Posts tagged ‘Cicely Williams’

Aug 16

Starved Out

Two years ago today, police opened fire on a group of striking mineworkers encamped on a koppie outside of Marikana. Mainly rock drill operators doing some of the most basic and difficult work on the mine, these men demanded that Lonmin – in whose platinum mine they worked – raise their salary to match that of literate, better skilled miners, to about R12,500 per month.

After weeks of sporadic violence on both sides – during which policemen, shop stewards, and workers were injured and killed – mine bosses urged the police to end the standoff. Jack Shenker writes:

It was the police who escalated the standoff at Marikana mountain, bringing in large numbers of reinforcements and live ammunition. Four mortuary vans were summoned before a single shot had been fired. Lonmin was liaising closely with state police, lending them the company’s own private security staff and helicopters, and ferrying in police units on corporate buses. Razor wire was rolled out by police around the outcrop to cut the miners off from Nkaneng settlement; pleas by strike leaders for a gap to be left open so that workers could depart peacefully to their homes were ignored.

Police opened fire as workers approached them. In the end, thirty-four were killed, seventeen of them at a nearby koppie where it appears that they were shot at close range. The Marikana massacre has been described as post-apartheid South Africa’s Sharpeville. As the inquiry into the events near the mine has revealed, police arrived not to keep order, but, rather, to end the strike through any means possible.

The poster for Rehad Desai’s documentary on the Marikana massacre, Miners Shot Down.

The killings were followed by a strike – the longest in South African history – until May. Of all the details to emerge in the coverage of life in the platinum belt, the one that seemed to encapsulate the desperation of striking miners and their families was in a 2006 report commissioned by Lonmin: researchers had discovered children suffering from kwashiorkor near the mine.

Although already identified in 1908, kwashiorkor was named by Dr Cicely Williams, a Colonial Medical Officer, in the Gold Cost during the 1930s. Tom Scott-Smith explains:

she noticed a recurring set of symptoms amongst children who were aged between one and four: oedema in the hands and feet, darkening and thickening of the skin followed by peeling, and a reddish tinge to the hair in the worst cases. There was a clear pattern in the incidence of this disease, since it occurred in children who had been weaned onto low-protein, starchy foods such as maize, after being displaced from the breast by a younger sibling. Williams’ description first appeared in print in 1933, and two years later she identified the condition by its name in the local language: kwashiorkor, the ‘disease of the deposed child’.

Williams diagnosed kwashiorkor as a from of inadequate nutrition – similar to pellagra, which is caused by a diet insufficient in vitamin B3 – related specifically to an intake of too little protein. Williams had noticed that newly weaned babies and young children – the ‘deposed’ children referred to by the word kwashiorkor – were particularly vulnerable to the condition, and surmised that longer breastfeeding or a diet rich in the nutrients non-breastfed children lacked – protein especially – would eradicate kwashiorkor.

By the 1970s, though, doctors argued that this emphasis on protein supplements – which had driven United Nations and other organisations’ efforts to address kwashiorkor – was incorrect. Kwashiorkor, they argued, was the product of under nutrition: of not consuming enough energy. Scott-Smith writes:

Evidence from the 1960s demonstrated that a less protein-rich, more balanced diet could cure kwashiorkor equally well, and by the 1970s a number of other causes for the disease were suggested – even today, the details of kwashiorkor are still not fully understood.

Had scientists paid closer attention to the name ‘kwashiorkor’ they may have come to this realisation sooner. It is a disease of poverty where adults are unable to provide weaned children with adequate nutrition. As a result, its solution is distressingly simple: better and more food.

If there is any indicator of the extent of poverty in the platinum belt, then it is the fact that children suffer from kwashiorkor. While Lonmin has ploughed some of its profits back into communities surrounding the mines – opening schools and running feeding schemes, for example – it remains the case that mineworkers and their families are still desperately poor.

Keith Breckenridge argues that the wealth generated by workers operating in exceptionally dangerous conditions is channelled largely to a small group of beneficiaries. He adds:

Under the current arrangements in the platinum belt there is almost no movement of resources from mining to the wider problem of maintaining the physical and emotional well-being of the general population working in the mines. Mine managers have retreated from maintaining order and health in the hostels, and they have ceded control over the key human resource questions – employment and housing – to union officials and their allies. Like foreign shareholders and local royalty owners, these union leaders, using their monopoly over jobs and housing, have tapped into the demand for employment to enrich themselves (often at the expense of the working and living conditions of union members). Local government – caught between the mines and the prerogatives of tribal authorities – has all but abandoned the project of regulating the living spaces around the mines.

Where once miners were coralled into the prison-like conditions of single-sex hostels where their food, accommodation, and other expenses were covered by mining companies, now meagre housing allowances are meant to support these workers and their families in the otherwise badly provisioned and serviced towns and villages in the platinum belt. Salaries tend to go straight to pay interest on loans granted by micro lenders, charging exorbitant interest rates.

As the incidences of kwashiorkor reported to Lonmin suggest, these men were not earning enough to feed themselves and their children. While under cross examination at the Farlam Commission of Inquiry into the Marikana massacre, Cyril Ramaphosa – current Deputy President and Lonmin board member who had emailed the then-Police Minister, demanding an end to the workers’ strike – remarked:

The responsibility has to be collective. As a nation, we should dip our heads and accept that we failed the people of Marikana, particularly the families, the workers, and those that died.

I dispute the ‘we,’ Mr Deputy President.

Sweetness and Light

This weekend some friends and I cooked a Lusophone world-themed dinner. I contributed pudding: an updated version of bebinca – a Goan dessert consisting of layers of coconut pancakes – and brigadeiros, a Brazilian interpretation of chocolate truffles made of condensed milk and cocoa. The recipe for the latter is incredibly easy:

1 tin sweetened condensed milk

½ cup cocoa (not drinking chocolate)

2 Tblsp butter

Silver balls, hundreds and thousands, or more cocoa, for coating

1. Combine the condensed milk, cocoa, and butter in a heavy-based saucepan.

2. Stirring continuously (preferably with a rubber spatula), cook over a low-to-medium heat until the mixture is so thick it’s possible to draw the spatula across the bottom of the pot, leaving a wide gap.

3. Pour the mixture into a well-greased 20cm square cake tin, and allow to cool.

4. Pinch off pieces of the mixture and roll into small balls – about halfway in size between a hazelnut and a walnut. Roll in the extra cocoa or decorations. Allow to set in the fridge.

This is an unbelievably sticky procedure: oil everything (utensils, crockery, yourself) before attempting to roll the mixture because otherwise there may be, frankly, quite a lot of swearing. Also, clean up thoroughly. The ants which attempt periodically to invade my kitchen had a short-lived fiesta on my counter tops before being swiftly washed away.

As I was looking for recipes, I was struck by how frequently particular ingredients and dishes recurred within Brazilian, Mozambican, Goan, and Macauan cuisines: limes, chillies, coconut, spicy chicken (sometimes called piri piri, or similar), and custards. These continuities are not particularly surprising. In the circulation of people and things around the Lusophone world – from Portugal to Brazil, to Angola and Mozambique, to Goa, and parts of southeast Asia – recipes, plants, and animals were exchanged and traded.

Another, more unexpected, similarity between these cuisines is sweetened condensed milk. It appears in beverages, cakes, and other puddings, be they Brazilian or Goan. For cultures unused to cooking with dairy products – in India, for instance, or parts of southeast Asia – condensed milk is more easily incorporated into dishes as a sweetener. Also, tins of milk keep far more easily than bottles of fresh milk in warm climates.

The person who patented the recipe for condensed milk was the American inventor, adventurer, and politician Gail Borden. Having initially devoted himself to coming up with a recipe for ‘meat biscuits’ (high protein bars to be supplied to soldiers), he turned his attention to preserving milk. He was not the only person interested in extending the shelf-life of milk: evaporated and dried milk products were being experimented with at the same time. The process that Borden used – adding sugar and then condensing milk via a vacuum process – created a product which tasted delicious and had a long shelf life. In 1858, he and Jeremiah Milbank founded the New York Condensed Milk Company. Their fortunes were assured when, from 1861, the Company supplied the Union Army with condensed milk throughout the Civil War.

The first overseas condensed milk factory opened in Switzerland in 1866. Owned by two Americans – George and Charles Page, the latter being the US Consul at Zurich – the Anglo-Swiss Condensed Milk Company eventually merged with Nestle, another manufacturer of condensed milk, in 1904. Sweetened condensed milk spread around the world after the First World War. It arrived in Brazil in 1921, and was almost immediately incorporated into the cuisine.

Borden’s interest in milk and meat stemmed partly from anxieties about the cleanliness and purity of processed food. His Eagle Brand of condensed milk was advertised on the grounds that it was produced in hygienic conditions and could safely be fed to the very young and the very old. Indeed, sweetened condensed milk was regarded as having potentially healthy properties. The earliest incarnation of bircher muesli – fed to patients at Maximilian Bircher-Benner’s sanatorium in Switzerland – consisted of condensed milk, fruit, and oats. And it was seen as a decent substitute for breastmilk.

The marketing of condensed milk coincided with heightened concerns about high rates of infant mortality in industrialising cities all over the world. Having noticed that exclusively breastfed babies tended to be healthier than those who were not, by the end of the nineteenth century, scientists had established that the leading cause of death in early infancy – diarrhoea – was caused by ingesting dirty and rotting food, mainly milk products. For instance, in 1895 and 1896, Dr EB Fuller, Cape Town’s Medical Officer for Health, conducted a survey into the causes of infant diarrhoea in the city and discovered, as Peter Buirski explains:

Of the 140 deaths examined, the survey revealed that 97 were stated not to have had any breastfeeding, but to have been entirely dependent on the bottle and other sources, whilst 16 were said to have been fed on both breast and bottle. As Fuller noted, ‘we have…very clear evidence of the fact that it is the hand fed children who succumb most extensively to the disease in question.’

Public health officials and infant welfare campaigners not only doubled their attempts to persuade mothers to breastfeed for as long as possible, but also established depots where they could receive clean, pasteurised fresh milk and, importantly, healthy preserved milk products too – mainly dried or evaporated milk.

But some paediatrians had been pointing out since at least the 1890s that even if sweetened condensed milk was a useful dietary supplement for particularly malnourished children, it was hardly health food. The doctor and public health campaigner Cicely Williams – who identified the disease kwashiorkor – had noticed as early as 1933 that adults in parts of West Africa were adding sweetened condensed milk to their diets. Soon she connected widespread malnutrition in babies and young children with the use of sweetened condensed milk in the place of more nutritious products – including, worryingly, breast milk. Writing about Singapore in the early 1940s, she explained:

there is the misguided popularity of sweetened condensed milk. The palatable sweetness of this, when it is once started as a supplementary or as a complementary feed, often results in the baby refusing to take the breast, or taking the breast with no enthusiasm and finally in the drying up of the milk. With wearisome and deadly frequency one hears ‘the baby would not suck,’ ‘the breast milk disappeared in three weeks,’ and in every case it is proved that sweetened condensed milk had been given.

Although recognizing that doctors and clinics could do more to inform mothers about breastfeeding, Williams argued for the better control of milk companies:

The advertisements of the milk firms are responsible for a certain amount of misguided propaganda. The people they employ are not always wise in their methods and it may be found that artificial feeding and infant mortality are higher in those areas where milk firms have their ‘nurses’ working than in those where they do not.

In 1939 she published the pamphlet ‘Milk and Murder’ in which she blamed the advertising strategies of companies like Nestle for causing mothers to give up breastfeeding – contributing, thus, to high rates of infant mortality in regions such as West Africa and South Asia. That pamphlet formed the basis for War on Want’s 1974 report The Baby Killer – the manifesto for the Nestle boycott which resulted, eventually, in the adoption of the 1981 International Code of Marketing of Breast-Milk Substitutes by the World Health Organisation.

Even if its advertising of artificial baby food had been largely constrained, Nestle still seeks out ways of selling its products – including sweetened condensed milk – to new, unsuspecting markets. Four years ago it was particularly sharply criticised for sending ‘floating supermarkets’ down tributaries of the Amazon, aimed specifically at potential shoppers unaccustomed to processed food.

My point is not that we should all abandon sweetened condensed milk. Far from it. What an understanding of the fraught history of sweetened condensed milk demonstrates is a continuity in the ways in which ingredients and foodstuffs are circulated around the world. As chillies and limes and coconuts were carried around the Portuguese empire, shaping and remaking local cuisines, so Nestle has added sweetened condensed milk to an increasing number of Brazilian and Indian kitchens during the twentieth and twenty-first centuries. The difference, obviously, is that Nestle could advertise its products as the healthy, responsible choice for nursing mothers – piggy-backing, effectively, on to public health concerns about infant mortality. The question then, is should we control or limit the sale of sweetened condensed milk and other, less-than-healthy processed foods, in poor areas unaccustomed to the wiles of Big Food?

Sources

Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding, 1890-1950 (Madison, WI: University of Wisconsin Press, 1987).

PJ Atkins, ‘White Poison? The Social Consequences of Milk Consumption, 1850-1930,’ Social History of Medicine, vol. 5 (1992), pp. 207-227.

Peter Buirski, ‘Mortality Rates in Cape Town 1895-1980: A Broad Outline,’ Studies in the History of Cape Town, vol. 5, ed. Christopher Saunders, Howard Phillips, Elizabeth van Heyningen, and Vivian Bickford-Smith (History Department and the Centre for African Studies, University of Cape Town, 1983).

M. Hickey, ‘Current Legislation on Concentrated and Dried Milk Products,’ in Dairy Powders and Concentrated Products, ed. AY Tamime (Wiley-Blackwell, 2009).

Harvey Levenstein, ‘“Best for Babies” or “Preventable Infanticide”? The Controversy over Artificial Feeding of Infants in America, 1880-1920,’ The Journal of American History, vol. 70, no 1 (June 1983), pp. 75-94.

Cicely D. Williams, ‘A Nutritional Disease of Childhood Associated with a Maize Diet,’ Archives of Diseases in Childhood, vol. 8, no. 48 (1933), pp. 423-433.

—. ‘Rickets in Singapore,’ Archives of Diseases in Childhood, vol. 21, no. 37 (1946), pp. 37-51.

Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.

Apr 1

2 Comments

No Sweeteners

One of the best things about being an academic is the stuff that people send you in the – usually entirely correct – belief that you’ll find it interesting. I’ve had emails about pink slime (for the blog) and on programmes about children’s literature (for my research). Recently, my friend Elizabeth, who’s a lawyer, forwarded me this from Legalbrief:

New draft baby feeding regulations will forbid formula manufacturers from ‘aggressively marketing’ their products to mothers and from sponsoring meals and professional development courses for healthcare practitioners, says a Weekend Argus report. It adds the standards set in the draft regulations, which the Department of Health has released for public comment, intend to promote safe nutrition for babies and young children and restrict inappropriate marketing practices. The department stressed that the regulations would not stop baby formula and complementary foods from being sold at retailers. ‘Although breastfeeding is best, government recognises that some women cannot breast-feed or decide not to breast-feed. These regulations do not in any way compel women to breast-feed against their will,’ the department is reported to have stated.

The proposed regulations, which fall under Section 15 (1) of the Foodstuffs, Cosmetics and Disinfectants Act, 1972, make for fascinating reading. Other than banning trans fats and artificial sweeteners in baby formula, their emphasis is on curtailing the advertising and promotion of artificial foods.

For instance, the packaging of baby formula may not have pictures of infants, young children, or any other ‘humanised figures,’ except for those included in instructions for preparing the product. Tins and containers may not ‘contain any information or make any negative claim relating to the nutritional content or other properties of human milk’, and they’re not allowed to include toys or gifts. Packaging must include in English, in bold letters at least 3mm tall, the message: ‘Breast milk is the best food for babies.’

The regulations will also radically limit the advertising of baby formula shops, in print and online, ban the distribution of gift packs and free samples, and prevent formula manufacturers from sponsoring or donating equipment bearing the logo of their products. These manufacturers may not

provide research grants or any other financial assistance relating to infant or young child nutrition to health care personnel working in a health establishment or health care personnel linked to a health establishment.

Nor may they give doctors, nurses, and health workers gifts, and ‘heads of health establishments, national, provincial and local health authorities shall take measures to promote, support and protect breastfeeding.’

It’s an ambitious piece of legislation, but one which is entirely in line with the World Health Organisation’s International Code on the Marketing of Breast Milk Substitutes. The Code was adapted in 1981, and places stringent regulations on how baby formula is advertised: it advises that baby milk formula should not be allowed to market products directly to pregnant women and mothers with young children, including handing out samples. Products should also state that breast milk is superior to formula.

Implementation of the Code has been slow, and there is evidence to suggest that it has been particularly poorly policed in developing nations where oversight of the activities of powerful multinationals is often lax. The South African regulations are far stricter than the Code, particularly as regards the relationship between the pharmaceuticals industry and academic research, but address a problem which campaigners have long identified: that there is a link between the way in which formula is advertised and how women feed their babies.

This isn’t to suggest that women should have their choices about how they feed their babies curtailed – or that it’s only advertising which causes women to choose to use baby formula. Far from it. The problem, though, is that, particularly in poor nations, advertising or other promotional methods encourage breastfeeding mothers to switch to baby formula when it’s unlikely that they’ll be able to afford to buy more formula, and where they may dilute formula with too much water to make it go further. This water may not be clean, and it’s difficult to keep bottles and teats sterile without electricity or plumbing.

The purpose of these regulations is to ensure that formula manufacturers don’t use the often less than ideal conditions in which mothers in developing nations raise their babies, to their own advantage.

We tend to associate the WHO’s Code with the Nestle Boycott, which was launched in 1977. The Boycott was based on a pamphlet published by War on Want in 1974, titled ‘The Baby Killer’ and, in Switzerland, ‘Nestle Kills Babies’. The charity alleged that Nestle’s advertising strategies were responsible for high rates of child mortality. After a legal tussle as well as an attempt to refute the Boycott’s allegations, Nestle agreed to implement the Code in 1984, although there remains some scepticism as to Nestle’s, and other companies’, commitment to this.

But concern about the advertising of baby formula predated the 1970s, and even the 1940s, when breastfeeding began to decline globally. As I’ve sat in the National Library over the past few months, reading Child Welfare and other child health magazines from the first half of the twentieth century, I’ve been struck by the number of advertisements for baby formula. They all feature fat, healthy babies and testimonials from relieved mothers who claim that the child was fed from birth on Lactogen or whichever other patent food.

Even Truby King, early twentieth-century breastfeeding evangelical and founder of the global mothercraft movement, developed artificial baby food which was produced in New Zealand and then shipped all over the world. Kariol, Karilac, and Karil were meant to be prescribed for babies who were not, for whatever reason, breastfed either as a supplement to cows’ milk, or to be taken on their own.

Although King’s patent foods seemed to contradict his enthusiasm for breastfeeding – and he came under enormous criticism in New Zealand and Australia for his promotion of Kariol and Karilac – there was a certain logic to his decision to manufacture wholesome baby formula. During the early decades of the twentieth century, doctors in Britain and the United States noticed that bottle-fed babies were considerably more likely to die during early infancy than those who were breastfed. Artificial foods – which ranged from thin porridges and condensed milk to baby formulas – were often nutritionally inadequate, particularly in poor families who could not afford better and more expensive substitutes.

But they also identified a link between bottle feeding and diarrhoea, then, as now, one of the main causes of death in infancy. William J. Howarth, the Medical Officer of Health for Derby

arranged in 1900 to receive weekly lists of the births registered during the past seven days from the local registrar. From November of that year until November 1093 women inspectors enquired into the feeding method of each registered child by personally visiting the mother and infant at home.

The results of the study, published in 1905, were telling. Of the infants surveyed, 63% were breastfeed, 17% were partly bottle-fed, and 19% entirely bottle-fed:

The mortality rates from ‘diarrhoea and epidemic enteritis’ in addition to those from ‘gastritis and gastro-enteritis’ were as expected: 52, or 10 per 1,000 of the breastfed, 36 or 25.1 per 1,000 of the mixed-fed, and 94 or 57.9 per 1,000 of the bottle-fed babies died. In other words the mortality rate of the bottle-fed infants was nearly six times greater than that of the breast-fed babies.

Howarth concluded: ‘In not one single instance does the death-rate in any class of disease among hand-fed children even approximate that recorded among children who are breastfed; the rate is invariably higher.’

The problem, in terms of the link between bottle feeding and diarrhoea, was not so much the nutritional content of artificial foods, but the difficulties in keeping them free from contamination, and particularly during summer when infant mortality rates soared.

Indeed, South African advertisements for Lactogen emphasised that the product did not spoil in warm weather. As criticism of artificial foods grew louder, so advertising became more subtle, and better adept at appealing to mothers aware of the potential problems of bottle feeding. Doctors were, though, also aware of the effects of advertising on mothers’ choices, as a medical officer based in Johannesburg wrote in 1925:

No one can deny the fact that the proprietary foods of today are a vast improvement upon those of twenty years ago. They all contain very sound instructions as to the preparation of the food and the amount to be given. The advertising of such foods is carried out on a most extensive scale and in a clever and attractive manner. No hoarding today is without a picture of a flabby and over-fat infant alleged to have been reared solely on the proprietary food advertised thereon. Many a mother who for one reason or another, is not satisfied with the progress of her baby, sees this advertisement, and immediately rushes off to secure this particular food for non-thriving infant.

But not only mothers were influenced by this advertising. He admitted that it was ‘only too true that many medical men and trained nurses are also gulled by such advertisements and circulars’. Dr Cicely Williams, best known for her identification of the condition kwashiorkor in the 1930s, worked in the Colonial Medical Service in West Africa and southeast Asia before World War II and became particularly interested in the treatment of the diseases of early infancy.

She was critical of the introduction of baby formula to Singapore and Malaya, where white-coated sales reps distributed samples of artificial foods to poor mothers. In 1939 she published a pamphlet, ‘Milk and Murder,’ in which she pointed out the benefits to both mothers and babies of breastfeeding.

Nevertheless, Nestle and other companies were still using the same strategies to convince mothers in developing nations to use baby formula in the 1970s, and there are still concerns that they are not fully compliant with the Code on breast milk substitutes. The new South African regulations, if passed, are aimed at remedying this.

The cause for these new regulations and other measures introduced internationally to encourage mothers to breastfeed for the first six months of life, is a concern that rates of breastfeeding remain low in comparison to what they were during the early twentieth century. For all the good that the Code and other laws have done, it remains the exception, rather than the rule, for women to breastfeed for such an extended period of time.

However true it may be that advertising does have an impact on women’s choices, it’s certainly not the only factor which influences how women feed their babies. What’s missing from these measures is any attempt to communicate with mothers themselves. As doctors in the early twentieth century believed that mothers, whom they characterised as emotional and irrational, simply followed any and all advice which they read or heard, so campaigners and governments today seem to be too quick to seek only one reason for women’s decision to breast- or bottle-feed.

In fact, we need to make it easier for women to choose to breastfeed: to eliminate the ridiculous prejudice against breastfeeding in public spaces; for work and childcare not to be mutually exclusive; and for sympathetic advice and information to be made available for all new mothers.

Posts tagged ‘Cicely Williams’

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