Perhaps one of the most disconcerting aspects of the Covid pandemic, in addition to the mass morbidity, mortality, and public health failures of the world’s wealthiest and most powerful nation–is the culture war battleground of empirical knowledge and science waged between left and right in the US. The pandemic only highlighted the starkness of a debate over the verifiability of reliable information laid bare in the Trump era of fake news and alternative facts. One could argue that science’s politicization in the US dates all the way back to the Scopes Monkey Trial or that in Western culture is even as old as the modern era itself with the Catholic Church’s persecution of Galileo and Copernicus.

That “believe science” is a slogan denoting one’s political stance in the 21st century is troubling enough, but even deeper than liberal and conservative polarization over battleground truth is the underlying illiteracy of scientific research and how people misinterpret it–or ignore it outright–on all ends of the political spectrum. This is very discernible through the lens of women’s and children’s health, reproductive life, breastfeeding, and pediatric nutrition. 

Any cheerleader for breastfeeding, for example, is familiar with the touted benefits offered by it as the premiere mode of providing infants with sustenance. Decades of research on its effects on both parent and child yielded a world of information on its public health impact, some consistently based on high quality scientific evidence and some remaining tied to outdated and pseudoscientific modes of thinking. The most notable of the latter is the claim that breastfeeding is sure to boost children’s IQ. 

The dubiousness of IQ as an argument to promote any public health behavior is rooted in its imbrication with ideologies of race betterment and social Darwinism. While IQ testing originated in France under more innocuous efforts to improve schools, eugenicists in the US quickly co-opted it to support their efforts during the early twentieth century. IQ testing became their means to justify the marginalization and oppression of African Americans, immigrants, the disabled and mentally ill, and the socio-economically disadvantaged. 

During the Progressive Era, eugenicists weaponized IQ and asserted their superiority over these groups while contemporaries like journalist Walter Lippman and attorney Clarence Darrow pointed out that IQ testing was anything but an objective metric of intelligence. Educators, psychologists, social scientists, etc. subsequently spent generations dismantling the notion that IQ is a static, fixed, or even measurable trait. While an entire movement of standardized exams can be traced directly to the adoption of IQ testing, many still in use today including the SAT, anthropologists, teachers, and activists proved the ubiquity of cultural bias in standardized tests as early as the 1970s.  

Eugenicism’s detractors initially questioned whether or not IQ represented an innate quality. Today most scientists agree that intelligence is a subjective, complex, multifaceted, evolving aspect of the human experience that is influenced by myriad economic, social, and cultural factors. Gardner’s theory on multiple intelligences, or some variation of it, is widely accepted by educators and cognitive specialists as an alternative to the notion that IQ is a singularly coherent or quantifiable characteristic. 

So why do breastfeeding advocates still insist that IQ is a reason to encourage breastfeeding? Despite human milk being the primary subsistence provided to infants for the vast majority of human history, the controversy that surrounds breastfeeding today seems more polarized than ever. There is no shortage of shame or guilt doled out for the entire spectrum of women’s life choices and pressure abounds from all directions to raise children in specific ways. And whatever the ruling paradigm of the day, there are sure to be naysayers and those challenging the status quo.

While people have been supplementing or replacing breastmilk for probably as long as human history itself, the practice did not become widespread until the late nineteenth century. Since the transformations in women’s labor and family life that began in the Gilded Age and progressed throughout the twentieth century, formula use became omnipresent by the 1950s and all but replaced breastmilk in many Western nations as the most common food given to infants within one hundred years of its invention.

As early as formula began being widely used, breastfeeding proponents pushed back against the narrative that it posed a solution to pediatric nutritional deficiency and questioned it as a viable alternative to human milk on a mass scale. By the 1970s, despite debates amongst second-wave feminists over the contradiction between working and staying at home to breastfeed, public health advocates organized to bring back breastfeeding for American families. Breastfeeding promoters argued that the practice offered a holistic solution to issues that compromised children’s health and limited women’s options as mothers, workers, and complete human beings. While the invention and extensive availability of the breast pump helped quell some of these contradictions, it in no way halted the conflict between those seeking to make breastfeeding more accessible and those scoffing at its value.

It took a generation of public health activism and rigorous epidemiological study to convince the medical establishment that human milk was, in fact, preferable to formula for a whole host of reasons. Today, those at the forefront of evidence-based medicine are increasingly accepting the suitability of breastfeeding and the risks of formula feeding by comparison; however, not without great pushback and contention. As soon as breastfeeding has begun to regain its mainstream credibility, skeptics are grasping for sources to argue for the doubtfulness of its benefits.

Contemporary criticism of breastfeeding promotion, much like that of the 1970s, takes aim at pressure put on women to breastfeed their babies and the incumbent difficulty of working while raising children. While the impetus behind this argument is well-intentioned, critiquing mom-shaming and questioning sweeping generalizations about breastfeeding’s advantages, it rests on a foundation of decidedly ignoring what over fifty years of high-quality scientific research has taught us about breastfeeding. In an oft-cited article claiming that  breastfeeding’s benefits are greatly exaggerated and not supported by evidence, Amy Kiefer claims that the lack of randomized control trials (RCTs) on breastfeeding’s effects and reliance on observational studies indicates a dearth in evidence to make a reliable case in support of the practice. 

Kiefer points out that conducting an RCT that deprives an infant of a potentially lifesaving or beneficial intervention–breastfeeding–would be unethical. She falls short in asserting that there is thus no way to study breastfeeding without controlling for confounding factors in the absence of RCTs. Keifer demonstrates a reductive understanding of scientific research in considering RCTs the “gold standard” of healthcare studies and claiming that there is therefore no way to develop any empirical certainty without them. Critics of breastfeeding advocacy cite her piece as though it was an RCT itself and use it to claim that promoting breastfeeding puts an undue strain on mothers in a harmful and anti-feminist way.

While RCTs do represent the most reliable method of experimental study and serve as the basis for evidence-based medicine by testing medical interventions on human subjects, meta-analyses and systematic reviews aggregate large bodies of data (often RCTs but other types of studies as well including observational research in their absence) and are widely recognized by medical researchers as the highest axiom of evidence because of the sheer volume of information on which they base their conclusions and because, like RCTs, they are peer reviewed. A very rigorous RCT may use a sample size of up to hundreds of test subjects (although most do not use this many), but meta-analyses use studies that look at thousands or even hundreds of thousands of participants when combined. When RCTs are not possible, observational studies and quasi-experimental research also afford verifiable evidence and use statistical analyses to control for confounding factors. 

Public health specialists draw on the enormous wealth of these studies to make the case for breastfeeding, especially in its impact on SIDS risk reduction along with many other childhood illnesses including diabetes, cancer, respiratory, and GI disease. For half a century, such data collection has, in fact, provided for a scientific consensus on breastfeeding’s public health worth.

Which begs the question, should one have to have an advanced science degree to demonstrate a level of understanding regarding what constitutes trustworthy scientific evidence? If not, how could such an understanding be democratized? There is probably a large cross-section of people who share or cite Kiefer’s article with “believe science” stickers on their cars or who were first in line for the Covid vaccine. Why are liberal rationalists willing to trust what research indicates when it comes to climate change or pandemic best practices but remain skeptical on the effects of breastfeeding in the face of generations of robust scientific evidence? 

Perhaps the realm of healthcare guidelines, rules, and protocol for women and our children is just so saturated that it is too hard to pierce through the din of advice even with the most reliable information in a world where women are constantly being told what to do with our bodies and families. An interview with Virginia Sole-Smith illustrates the tension between reliance on evidence-based medicine versus frustration with technocracy and the need to be empowered to make our own decisions as parents, especially for marginalized people. Author, journalist, and pod-cast host, Sole-Smith, critiques pediatric dietary guidelines as being rooted in a “fear of fatness,” advising parents to relax when it comes to concerns over what our children eat. 

Sole-Smith makes some cogent points regarding our collective obsession regarding what we feed our kids. However, what is greatly concerning is her criticism of the American Academy of Pediatric’s (AAP) obesity guidelines. She complains that every wellness visit begins with “a weigh-in and assessment of where your child falls on the growth chart,” and calls the AAP recommendations on child obesity “fat phobic” (ignoring that pediatricians use growth charts to track the development of children who are below the statistical average as much as those who are above). Much like breastfeeding advocacy critics who call breastfeeding promotion anti-feminist, Sole-Smith takes on the AAP as being tone deaf in its fight against childhood obesity and claims that there is at best a tenuous link between weight and health outcomes. 

While Sole-Smith has produced a significant and poignant body of writing in which she contextualizes anti-fat bias and its role in research, polemic takes the place of trustworthy evidence in her assertion that weight has no adverse health impact for children. She does cite research in her claims, including a meta-analysis that demonstrates that higher BMI individuals were not at a greater risk for death when regularly exercising. However, none of the studies that Sole-Smith uses include evidence on pediatric patients, disqualifying this data from disproving the AAP’s recommendations.

The meta-analysis she cites does pose a compelling wealth of information that points to the importance of exercise on health for all body types. It shows that higher BMI may not necessarily put one at higher risk for cardiovascular mortality, however, it does not disprove the relationship of BMI with morbidity, namely when it comes to chronic illnesses like diabetes, hypertension, and kidney disease. When accounting for the risks of complications from obesity starting early in life, this is an especially significant consideration. 

It is without a doubt a worthwhile endeavor to question ruling medical dogma and to be empowered to make our own choices when it comes to healthcare, especially as underrepresented people. But at some point we need to reckon with what it really means to “do our own research” and how there is very little daylight between us and anti-vaxxers, for example, without the scientific literacy needed to do so. Choosing not to follow the AAP’s recommendations is one thing, and without a doubt the prerogative of every parent. But publishing and spreading ideas without the appropriate expertise to properly glean what epidemiological evidence shows us, and thus undermining public health messaging, is quite another.

To emphasize the historical rootedness of oppression in medical practice–of women and larger bodied individuals, for example–is necessary while deciding how to integrate healthcare guidelines into our lives. But at what point do the political aspects of these debates obfuscate how to best use public health information? Or perhaps the deeper and more salient question is are these controversies actually pretty superficial and lacking in an intersectional analysis, decidedly ignoring the widespread impact of our failed public health infrastructure on low-income people and People of Color?

There is no way to grapple with the effects of low breastfeeding rates or the high incidence of childhood obesity in the US without a discussion of who is most at risk for morbidity and mortality. African American and working families have the lowest rates of breastfeeding and experience the highest incidence of the concomitant complications linked with not breastfeeding, like SIDS, asthma, diabetes, respiratory, and GI illness. Similarly, low-income children and People of Color are the most adversely affected by childhood obesity, seeing not only higher rates of it but also the risks of lifelong illness associated with higher BMI in children including but not limited to kidney and cardiovascular disease, sleep apnea, and fatty liver disease.

What the hot takes of people like Sole-Smith and Kiefer ignore are the broader, systemic concerns facing those who are the most vulnerable to the healthcare failings of our current economic system–people living in food deserts, parents working 60 hours a week who have no time to cook, children who are uninsured and have no access to the treatments needed for chronic conditions linked to formula feeding or childhood obesity. For someone like Sole-Smith, giving your kids Oreos with milk poses no real problem when you can easily pull the blueberries out of the fridge at any time to counter the risk of malnutrition. But for the mother who works overtime cleaning hotel rooms just to keep the lights on, sometimes MacDonald’s every day is the only option and feeding her kids fresh fruit administered by WIC instead of junk food might make an enormous difference in the health outcomes of her kids. Her knowledge of just how important such an alternative could be is dependent on clear, unequivocal, and trustworthy public health messaging.

Such consistent, reliable information benefits the whole of US society, but especially families who struggle to ensure their basic human needs are met. In the only developed country in the world that does not enjoy the guarantee of healthcare as a human right, we have a moral imperative to put faith in the public health institutions tasked with safeguarding our well-being. Without even the glimmer of a public option on the distant horizon, let alone the universal, socialized medicine offered by nearly every other nation to its people, the AAP (along with the CDC and other organizations devoted to the common good through public health) and its expertise in identifying, analyzing, and interpreting scientific evidence is all we have.

In a historical moment when misinformation pervades our knowledge systems there is great danger in relying on dilettantes and tastemakers to provide us with health advice. And superficially woke viewpoints that lack a critical analysis of class and race run the risk of failing to elicit the true causes of inequality and how it pervades our healthcare. We owe it to the most marginalized members of our society to build up our public health infrastructure and trust the science that is needed for it to thrive.

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Susie Aquilina is a historian, writer, registered nurse, and nurse practitioner in training who researches social justice and culture-making in the U.S.-Mexico borderlands, class inequality, epidemiology and healthcare disparities. 

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