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Step to decrease AIDS in Botswana backfired fatally

Formula urging led to diarrhea, malnutrition

Chandapiwa Mavundu, 28, has HIV and didn't breast-feed her son because nurses warned her not to. He died at 8 months. Chandapiwa Mavundu, 28, has HIV and didn't breast-feed her son because nurses warned her not to. He died at 8 months. (Craig Timberg/Washington Post)

NKANGE, Botswana -- Doctors noticed two troubling things about the limp, sunken-eyed children who flooded pediatric wards across Botswana during the rainy season in early 2006: They were dying from diarrhea, a malady that is rarely fatal in Nkange. And few of their mothers were breast-feeding, a practice once all but universal.

After the outbreak was over and at least 532 children had died -- 20 times the usual toll for diarrhea -- a team of US investigators solved the riddle.

A decadelong, global push to provide infant formula to mothers with the AIDS virus had backfired in Botswana, leaving children more vulnerable to other, more immediately lethal diseases, the US team found after investigating the outbreak at the request of Botswana's government.

The findings joined a growing body of research suggesting that supplying formula to mothers with HIV -- an effort led by global health groups such as UNICEF -- has cost at least as many lives as it has saved. The nutrition and antibodies that breast milk provide are so crucial to young children that they outweigh the small risk of transmitting HIV, which researchers calculate at about 1 percent per month of breast-feeding.

"Everyone who has tried formula feeding . . . found that those who formula feed for the first six months really have problems," Hoosen Coovadia, a University of KwaZulu-Natal pediatrician and author of a recent study on formula feeding, said from Durban, South Africa. "They get diarrhea. They get pneumonia. They get malnutrition. And they die."

That's what happened in Nkange, a tiny village on the sandy northern edge of the Kalahari Desert. In a cluster of several dozen homes here, eight children under 2 died during the four-month-long diarrhea outbreak, according to interviews with families. Only two had ever been breast-fed, and only one was being breast-fed at the time of the outbreak.

Chandapiwa Mavundu, 28, a mother of three who has HIV, said she never breast-fed her son, Kabelo, because government nurses warned her not to. He died at 8 months, after two months of diarrhea and vomiting.

"That was the only boy child I had," said Mavundu. "I loved him very much."

The medical records kept by Mavundu and other families here echoed the finding of the US investigators: Government clinics often ran out of cans of formula, forcing parents and grandparents to buy cow milk or feed their children with diluted porridge or even flour and water.

Many of the babies had recurrent sicknesses and registered steep drops in their growth patterns during their final months. When the diarrhea struck, it was severe, prolonged, and difficult for doctors to cure. One child survived diarrhea only to die soon after from pneumonia, another disease that breast-feeding helps prevent.

The vast diamond reserves in this landlocked southern African nation have allowed Botswana's government to build a safety net unmatched on the continent, offering its 1.8 million citizens cradle-to-grave support for education and healthcare.

And though it has one of the world's highest rates of HIV, with 1 in 4 adults infected, it has some of Africa's most celebrated programs to combat AIDS, including effective measures to prevent mothers from infecting their children during pregnancy and birth.

The country was also a pioneer in the international drive to protect babies at risk of becoming infected through breast-feeding. In 1997, the United Nations began urging new mothers with HIV to use formula wherever supplies could be provided safely and reliably.

Botswana, with an extensive public water system, good roads, and a legacy of competent governance, joined the UNICEF-led effort and agreed to pay for the program as a standard service to new mothers.

There were skeptics. Some international public health specialists, including Coovadia, cautioned that few Africans had the means to prepare formula in a sanitary manner -- a process that requires access to clean water, utensils, formula powder, and heat for sterilization.

And even for those who could make formula safely, some specialists warned, breast-feeding's other health benefits could not easily be replaced.

A study by Coovadia and other South African researchers published in the medical journal Lancet in August 1999 found that breast milk, when not mixed with other foods, was no more likely to infect children than formula.

Under the program, pregnant women with HIV received a series of antiretroviral pills in the final weeks of their pregnancies, and their newborn children received a dose of syrup laced with another powerful anti-AIDS drug in their first hours of life.

The rate of HIV among babies born to mothers with the virus fell from 40 percent in 2002 to 6 percent.

Demand for the free government formula soared -- but that soon led to shortages.

The government has blamed hitches in its contracting system for the formula shortages. But supply was not the only problem uncovered by the investigators from the US Centers for Disease Control and Prevention, which announced its findings at a scientific conference in Los Angeles in February.