In May, a US delegation to the World Health Organization issued stunning trade and military threats in its opposition to a well-established and otherwise uncontroversial resolution encouraging breastfeeding, according to new reporting by The New York Times.

The hundreds of delegates in attendance expected an effortless approval of the resolution by the World Health Assembly, which is the decision-making body of WHO. The resolution simply put forth that mother’s milk is the healthiest option for infants and that countries should work to limit any misleading or inaccurate advertising by makers of breast-milk substitutes. It affirms a long-held position by the WHO and is backed by decades of research.

But more than a dozen participants from several countries—most requesting anonymity out of fear of US retaliation—told the Times that the American officials surprised health experts and fellow delegates alike by fiercely opposing the resolution. At first, the US delegates attempted to simply dilute the pro-breastmilk message, voiding language that called for governments to “protect, promote, and support breastfeeding” and limit promotion of competing baby food products that experts warn can be harmful. But when that failed, the US reportedly put the squeeze on countries backing the resolution by making aggressive trade and military threats—a move that further stunned the assembly.

The Ecuadorian delegation, for instance, was expected to introduce the resolution but was weaned off the idea after the US threatened to impose harmful trade measures and withdraw military assistance—which the US is providing in the northern part of the country to help address violence spilling over the border from Colombia.

Officials from the US, Uruguay, and Mexico said that at least a dozen other countries—many of which are poor countries in Africa and Latin America—dropped the resolution after the US sucked away their interest.

“What happened was tantamount to blackmail, with the US holding the world hostage and trying to overturn nearly 40 years of consensus on the best way to protect infant and young child health,” Patti Rundall, a breastfeeding advocate who attended the assembly, told the Times.

Feeding fears

A spokesperson for the Department of Health and Human Services—the US agency that led the effort to drain the resolution—denied threatening Ecuador but explained the agency’s opposition to the resolution, saying:

The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children. We recognize not all women are able to breastfeed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies and not be stigmatized for the ways in which they are able to do so.

Though high quality, safely prepared substitutes can provide adequate nutrition for infants, emphasis on breastfeeding stretches back through decades of concern from health experts and officials that milk-substitute makers were causing harm with their marketing strategies. Advocates argue that companies such as Nestlé have a long history of making misleading nutritional claims about milk substitutes and donating the substitutes to hospitals in developing countries. Starting infants out on a substitute in a maternity ward can make breastfeeding more difficult for mothers later. And once mothers leave the hospital or clinic after giving birth, they may not have access to sanitary conditions or clean water in which to mix powdered substitutes and/or be able to afford enough substitute to keep their infants nourished. These scenarios open infants up to disease and malnutrition, advocates say.

The Times notes a 2016 series in the Lancet in which researchers estimated that universal breastfeeding could spare the lives of 823,000 children each year and save $302 billion in economic losses. The WHO has long said that breastfeeding is the optimal feeding method for infants and recommends exclusive breastfeeding for the first six months of a child’s life and continued feeding with introduction of other foods up to two years of age.

In the end, the US’s effort to dash the WHO resolution encouraging breastfeeding was largely unsuccessful. Russia ultimately sponsored the resolution and the American delegation did not issue any threats to the country.