I LOVE Kathy Dettwyler. Her body of work has made a huge impact on how I view breastfeeding and “extended” breastfeeding. Back in July she posted an essay on her facebook account entitled Is breastfeeding advocacy anti-feminist? She then gave her permission, for those interested, to re-post the essay on their blogs.
Is Breastfeeding advocacy anti-feminist?
An essay by Katherine A. Dettwyler (permission to re-post by author)
“The anthropological study of women should rest upon a sound understanding of women’s reproductive heritage.” Harrell (1981)
I began graduate school at Indiana University, Bloomington in 1977, and there were almost as many female anthropology graduate students as males in my cohort. In the late 1970s, the field was still in the early stages of a revolution against the traditional anthropological focus on males and male activities. Within the department, there was a decided preference among the social-cultural anthropologists for the far-away and exotic – few professors encouraged students to study in the US or other Western countries. Additionally, there was a preference for the “extraordinary” – elaborate, important religious rituals, “systems of thought,” or public performances that marked special occasions in the life of the group. The three physical anthropologists focused on osteology/paleopathology, human variation, and growth and development. The program truly embraced the four-field approach, and the physical anthropologists in particular urged students to consider the links between human evolution, human biology, and culture.
In 1981, when I set off for research in Mali, West Africa with my husband and young daughter, my research topic – cultural beliefs and practices surrounding infant feeding and their effects on the growth, development, and health of the children of Mali – was fully supported by my committee. Infant feeding studies were beginning to attract the attention of a number of anthropologists. The year I finished my degree, 1985, saw the publication of three books with a focus on breastfeeding: Breastfeeding, Child Health and Child Spacing: Cross-cultural Perspectives, edited by Valerie Hull and Mayling Simpson, Infant Care and Feeding in the South Pacific, edited by Leslie Marshall, and Only Mothers Know: Patterns of Infant Feeding in Traditional Cultures, by Dana Raphael and Flora Davis. These were joined the following year by The Infant-Feeding Triad: Infant, Mother, and Household, by Barry M. Popkin, Tamar Lasky, Judith Litvin, Deborah Spicer, and Monica E. Yamamoto (Dettwyler 1998). It was a good time to be studying breastfeeding, which was experiencing a cultural resurgence in the US and other Western countries, and attracting attention from national and international public health organizations as the negative consequences of the marketing practices of infant formula companies became more and more apparent, especially in developing country contexts.
The biocultural approach was still struggling to gain legitimacy, at least in part because many anthropologists still had difficulty accepting the notion that the constraints of human biology and physiology affected culture, as well as the notion that cultural beliefs and practices could affect human health. Perhaps more importantly, the ‘numbers crunchers’ reviewing journal manuscripts didn’t see the need for ‘all that ethnographic information,’ while the mainstream cultural anthropology reviewers cringed at the sight of data tables and statistical analyses. Gradually during the decade from 1985-95, the cross-cultural and biocultural study of infant feeding gained ground. Studying breastfeeding and lactation from an evolutionary and/or cross-primate perspective, however, was still virtually unknown. When life-history variables among primates were compared, the data for breastfeeding in modern humans was based on Western cultural practices, rather than any real understanding of what the underlying biology might be.
In the early 1990s, I began discussions with Patricia Stuart-Macadam about collaborating on an edited volume about breastfeeding that would specifically highlight biocultural and evolutionary perspectives. Stuart-Macadam was well-known at the time for her work on iron-deficiency anemia, and her assertion that women were stronger physiologically than men, and had lower rates of morbidity and mortality at all ages as a result of the strong impact of natural selection on female reproductive success. I originally suggested that in addition to writing a chapter about the cultural context of breasts and breastfeeding in the US (and how they inhibit breastfeeding), I would put together a review of the literature concerning what was known about ‘natural’ patterns of infant feeding and weaning in modern humans, based on comparisons with the nonhuman primates. To phrase it another way, I wanted to know what answers other researchers had found to the question of what the underlying human patterns might be if not influenced by specific local and relatively recent cultural beliefs. From an evolutionary perspective, how often, and for how long, would we expect human infants to nurse?
I quickly discovered that no one had ever asked the questions before. It was simply assumed that modern Western beliefs and practices were standard for the species, with no negative repercussions. And it was understood that in places where women nursed their children ‘often’, or for a long time, it was because they had to, due to lack of adequate weaning foods, lack of clean water with which to mix infant formula, and widespread disease. My research to try to answer this question (Dettwyler 1995) concluded that the ‘natural’ age of weaning for modern humans was between 2.5 and 7.0 years, with most of the predictions leaning toward the upper end of the range. In addition, I found no evidence that the biological underpinnings of this duration of breastfeeding had changed since the emergence of modern humans. As I began to present these data at conferences, and especially after they were published in 1995, I found an eager audience for my message among women in the United States (and internationally) who were breastfeeding their children for several years.
While appreciating that, as scientists, the kinds of questions we ask, and the methods we use to try to gather data to answer them are heavily influenced by our own culture and the times in which we live, I still believe that the scientific approach is our best hope for an objective, self-correcting, understanding of the world. In numerous presentations at conferences aimed either at breastfeeding mothers or at health care professionals, my goal has always been to encourage audiences to understand the evolutionary perspective and the insight we can gain from using it as our starting point. I have never denied the importance of cultural or personal beliefs, or the constraints that specific women face in their daily work to balance their productive and reproductive work.
Specifically, my publications and presentations always emphasized that I was not sending a ‘prescriptive’ message of “You must breastfeed, and you must breastfeed for this long.” On the contrary, the main take-home messages were always: (1) Breastfeeding matters, for the health of the child and the mother, and therefore women deserved to know the consequences of the choices they were making when they decided how to feed their children; (2) Breastfeeding a child for many years is normal for humans as a species, and therefore mothers who nurse their children beyond local/recent cultural norms should not be criticized, viewed as pathological, charged with sexual abuse, or face losing custody of their children in divorce cases due to long-term breastfeeding; and (3) The cultural context of mothering in the US, with its fairly strict separation of women’s productive and reproductive work, and a general devaluing of reproductive work, make it difficult for many women to breastfeed at all, or for as long as they want, and therefore we should work to change the sociocultural systems that impede breastfeeding, so that women who wanted to breastfeed, could, and those who wanted to breastfeed for a long time, could do so with impunity.
My ultimate goal has always been that all women have access to the information and support they need to breastfeed for as long as they want, wherever they want, couched within an understanding of the evolutionary history of our species. Within the scholarly community, both in anthropology and in related disciplines, my work has been variously embraced, dismissed, misinterpreted, or attacked. A number of people have cited my work to support their claim that the natural age of weaning is about 2 years, or about 3 years, even though my research suggests a range from 2.5 to 7.0 years. One biological anthropologist simply dismissed the research, telling me that, apart from women and children in dire straits, “Only you and your weird friends nurse children for that long.” [Bogin, pers. comm., 1996]. More recently, several authors have specifically accused me of being not only anti-feminist, but also racist, for suggesting that breastfeeding matters.
The perspective that not breastfeeding has consequences for the health of mothers and children has been portrayed as ‘essentializing’ women, reducing them to their biological functions, and as a call for a return to a patriarchal, pre-feminist system where women devoted all their time to child-bearing and child-rearing. Many of these personal attacks have been part of a larger set of criticisms of everyone involved in the promotion of breastfeeding for daring to promote breastfeeding at all, especially to ‘modern’ Western women, and most especially to modern African-American women who (everybody else seems to know) can’t breastfeed their children because of their history of slavery and the continuing constraints they face in US society (Wolf 2007).
To explore this recent criticism, in the following sections I lay out the foundations of both the evolutionary and feminist perspectives, as I understand them, and endeavor to convince the reader that understanding women’s reproductive heritage is not anti-feminist in the least.
The fundamental goals of the “human evolutionary medicine and health” project are, first, to understand the underlying biological and physiological heritage that we bring with us into our current world from our mammalian, primate, and early hominid evolutionary past. And second, to clarify that the forces of evolution, particularly natural selection, have left us with certain expectations that are, at times, wildly out of synch with the complex and ever-changing socio-cultural worlds we construct.
Within the evolutionary medicine and health paradigm, we ask, as scientists: To what extent do these mismatches between our evolutionary heritage and modern lifestyles contribute to poor health/illness/disease? And, once we understand the consequences, are there cultural changes we can make to reduce the mismatch, and/or to mitigate the effects?
The fundamental goals of the feminist movement have been, from the beginning, to offer women the same degree of agency and choice that men have traditionally enjoyed in Western cultural contexts. However, somewhere along the way, a few feminists have come to the conclusion that the goals of feminism are undermined by the evolutionary medicine and health perspective within anthropology and therefore, that the perspective must be wrong or irrelevant, and its advocates – especially its female advocates – must be anti-feminist.
Within mainstream US culture, the traditional (pre-feminist) cultural construction of the biological differences between the sexes, and therefore the proper roles for men and women in society, had two basic premises. First: “Women can’t do the things men do because all women are (a) Too weak (physical limitations, especially strength); (b) Too stupid (cognitive limitations, especially for science/math); and (c) Morally deficient (too emotional, not rational).” Second: “Only the things that men do are important: productive activities in the public sphere.” A corollary of the second premise is that the things that men specifically can’t do because of their biology – menstruating, conceiving, gestating, birthing, and lactating – are unimportant. These reproductive activities are part of the private, domestic sphere; they are ‘taken for granted’ as being what women do since they aren’t capable of achieving in the men’s world of true/real accomplishments.
Many feminists have devoted much of their time arguing against the first proposition (and rightly so), claiming and going on to prove that (at least some) women are capable of, and interested in, traditionally male productive activities, and deserve to have the opportunities to pursue them if they want. At the same time, some feminists have accepted – lock, stock, and barrel – the second proposition, agreeing with the general male view that only the things men do are important, and that the things only women can do, because of female biology, are unimportant. Anything that detracts a woman from pursuing success as defined in a male way, is viewed as oppressive by these feminists, because women’s contributions as the reproducers of the population, both biologically (through birth) and culturally (through child-rearing) are devalued in traditional Western cultural belief systems.
In direct contrast, human evolutionary biology, like all evolutionary biology, is valued in the coin of the realm, which is relative reproductive success – the number of children you reproduce and raise to adulthood. The more copies of your genes you leave behind, the better your reproductive fitness. For men, this is possible even while pursuing a strategy of traditional male success in career/politics/sports, or whatever, because reproductive success for men depends mainly on how many women you can impregnate. For many men, in a variety of cultural and environmental contexts, being successful as a man translates quite directly into more opportunities for sex, and fathering many children. Likewise, being unsuccessful as a man – a poor hunter, a poor provider, a coward – often translates into having few or no children.
For women, the situation is very different. For each reproductive attempt, a woman must devote nine months to the pregnancy, several years to breastfeeding (before modern replacements/antibiotics/immunizations/clean water/sewer systems, etc. etc. etc.), and even more years to general care of the children. For many women, especially in Western cultures, pursuing a strategy of reproductive success (many children) is directly at odds with pursuing productive success in the workplace, in terms of career, salary, travel, independence, prestige, etc. And likewise, if a woman devotes much of her time and energy to productive success in the public sphere, then she can’t devote as much time and effort to reproduction.
Since the first appearance of stone tools at 2.5 million years ago, cultural constructions have been a significant part of human adaptation to the environment. Systems of cultural beliefs and practices, emerging from a larger, more complex brain, can overcome significant biological limitations. Cultural constructions can also contribute to the problems that humans must adapt to. In the case of a modern woman living in a Western culture who wants to combine productive and reproductive labor, much of her reproductive work can be farmed out: a woman can pay someone else to be pregnant for her (and thus give birth for her); she can pay someone else to take care of her children part- or full-time, and she can use artificial infant formula instead of breastfeeding. If wealthy enough, she can even pay someone else to breastfeed her children for her.
In the early days of the feminist movement, many ‘career’ women only had careers until they got married (prairie school teachers are the perfect example of this). Then we moved on to a generation or more, with some overlap, of women who chose to have a career instead of marriage and a family, as even taking care of a husband was seen as incompatible with working outside the home and pursuing success as defined by males. Then we moved on to a generation of women who had careers and got married, but chose not to have kids – they could deal with the demands of a husband, maybe, but not the demands of children. Eventually, we moved on to a generation of women who had careers, got married, and had kids, but didn’t take any time off, didn’t care for the children much themselves, and didn’t breastfeed. Today, we have finally moved into a generation where a few women are having careers, getting married, and having kids, and some are breastfeeding their children, at least for a while. In the last decade a trend toward more and more women breastfeeding, with longer and longer durations of breastfeeding, has gathered strength and shows no signs of stopping.
We are also now starting to see the emergence of a generation of women who came of age after the major gains of the feminist movement had been made – who take it for granted that they can combine careers and children, and some of whom are even opting to deliberately drop out of the ‘rat race’ and stay home with their children for some years in the middle of a career they fully intend to return to when their children are older. But the conflict between the two sides in the “Mommy Wars” continues. Which is more important, reproductive success, or productive success? Can they be successfully combined?
The compromise that many modern Western women have settled for is to have only a few children, and to turn much of the care of those children, including bottle-feeding, over to others. Some women have chosen to adopt children, rather than go through pregnancy and childbirth themselves, in order to reduce the amount of time and effort they must take away from their jobs. This provides many of the joys of parenthood, but from a strictly evolutionary perspective doesn’t count as reproductive success. Others do give birth to their own biological children, but insist that childrearing is not their primary focus, and that breastfeeding and other activities that require mother-infant contact are luxuries they can’t afford.
However, an explosion of research into infant nutrition and health over the past 20 years has shown unequivocally that formula-feeding is harmful to children, raising their lifetime risk of morbidity and mortality by interfering with normal immune system development and having adverse impacts on their cognitive development by interfering with normal brain growth and development. In addition, not having many children, and not breastfeeding raises a woman’s lifetime risk of reproductive cancers, and osteoporosis. If she does give birth, but doesn’t lactate, then she is left trying to “mother” her children without the benefit of the mothering hormones – oxytocin and prolactin – provided automatically by lactation. This lack of mothering hormones likely contributes to the high rates of child abuse and neglect, and postpartum depression among mothers in the United States.
This has led to a perplexing conundrum. Modern Western women live, for the most part, in cultures that are not supportive of their reproductive work, and that are not organized to allow women to combine their productive and reproductive work. We make it overly difficult. A sociocultural system that was truly supportive of women’s reproductive labor would look very different from what we have today. But rather than work to change the cultural milieu, a few feminist scholars have decided instead to attack the “near enemy” – their colleagues who insist that reproductive labor is important, and that breastfeeding matters (Goldin et al. 2006, Wolf 2007). Hausman (2003) provides an in-depth analysis of the rhetoric on both sides of the controversy.
When extremely well-supported research about the evolutionary underpinnings of human biology and physiology are presented, and when the consequences of not following the human biological pattern of childrearing and feeding are pointed out, we come up against resistance, and a backlash consisting of both denying the scientific evidence and accusing the researchers of being unscientific and anti-feminist. Critics of the human evolutionary medicine and health approach, and critics of breastfeeding advocacy in particular, frame their attacks in several ways. They deny the validity and reliability of research showing that children are healthier when breastfed (sicker when bottle-fed); they deny the research showing that mothers are healthier when they breastfeed (sicker if they don’t reproduce and/or don’t breastfeed or not for very long); and they deny the perspective that reproductive labor is important, insisting that only productive labor, success in the public ‘masculine’ sphere, counts.
Two brief examples will illustrate the lengths to which the critics go to discredit breastfeeding advocates. First, from the George Mason University STATS website (2006-present), which claims that none of the research on the adverse consequences of bottle-feeding is valid: “These kinds of arguments are simply bad (social) science, and are fed by conviction or opportunism rather than hard evidence. Even worse, it makes one suspect that scientific studies are biased by well-intentioned but possibly misguided doctors predisposed to nursing. . . There are many reasons to want to know if nursing is truly better, or if this is just a throw back public health campaign based on voodoo science.” Joan Wolf (2007) writes: [According to breastfeeding advocates] “Bottle-feeders, smokers, and people who are overweight are maligned for weakness, gluttony, and lack of selfdiscipline; for ignoring the imperative to take responsibility for their own health; and for preventing others from caring for themselves.”
Table 1 summarizes the conflict between what the breastfeeding advocates (BFAs) have said, and the implications that have been taken from their statements by the critics of the evolutionary perspective.
Table 1. Comparison of what breastfeeding advocates (BFAs) say and intend to imply, versus how their perspectives have been portrayed by their critics
|Statement by breastfeeding advocates in the scholarly literature||Statements by the critics||Intended implications, clearly stated in the BFA scholarly literature|
|Breastfeeding is normal||BFAs claim that women who don’t breastfeed are bad mothers||All children would benefit from breastfeeding and breastfeeding mothers should be supported|
|Infant formula is dangerous to the health of children||BFAs are unscientific fanatics who twist and misrepresent the facts to promote their views||Mothers have a right to accurate information about the consequences of the choices they make|
|“Extended” breastfeeding is the norm for modern humans (2.5 to 7.0 years)||BFAs think all women should breastfeed their children for 7.0 years||Women who breastfeed their children past local cultural norms (six weeks, six months, a year, etc.) are not sexual perverts and are not overly emotionally involved with their children; they should not be accused of child abuse or lose custody in divorce cases because of “extended” breastfeeding|
|All women should be supported to breastfeed their children for a minimum of 2.5 years||BFAs think all women should be forced to breastfeed for a minimum of 2.5 years, even though this means staying out of the workforce and giving up their career aspirations||We need to make significant changes to US culture to provide adequate maternity leave, on-site child care, the ability to combine reproductive and productive labor so that women can continue their careers/jobs while providing breast milk to their children|
|We have a culture that is not supportive of breastfeeding, making it difficult for women to do||Because it is difficult, we (the critics) should deny that it matters and claim all the scientific research is flawed/biased so that mothers don’t feel guilty||We should change the culture to make it easier for women to breastfeed, and we need to know how to mitigate the negative health consequences of formula-use for mother and child|
|Breastfeeding matters||Breastfeeding advocates are anti-feminist, because (the critics assert) only women’s productive work is important||Women’s reproductive work is as important as their productive work; from an evolutionary perspective, it is more important|
In developed countries such as the United States, the risks of infant formula are partially mitigated by the cultural systems that provide (for most of us) sewage treatment, clean/safe water sources, immunizations, and antibiotics. But even all of these modern wonders haven’t completely erased the health consequences of not breastfeeding for children, and none of them affect the health consequences of not breastfeeding for mothers. However, proponents of an evolutionary understanding of female reproductive history are not suggesting that all women ought to spend their adult reproductive lives pregnant or lactating.
We are suggesting:
(1) That women have a right to know the consequences of the choices they make, both for themselves and their children, in terms of infant feeding;
(2) That women have a right to instrumental support for the choices they make. If that means breastfeeding, then it might include better maternity leave, on-site child care, and the ability to combine productive and reproductive work in creative ways. These might involve legislation that protects women’s right to breastfeed in public, as well as more general cultural changes that de-emphasize the sexual role of breasts, as well as many others. If a mother’s choice means not breastfeeding, or not breastfeeding for very long, then instrumental support might include research to improve infant formula (an ongoing project of the infant formula companies, as evidenced by the inclusion of DHA and ARA in formulas within the past decade), an understanding of the role of suckling, which would lead to tolerance for pacifier use and thumb-sucking to the age of 6-7 years. Or it might mean better designs for pacifiers and bottle nipples that more closely mimic the experience of breastfeeding, so that children’s facial bones and muscles develop correctly. There are many other approaches that might help mitigate the loss in IQ potential and visual acuity from not breastfeeding, including quicker treatment of infections, better compliance with immunization schedules, educational interventions, etc. (see detailed discussion in Dettwyler 1999);
(3) That everyone needs a better understanding that breastfeeding matters, and that the decision to have a child means many compromises, many opportunity costs, many consequences for mother and child – if women are not willing to make those adjustments, then no one is suggesting that they must have children. Because of the work of generations of feminists whose shoulders we stand on, women in Western countries now have the choice of whether or not to have children at all. No one calls into question our femininity or worth as people if we choose not to reproduce. Our culture has made childlessness a much more acceptable choice.
One particularly outspoken critic of breastfeeding advocacy suggests that a mother’s wants should trump her child’s needs. Wolf writes: “When mothers have wants, such as a sense of bodily, emotional, and psychological autonomy, but children have needs, such as an environment in which anything less than optimal is framed as perilous, good mothering is construed as behavior that reduces even minuscule or poorly understood risks to offspring, regardless of potential cost to the mother.” (Wolf 2007). She is referring here to breastfeeding being defined as good mothering, and bottle-feeding being defined as bad mothering.
Of course, the reality is that for many children in the US, bottle-feeding doesn’t represent a “miniscule or poorly understood risk” – it represents a well-established higher risk of many different diseases both in infancy and throughout life, as well as a risk of a lower cognitive functioning. And for some children, their mother’s choice to bottle-feed will result, directly or indirectly, in their death. Chen and Rogan (2004) have estimated that approximately 800 children in the US die every year because they were not breastfed. The problem is that for any specific mother and child, the consequences of not breastfeeding/formula-use cannot be known at the time the decision must be made.
Thus, mothers who choose not to breastfeed are accepting an unknown level of risk on behalf of each specific child. For some children, not being breastfed may have no lasting significant impact, but for others it will mean illness or even death. It is difficult to understand how denying this ambiguity (by claiming that formula-feeding carries no risks at all), or claiming that breastfeeding is oppressive, contributes to woman’s “sense of bodily, emotional, and psychological autonomy.” On the contrary, withholding information, or misleading women about the consequences of the choices they make, is intensely paternalistic and anti-feminist. A woman whose wants for “a sense of bodily, emotional, and psychological autonomy” are so intense that she would consider risking her child’s health and cognitive development to meet them may well decide against having children at all – which should be her choice to make.
A truly feminist perspective on women acknowledges that women’s reproductive work is what matters in terms of long term evolutionary fitness. A truly feminist perspective on women acknowledges that choosing not to reproduce, while not adaptive in an evolutionary sense, is perfectly acceptable in cultural terms. A truly feminist perspective on women acknowledges that cultural constructions can help or hinder women, whatever choices they make, but that denying women knowledge about the consequences of their choices is profoundly non-feminist and unfair.
Chen, Aimin, and Walter J. Rogan 2004 Breastfeeding and the Risk of Postneonatal Death in the United States. Pediatrics, Vol. 113, No. 5 (May, 2004), pp. e435-e439.
Dettwyler, K.A. 1988 Book reviews of Breastfeeding, Child Health and Child Spacing: Cross-cultural Perspectives , edited by Valerie Hull and Mayling Simpson (1985),Infant Care and Feeding in the South Pacific, edited by Leslie Marshall (1985),Only Mothers Know: Patterns of Infant Feeding in Traditional Cultures , by Dana Raphael and Flora Davis (1985), and The Infant-Feeding Triad: Infant, Mother, and Household , by Barry M. Popkin, Tamar Lasky, Judith Litvin, Deborah Spicer, and Monica E. Yamamoto (1986), Medical Anthropology Quarterly, 2(3):303-306.
Dettwyler, K.A. 1995 A Time to Wean: The Hominid Blueprint for the Natural Age of Weaning In Modern Human Populations. In Breastfeeding: Biocultural Perspectives , edited by Patricia Stuart-Macadam and Katherine A. Dettwyler, pp. 39-73. New York : Aldine de Gruyter.
Dettwyler, K.A. 1995 Beauty and the Breast: The Cultural Context of Breastfeeding in the United States . In Breastfeeding: Biocultural Perspectives, edited by Patricia Stuart-Macadam and Katherine A. Dettwyler, pp. 167-215. New York : Aldine de Gruyter.
Dettwyler, K.A. 1999 Evolutionary Medicine and Breastfeeding: Implications for Research and Pediatric Advice. The 1998-99 David Skomp Distinguished Lecture in Anthropology, Department of Anthropology, Indiana University, Bloomington, IN, 47405.
Dettwyler, Katherine A. 2004 When to Wean: Biological Versus Cultural Perspectives. Clinical Obstetrics and Gynecology, 47(3):712-723.
Goldin, Rebecca, Emer Smith, and Andrea Foulkes 2006 What Science Really Says About the Benefits of Breast-Feeding (and what the New York Times didn’t tell you). STATS at George Mason University: Checking out the facts and figures behind the news. Website: http://www.stats.org/stories/breast_feed_nyt_jun_20_06.htm. Accessed 17 January 2008.
Harrell, Barbara B. 1981 Lactation and Menstruation in Cultural Perspective. American Anthropologist, New Series, Vol. 83, No. 4 (Dec., 1981), pp. 796-823.
Hausman, Bernice 2003 Mother’s Milk: Breastfeeding Controversies in American Culture. New York: Routledge.
Wolf, Joan B. 2007 Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy, and Law, Vol. 32, No. 4, August 2007.
BTW – If you are interested in learning more about Kathy you can head over to her Wikipedia page for a quick overview.