Here & Now's Tonya Mosley speaks with Andrea Freeman — whose book "Skimmed: Breastfeeding, Race, and Injustice" looks at how formula was marketed to black women in the late 20th century.

Book Excerpt: 'Skimmed'

Introduction

A FORMULA FOR DISCRIMINATION

On May 23, 1946, in the rural southern town of Reidsville, North Carolina, a small miracle occurred. The woman responsible for this miracle was Annie Mae Fultz. Annie Mae was a tall, beautiful, Black-Cherokee mother of six children. She had lost her ability to speak and hear during a childhood illness. Beginning at 1:13 a.m., Annie Mae gave birth, in short intervals, to the world’s first recorded identical quadruplets. Against the odds, each of these four tiny girls survived their first few hours and began to grow steadily. Word of their birth spread quickly throughout the country. Annie Mae’s joy at her perfect new daughters was irrepressible, expressed in exuberant debates with friends and relatives at her hospital bedside about possible names for the girls. But this overwhelming happiness was far too short-lived.

Andrea Freeman.

Fred Klenner was the White doctor who delivered the girls in Annie Penn Hospital, in the basement wing reserved for Black patients. Dr. Klenner quickly realized how his new patients’ instant celebrity could benefit him. He began testing his controversial theories about vitamin C on the girls on the day of their birth, injecting them with fifty milligrams each. He did not stop there. Dr. Klenner snatched the privilege of naming the girls from Annie Mae and their father, Pete, a tenant farmer on a nearby tobacco farm. Dr. Klenner gave all the sisters the first name Mary; then middle names belonging to his wife, sister, aunt, and great-aunt: Ann, Louise, Alice, and Catherine.

Dr. Klenner was still not done. He began negotiating with formula companies that sought to become the newly famous Fultz Quads’ corporate godparent. The company with the highest bid would be the first to target Black women with a formula advertising campaign. Dr. Klenner selected St. Louis’s Pet Milk company for this honor. The deal he made with Pet Milk set in motion a chain of events that would lead to Annie Mae losing, not just the right to name her girls, but the girls themselves.

The consequences of this contract reached far beyond the Fultz sisters. Pet Milk’s campaign directed at Black women reaped unexpectedly high profits. The company was one of the first to market anything but alcohol, tobacco, or beauty products directly to Black families. Through Pet Milk’s bold marketing scheme, many Black women became convinced that formula was just as healthy as, or even healthier than, breast milk. This comforting belief made it easier for them to succumb to a host of external pressures not to breastfeed.

Over the following decades, as images marketing formula to Black women increased, positive images of Black women breastfeeding remained virtually nonexistent. Magazines such as National Geographic portrayed breastfeeding Black women as exotic and savage. Popular and media imagery reflected and perpetuated wide disparities in breastfeeding rates between Black and White mothers. Selling formula to Black women aligned with the stereotype, first popularized in slavery, of Black women as cold and incompetent mothers.

Half a century after the birth of the Fultz sisters and Pet Milk’s ad campaign, the Bad Black Mother stereotype played a role in the misfortune that befell Tabitha Walrond, a young Black woman from the Bronx, and her son, Tyler. After nineteen-year-old Tabitha became pregnant, she spent weeks struggling to break through the bureaucracy of New York’s Medicaid offices to get a card for her son before his birth. Despite her exhaustive efforts, when Tabitha went into labor, Medicaid still had not corrected the computer error that had caused the delay. The system’s indifference to the needs of a young, poor, pregnant Black woman was typical. In this case, it proved fatal.

Tabitha’s delivery was rife with complications, forcing her to extend her hospital stay by a few weeks and to delay breastfeeding. Eventually, Tabitha’s doctors released her and Tyler from the hospital. When they did, they discharged her with false information. It is common for doctors not to see Black women as individuals and to ignore symptoms that they would pay attention to in White women. Tabitha’s doctors overlooked the fact that her difficult delivery and a previous surgery would affect her milk supply. The hospital staff negligently assured Tabitha that her baby would thrive on a steady diet of her breast milk. They were wrong.

Instead, Tyler lost weight. Tabitha did not notice, because, as a new mother who never left her infant’s side, she could not easily perceive changes in his size. Although friends and family urged her to take him for a postnatal checkup, no doctor would see him without a Medicaid card. Tyler was born on August 27, 1997. He died from inadequate nutrition eight weeks later, in a taxi on the way to the emergency room. White mothers who lost children under similar circumstances received sympathy and inspired legal changes in the length of required hospital stays. In Tabitha’s case, the prosecutor charged her with second-degree manslaughter. Mourning the loss of her son, Tabitha faced the prospect of losing her freedom as well. Throughout her ordeal, the press pounced on the opportunity to demonize Tabitha and blame her for Tyler’s death.

Although separated by almost fifty years, the experiences of Annie Mae Fultz and Tabitha Walrond reveal similar truths. Cavalier attitudes toward Black mothers and children allowed a corporation to take over the Fultz sisters’ upbringing and the medical bureaucracy to fail Tyler Walrond. Dr. Klenner thought nothing of using Annie Mae Fultz’s girls for his own gain. The doctors in the Bronx neglected to see Tabitha Walrond as an individual. Multiple refusals to care for a Black newborn caught up in red tape cost him his life.

These stories are also connected by the profits that the formula industry made from them. Formula companies benefited from Annie Mae’s and Tabitha’s losses. Pet Milk made unprecedented millions from the Fultz Quads campaign. And after Tyler’s death and Tabitha’s prosecution, formula manufacturers teamed up with the CBS television network to create a cautionary episode of Chicago Hope based on the Walronds’ story. They scripted the show to scare its millions of viewers away from breastfeeding and to sell formula. The screenwriters whitewashed Tabitha, casting a White actor to play the grieving and misinformed mother. This move ensured that viewers would see breastfeeding, not bad parenting, as the cause of the infant’s death. To maximize its profits from Tabitha’s tragedy, the formula industry had first to recognize and then distract the television audience from the Bad Black Mother stereotype.

Trading on the popularity of the Fultz sisters and, later, the horror of Tyler’s death, the formula industry sold Black families lies about formula. It invited Black women to believe that their formula purchases proved they were good mothers. Modern marketing continues to associate successful Black parenting with formula use. At the same time, popular images equate ideal parenting with White breastfeeding. The message is clear: because bad Black mothers use formula, good White mothers can raise themselves above them by breastfeeding. A Black woman, like Tabitha, who pursues the breastfeeding ideal but falls short of it is a criminal. A White woman who tries but fails is a saint.

Formula is a seventy-billion-dollar industry. First designed to help infants without access to breast milk survive, formula now serves as a common replacement for human milk. The product allows many women to participate fully in the workforce, absent the structural support necessary to make both working and breastfeeding possible. Formula’s transformation from emergency supplement to common food item arose from employment demands combined with pervasive marketing touting its near equivalency to breast milk. Medical professionals’ and government programs’ promotion and purchase of formula in exchange for contributions and support from the industry also create high demand for the product.

Black mothers use formula much more than White mothers. Black women and children suffer from conditions and diseases linked to formula feeding at significantly higher rates. These disparities usually do not arise from lack of education or cultural or personal preferences about infant feeding. Instead, for the most part, they reflect the absence of choice created by government policies and unaccommodating social structures.

An Unhealthy Alliance

The federal government, through the US Department of Agriculture (USDA), is the single largest purchaser of formula in the United States. The USDA receives generous rebates on these purchases, paying only about 80 percent of the regular price of formula. The rebates go directly into the budget of the federal nutrition program for Women, Infants, and Children (WIC), allowing it to provide services to a wider cross section of communities. WIC, in turn, distributes formula free to women in its program, significantly increasing the likelihood that these women will choose not to breastfeed their children. The proportion of WIC participants who choose formula over breastfeeding is higher than in the general population. Families that have received formula free through WIC go on to purchase it later. These sales compensate for the hit the companies take from the rebates, allowing them to come out ahead even with the discounts.

The USDA also benefits from distributing free formula to poor families because most of the ingredients in formula are subsidized commodities that the agency is responsible for. Formula contains primarily corn (in the form of corn syrup) and either milk or soy. Through the Farm Bill, corn, dairy, and soy receive significant subsidies, which incentivize farmers to produce more of these foods than consumers want. The USDA, under its institutional mandate, must purchase and resell or distribute the resulting surpluses. The agency has found creative ways to do so. Its strategies include grocery store giveaways and collaborations with fast food companies to develop and promote products, such as Domino’s seven-cheese American Legends pizza, that contain obscene amounts of milk. The USDA also distributes foods made from subsidized commodities, such as chicken nuggets, cold cuts, and pizza, to low-income public school students through its National School Lunch Commodities Program.

Using its WIC and School Lunch nutritional programs to redistribute the food that consumers do not want to buy is a particularly elegant, if suspect, solution. Women and children in need of government assistance cannot afford to refuse free food, regardless of its harmful effects on their health. Exploiting this vulnerability in the context of children’s first food seems particularly egregious and has enduring consequences. The taste preferences that infants develop can last a lifetime. When high-sugar processed formula is their first food, they are likely to crave this type of food into adulthood. This diet creates a high risk of obesity, type 2 diabetes, and other preventable conditions.

Breastfeeding Facts

The health advantages of breastfeeding over formula feeding are numerous and virtually undisputed. The most esteemed global health entities, the World Health Organization and UNICEF, recommend breastfeeding for at least two years. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists advise breastfeeding for at least one year. The US government, through multiple agencies, including the Centers for Disease Control and Prevention, the Surgeon General, and the Department of Health and Human Services, urges mothers to breastfeed for as long as possible to avoid a host of harms, from ear infections to premature death. A UNICEF statement lays out exactly how high the stakes are: “Breastfeeding is the closest thing the world has to a magic bullet for child survival.” Globally, multiple studies link low breastfeeding rates to high infant mortality. Of the twenty-six largest industrialized and twenty wealthiest nations, the United States has the highest rate of infant mortality. This rate is twice as high for Black infants as for White ones.

The factors that contribute to Black women’s low breastfeeding rates are manifold, complex, and interconnected. They include race-targeted marketing, unequal distribution of resources for new mothers, and historical and present discrimination. Underlying these factors is the symbiotic relationship between the US government and formula corporations that gives the government a stake in the formula industry. This partnership harms women and infants in all communities but has a disproportionately negative impact on Black women and children.

Black women are overrepresented in the government assistance programs that distribute free formula. Too often, Black women live in “first food” deserts, a term for neighborhoods bereft of government services for new mothers. The hospitals in their communities dispense more free formula than hospitals in White neighborhoods do and discharge new mothers before they can receive guidance and support for nursing their newborns. Laws designed to protect breastfeeding mothers at work do not apply to part-time jobs or the small businesses that employ many Black women. Under 1996 welfare-to-work reform, many Black women, who make up a disproportionate number of welfare recipients, must return to work before their infants are ready to stop nursing, under conditions that make breastfeeding impossible.

Long-standing false narratives about Black mothers obscure the structural causes of their low breastfeeding rates. Collective belief in the existence of the Bad Black Mother leads to low or no investment in resources for breastfeeding Black mothers. It also underlies health care professionals’ assumptions that Black women do not require nursing support or education. The Bad Black Mother stereotype has its roots in slavery.