The Formula Tragedies

We are in the midst of the final week of 2022.  We look backwards and forward at the same time, and it is right that we do so.

If we forget history, as the saying goes, we are doomed to make the same mistakes again.

Earlier this year, there was a major crisis in our United States over supplies of infant formula.  There were various causes, including supply chain problems and the closure of a formula process plant after the deaths of several babies and a formula recall.  As far as I know, the formula supply still isn't at 100%.

Formula had to be imported from other countries.

But did you know that, 60 years ago, there was another formula tragedy, at a time when many parents (and hospitals) made their own formula from ingredients available in grocery stores? (During the 2022 crisis, parents were discouraged from trying the old time recipes).

One of the ingredients in homemade formula was sugar.

Several times in the past, I've blogged about a tragedy that occurred in the small city of Binghamton, New York (where I worked for many years) in March of 1962. It was a tragedy that I vaguely remember reading about at the time in my Mom's Look or Life magazines.  I was only around nine years old and living in New York City, but I can also remember the emotional reactions of adults in my life.  

I never dreamed the community of Binghamton would be part of my life for almost half of my years.

A documentary has finally been released by a local PBS station, WSKG.

Here is a blog post I wrote in 2014. 

From comments made on my blog, I know there are still families in this area that were impacted by this tragedy.  

I never knew that a doctor at Johns Hopkins, Dr. Finberg, an expert on peritoneal dialysis (a procedure rarely done back in 1962), had written an article in 1960 warning of the possibility of salt poisoning.  Sadly, it came to pass less than two years later.

Briefly, according to the documentary, around 29 babies in Binghamton General Hospital (a hospital that is still operating)  were fed hospital made infant formula made with salt rather than sugar due to a horrific error in filling a sugar bin. There were three formulas in use at the hospital, two that used sugar and one that didn't.  A handful of mothers were breastfeeding, a practice that had fallen out of favor by 1962.

For a couple of days, after babies started to become seriously ill,  no one knew what was happening. A contagion was thought to be the most likely cause. The true cause was finally figured out when a nurse took some sugar for her coffee from the sugar bin (against rules but this nurse reported what she had done) and the coffee was salty.  She then tasted the sugar in the sugar bin, and found it was salt.

The babies were suffering from salt poisoning.

Six babies died and the rest of the young lives were saved only through heroic measures, including the same type of dialysis that only a handful of doctors in this country even knew how to perform. 

In my 2014 blog post I referred to a documentary that was being made about this incident.  I finally got to see the documentary earlier this week.  A reader alerted me that it was available online and should be online through sometime in January.  The one hour video can be viewed via this link.

I highly recommend it, whether or not you've ever heard of the Binghamton Salt Baby Tragedy, as it is now known as.

Some of the early parts of the documentary (the history of Binghamton General Hospital) might not be of much interest to people outside of this area, but I encourage you to stick with it.  The causes of this tragedy as outlined by the documentary are universal themes that could happen today:  cost cutting, understaffing, a nurse who hesitated to report the salty tasting formula one of the mothers reported to her (the delay may have cost lives), and a practical nurse, pregnant herself with her fourth child, being blamed when she was only carrying out procedures that people above her were responsible for implementing.

As a result of this horror, reforms were put into place in New York State and throughout the United States so that something like this could never happen again.

But those reforms were little solace for the families that lost their babies.  The pain still exists in our community today in the surviving family members.  I am honored that some of them, and at least one nurse who was on the scene, have commented on my past blog posts. 

I do not blog about this to reopen old wounds, but rather, to recognize that the 2022 formula crisis was not the first time formula made the national news.  The circumstances were different but the end, in both cases, was tragic.

This week, we look back to what happened in 2022.  When we look ahead once more, let us try to fix a system once again broken.