Editor’s note: This is an article from the Summer 1999 issue of UCLA Magazine.
The late Derrick Jelliffe, a professor of public health and pediatrics at UCLA and the former chair of pediatrics at Kampala University in Uganda, East Africa, spent his life educating anyone who would listen about the importance of breast-feeding, particularly in developing countries. It seems like a no-brainer: Breast milk is free, readily available and sterile and helps to protect the infant from infections. Dr. Jelliffe’s drumbeat of “breast is best” has been heard, and breast-feeding is now the norm in nearly all developing countries. Breast-feeding — the longer, the better — is crucial for infant survival in these countries. That was accepted wisdom, at least until a few years ago.
Accra, Ghana, 1972
The importance of breast-feeding was strikingly reinforced during my first visit to Africa to study issues of malnutrition in children. The setting for our team of pediatricians, nutritionists and immunologists was Princess Marie Louise Hospital for malnourished children, a modest, two-story, cement-block building with a corrugated iron roof, surrounded by a dusty courtyard with a single tree.
On our first morning there, we threaded our way through throngs of mothers and infants waiting to see the single Ghanaian doctor in the first-floor clinic. He examined each infant quickly, passed out medicines for the sick babies or sent the well babies to the immunization station. All the while he cast a keen eye for the swollen legs, protuberant abdomen and reddish tinge of the hair, which are the telltale signs of early kwashiorkor, the dreaded African disease of protein malnutrition. Kwashiorkor is a West African word that means “the disease that occurs when the next baby comes.” It typically occurs when babies are between 1 and 2 years old, two to three months after the mother weans the infant so she can breast-feed her new baby. The weaning food is kasava, which tastes and looks like milk but is almost completely devoid of protein. So while the baby grows, the immune system weakens. Kwashiorkor is curable if recognized early, but in advanced cases, diarrhea, measles or pneumonia can lead to rapid death. In the afternoon, the Ghanaian doctor looked after the hospitalized, malnourished children, treating them for parasites, malaria, anemia and infections and starting them on protein feedings, usually a thin stew of nuts and rice. Our task was to pinpoint the immunologic defects in these children; what we learned was that their immune defects could be as severe as those found in David, the so-called “boy in the bubble” who was born without an immune system. But, we determined, all these immunological problems could be prevented simply by breast-feeding. I was a convert: Breast is best.
Los Angeles, May 1986
Late one spring afternoon, 14 years after my first trip to Ghana, my UCLA colleague, Dr. Richard Fine, asked me what I thought of a 4-year-old girl with kidney disease, anemia and persistent thrush of her mouth. I responded that I thought she had a severe problem with her immune system. I examined the little girl, Ariel, and confirmed the presence of thrush. And I learned that she had been perfectly well for the first few years of her life, indicating that she did not have a congenital deficiency of her immune system. I asked her mother, Elizabeth Glaser, the wife of actor Paul Michael Glaser, if Ariel had ever had a blood transfusion — pediatric AIDS had recently been identified in children who were transfused at birth. She said that Ariel had not.
But her answer to my next question, “Have you ever had a blood transfusion?” changed the face of AIDS in this country. “Yes,” Elizabeth said. “Twelve times, right after Ariel’s birth.” Ariel had been born by emergency cesarean section because the placenta was attached over the opening of the womb, and afterward Elizabeth developed severe bleeding and needed l2 pints of blood. “But I recovered completely,” Elizabeth added, “and was able to start breast-feeding in just a few days.” Upon hearing that, I suspected that both mother and child had contracted AIDS, Elizabeth from the blood transfusions and Ariel from her mother’s milk.
There had only been one other reported instance of HIV transmission via breast milk, in 1985 in an Australian child under circumstances similar to Elizabeth’s and Ariel’s. Blood tests confirmed that Ariel, Elizabeth and the Glasers’ son, Jacob, 2, all were infected. Ariel died from AIDS in 1988; Elizabeth died in l994. Jacob, now l5, is doing well on antiviral medicines. Shortly after her diagnosis, Elizabeth Glaser and two friends, Susan Zeegan and Susan De Laurentis, founded the Pediatric AIDS Foundation, now known as the Elizabeth Glaser Pediatric AIDS Foundation. Throughout the remainder of her life, Elizabeth was a tireless advocate for pediatric AIDS, raising research money, lobbying Congress, sponsoring conferences and agitating for the development of AIDS drugs for children.
Breast-milk transmission of AIDS in developed countries is a rare event; indeed, most HIV transmission from mother to infant occurs through the womb or at the time of birth. But because of the slight risk, U.S. mothers with HIV infection do not breast-feed their infants. Breast was not best for Ariel Glaser.
Nairobi, Kenya, 1999
Fast-forward. The scene is again a small, two-story hospital in Africa near downtown, but the city is Nairobi. This modest building, no larger than the emergency ward of a typical hospital in the U.S., is Pamwani Maternity Hospital. After years of work and travel in sub-Saharan Africa, I thought nothing in the medical realm could shock me. I had seen lepers die of smallpox in Ethiopia, toddlers blinded and swollen by kwashiorkor in Ghana and infants horribly burned from convulsions triggered by a brain parasite as they slept next to a fire in their Masai village hut in Tanzania. But Pamwani was an unforgettable experience. It houses the world’s largest maternity service. Each day, 100 women come to have their babies — 36,000 a year. Most have received no prenatal care and come by bus from small villages a few days before the expected delivery.
When labor starts they are admitted and put to bed, not infrequently with another woman. Just before delivery, the mother-to-be moves to another bed. The births are natural, in the bed, and largely unassisted; the doctor or the midwife attends only those deliveries with an obstetrical difficulty. Cesarean section is rarely performed, even after prolonged labor. Following delivery the infant and mother are examined, the infant’s eyes and cord are attended to and the baby is left with the mother to start breast-feeding. After several hours, the new mother and her baby move to the waiting room and are discharged, sometimes just six hours after admission.
In 1976, just a few years before the start of the AIDS epidemic, our team came here to study the effect of maternal malnutrition on the newborn immune system. We collected many blood samples from mother and baby and, as we suspected, learned that maternal malnutrition also depressed the baby’s immune system, making the infants more susceptible to infections during the first year of life. That was 23 years ago, and subsequent tests on the blood we collected indicated none of the mothers or infants we studied were infected with AIDS. But today, in 1999, 2,000 Pamwani newborns will contract AIDS from their mothers. This number, from a single hospital, is 10 times the number of babies who will be diagnosed with AIDS in the entire United States.
Why? Because 1 in 5 of all mothers in Nairobi, 20 percent, are infected with HIV, compared with 1 in 300, 0.3 percent, of American mothers. And the rate of maternal-infant transmission is 30 percent in Kenya, but only 3–5 percent in the U.S.
There are many factors for the disparity: lack of prenatal diagnosis, more advanced diseases and fewer cesarean sections, among them. But the two most important factors are the lack of AIDS drugs and prolonged breast-feeding.
Several years ago, a U.S. government-supported study showed that giving the antiviral drug AZT to the mother during pregnancy and labor and to her infant after birth decreased the rate of AIDS transmission from 25 percent to 7 percent. Today in the U.S., all HIV-infected mothers receive AZT (and other antivirals) during pregnancy and the transmission rate is down to 3–5 percent. For the 6,000 HIV-infected mothers in the U.S., only 200 of their babies will become infected. This is the most dramatic therapeutic triumph in the battle against AIDS to date, but AZT is unavailable for most African mothers. It is just too expensive.
All Pamwani mothers breast-feed their infants, often for as long as 24 months. We now know that breast-feeding, particularly beyond six months, increases the chance of AIDS transmission by about 25 percent. Thus, we are faced with a tragic Catch-22: Breast-feeding protects against most infections, but for those infants born to mothers infected with AIDS, this otherwise life-sustaining practice can be deadly. Breast is not best for these infants.
What can be done? For starters, we can use new, simplified, rapid AIDS tests to identify infected mothers-to-be. We can use shorter and less expensive drug regimens to prevent HIV transmission. And we can wean the high-risk infants at 6 months of age if a safe, alternative formula can be identified. How long must we beat the drum on this issue before such practices can be put in place? I don’t know. But there is where we must begin. So back to Africa we will go.
E. Richard Stiehm is chief of the Division of Immunology, Allergy and Rheumatology at Mattel Children’s Hospital and co-director of the Los Angeles Pediatric AIDS Consortium.
