Lactation non-profits and the ethical lactation medicine of the future
There can be a cruelty in the pure
It seemed churlish when a key member of the Breastfeeding Medicine Network of Australia and New Zealand Board, with whom I’ve had a handful of friendly-enough conversations over the past 12 years, greeted me at the 2024 BMNANZ conference (just 8 months after the devastatingly painful closure of the Possums charity that I’d founded 2013-2023) with: “How’s your business going?”
The handful of doctors most prominent in the field of lactation medicine throughout my professional life-time in this country have invested substantially in voluntary contributions to the Australian Breastfeeding Association (ABA) – something someone like myself could never afford because I lacked financial security (or generational wealth). Whenever I worked I needed to earn to support my family. Throughout most of my life the doctors who enjoyed what was described recently by ABA as a “special buddy” relationship had to have the family circumstances that allowed them to afford this generous volunteer service. Until more recently, if doctors wanted to take on voluntary roles with IBLCE and ABM, they also needed the financial independence to be able to afford very regular international trips.
The doctor who asked me how my business was going didn’t ask “how’s Possums going?" or "how are you recovering?" or "how’s your research?" or "how’s the writing?" or "how’s the education going?”. It took me a moment to orient before I replied, explaining it was early days and I didn’t quite know where the Possums project would go next but there were reasons to be hopeful.
Her unusual focus on my work as business told me things about the box she felt she needed to put me in. Already, in two of the handful of our other conversations over the years, the same doctor had told me to my face that “Pam Douglas stands up and says exactly what I do every day, but packages it as Possums”. This had surprised me each time, though I hadn't made a response. It was clearly not true, from the way she herself offered clinical management recommendations. Her comments were a measure of how little she knew about, or considered it worthwhile knowing about, my work. It’s a statement that intends to exclude, by asserting that Possums is simply a package of what everyone else is doing - maybe to be sold for money, to line my pocket? I could have quite legitimately asked her back “how’s your business going?” since she like most Australian GPs is engaged in the small business of being a contractor offering clinical and perhaps sometimes educational services. But I didn’t. I do my best to celebrate the efforts of other women, not take them down.
Others have told me similar stories over the years. It’s why so many doctors in other fields shake their heads when you talk about lactation medicine - those in lactation medicine and lactation support often share an unconscious (or conscious) belief in their own rightness, or purity. The leaders of our lactation non-profit's belief in their own and their organisation's purity has measurable impact upon a mother with the ulcerated, bleeding nipples who is still trying to breastfeed her baby, for example (- if anyone had interest in and was willing to put research funding into measuring the effect of lactation non-profit ideology on the education of health professionals and the effect on clinical management).
Non-profits are not necessarily operationally pure and pull commercial levers to ensure their own survival
Lactation non-profits leverage goodwill from the belief, which I would say now from intimate personal experience is quite naïve, that the lactation non-profit is a pure or superior form of governance structure for supporting breastfeeding women, compared to a business or social enterprise structure.
This belief in the governance purity of the non-profit fails to take into account the growing critiques of charity and non-profit operations. Because they too need to survive commercially, non-profits can quite easily take on the worst of predatory business practices. Others may be tightly controlled by families or founders, in order to secure founders’ incomes, though this may not be transparently declared as a conflict of interest. Others use levers to exclude or silence perceived competitors under the guise of non-profit purity of intent. This naivity concerning the governance structure of lactation non-profits does not serve the best interests of lactating women and their babies.
I personally have rarely received research funding. The most I had was $10,000 in 2009. The Chris Silagy award from the RACGP in 2009 gave $20,000 – but stipulated none could go to the researcher herself. The NDC Rural project funded project managers and execution of the project itself, not me. My own role in my 30 or so research publications has been self-funded. That is, most of the work I’ve done over the years has been ‘voluntary’, funded by seeing my patients in the clinic (and latterly, by investing my superannuation).
I feel an ache when BMNANZ’s automatic emails refer how the organisation is run by volunteers, asking the recipient to understand and forgive delays and so on. I feel an ache because I am confident I have invested many multiple times more of my personal finances and indeed my own future into the largely voluntary work that I have and still perform in this field relative to any other volunteer participant in BMNANZ. BMNANZ has the right to ask for special understanding because it's run by volunteers (though that's not true of their conference) yet BMNANZ declines to allow network members and Australian doctors to know about the Lactation Fellowship, or the Guest Speaker series, or the Lactation Medicine Lab - because The NDC Institute operates as a social enterprise, not a non-profit.
My willingness to expose myself to financial risk in the absence of spousal protection or generational wealth is a kind of crazy-brave bone-deep commitment to the future of families who seek the help of lactation medicine doctors and other lactation professionals, for which I take complete responsibility. This investment of my own financial security has been a clear-eyed choice and I understand that most would see it as foolish. For me, it has been a matter of purpose, of meaning, and I’ve not known what else I can do to earn a living into the future in a way that uses my skills (since I can’t afford to stop paid work).
But I'm very sad that my own volunteer work is not considered by my colleagues on the BMNANZ Board as something to respect and honour and support, even celebrate.
Lactation medicine needs to be embedded in a 21st understanding of complex systems
Each of these beliefs – that the disruptive outsider who disrupts group purity requires stigmatising punishment, that the lactation non-profit mission is pure, that there is a purity of knowledge and authority in lactation education - these beliefs are simplistic distillations of very complex realities. For instance, the disruptor does cause discomfort and inconvenience, even though she needs to be invited into the group, for the sake of the health of the group and ultimately for the sake of the families they serve.
21st century knowledge of complex systems teaches us that If we start to behave according to simplistic or reductionist paradigms, we risk causing unintended and sometimes very dangerous outcomes, in a world and in families which operate as complex systems. This is the tragedy of lactation medicine today, even as it begins to gain traction as a standalone special interest or field within medicine.
It’s why I’m calling for change. I lift my often quite afraid but resolute older woman’s voice (since what else is there for me to do really in what’s left of my professional life, having given so much to this field?). I lift my older woman’s voice to say that the lactation non-profits globally are driving dangerous levels of overmedialisation, paramedicalisation, and overdiagnosis, and this is because of a historical ‘purity’ of thinking, that fails to grasp either intellectually or viscerally the nature of the complex systems of the times we are forced to inhabit. I lift my older woman’s voice to say to the younger ones that isn’t time to mess around: leaders in every field of human endeavour, including in lactation medicine, need to get real about the extraordinarily complicated nature of our times, and quickly. We need to get real about complexity, and abandon fantasies of purity.
There’s something cruel about the smallness of purity. There’s something cruel about excluding women who find, in the face of shocking nipple pain or damage, in the face of the exhaustion of long-term triple feeding (that’s direct breastfeeding, pumping, then bottle feeding routines) and baby weight gain concerns, in the face of a little one who fusses on and on at the breast, they need to change over to formula. There’s something cruel about excluding them from the title lactation medicine which at the same time is now, I notice, claiming special expertise in multiple domains of infant care.
There’s something cruel about excluding women (it is mostly women researchers and educators who are affected, though not always) from educating in a field that they are passionate about, have devoted their life to, are courageously attempting to make a contribution in – at the same time as their work is extracted, without appropriate acknowledgement, often without recognition of where the work comes from since this has been going on for so many years, without celebration.
Most researchers will not be personally financially impacted since they have university or project grant income as academics. I’m a very unusual situation of trying to make some income to sustain my work in education, even as I publish research. You’d think this might be something to celebrate and it is in other fields of medical practice. I read an obstetrician this year refer to that “rare and previous breed of clinician researcher” in the medical news. But in lactation medicine, we shut out her out, we silence her, we make sure either that our colleagues who are interested in lactation medicine don’t know of what she's offering, or that those who do feel embarassed about or constrained from freely claiming the influence of her work, even as they themselves teach other doctors in BMNANZ education workshops.
I suppose it might be different if I was dead, but I'm still here, very much alive in Brisbane, planning to be around for a long time yet, and still working hard to make the most meaningful contribution I can to the wellbeing of families and their babies!