive mothers are advised to use formula.

Earlier this month, in South Africa, I saw HIV-positive mothers collecting their free packets of formula from the Chris Hani Baraganath hospital, in Soweto. The hospital cares for 30,000 pregnant women a year, of whom 8,000 are HIV-positive, and almost all take the free formula. Very few of those 8,000 women breast feed.

The concern is that the resistance to breast feeding will spread. The pressure group, Baby Milk Action, says it is "very worried about the commercial exploitation of HIV by the baby milk companies". Unicef calculated that while 1.5 million children may have died after contracting HIV at birth, 30 million had died - from diarrhoeal disease - because they had not been breast fed.

The campaigners are putting their faith in research at the University of Natal in Durban which suggests that the babies of HIV-positive mothers who are breast-fed exclusively for the first six months do not contract HIV.

The theory is that mixed feeding - breast and bottle, which was the norm - damages the lining of the developing gut, allowing the virus to pass. By sticking exclusively to breast milk, the baby is protected.

The World Health Organisation remains unconvinced, stressing that this is only one study and requires confirmation. Experts in the field argue that even if the theory is proved, which they believe is unlikely, exclusive breast feeding is impractical in Africa, where few women produce enough breast milk to sustain a baby.

So a simple message - breast is best - has turned into a complex one, muddied by disease, competing claims and commercial interests. Mothers' milk was once a symbol of purity. Now it has become a battleground.