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The Remedia affair, in which two babies died and others appear to be left with irreversible damage to the nervous system after being fed with the company's soy-based infant formula, is highly sensitive ground for those who promote breast-feeding in Israel. Esther Grunis, one of the country's most veteran lactation consultants, refused to appear on a current affairs show two days after the scandal broke in November last year.

"They wanted me to say `You should have been breast-feeding,'" says Grunis, who works at Lis Maternity Hospital in Tel Aviv Medical Center. "I didn't want to rub their noses in it. Those mothers are grieving in a way you can't imagine. It's not my place to say `I told you so.'"

Grunis reports that lactation consultants across the country - the 44 Israelis who are qualified according to the rigid standards of the International Board of Lactation Consultant Examiners - tried to respond more practically by opening up clinics to offer advice and support on breast-feeding, free of charge for a full day the following week.

Dr. Dorit Nitzan Kaluski, head of the Food and Nutrition Administration in the Health Ministry, says ministry officials briefly considered using the extensive publicity generated by the Remedia Affair as a springboard to boost its ongoing campaign to encourage breast-feeding. "But we thought of those poor mothers who lost their babies and decided against it," she says.

Despite this muted reaction to the affair, in which initial reports indicate that vitamin B1 was removed from Remedia's soy-based product as a result of human error, some believe the high-profile incident is likely to impact significantly on the breast-or-bottle choice made by new mothers.

"As tragic as it was, it was a big boost for breast-feeding," says a senior nurse from a Jerusalem branch of Tipat Halav (well mother-baby clinics), who has noticed a marked increase in breast-feeding among new mothers since the Remedia scandal appeared in the press.

Another nurse says she has received far more questions than usual from mothers about how to return to breast-feeding and points to a recent shortage of breast pumps available for hire. Yad Sarah, the charity that is the main lender of breast-feeding pumps in Israel, has ordered another 600 pumps to cope with the increased demand in the last couple of months. But others working in the field have observed little change since the Remedia affair broke. They say that mothers' desire to breast-feed is not the key factor that needs to be worked on order to encourage exclusive breast-feeding (which health professionals in Israel and across the globe agree to be the healthiest choice for babies until the age of six months, after which they recommend the gradual addition of complementary foods.) Rather, practitioners in the field point to statistics produced by a Health Ministry survey in 2001, which show that while 89 percent of pregnant Israeli women plan to breast-feed, two weeks after the birth only 55 percent are exclusively feeding their babies with breast milk.

"The [Remedia] scandal will heighten awareness for a while, but I wouldn't say it will promote breast-feeding," says Dr. Mira Leibovich, a specialist in family medicine who runs one of the very few breast-feeding clinics in the country at Moshav Udim. "Most women know that breast is best and would like to try. Awareness of [the health benefits of] breast-feeding is not the problem. The problem is what happens to women who run into difficulties with breast-feeding; they just don't get enough help."

Be prepared

According to Leibovich, mothers-to-be should be better prepared for breast-feeding during antenatal classes. "Many women read an awful lot about the labor, but know very little about breast-feeding by the time they give birth," she says. "After the birth, it's very difficult to learn: Your body hurts, you're tired and your baby's crying. The more you learn before, the fewer problems you will run into."

Leibovich also advocates more support for women trying to breast-feed in hospital. She says nurses are often too busy to sit with individual mothers, and even the few lactation consultants who work in Israeli hospitals are mostly employed on a part-time basis. "A mother who has her baby on a Thursday afternoon will be at home by the time the lactation consultant next comes to work on the Sunday morning," she points out.

Expert help with breast-feeding in the early weeks of motherhood can also be difficult to come by, says Leibovich; one of the few options is a private session with a lactation consultant, which costs around NIS 400. While many nurses in the public health system have attended a basic, five-day course in breast-feeding, Leibovich says that at medical schools trainee doctors usually learn only that breast-feeding is important, and not about breast-feeding management or how to help a breast-feeding mother. "Many health care professionals still see breast-feeding like the weather,"she says. "If it works, it works, but there's no point talking about it because there is nothing you can do about it anyway."

Leibovich describes Israel as a "bottle-feeding culture," where many new mothers have never seen a baby breast-feeding before, let alone know what behavior to expect from a breast-feeding baby. "They expect a baby to have a meal every three hours, then sleep for three hours, whereas a breast-feeding baby can feed again and again for a few hours, and only then go to sleep. People [unfamiliar with a breast-feeding baby] tend to think that if the baby wants more milk after being fed, the mother is not providing enough milk or her milk is not satisfying, whereas this is the normal behavior of a breast-feeding baby. New mothers are frequently told how good and important breast-feeding is, but often the only help they get is the offer of a bottle of formula."

Acknowledging there are mothers who find breast-feeding too exhausting and too focused on them alone, she adds: "If a woman knows about the value of breast-feeding and feels she just can't take it, it's fair enough. It's very personal and evry woman has to make her own decision. It's like most of us eat fast food even though we know it's not the healthiest choice. I hate cooking and my kids eat a lot of frozen pizza and they feel terribly guilty about it. But there are many other things in life than health issues."

Leibovich says she educates lactating mothers at her clinic about signs which indicate that the baby is okay, adding that many problems with breast-feeding can be fixed, such as if the baby is not sucking efficiently. She says that only a small minority of women, including those who have specific hormonal conditions or certain kinds of breast surgery, are not able to breast-feed at all with the right support.

"People say it's natural [to breast-feed], but you have to learn how to do it," says lactation consultant Dori Sperer. "We're not in a society where everyone around us breast-fed, our mothers, aunts, cousins and neighbors, so where do you go for help?"

Nitzan Kaluski of the Health Ministry acknowledges that there are simply not enough resources available to support mothers in Israel who wish to breast-feed. She points to several initiatives to promote breast-feeding over recent years - breast-feeding courses for nurses in contact with new mothers; the introduction of new restrictions to prevent infant formula companies from promoting its products in public health settings; and cooperation with La Leche League, the international volunteer organization which helps mothers to breast-feed, but Nitzan Kaluski admits this is not enough help for many new mothers.

She also identifies factors working against the promotion of breast-feeding in Israel, including the pervasive marketing of infant formula products, the need for many mothers to return to work three months after giving birth and the lack of role models to imitate: She notes that most grandmothers of new babies did not breast-feed and therefore they cannot offer support on what to expect from a breast-feeding baby.

Although she would like to see more Health Ministry manpower allocated to helping women breast-feed, Nitzan Kaluski says the severe budget cuts across public health services are working against this. Although by not investing more in breast-feeding, the financial savings for the state are only short-term, she suggests, as assisting mothers with breast-feeding is highly cost-effective, due to the health benefits of breast-feeding for the baby.

Evie Adams, who represents the International Board of Lactation Consultant Examiners in Israel, proposes other measures be implemented to encourage breast-feeding. She would like to see the World Health Organization code prohibiting the advertising and promotion of infant formula products directly to the public to become law in Israel (former Hadash MK Tamar Gozansky failed to pass a similar bill during the last Knesset). Adams also advocates more breast milk pumping areas and child care centers be set up in the workplace, and the establishment in Israel of milk banks, such as those which exist in Europe and the United States and provide donated breast milk to babies whose mothers cannot produce it themselves. Adams remains hopeful for the future: "Things in this country can catch on really fast."

`We're not fanatics'

"Breast-feeding is an extremely emotional issue and for many people who have not breast-fed their babies, it's very difficult to fully support breast-feeding," says Dr. Mira Leibovich in an effort to explain why those who work in the field of breast-feeding promotion are sometimes labeled fanatic. "In Western culture, bottle-feeding has become the norm," says Leibovich, who runs a breast-feeding clinic at Moshav Udim.

"I don't know why many people don't believe the studies [demonstrating the health benefits of breast-feeding], but I know that I don't feel like a fanatic, and that I do feel sympathetic to women who for some reason decide not to breast-feed.

I see my mission as helping those women who want help." Leibovich's sentiments were echoed by most of the nurses and health professionals who were interviewed for this article; yet all acknowledge that the promotion of breast-feeding does carry the stigma of fanaticism.

Learning about breast-feeding "pushes a button" in certain people as it may mean accepting that your child got second-rate food, says Esther Grunis, lactation consultant at Lis Maternity Hospital in Tel Aviv. "If I'm teaching a course telling you that, it's really going to bother you," she says, adding that she views the label of fanatic as a defense mechanism.

"I've never sat with a woman and tried to convince her to breast-feed," says Doris Sperer, a lactation consultant who has worked with breast-feeding women for more than 20 years. "One mother recently told me she hated breast-feeding.

When women decide they don't want to, I respect that. It is better to give a bottle and have a good connection with the baby, although I do want them to make their decision on the basis of knowledge," she adds.

Sperer believes that part of the sensitivity around breast-feeding can be attributed to poor knowledge about breast-feeding among the older generation, which she says often results in new mothers being overloaded with contradictory advice. She hopes to run a course in the future about breast-feeding for grandmothers: "They are a very big influence and we can teach them to help in ways other than by giving a bottle."

Another lactation consultant also points to the information gap between generations as adding to the sensitivity of the topic, but the label of fanaticism still puzzles her. "When I had my babies, we didn't have car seats for them, but people don't get upset today when you say their child must travel in one," she comments.

"I don't think of myself as a fanatic," says Evie Adams, who was involved with the La Leche League in the United States before immigrating to Israel over 30 years ago and later became the first internationally certified lactation consultant in the country.

"I know too many people around me who agree with me, including at the highest international levels, and it's all backed up with science. Even the La Leche League is now viewed as mainstream. Anyone who calls me a fanatic is really out of date: Breast-feeding is in."