HealthLawProf Blog

The Hamdan Decision

Although not technically a health law decision, Ramdan v. Rumfeld is a decision that improves the public health of the United States is you read "public health" broadly to include the protection of our constitutional values and the rule of law.  SCOTUSblog has a great discussion and examination of Hamdan and Firedoglake has a wonderful write-up as well wilth links to many other discussions around the web concerning the decision.    [bm]

Solving Childhood Obesity

You were thinking that encouraging more exercise and fast food might be the only answer.  Well, apparently there are more creative minds at work than mine and they have developed new heavier toys to help with the childhood obesity problem.  CNN reports on this development:

Researchers at Indiana State University in Terre Haute tried a small experiment to test the effects of having kids play with heavier toys. They found that 10 children ages 6 to 8 burned more calories and had higher heart and breathing rates when they moved 3-pound toy blocks instead of unweighted blocks.

So could adding a small weight to stuffed animals and other toys help kids get fit?

"This is not going to solve the obesity problem," said John Ozmun, a professor who did the study with graduate student Lee Robbins. "But it has a potential to make a positive contribution."

Some experts caution that children could hurt themselves trying to lift too much too soon and said more activity is preferable to heavier toys. But all agree childhood obesity is a big problem. . . .

Kara Tucker, youth development coordinator for the National Institute for Fitness and Sport in Indianapolis, said active playing helps youngsters work out without realizing it.

Weighted toys might be another way to sneak in exercise, but not everyone thinks a 3-pound stuffed animal sounds like fun.

Rambunctious kids could throw heavy toys at playmates, said Celia Kibler, president of Funfit, a family fitness club in Maryland. Kibler also fears children could hurt themselves if they lift too much weight before their bodies are fully developed.

"I think that can be more dangerous than beneficial," she said. "There's so much activity that a child can do that can keep them in shape without the use of weights. That's what they should be concentrating on."

The study's authors stressed that their report is a starting point, and involved only a few children under very controlled circumstances.

Weighted toys in the real world would have to be designed to be safe while holding a child's interest, said Ozmun, acting associate dean of Indiana State's College of Health and Human Performance. . . .

"Having a 3-pound teddy bear may not only help with strength, but with balance and coordination," he said.

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Second Hand Smoke

The U.S. Surgeon GeneralRichard H. Carmona issued a report earlier this week that concludes that there exists no safe level of second-hand smoke.  The report is entitled, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.   In sum, it states that nonsmokers exposed to scondahnd smoke at home or work increase their risk of developing heart disease and lung cancer by as much as 30 percent.  The report further finds that even brief exposure to secondhand smoke can cause immediate harm and that the only way to protect nonsmokers is to eliminate smoking indoors. 

A news release from the Department of Health and Human Services states, 

“The health effects of secondhand smoke exposure are more pervasive than we previously thought,” said Surgeon General Carmona, vice admiral of the U.S. Public Health Service. “The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.” Secondhand smoke contains more than 50 cancer-causing chemicals, and is itself a known human carcinogen. Nonsmokers who are exposed to secondhand smoke inhale many of the same toxins as smokers. Even brief exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and increases risk for heart disease and lung cancer, the report says. In addition, the report notes that because the bodies of infants and children are still developing, they are especially vulnerable to the poisons in secondhand smoke.

“The good news is that, unlike some public health hazards, secondhand smoke exposure is easily prevented,” Surgeon General Carmona said. “Smoke-free indoor environments are proven, simple approaches that prevent exposure and harm.” The report finds that even the most sophisticated ventilation systems cannot completely eliminate secondhand smoke exposure and that only smoke-free environments afford full protection. . . . .

“Our progress over the past 20 years in clearing the air of tobacco smoke is a major public health success story,” Surgeon General Carmona said. “We have averted many thousands of cases of disease and early death and saved millions of dollars in health care costs.” He emphasized, however, that sustained efforts are required to protect the more than 126 million Americans who continue to be regularly exposed to secondhand smoke in the home, at work, and in enclosed public spaces.

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Rush's Doctors

As you are now probably more aware than you ever wanted to be, Rush Limbaugh, the conservative radio host who recently had made headlines for his legal problems surrounding his addiction to oxycontin, was detained at U.S. customs and found to have a bottle of Viagra in his physician's name.  Setting aside Rush's potential legal problem, I did find it interesting that his attorney, Roy Black, stated that the  prescription was written in his doctor's name "for privacy purposes." I have never been offered such a service by my physician (and really haven't we all had some medications prescribed that we didn't want our names on)  . . .  and doesn't HIPAA already provide some privacy protection in this arena. . . .   

Well, it turns out the physicians may be in a little trouble for their help in protecting Rush's privacy in this manner.  Talkleft reports on a recent article in the Florida Sun-Sentinel  and quotes that paper stating:

Florida civil rules governing doctors and pharmacists require that the true patient's name and address are on the label, according to two attorneys and a Florida Medical Association spokeswoman.

Doing otherwise "is technically a violation of dispensing and prescribing by the doctor," said Allen R. Grossman, a Tallahassee attorney who defends physicians in disciplinary cases. Grossman formerly was general counsel to the Florida Board of Medicine, which licenses and oversees doctors.

TalkLeft continues by discussing the issue. 

           Other Florida experts, including those involved with professional and medical boards weigh in:

"The department is aware of it and we'll have more information on that later," board spokeswoman Thometta Cozart said. However, the three professionals said state civil rules forbid doctors from prescribing drugs without a name or under a third person's name, as a way to prevent people from passing medicine to others.

"That would be considered a fraudulent prescription," said Lisette Gonzalez Mariner, a spokeswoman for the Florida Medical Association, the trade group for doctors. "You cannot do that. It's not commonly done and that's illegal." Likewise, pharmacists cannot dispense drugs to someone other than the name on the prescription label or their representative, said attorney Edwin Bayo, a former general counsel of the Florida Board of Pharmacy licensing board.

On another issue, I haven't heard much about any potential insurance fraud concerns but there may be some problems with having someone else's name on your prescription with regard to insurance as well. [bm]

FDA's Enforcement Declines

According to a story in the New York Times, a new study reveals that the Food and Drug Administration has cut back its enforcement efforts rather dramatically in recent years.  The Times states,

A 15-month inquiry by a top House Democrat has found that enforcement of the nation's food and drug laws declined sharply during the first five years of the Bush administration.

   

For instance, the investigation found, the number of warning letters that the Food and Drug Administration issued to drug companies, medical device makers and others dropped 54 percent, to 535 in 2005 from 1,154 in 2000.

The seizure of mislabeled, defective or dangerous products dipped 44 percent, according to the inquiry, pursued by Representative Henry A. Waxman of California, the senior Democrat on the House Government Reform Committee.

The research found no evidence that such declines could be attributed to increased compliance with regulations. Investigators at the F.D.A. continued to uncover about the same number of problems at drug and device companies as before, Mr. Waxman's inquiry found, but top officials of the agency increasingly overruled the investigators' enforcement recommendations.

The biggest decline in enforcement actions was found at the agency's device center, where they decreased 65 percent in the five-year period despite a wave of problems with devices including implantable defibrillators and pacemakers. . . . .

Aside:  You would think that Vice President Cheney would be concerned by this news.  The article continues,

David K. Elder, the director of the agency's Office of Enforcement, explained that the F.D.A. had increasingly focused on the most serious violations.

"As a result of F.D.A.'s focus on those firms and those violations that present the highest risk to consumers and public health," Mr. Elder said in a statement, "the agency has taken prompt, targeted and aggressive action against firms that are in violation of law."

Jack Calfee, a resident scholar at the conservative American Enterprise Institute, said the decline in the statistics was meaningless because most of the violations involved paperwork problems.  "I doubt that it makes a significant difference in the safety of drugs or other products," Mr. Calfee said.

Mr. Waxman began his inquiry after Congressional hearings in 2004 suggested that the agency was partly to blame for a shortage of flu vaccines. His staff requested thousands of documents from the F.D.A.  The investigation found that by almost every measure, enforcement actions had significantly declined from 2000 to 2005. The lone exception was in the number of products that had to be recalled from the market: that increased 44 percent. "Since one of the goals of an enforcement system is to deter violations and keep dangerous products off of the market," the report said, "the increase in recalls is not a hallmark of effective enforcement."

Hope everyone stays healthy because this doesn't look like good news in the long run.  [bm]

Buffett's Billions and Health Care

With all the rather depressing news in the world, the Buffett billions and all the good that the Gates' Foundation will be able to do with the money were some welcome cheer.   The New York Times reports,

Warren E. Buffett's $31 billion gift to the Bill & Melinda Gates Foundation will help the foundation pursue its longstanding goal of curing the globe's most fatal diseases, Mr. Gates said yesterday, along with improving American education.

The foundation hopes to use the enormous gift, among other things, to find a vaccine for AIDS, Mrs. Gates said. And Mr. Gates went further, saying that while he might be "overly optimistic," he believed there was a real shot at finding cures for the 20 leading fatal diseases, as well as ensuring that every American has a chance at a decent education.

"Can that happen in our lifetime?" Mr. Gates said, sitting next to Mr. Buffett at the New York Public Library, where the gift was formally announced after news of it broke on Sunday. "I'll be optimistic and say, Absolutely."

But Mr. Gates acknowledged that spending the money effectively would be difficult. The scientific tasks the foundation has set for itself in fields like malaria and tuberculosis take time as well as money, because they require years of laboratory work followed by years of clinical trials, sometimes ending fruitlessly. Improving American education — once better ideas have been found — can take just as long. . . .

Mr. Buffett, for his part, said he saw no need to tinker with the foundation's essential goal: improving the lot of poor people elsewhere in the world without regard to their color, religion or other differences.

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Pay for Performance Medicine

Ezra Klein has an interesting post on the pay for performance medicine (P4P) idea.  He states,

. . . .  Our surgeons may be on the cutting edge (thanks folks, I'll be here all week), but stepping back a bit from the frontier, the vast majority of care is either inefficiently delivered, or simply forgotten. Studies show that we receive only about 55 percent of the recommended treatments for most serious complaints -- and we're not talking CAT scans here, but easy lifesavers, like aspirin and beta blockers after a heart attack. America offers the world's best care for its most exotic and complicated problems, but if you're unlucky enough to suffer something more mundane, you're better off in a host of other hamlets.

The policy response here is something called pay For Performance medicine, or P4P. At base, the incentives in our system are to offer treatments, particularly intensive ones. It's called fee-for-service, and it offers no incentives for quality care or low intensity (aspirin) treatments. P4P, by contrast, pays based on outcomes, on percentage of suggested care delivered (for a fuller explanation, see this reviewended. Utilizing more than 200 hospitals and 38 states, Medicare instituted P4P systems, paying based on treatment quality and comprehensivity and offering bonuses for outcome improvement. The results? Not only did care get better, but it got cheaper. "2004 hospital costs for pneumonia patients were $10,298 for patients who received a low number of the care measures and $8,412 for those who received a high amount. Hospital costs for heart bypass surgery patients also varied widely, with those receiving a low number of measures costing $41,539 while those who had the highest amount cost $30,061."

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On a lighter note

In case you need a pick me up after depressing news, check out the cuteoverload.com website for overwhelming warm fuzzies.
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Oath Betrayed

Stephen Miles, a medical ethicist has written a' new book, "Oath Betrayed," discussing how some in the medical profession participated in torture during this War on Terror and its coverup.  Andrew Sullivan of Time magazine has a brief review and the excellent editors at TalkLeft have some further discussion.   Here is a brief excerpt from the Time magazine article by Mr. Sullivan:

One of Defense Secretary Donald Rumsfeld's first instructions for military interrogations outside the Geneva Conventions was that military doctors should be involved in monitoring torture. It was a fateful decision — and we learn much more about its consequences in a new book based on 35,000 pages of government documents obtained under the Freedom of Information Act. The book is called Oath Betrayed (to be published June 27) by medical ethicist Dr. Stephen Miles, and it is a harrowing documentation of how the military medical profession has been corrupted by the Bush-Rumsfeld interrogation rules.

One of those rules was that a prisoner's medical information could be provided to interrogators to help guide them to the prisoner's "emotional and physical strengths and weaknesses" (in Rumsfeld's own words) in the torture process. At an interrogation center called Camp Na'ma, where the unofficial motto was "No blood, no foul," one intelligence officer testified that "every harsh interrogation was approved by the [commander] and the Medical prior to its execution." Doctors, in other words, essentially signed off on torture in advance. And they often didn't inspect the victims afterward. At Abu Ghraib, according to the Army's surgeon general, only 15% of inmates were examined for injuries after interrogation.

 

Some of the medical involvement in torture defies belief. In one of the few actual logs we have of a high-level interrogation, that of Mohammed al-Qhatani (first reported in TIME), doctors were present during the long process of constant sleep deprivation over 55 days, and they induced hypothermia and the use of threatening dogs, among other techniques. According to Miles, Medics had to administer three bags of medical saline to Qhatani — while he was strapped to a chair — and aggressively treat him for hypothermia in the hospital. They then returned him to his interrogators. Elsewhere in Guantánamo, one prisoner had a gunshot wound that was left to fester during three days of interrogation before treatment, and two others were denied antibiotics for wounds. In Iraq, according to the Army surgeon general as reported by Miles, "an anesthesiologist repeatedly dropped a 2-lb. bag of intravenous fluid on a patient; a nurse deliberately delayed giving pain medication, and medical staff fed pork to Muslim patients." Doctors were also tasked at Abu Ghraib with "Dietary Manip (monitored by med)," in other words, using someone's food intake to weaken or manipulate them.

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Number of Uninsured Drops

The KaiserNetwork.Org reports on a study showing that the number of uninsured last year was 41.2 million.  It reports that this is a small improvement over 2004.  Thanks to Ezra Klein for the cite - he also has some further thoughts on the study.  [bm]         

South Dakota's Abortion Ban

This week's New Yorker runs a piece by Cynthia Gorney about South Dakota's abortion ban entitled, "Letter from South Dakota:  Reversing Roe."  The law bans abortion except where the life of the mother is threatened.  Opponents to the law have run a successful petition drive to place the law on the ballot this fall for the citizens of that state to vote on whether they want to keep such a ban.  The article  provides an interesting overview of the current state of the abortion debate and demonstrates how the South Dakota law has divided some within the pro-life movement.  The New Yorker article is not available on-line but an interesting interview between Ms. Gorney and Mr. Ben Greenman discussing abortion and the South Dakota law may be found here.   

More Humane Lethal Injections

The New York Times reports today on how doctors have worked to make lethal injections for death penalty inmates more humane.  The Times states,

. . . . medical experts say the current method of lethal injection could easily be changed to make suffering less likely. Even the doctor who devised the technique 30 years ago says that if he had it to do over again, he would recommend a different method.

Switching to an injection method with less potential to cause pain could undercut many of the lawsuits. But so far, in this chapter of the nation's long and tangled history with the death penalty, no state has moved to alter its lethal injection protocol.

At the core of the issue is a debate about which matters more, the comfort of prisoners or that of the people who watch them die. A major obstacle to change is that alternative methods of lethal injection, though they might be easier on inmates, would almost certainly be harder on witnesses and executioners.

With a different approach, death would take longer and might involve jerking movements that the prisoner would not feel but that would be unpleasant for others to watch.

The care and concern for the witnesses strikes me as a bit out-of-place.  The article discusses the pending lawsuits in many states concerning the current method of lethal injection and whether it is an unconstitutional cruel and unusual punishment.   In response to the lawsuits and these new techniques, the article says that some states may change their procedures to avoid future liabililty.  Overall, it is a rather depressing subject and I understand why many doctors refuse to participate in executions.  [bm]

Pediatric Cancer Stories

One of the reasons that I enjoy living in Cincinnati is the wonderful Children's Hospital Medical Center.  Last night PBS had a wonderful program, entitled, "Lion in the House," concerning Children's Hospital and some of the pediatric cancer patients it has treated.  It was a very moving program that addresses the issues facing the children and their families as well as the physicians, nurses and other caregivers who treat them.  Here is a brief abstract of the program:

A LION IN THE HOUSE follows the stories of five exceptional children           and their families as they battle pediatric cancer. From the trauma           of diagnosis to the physical toll of treatment, this series documents           the stresses that can tear a family apart as well as the courage of           children facing the possibility of death with honesty, dignity and           humor. As the film compresses six years into one narrative, it puts           viewers in the shoes of parents, physicians, nurses, siblings, grandparents           and social workers who struggle to defeat an indiscriminate and predatory           disease.

These are some truly inspiring people.  The PBS website has further information about the program and also provides some helpful biographies.  [bm]

Update your favorites

Majikthise points out that Effect Measure (the terrific public health policy blog)has moved and joined a network of science blogs.  You should check it out - there are many wonderful websites with terrific information there.  [bm]

For Profit/Not-for-Profit Quality Issues

Erza Klein points out a new study published in the Health Affairs journal and summarized briefly here that shows that not-for-profit hospitals and nursing homes provide a higher quality of care.  From the summary:

For-profit nursing homes and hospitals on average provide an inferior quality of care compared with their nonprofit peers, according to an extensive review of studies published on Tuesday.

Authors writing in the journal Health Affairs found that a systematic analysis of 162 studies of nonprofit versus for-profit health care providers supports the concept that a facility's ownership status makes a difference in outcomes and in the cost of health care.

"Their work should lay to rest claims that little distinguishes nonprofit versus for-profit health care," University of Michigan professor Jill Horwitz wrote in editorial also running in the policy journal.

 

The analysis found a pattern of differences between nonprofits and for-profits in cost, quality and accessibility, said Bradford Gray, a principal research associate at the Urban Institute -- a nonprofit research group -- and lead study author.

For-profit ownership is climbing in most sectors of health, from hospitals to hospice care. For example, for-profit hospitals accounted for 11 percent of all hospitals in the early 1990s and now account for 16 percent.

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Supreme Court Grants Cert. to Partial-Birth Abortion Ban Act

From Willamette Law Online – Willamette University College of Law comes the news that the Supreme Court has granted certiorari in the Gonzales v. Planned Parenthood case.  The Ninth Circuit opinion can be found here:  435 F.3d 1163 (9th Cir. 2006); http://caselaw.lp.findlaw.com/data2/circs/9th/0416621p.pdf

Here is the Williamette Law Online summary of the case:

The United States Court of Appeals for the Ninth Circuit held that the Partial-Birth Abortion Ban Act is unconstitutional on three grounds,invalidated the law, and permanently enjoined enforcement of the law in its entirety.

 

Immediately after President George W. Bush signed the Partial-Birth Abortion Ban Act (Act), 18 U.S.C. Sec 1531(b)(1), into law in 2003, thePlanned Parenthood Federation of America, Inc. (Planned Parenthood) filed suit, claiming that the Act violates constitutionally guaranteed rights.

The City and County of San Francisco successfully intervened as a plaintiff. In 2004, the United States District Court for the Northern District of California (District Court) found the Act unconstitutional on three grounds and entered a permanent injunction against its enforcement. First, the Act was held to impose an undue burden on a woman’s right to choose to terminate pregnancy before viability because it creates a substantial risk of criminality for virtually all abortions performed after the first trimester. Second, the District Court found the Act unconstitutionally vague. The District Court reasoned that the Act’s use of unrecognized medical terms inhibits fair notice to physicians and encourages arbitrary enforcement. Finally, the District Court held that the Act’s failure to include a health exception is unconstitutional. The United States Court of Appeals for the Ninth Circuit (Court of Appeals) affirmed the District Court’s decision, stating the Act unconstitutional on all three grounds and also affirmed enjoinment of the Act’s enforcement in its entirety as the proper remedy. The United States Supreme Court granted Certiorari. [Summarized by Viva Foley.]

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Probabilities in Health Care

Erza Klein has a great post entitled, "The Problem with Probabilities," discussing the medical dilemma faced by one individual to demonstrate the probabilities issue.  He writes:

"Nice illustration of a constant medical dilemma by Ogged, who happily appears to be stomach-cancer free:

the debate hadn't been between those recommending a gastrectomy and those favoring a follow-up endoscopy, but between those favoring a follow-up endoscopy and those who wanted to send me home and tell me to forget the whole thing. The latter group was convinced that the original finding were just a strange anomaly--not a mistake, exactly, but not worth worrying about. Older, more cautious doctors eventually brought everyone around to the consensus that they couldn't take even the small chance that I do have cancer lightly, so a follow-up is warranted. But even the doctor I talked to "officially" said "we don't expect to find anything."

So much of medicine is probabilistic. If you wanted to really cut costs, you'd take a coldly statistical view of the whole thing, with those who ended up on the wrong side of the numbers regrettable sacrifices. As a society, we're not ready or willing to do that -- and rightly so. But this is the essential conflict: politicians and hospital administrators look at the global budget, while doctors and patients look at the individual's health. The latter militates for constantly seeking the lowest possible error, the former for going with the statistics and saving money where you can.. . . ." [bm]

 

Childhood Obesity

National Public Radio's Diane Rehm show had a terrific discussion about the causes and potential solutions to the childhood obesity issues facing this nation.  It is entitled, "Fighting Childhood Obesity.  Click here for an interesting listen.  [bm]

La. Governor Signs S.D.-Style Abortion Ban

From Jurist comes this news:

Governor Kathleen Blanco [official website] of Louisiana signed a bill [PDF text; SB 33 summary] Saturday that could ban most abortions in the state. The bill, which would apply to all abortions except when the life of the mother is threatened, will take effect only if the US Supreme Court [official website] overturns the 1973 Roe v. Wade [text] decision or if the US Constitution is amended to allow states to prohibit abortions. The Louisiana Senate [official website] unanimously approved the bill [JURIST report] earlier this month.

Blanco said in a statement [text] that while she had hoped the bill would include additional exceptions for victims of rape and incest which did not pass, "the central provision of the bill supports and reflects my personal beliefs." The law is similar to South Dakota legislation [JURIST report] approved in March. Reuters has more.

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Breast Feeding Debate

On Tuesday, the New York Times had a focus on the wonders of breast feeding.  I was surprised how much the government appears to be encouraging breast feeding.  The article states,

There is no black-box label like that affixed to cans of infant formula or tucked into the corner of magazine advertisements, at least not yet. But that is the unambiguous message of a controversial government public health campaign encouraging new mothers to breast-feed for six months to protect their babies from colds, flu, ear infections, diarrhea and even obesity. In April, the World Health Organization, setting new international bench marks for children's growth, for the first time referred to breast-feeding as the biological norm.

"Just like it's risky to smoke during pregnancy, it's risky not to breast-feed after," said Suzanne Haynes, senior scientific adviser to the Office on Women's Health in the  Department of Health and Human Services. "The whole notion of talking about risk is new in this field, but it's the only field of public health, except perhaps physical activity, where there is never talk about the risk."

A two-year national breast-feeding awareness campaign that culminated this spring ran television announcements showing a pregnant woman clutching her belly as she was thrown off a mechanical bull during ladies' night at a bar — and compared the behavior to failing to breast-feed.

"You wouldn't take risks before your baby's born," the advertisement says. "Why start after?"

Slate.com's Sydney Speisel has slightly different point of view and believes that breast feeding and its benefits may be overstated.  He states,

Nursing is credited with preventing infants from getting cancer, allergic diseases, Crohn's disease, cavities, SIDS, and with improving IQ. For mothers, it's also asserted to prevent diabetes, certain cancers, and postpartum depression. In most cultures, however, vast differences—economic, educational, ethnic, psychological, biological—separate women who choose to breast-feed from women who choose formula-feeding. These differences are exaggerated when researchers compare, as they commonly do, the babies of women who breast-feed exclusively for six months and those who exclusively formula-feed for that length of time. The difficulty of doing research on humans thus poses a particular problem for studies of breast-feeding. Breast-fed babies may on average have higher IQ scores, say, but is the difference because of the breast-feeding or some other factor, like coming from a family with a higher income level or more education or fewer siblings? In the studies that have been done to date, untangling the observed effects is a nearly impossible exercise in subjective judgment. That's especially the case for evaluating subtle effects like IQ level, or the much later development of childhood cancer, allergies, or tooth decay.

Other benefits of breast-feeding seem pretty clear and incontrovertible. Large-scale studies in the developing world have reported a striking drop in infant mortality as formula-feeding is replaced by nursing. But while the role of breast-feeding in preventing infection is real, it is also widely misunderstood.

When you ask a bunch of doctors about how breast-feeding prevents infection, they get it wrong—I know they do, because I've asked the question. Doctors tell you that colostrum (produced in the first three days or so after a baby is born) and breast milk are full of maternal antibodies. Next, doctors say that these maternal antibodies are absorbed into the infant's blood circulation and thus serve to protect infants from disease.

That's the correct description of the immunology of breast-feeding for most mammals. It's also true that human colostrum and milk are rich in maternal antibodies—colostrum is pretty much antibody soup. And babies take in these antibodies as they nurse. But human babies are never able to absorb maternal antibodies from milk or colostrum into the bloodstream, except perhaps in the minutest amounts. Maternal antibodies in milk and colostrum protect against infection—but only locally, working inside the baby's gastrointestinal tract. . . .

None of this is my discovery. It was well-known, even commonplace, in the immunological literature of 40 years ago. But as the field turned to other matters, these findings just sort of fell out of fashion (though I've certainly come upon plenty of modern papers whose authors understand the idea). Because of the modern aversion to looking at older research, a surprisingly large number of doctors, especially nonimmunologists, have either forgotten this aspect of human immunity or never knew about it. And perhaps nobody wanted to bring the older findings to light for fear that doing so might discourage breast-feeding. (I can assure you that I feel some trepidation as I write this.)

What should we make of the facts about the immunobiology of lactation? First, it bears repeating that even if the immunological benefits are often overstated, there is clear and obvious benefit to breast-feeding in most of the developing world. Second, though it is harder to demonstrate in a scientifically satisfying way, there are probably other biological benefits. And there are surely economic reasons to give babies human milk instead of formula, which costs between $1,500 and $3,000 a year. In the developing world, the economic case against formula-feeding might be as potentially lifesaving as the immunological one: Money stolen from a poor family's budget for formula will not be available for food, housing, education—or even soap.

In the end, though, I find myself falling back on the same logic (or lack of logic) that appealed to me when my babies were born. Biologically speaking, it seems as if breast-feeding ought to be better for babies. At the same time, I am strongly convinced that there are two kinds of nutrition, physical and psychological, and that both are equally important. This conviction persuades me that it's better for a mother to formula-feed her baby pleasurably than to breast-feed and hate it. Fortunately, the majority of mothers enjoy nursing. But not all. Some women don't like to nurse, and others, even with the best help, find it physically difficult or daunting or intolerably uncomfortable. Sometimes, also, babies just aren't good nursers. In the end, I always encourage a mother to choose the feeding method that is most satisfying to her.

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