Hippos do it. So do orangutans. There's no question that for us mammals, nursing is one of those defining behaviors in nature. The question is whether public health officials, in promoting breast-feeding among human mothers, should deploy the term "natural."
Two academics pondering these and other linguistically charged questions sparked an online frenzy recently with a paper on the unintended consequences of promoting breast-feeding as a "natural" practice — and relating it to the anti-vaccine movement.
University of Pennsylvania ethicist Anne Barnhill and medical historian Jessica Martucci, writing last month in the journal Pediatrics, suggest that by using the word "natural" in campaigns endorsing breast-feeding, public health officials and medical professionals may be inadvertently fueling other groups that reject public health efforts -- like anti-vaxxers.
"We are concerned about breast-feeding promotion that praises breast-feeding as the 'natural' way to feed infants," Barnhill and Martucci write. "This messaging plays into a powerful perspective that 'natural' approaches to health are better. ... Promoting breast-feeding as 'natural' may be ethically problematic, and, even more troublingly, it may bolster this belief that 'natural' approaches are presumptively healthier. This may ultimately challenge public health’s aims in other contexts, particularly childhood vaccination."
They go on to connect the dots between the idea of natural as "pure" and "good" and "harmless," compared to synthetic, mass-produced technology which arouses "suspicion and distrust" whether the topic is vaccines, organic versus conventionally grown foods, or fluoride in drinking water.
Citing the measles outbreak of 2014-'15 and subsequent discussions about parents who did not have their kids vaccinated, Barnhill and Martucci write:
...some in the antivaccine camp believe that vaccines cause autism or contain harmful levels of toxins and impurities. Beneath the concern of many Americans over vaccine safety, a specific and not necessarily illogical worldview is discernable: a rejection of the manufactured, the synthetic and the “unnatural,” and an embrace of the “natural” as healthier and intrinsically better. Vaccines are often seen as “unnatural,” and boosting immunity “naturally” is viewed by some as the healthier and better approach.
Not surprisingly, linking "breast-feeding," vaccines" and "natural" approaches to parenting in a single paper is bound to unleash a backlash. The topics tend to be polarizing on their own, and often trigger an extreme emotional response. (See Adele, on breast-feeding: “All those people who put pressure on us, you can go f--- yourselves, all right?”) And this paper is no exception.
The American Academy of Pediatrics section on breast-feeding leadership commented on the paper (published in the group's own journal):
While we agree that the words we choose to encourage healthy behaviors certainly matter, equating breastfeeding as “natural” with the supposed “natural” of the anti-vaccine movement is neither logical, nor appropriate...Breastfeeding is the normative standard for infant feeding, and the standard by which all other feeding methods should be compared. Infant formulas are inferior to this standard, as documented in multiple evidenced-based studies...Just as the authors are concerned about a theoretical effect of breastfeeding promotion on vaccine rates, we are concerned about the effect of their article, and other similar articles, on breastfeeding promotion and rates.
After Slate covered the paper, more than 650 commenters weighed in, many particularly snarky: "So what should we call an infant mammal suckling at its mother's teat? Inconvenient? The Orwellian march continues apace," is just one example.
The authors said they even got a death threat on Twitter.
I spoke with Barnhill and Martucci, who said some readers may have misinterpreted their piece as a critique of breast-feeding and its promotion, which was not their intention. "Ours is just a critique of the use of the word 'natural' by public health and medical authorities to promote breast-feeding," Barnhill said.
And the bottom line, really, is that words matter.
"Given that this rhetoric is part of the anti-vaccine movement, for example, it seems reasonable to suggest that we ought to choose our words carefully," Martucci said, "and avoid ideologically charged language that could inadvertently stir up this broader cultural and political movement."
Here, edited, is more of our conversation:
Rachel Zimmerman: To be perfectly clear, what is the main message of your paper?
Martucci: The bottom line is that "natural" has a lot of connotations, evokes a lot of things.
And some of those things are things public health officials and medical professionals should not evoke. The anti-vaccination movement, we use that as an example: It's clearly a case in which the same kind of language and terminology of the natural is used to do something anti-public health.
The same language you use to promote breast-feeding is being used by anti-vaxxers against public health. ... Our goal was to convince medical and public health authorities to think more carefully about the kind of language they use.
RZ: Many of the comments on your piece reflect the idea that breast-feeding really is about as natural as you can get. And they oppose a ban on the word "natural" when it relates to something, well, natural. What do you think?
Martucci: Scholars have been theorizing "the natural" for decades — demonstrating how what we consider "natural" is not a fixed category, it changes over time and place. This discussion, however, has not moved very far beyond the walls of the ivory tower, and so many people believe there is something immovable, universal and timeless about “nature” that allows us to use it as a reference point.
When people talk about breastfeeding as “natural” they often believe they are referring to this very clear and very obvious thing, when in reality breast-feeding is today and always has been a cultural practice. It’s not simply a matter of human instinct and biology. Women have to be taught how to breast-feed; breast-feeding as a process looks different in different societies across time and place.
So when we critique the use of “nature” in breast-feeding promotion we’re trying to call public health’s attention to these realities. We're not arguing against efforts to convince people that breast-feeding is a “normal” act in order to help de-stigmatize things like women breast-feeding in public places, etc. But using the word “natural” in breast-feeding promotion implies a whole set of historically produced meanings — specifically ideas about what a “good mother” does and should do, and how the division of labor in a household should fall along gendered lines — which I chart in my book, "Back to the Breast: Natural Motherhood and Breastfeeding in America."
We reiterate that we are not critiquing individual women or lay organizations for referencing breast-feeding as a natural act -- that’s how they understand and find meaning in breast-feeding. However, we think that public health campaigns shouldn't use language that can evoke ideologies and values about gender and nature that have nothing to do with the health benefits associated with breast-feeding.
After having written this, do you think that given how charged and controversial breast-feeding is, it's even possible to write about semantics in this context?
Martucci: I think that it is exactly because breast-feeding is so charged and controversial that we need to continue to try to offer careful critiques that complicate the highly polarized nature of the discourse surrounding breast-feeding. Breast-feeding is a topic that encapsulates so many of our political and cultural arguments about motherhood that it is bound to be charged and controversial -- all the more reason for careful analysis that provokes more thoughtful discussions about the meanings our language invokes when we talk about breast-feeding and motherhood.
Are you surprised by all of the animosity directed your way?
Barnhill: Both of us have published on breast-feeding before. Mostly my experience, as an academic, is being irrelevant ... meaning that my academic work hasn't been drawn into or been seen as relevant to these polarized public debates about breast-feeding.
Martucci: Actually, the media coverage has been pretty nuanced; the reception by the public at large is where the messaging has gone off a bit.
If you were to write it again, would you reframe things?
Martucci: One of our primary regrets about the original piece is there's a section where we accidentally imply we're talking about individual behavior. [The section focuses on a public health campaign in New York City that seems to elevate breast-feeding as preferable, describing it as "Mom-made" compared to formula, which is depicted with a red circle that says "factory-made."]
A lot of the ire from the public has come from that...our intention was to focus public health on how hypocritical this use of the construct natural is. But it's not about individuals, it's more like: Look at how ridiculously obvious this paradigm is that they're setting up: natural being good, unnatural being bad. So how can they be angry or surprised when people use that exact same language to resist vaccinations?
So what might a breast-feeding campaign look like that doesn't rely on the word "natural" or evoke that concept?
Martucci: You can certainly emphasize specific health benefits, and you could also mention other aspects of breast-feeding that don't rely on the rhetoric of the natural, for instance, a dynamic process between mother and baby.
What's the next paper you're thinking about writing?
Barnhill: I think a lot about ethical issue pertaining to food, agriculture and nutrition. We see natural cropping up in other issues: genetically modified foods and agriculture. I think there's another interesting paper to be written about the categories of sustainability and the natural, and how it's important to keep them distinct, just like it's important to keep the categories of healthy and natural distinct.