Breast-feeding Gets Cold Shoulder in B.C. Hospitals

By Alex Roslin
July 3, 2008
The Georgia Straight
[original story]

Breast is best; it’s widely known. But just 29 percent of B.C. moms breast-feed their babies exclusively for the first six months of their lives as recommended by Health Canada and the World Health Organization.

Why so few? One key reason, say breast-feeding advocates, is the solid grip that infant-formula makers have on doctors and nurses. Case in point: the controversy over Nestlé that erupted last month in the maternity ward at Burnaby Hospital.

When Nestlé Nutrition, a leading formula company, invited health professionals in Burnaby for cocktails and dinner at the city’s Hilton Vancouver Metrotown hotel in June—oh, yes, and a little talk on infant nutrition and formula titled “The Infant Feeding Maze”—a staff member at Burnaby Hospital e-mailed the invitation to employees via an internal mail list.

When word got out to breast-feeding advocates, they mobilized and bombarded Nestlé and health authorities with angry e-mails. They said the event violated the World Health Organization’s 1981 International Code of Marketing of Breastmilk Substitutes. The code, which Canada and the B.C. Health Ministry have signed, says formula makers shouldn’t offer “financial or material inducements” to health-care providers to promote their products.

Even B.C. Health Minister George Abbott waded in with a letter in which an official writing on his behalf said “it is clear that Nestlé is violating the [WHO] code.”

Nestlé bowed to the pressure and cancelled the event after getting “over 100” protest e-mails, said Catherine O’Brien, a spokeswoman at the company’s office in Toronto. Yet she rejected Abbott’s letter (“He had no knowledge at all of what the event was all about”) and insisted the meeting wouldn’t have violated the WHO code because “refreshments” and a meal are not a “material inducement”.

In fact, the event was the second in B.C. that Nestlé has had to cancel. Last September, staff at Burnaby Hospital invited the company to put on a similar information session, which was to have been held in the hospital itself, O’Brien said. That event was also cancelled after community protests. (The WHO code prohibits any promotion of formula products within hospitals.)

Michael Bernard, a spokesman for the Fraser Health Authority, which oversees Burnaby Hospital, said he would call back with a comment, but he had not done so by press time.

Although breast-feeding advocates were rejoicing at the latest cancellation, the dispute left maternity-care professionals at the hospital divided and prompted the resignations of lactation consultants Linda Good and Renee Hefti-Graham. “Women in Canada are paying the price for these free meals,” Good said in reference to Nestlé’s wine-and-dine. Hefti-Graham said many of their coworkers at the hospital were ambivalent about supporting breast-feeding, while one manager dismissed WHO literature on the subject—as well as documented international information on Nestlé WHO code violations—as “propaganda”.

The conflict sheds light on the persistent obstacles to breast-feeding in B.C. and Canada nearly three decades after the adoption of the WHO code. Despite Abbott’s support in the Burnaby dispute, many experts fault his government and the broader medical community for not doing enough to promote breast-feeding or reduce the sway that formula companies have over infant feeding.

The stakes in the battle over the bottle are huge. Research shows that breast-fed babies have fewer ear and respiratory infections, fewer allergies, less diarrhea, a stronger immune system, higher IQ, less risk of diabetes later in life, better oral development, and more bonding with Mom. Mothers also benefit by losing weight quicker, experiencing a faster contraction of the uterus, and having a lower risk of osteoporosis and ovarian and breast cancers.

In fact, research shows breast-feeding is literally a life-and-death issue in some cases. A May 2004 U.S. study of 9,000 infants published in the journal Pediatrics found a 27-percent higher chance of death among kids who had never been breast-fed compared to those who had, including a 19-percent greater risk of sudden infant death syndrome and 69 percent more chance of death by injury.

“Breast-feeding is associated with a reduction in risk for post-neonatal death,” the study said. “Promoting breast-feeding has the potential to save or delay approximately 720 post-neonatal deaths in the United States each year.”

In B.C., officials like to tout the fact that 95 percent of women breast-feed at birth, the highest rate in the country. “We play that up and pat ourselves on the back,” said Karyn-grace Clark, a lactation consultant in Nanaimo. “Though we get them breast-feeding, we can’t keep them breast-feeding.”

Less known is the fact that hospital staff give many of those women infant formula even when their babies are healthy and breast-feeding. The practice is a violation of guidelines established by the WHO and UNICEF in 1991 as part of a program called the Baby Friendly Initiative. The initiative, which the B.C. Health Ministry and Health Canada have endorsed, is intended to reform hospital practices worldwide in order to promote breast-feeding and reduce reliance on formula.

The Baby Friendly guidelines say there are only a few exceptional situations in which formula truly is a medical necessity for newborns, such as when they or their mothers are severely ill.

Yet as many as 60 percent of healthy, breast-feeding newborns are being given supplementary formula in B.C. hospitals, estimated Sandra Yates, a doyenne of the province’s lactation consultants who teaches courses on breast-feeding to health-care providers at Douglas College.

“Nurses are overworked; formula is used as a quick-fix solution,” Yates said. “Often the problems are shovelled off to the next level because there isn’t time to do it. It takes time to sit with a mom through an entire feed.”

Sharon Prindle-Collins, chair of the Fraser Health Authority’s Breast-feeding Practice Council, estimated that about 40 percent of healthy babies get formula in the eight maternity hospitals in her region. She agreed that many of the cases aren’t motivated by any medical necessity.

“There is a bed crunch,” she explained; in order to make way for new arrivals, formula is sometimes given in order to promote a baby’s weight gain so she can be discharged. “If weight [of the baby] is not up by the time they go home, sometimes the health-care provider would recommend formula to get the weight up,” she said. The recommendation typically happens in the event of weight loss of 10 percent or more, she said.

There’s just one problem: it’s normal for breast-fed newborns to lose up to 10 percent of their birth weight due to fluid loss, according to the WHO/UNICEF guidelines. Weight gain usually doesn’t start until day four or five after birth—after the baby goes home. (The usual postnatal hospital stay is one to three days.) In other words, a lack of weight gain in hospital is pretty much the norm.

In fact, the Baby Friendly Initiative says the only weight-related situations in which formula is a medical necessity are when a baby has “very low” birth weight—less than 1.5 kilograms—or hasn’t regained his birth weight after two to three weeks. “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements,” the guidelines state.

Aren’t some women just unable to breast-feed? Linda Good, one of the lactation consultants who resigned from Burnaby Hospital, said just three percent of moms can’t produce enough milk to breast-feed their babies exclusively, usually due to damage to breast ducts or nerves from cancer, burns, or surgery. But even these women can still usually breast-feed to some extent. Fewer than one percent of women can’t breast-feed at all; even women who adopt can produce breast milk, Good said.

Yet formula use in B.C. hospitals actually appears to be on the rise. Between 2005 and 2007, the percentage of all breast-feeding new moms (including those with pre-term babies and cesareans) who got some formula while in hospital went up from 24.2 to 25.3 percent, according to the B.C. Health Ministry’s Perinatal Health Program. The rate rose in four of the province’s six health authorities. (Barbara Selwood, a perinatal nurse consultant with the program, speculated that the higher numbers may just be due to more accurate data collection.)

As well, none of the province’s six health authorities managed to hit the WHO/UNICEF standard of 80 percent of all babies getting nothing but breast milk while in hospital (including those born by cesarean section). Overall, 69.2 percent of B.C. moms exclusively breast-fed their babies while in hospital last year, down from 69.5 percent in 2005.

It’s really no big surprise that health care in B.C. falls short of the WHO/UNICEF standards. Just one hospital in the province has thus far been certified as a Baby Friendly facility—Quesnel’s G. R. Baker Memorial Hospital, which got the designation last January.

To be sure, the situation isn’t much better elsewhere in Canada. Seventeen years after Health Canada endorsed the Baby Friendly Initiative, only 18 of Canada’s some 500 hospitals and health facilities offering maternity care have gotten the certification. (Thirteen are in Quebec, the only province to mandate all its maternity facilities to achieve the designation.) About 20,000 hospitals have been certified worldwide, but only 500 are in industrial countries.

In B.C., authorities have talked a good talk about Baby Friendly. Back in 2003, the province’s deputy health minister, Dr. Penny Ballem, wrote a letter to the CEOs of the six regional health authorities urging them to get certified. But no funds were attached to the recommendation, and it remains up to each authority to decide whether or not to go for it.

The B.C. Women’s Hospital and Health Centre has been working toward accreditation since 2004 and hopes to get it this month. That process, which typically takes five to 10 years, is just beginning for the Vancouver Coastal Health Authority, whose senior executive team will decide whether or not to pursue the designation in coming weeks, according to spokesperson Viviana Zanocco.

Baby Friendly would usher in a sea change in hospital routines in B.C. Getting certified means changing practices like taking babies from mothers right after birth in order to do a physical exam, administer a shot and eye ointment, and swaddle them. That process, which can last five minutes, has been shown to interfere with the establishment of breast-feeding, Yates said. Instead, Baby Friendly rules say newborns should be immediately placed on Mom’s chest so they can start trying to suckle; nurses can examine the baby there.

The WHO/UNICEF guidelines would also mean education for all maternity-care providers and moms on breast-feeding techniques. It used to be that a new mother’s aunts or mother would show her what to do, but after doctors and nurses started touting infant formula as being as good as breast milk in the 1950s—a belief that numerous studies have since discredited—several generations of women lost that knowledge.

Today, the 40 percent of mothers who encounter problems with breast-feeding—like sore nipples, infections, failure of the baby to latch, or poor milk supply—usually turn for help to public-health nurses and family doctors, but few of those professionals have undergone the breast-feeding training that the WHO/UNICEF guidelines recommend.

In early 2007, the B.C. Health Ministry brought 90 nurses from across the province to Vancouver to take a 20-hour course on breast-feeding, with the idea that they’d return to their facilities and teach the course to their coworkers. That second phase has stalled, however, amid squabbling between the ministry and health authorities over who will pay for staff to take time off work for the training.

Lactation consultants say change is also needed at the federal level and in the broader culture. Ottawa has yet to adopt the 1981 WHO code on formula marketing as law, which means formula companies are free to flout the code’s admonishments against formula ads in the media and giveaways of product samples to parents at Vancouver’s frequent baby fairs.

“Formula is so ubiquitous and integrated into our thinking that when we think of a baby, we think bottle. When there are breast-feeding challenges, the first thing women try is the bottle,” Yates said.

Good, who worked as a midwife in South Africa before she emigrated here 25 years ago, agreed. “I was shocked when I came to Canada. It felt like it was almost a different species. Mothers [here] live in a culture where we never see a baby on a breast. The whole society doesn’t know what breast-feeding should look like.”

On the other hand, many breast-feeding experts are heartened to see new generations of women challenge the medical community and formula companies like Nestlé. “As a culture, women have to take their power in breast-feeding,” Yates said. “They should do the research beforehand and know the potential problems [with breast-feeding], much as they plan out the birth. Then women won’t be as easily misled by health professionals.”

For more on this subject, check out Pieta Woolley's blog post on the trials and tribulations of being a breast-feeding mother in Vancouver.

The Quest for the Ultimate Addiction Cure

By Alex Roslin

October 25, 2007
The Georgia Straight

Could the root of an African shrub hold the key to getting millions of addicts off heroin, coke, and crack – oh, yeah, and cure alcoholism in its spare time? Can a single dose of an extract from the mysterious shrub's root bark be worth years on a therapist's couch?

Some of the answers may soon be found in a three-bedroom house on the Sunshine Coast. Tucked away there on a hill, with a stunning view of the ocean and surrounded by tall trees, is the Iboga Therapy House.

Forty years after globetrotting backpackers introduced a substance called ibogaine into the U.S. drug culture, the extract from western Africa's Tabernanthe iboga shrub has become an underground rage among drug-addled Hollywood celebs willing to plunk down between $3,500 and $10,000 for ibogaine treatment at any one of about a dozen unregulated clinics worldwide, including the one in B.C.

Because ibogaine is illegal in the U.S. – one of just three countries to ban the substance, along with Belgium and Switzerland – clients have to travel to clinics in countries such as Canada, Mexico, Costa Rica, and Slovenia for an "ibogaine experience".

Advocates liken the miracle drug – which can unleash a reality-shattering trip so powerful it has been described as "dying and going to hell 1,000 times" – to the Holy Grail of addiction cures, comparable in importance to the discovery of penicillin. Although ibogaine's alleged ability to quickly cure opiate addiction without withdrawal symptoms was discovered relatively recently, the substance has long been used in Gabon by hunters to stay alert and, in larger doses, in week-long sacred ceremonies in the Bwiti religion.

Yet despite the extraordinary claims about ibogaine's powers, a B.C. study launched last February is the first time the drug's therapeutic benefits for opiate addiction are being measured systematically in a public investigation. (Other clinics haven't released data.)

Preliminary results from the Sunshine Coast clinic have justified much of the hype. "I've witnessed people's lives being turned around," said Leah Martin, one of the study leaders. Of 20 pre-study clients who took ibogaine at the facility in 2004, 13 were found to be abstaining when evaluated later, after an average interval of six months. The abstainers included six out of seven cocaine or crack addicts, three of eight opiate addicts and four of five people with other addictions, including to meth and multiple substances.

With an overall abstinence rate of 65 percent, ibogaine does way better than the 10-percent average of conventional drug-treatment programs, Martin said. What's more, the clients at the B.C. facility are usually the hardest cases.

"People who contact the Iboga Therapy House have already done every type of program in their city and are scouring the Internet [for help]. They've been in detox multiple times and are highly resistant to other therapy. They say, 'This is my last hope,'" she said.

Ibogaine works in two ways. It eliminates cravings for heroin and other drugs in many people, but it also often works at a deeper level, getting them to revisit life experiences–good and bad–and helping many find ways to heal and ensure cravings don't come back. Scientists say it's like hitting a reset button for your brain. Traces of the drug remain in the body for up to six months, continuing to ward off addictive urges in unknown ways. "It truly is its own category [of drug]," Martin said. "Right after, it's common for people to say, 'Whoa, what was that?' But a month later, people might wake up and remember something and be able to move forward."

Ibogaine appears to work on "every neurotransmitter system we know about", Kenneth Alper, a psychiatry professor at New York University School of Medicine, told the Journal of the American Medical Association in a 2002 story on ibogaine. Alper, who is also a co-investigator in the B.C. study, has called the use of ibogaine "one of the biggest paradigm shifts regarding treatment for addiction in the span of my career".

In a testimonial on the Iboga Therapy House's Web site, one client says of the trip: "I pretty much died to my old self. I yelled, I kicked, I screamed (inside myself) but this new knowledge is too powerful to ignore." Says another: "I believe Iboga brings you into and through the land of the dead, to the land of the Gods."

The Georgia Straight connected with Martin early one morning near the end of her 8 p.m.-to-8 a.m. shift as a program worker at a Downtown Eastside residential detox centre run by the Portland Hotel Community Services Society. She spoke about her own ibogaine trip: "I felt as a facilitator I should know what it was like, to be able to relate."

An ibogaine experience usually lasts 24 to 36 hours, most of which is, typically, spent on your back because of impaired muscle coordination and perception. The first four hours usually involve plenty of vomiting, coupled with hallucinations and strange physical sensations. This isn't a drug for clubland.

Next is eight hours of what Martin called the "cognitive phase: the beginning stages of insights. You're remembering things or events. It tells a very interesting story of yourself and your life."

The intense visions are dreamlike, Martin said, but "if you find yourself in a vision you don't like, you can just open your eyes. There is a lot of randomness along with insights. It truly was a reflection of my mind and the things I obsess about. I laughed at myself a lot, realizing how ridiculous people can be."

This is the phase that can give people with addictions deep new insights into their troubles. "If you had trauma, people can relive that. After they're traumatized, sometimes they shut themselves off from the pain, and that's why they adopt certain habits. But to be able to see it in a healing way [with ibogaine] can be beneficial."

Then comes another 12 to 24 hours of "residual stimulation" as the person keeps dreaming but slowly comes down, often falling asleep.

Advocates say the drug isn't addictive itself partly because the trip is so hellacious. "It is not a recreational drug," said Rick Doblin, president of the California-based Multidisciplinary Association of Psychedelic Studies, which is helping to fund the Iboga Therapy House study. Doblin is also the principal investigator.

The ibogaine work is just one of MAPS's stable of groundbreaking research projects. The group is also funding the first-ever studies of therapy involving ecstasy, LSD, and magic mushrooms to deal with mental-health issues like posttraumatic stress, end-of-life anxiety, and obsessive-compulsive disorder. The U.S. studies all have an official okay from the U.S. Food and Drug Administration and even of the drug warriors at the Drug Enforcement Agency, and are attracting interest from the U.S. military for treating PTSD among Iraq vets.

Early results show ecstasy is not only safe for therapeutic purposes, but it can also help people who don't respond to conventional therapy or treatment with the pharmaceutical drugs normally given for posttraumatic stress: Zoloft and Paxil. Doblin described the ecstasy results as "dramatic"–far better than those from the standard treatments.

The work has still met ferocious resistance from the DEA, however. MAPS is battling the agency in court to get permission for scientists to grow marijuana in order to study its use for pain relief, control of nausea, and other medical purposes. Last February, a judge ruled in MAPS's favour, but the DEA has filed a series of objections, citing security concerns and likening Doblin to Colombian drug lord Pablo Escobar.

Speaking over the phone from his home in Boston, Doblin said he owes much of his doggedness and success to his own ibogaine trip in 1985, a year before he founded MAPS. "I feel it's been a major contributor to what I've been able to accomplish," he said, describing the experience as "lasting, powerful and very positive, although at the time it was horrendous".

Back then, already active in drug-policy reform, he said he suffered from a neurosis common to many activists–"a certain arrogance, that we know the better world". An underground therapist suggested ibogaine could help him grow personally and become a more effective activist.

Doblin took it one morning at the oceanfront house of a therapist, who stayed at his side. He lay in bed with his eyes closed all day, vomiting constantly, coughing and feeling like he was choking. The barf brought out complex emotions: "a line between self-criticism, self-perception, and self-hatred". He started to blame his intense nausea on his inability to just chill out and unwind. "I thought this was all my doing–that I couldn't relax. If only I was better, I could be a better tripper," he said. Then came realization: here was a metaphor for his struggles with his arrogance. "I was crucified on the cross of my own self-perfectionism," he said, laughing.

Twelve hours later, the stars came out, his guts relaxed, the upchucking stopped and everything got good. "I had one of the most blissful nights of my life. It felt like transcendence through exhaustion," he said. "I'm forever grateful for that experience. I think about it often."

The experience helped Doblin work out the arrogance thing; it also enabled him to develop the confidence to strike out and found MAPS. Yet he doesn't believe it's the easy wonder drug some suggest, and he supported the B.C. study partly because of the underground myths about ibogaine. "We've been deluded for a long time with the miracle-cure approach," he said.

One problem is many ibogaine clinics that offer the expensive treatment are happy to let potential clients believe it will solve all their problems, Doblin said. The clinics have little incentive to follow-up with clients or study the treatment's effectiveness, which, he said, is widely overestimated.

First off, he said ibogaine isn't for everyone. It requires one to be "open to the self-reflection that ibogaine permits. It takes a certain courage to go through an ibogaine experience." Even for these folks, he said, the trip has to be supported by aftercare and, possibly, a second dose.

There may also be safety concerns. About a dozen deaths have occurred during the 3,600 recorded ibogaine treatments that have taken place outside Africa since 1990. Advocates say pharmaceutical drugs also cause adverse reactions. Also, coroner reports in most of the cases placed the blame not on ibogaine, but on conditions like heart or liver disease and, in one case, a man choking on his vomit while eating a sandwich after the session had ended.

Just the same, the Iboga Therapy House screens potential clients for several medical conditions like ulcers, liver problems, blood clots, and heart trouble. Patients start with a small test dose and are observed for an hour for adverse reactions before the rest of the gram-sized full dose is given.

Gone, however, are the halcyon days when the clinic used to offer free ibogaine. In 2005, its founder, Vancouver pot entrepreneur Marc Emery, ran out of cash to fund the facility, so it had to close. Last February, the clinic reopened with money from MAPS. It now hopes to become self-sustaining by charging $4,700 for a five- to seven-day treatment session for dependence on heroin, methadone, and other opiates, cocaine, crack, or alcohol. (Shorter, cheaper sessions are also offered for spiritual or strictly therapeutic trips.)

Aside from the ibogaine, which the clinic buys for $700 a dose from a distributor in Spain, the sessions include therapy, massage, acupuncture, mild yoga, and elements of the traditional Bwiti ceremony to set the mood for the ibogaine session. Only one client or couple stays at the house at any time, and staff are on hand around the clock to monitor them.

Doblin said the B.C. ibogaine clinic is inexpensive when compared to hospital programs. Besides that, the cost doesn't seem high compared to addiction's drain on people and society. Almost 10 percent of the B.C. government's budget is spent on substance abuse and problem gambling, according to a 2005 drug-policy report by the City of Vancouver. That report recommended alternative treatments for drug dependency, including the therapeutic use of psychedelic drugs like peyote and ayahuasca.

Although ibogaine wasn't mentioned specifically, Zarina Mulla, a city drug-policy planner and report coauthor, spoke enthusiastically about it in a phone interview from her office.

"It helps users analyze some of the issues behind the drug abuse. Perhaps this is the most important thing because you can relapse and go back to the drug," she commented.

Mulla said alternative approaches are vital at a time when the Harper government has announced a new Canadian drug policy modelled on the U.S. police-and-prisons approach, which she called "a failure…There's such a large amount of money for enforcement [in the Harper policy] and none for harm reduction and only a little for prevention and treatment."

Leah Martin, for her part, said she's not holding out hope for any federal funds for the ibogaine clinic. It did apply once, but was rejected. "They were looking for teens that do [drug-education] tables at raves. We were a bit too obscure for them. People generally don't know about [ibogaine]."

And in the current climate, that's not all bad. "We're lucky ibogaine is unscheduled [not banned] in Canada. We play our cards so we kind of stay off the radar."

For more info:

Iboga Therapy House

Multidisciplinary Association for Psychedelic Studies: ibogaine page

Ibogaine.org: The Ibogaine Dossier

"Addiction Treatment Strives for Legitimacy," Dec. 25, 2002, Journal of the American Medical Association