Unintended Consequences of Invoking the “Natural” in Breastfeeding Promotion

The above commentary neglects to mention the medical community's heinous cooperation in the promotion of formula over nursing following WWII. The only reason breastfeeding even needs to be "promoted" today is because of the unholy alliance of the medical field with formula companies back in the 50s to convince families across the USA that nursing is passe and that formula feeding is "more scientific" and healthier for babies. An entire generation and more of mothers lost the community wisdom regarding nursing, and we have not come close to recovering from this damage today. And formula companies like Nestle continue to forward this false marketing campaign in third world countries even today. This kind of behavior leads to a distrust of medical interventions and of science in general.

By contrast, vaccines have been strongly promoted by the same medical community that told us that nursing was not necessary, as well as many other errant campaigns, including that Benzedrine and Valium were not addictive, that regular mamograms were helpful, and that HRT was necessary for menopausal women. Much medical "science" today continues to be corrupted by financial interests, to the point that less than half of "positive" scientific studies are replicable. The use of ethyl mercury in vaccines also created concerns which were denied and minimized by the medical community instead of being honestly addressed.

All of these factors together have created a distrust in the medical community, and in some cases, in science altogether, since many of these promotion campaigns (including the suppression of nursing) were framed in terms of "science" offering "better solutions."

I am not opposed to vaccines. Definitely prefer them to polio, tetanus, and COVID. However, it is more accurate for the medical community to take responsibility for CAUSING the distrust in medicine by promoting dangerous solutions in the name of economic gain. When people have been lied to and "science" has been used to promote those lies, belief in actual science naturally declines, leading to an over-commitment to "natural" solutions. Blaming the promotion of nursing for resistance to vaccines is an absurd misassignment of responsibility. People have less trust in the medical community than they used to because the medical community has engaged in less trustworthy behavior, starting with the intentional suppression of the very human, very "natural" process of feeding our babies through nursing. The medical community should admit these errors and start trying to earn back the trust they've lost, starting by disconnecting medical research from profit-driven enterprises that lead to perverse incentives and conflicts of interest.

Unbelievable. No words.

You mean to be Woke we must ignore the Science of Biology and the definitionof the word Natural?

I can only conclude that the person who wrote this article has no clue what a normal, healthy family looks like. Do what you want in your own home, but don't impose your sick values on others. This is disgusting.

Hello. Your article is drawing attention these days, especially the alignment of "natural" breastfeeding and how promoting breastfeeding may detract parents from accepting vaccines. "If breastfeeding promotion frames the "factory-made" option as risky or unhealthy, what should parents conclude when choosing between factor-made vaccines and boosting immunity "naturally".?

This is alarming to see posted in a pediatrician journal. This is reckless. While pharma is promoting the advanced medicine of "personalized" medicine, where chemo treatments and more can be decided based on a single persons DNA structure, why is a one-size-fits all vaccine promoted for all? What is the problem with natural immunity? If the person is rendered strong and immune, who cares how it got there. If a person is rendered weak and allergic to a vaccine, they should have the right not to ingest it. The authors are framing the minds of pediatricians on how to subtly market vaccines for compliance.

With the current vaccine movement and current legislation that has taken the CHOICE AWAY FROM DR's TO DETERMINE IF A CHILD IS FIT OR UNFIT to receive a vaccination, the entire medical community should be alarmed, on guard, and start to speak out. MEDICAL DOCTORS ARE BEING TOLD WHAT TO DO by the American Government. Doctors are losing their freedom to practice, to rely on their own education ,intelligence, and expertise when treating a patient. They are no different than a tech support center, reading off a script "If this, then that". No more than 20 minutes per call. No discretion in what you prescribe. You must adhere or your practice will be at risk

Please consider what is happening here and take action fast on the behalf of your (once esteemed) profession and us humans who deserve personalized healthcare in all facets of our lifespan. Do you want to be a mouthpiece for what the government tells you to do? Or do you want to help parents make informed choices?

Dr's should start to get more informed, both on the risk of vaccines for some at risk children, (not all) and also, for their profession.

This is a pathetic waste of medical fraternities time and money. By your impotent weak psychological perspective you can alter the realm of reality in your heads and your heads alone while the rest of humanity lives in reality. I literally hate Sigmund Freud and all forefathers of psychology because they cause a punk with no reality based medical discovery to come up with this inventive shit. Hatred for Karl Marx and the forefathers of Sociology because the mindless indulgence of the psychology departments shit anf facilitation of it to legislation. Obviously pointing out both fantasy based schools of thought have no intent on helping the mainstream functional ideal and grab at straws they wish to experiment upon the general public for a pissy handful of very disturbed disfunctional members of society. Wake up you self serving anarchy producing unprofessional morons!!

To try to argue that positing breastfeeding as anything other than Normal is problematic is really appalling
How do other mammals feed their young?
I'll wait
Why does this publication give over space to such spurious writing?

I just saw this now. This is a result of political correctness being involved in something as simple as breastfeeding.

Contrary to some of the gushing comments, this op-ed piece demonstrates that words may be placed in such a way as to imitate thought without any having occurred to produce the result. There was a time when the Academy took seriously its mission to forward the welfare of the child. That noble mission has been thrown over in submission to most recent zeitgeist. The basic presumption is that non-genderism is beneficial. No data has been presented for this assumption but ample data is available that it does not work (http://thefederalist.com/2018/09/13/study-half-transgender-female-teens-...). That idle and poorly disciplined minds come up with this sort of stuff is hardly surprising. That the Academy has fallen away from its true mission in abandoning children (who pay no bills) for those who do, is odious.

I'm curious. How long until pregnancy is declared anti-woman because it enforces gender roles?

The vile misogyny of this article is disgusting. Why did you publish this attack on women

It appears these writers receive formula money.

Science should not heed to PC “ethics” in its honesty to nature’s good will. I’m sorry if Nature is not compliant with your insecurity of how genders exist in the animal kingdom since creation. But if you pretend to be a scientist, stick to the facts. Don’t pander to the feelings of people who aren’t comfortable with scientific facts. Try as you will, nature always finds a way.

YOU HAVE A DEGREE IN FINDING IMAGINARY PROBLEMS IN EVERYTHING...YOU ARE A FUCKING JOKE AND PEOPLE ARE GROWING SICK AND TIRED OF THIS 'problematic' generation of ;'grievance jockeying'. THIS is really what American education has come to? From nuclear fission to moon landings to CRYING ABOUT BREAST FEEDING BEING CALLED NATURAL? GET THE FUCK OUT!!! YOU ARE AN EMBARRASSMENT AND YOU MENTALLY ILL SCUMBAGS ARE DESTROYING THE US EDUCATION SYSTEM!

So

In reading this article, I'm wondering if either Jessica or Anne have some connection to the alternatives of breast-feeding - such as Gerber, Johnson&Johnson - or any of the other numerous providers of baby formulas and foods.

The "natural" aspect of breast-feeding is just that. Defined as: "existing in or caused by nature; not made or caused by humankind. Or...of or in agreement with the character or makeup of, or circumstances surrounding, someone or something."

Additional interpretations of that word that might be made by people have nothing to do with the actual definition.

What is most important is the health of the infant and the health of the mother. Their argument seems to have neglected the "do no harm" portion of a physician's oath to their patients.

I'd like to know why they are pushing this agenda?

In developing countries exclusive breast feeding and clean water have been found to have the greatest impact on health in the under fives, see the WHO and UNICEF. Specifically UNICEF say that breastfeeding has THE most significant impact on child survival in the under 2s. In developed countries exclusive breastfeeding has been found to reduce all hospitalisation from respiratory disease, including whooping cough, and diarrhoea.

Are you aware that immune factors in milk provide protection against infections such as H influenzae, S pneumoniae, V cholerae, E coli, and rotavirus... isn't the public health aim to reduce infectious disease?

Therefore the suggestion that vaccine promotion comes with a price of potentially reducing breastfeeding is quite shocking. 'We should think twice before referencing the “natural” in breastfeeding promotion, even if it motivates women to breastfeed.' The alternative to breast feeding is formula. Can you show how formula fed fully vaccinated children are healthier than fully breast fed babies, even if they are unvaccinated please?

Are you seriously suggesting that vaccines are more important than breastfeeding in the under twos. evidence please? And in any event wouldn't it be better to find more robust evidence for vaccination instead of suggesting that the term 'natural' be censored in breastfeeding promotion?

Jessica Martucci, Anne Barnhill are right : we should all be concerned by people who try to inform themselves by social networks and internet. It is a non sense.

It would be a big trouble if they find the truth between the lines. On contrary, they should go to the physician without asking to much questions and let there health on the hands of professionals (like a car to be fixed) who has demonstrated in the past how right they always were.

1- If we consider the market of medecine and medical treatments. Using the word natural for any kind of solution brought efficiently by the nature with no charge, is a threat for the professionals and they start the feel the heat on them.

2- If we consider the market of (real) healing, we are waiting for the medecine miracle from pharmaceutical companies. Until now, only the nature has brought solutions. cf to professor valer Longo statements (university of south california)

Hopefully we can rely on the culture for teaching us the philosophy: Dr knock is a very good example of such behavior of medical professions.

Regards

Breastfeeding IS natural. This pseudoscientific attempt to manipulate people is appalling. The fact that breastfeeding is natural in no way dictates a gender role, because it is also optional. Women who have babies who lactate are engaged in a natural biological process, and when they feed babies the milk they produce both the woman and the baby are also engaged in a natural biological process.

This article has a not so hidden agenda, to pretend that males and females are the same. While, as humans, we are mostly similar, biological gender does manifest differently in males and females, and in the other chromosomal configurations besides XX and XY.

It is this kind of pseudoscience that alienates people from real science. The authors, Jessica Martucci, Anne Barnhill, would be wise to examine their motives in publishing such nonsense. Readers may wonder who paid them to write this? What is the agenda here?

If promoting something controversial is unethical, then I think you'll find you're stuck no matter what you do. I think you'll also find the AAP has had absolutely no problem being 'unethical' in this way in the past. At some point the author needs to address that in reality the gender ideas entailed by 'Breastfeeding is natural' are ones that the author simply does not prefer, and that promoting other ideas, no matter how 'controversial' are apparently not 'unethical' if the author prefers them, as is made clear in numerous places in the article. For example, denying that natural methods are better is obviously controversial, and the author seems to find nothing unethical about promoting that view. Denying traditional parenting gender roles is also controversial, author finds nothing unethical about taking that stance.

The bottom line, or the line drawn in the sand, is that many people want to know what is contained in the things they consume, use or ingest. Sure, people have come to use the term 'natural' or 'synthetic' to describe nature vs man-made, but if you take those terms away, the premise stands that the real concern is whether or not we are being exposed to things that harm us and cause disease. This could be in our food, our water, our clothing, our vaccinations and yes-in our baby formula. As a society, we should be questioning all sides, both natural and non-natural. What consumers want, when it comes down to it, is transparency and truth in research, health and medical sciences.

In developing countries exclusive breast feeding and clean water have been found to have the greatest impact on health in the under fives, see the WHO and UNICEF. Specifically UNICEF say that breastfeeding has THE most significant impact on child survival in the under 2s. In developed countries exclusive breastfeeding has been found to reduce all hospitalisation from respiratory disease, including whooping cough, and diarrhoea.

Are the authors not aware that immune factors in milk provide protection against infections such as H influenzae, S pneumoniae, V cholerae, E coli, and rotavirus... isn't the public health aim to reduce infectious disease or am I mistaken?

Therefore the suggestion that vaccine promotion comes with a price of potentially reducing breastfeeding is quite shocking. 'We should think twice before referencing the “natural” in breastfeeding promotion, even if it motivates women to breastfeed.' The alternative to breast feeding is formula. Can you show how formula fed fully vaccinated children are healthier than fully breast fed babies, even if they are unvaccinated please?

Are the authors seriously suggesting that vaccines are more important than breastfeeding in the under twos. evidence please? And in any event wouldn't it be better to find more robust evidence for vaccination instead of suggesting that the term 'natural' be censored in breastfeeding promotion?

The reads like something I'd find in The Onion.

This will probably not get posted because you don't want people to speak against you. But to the person or people who do read my comment, you are idiots to support this website, the study, any any person or organization affiliated with such blatant disregard for God's Creation and orderly ways of living. Don't like the word 'natural'? Fine, God-made, how's that for a replacement?

As a Pediatrician who is a strong proponent of both breastfeeding and vaccines I find your commentary fascinating food for thought.
I do find our confidence in "man made" solutions to our problems interesting as they often turn out to be problematic in the end due to our inability to see the whole picture- eg antibiotics and the the microbiome. I also think breastfeeding and vaccines can both be seen as our attempts to manipulate the natural to our ends as opposed to imposing our own solutions but that could be argued many ways.
I do take keen interest in your idea that breastfeeding may be used to enforce stereotypical parental roles. I am not for that. We have been actually attempting to include father/family more as we promote breastfeeding- doing skin to skin with both mom and dad, going to couplet care and relying on dad/support person to care for baby too, educating both parents during their post partum stay. If we encourage dad to take a more active parenting role from the start could we not use breastfeeding promotion to break down stereotypes instead?
Thanks for a thought provoking piece.

The authors’ argument—that it is “ethically problematic” to apply the term “natural” to the act of breastfeeding, and that to do so could inadvertently undermine vaccine promotion efforts and “support biologically deterministic arguments about the roles of men and women in the family”—is strained at best.

By all measures breastfeeding fits the Oxford Dictionary definition of natural: “Existing in or caused by nature; not made or caused by humankind.” Breastfeeding is a hallmark of all mammals; if it is natural for lions, whales and apes to nurse their young, why is it any less so for humans?

The idea that the use of “natural” to promote breastfeeding will lead parents to question the “unnaturalness” of vaccination hinges on a false dichotomy: that parents considering vaccination are faced with a binary choice between the natural (probiotics, herbs, nutritional supplements, etc.) and the unnatural (manufactured vaccines). In reality, parents often choose a mix of these measures, none of which are completely natural in the Oxford Dictionary sense. The drive to protect our children from infectious diseases—whether by amulets, prayer, vaccination, or the harvesting, processing, packaging and sale of herbs, supplements and the like—has always involved a substantial degree of human intervention.

Finally, the idea that the use of the word natural “may inadvertently endorse a controversial set of values about family life and gender roles” is far-fetched. With the exception of much of the 20th century in the industrialized West, breastfeeding has been the standard mode of infant feeding in all eras and under every sociopolitical system imaginable. (My grandmother’s 109 year-old child-rearing manual lauds breast milk as “the natural food of infancy.”) Whose “controversial set of values” should we fear?

Wow. Remind me to stop reading your magazine. This a stupid argument.

Jessica Martucci, Anne Barnhill
You lost your fvrigging mind or sitting deep in the big Pharma pockets!!! Either way, shame on you!!!

What is ethically problematic is changing accurate language for a politicization of the medical field according to a particular agenda in one political topic. One should not avoid the most appropriate language or one begings to live in an Orwellian world where five is three and stop is go.

The premise of your article is moronic. Anyone with sense will eventually see that, and this article demonstrates why: https://www.greenmedinfo.health/blog/major-journal-warns-calling-breastf...

The suggestion that breastfeeding is not natural is a natural consequence of acute clinical mental diarrhea whereby institutional board-think is conniving on how best to monetize the next popular cultural phenomenon where the public rejects their synthetic chemical alternatives.

This is the dumbest thing I have read in a long time.

OMG LOL!: "it is associated with such "problematic" practices as home birth, homeschooling and the rejection of GMO foods.." Ummm, WAYULL! I guess I'm just doing untold damage to my children by birthing them at home (to avoid unnecessary drugs as standard practice in hospitals and to acheive a healthy birth for both of us) and homeschooling (oh, LORD, I'm harming them, LOL!, by keeping my 4 year old from being killed by milk, eggs, wheat, tree nuts, peanuts, seeds, and about 15 other allergenic to him foods in preschools), and rejecting GMO as far as I am able to (because the evidence is still out on whether genetically modifiying foods can mess with our immune systems and actually CAUSE food allergies, and there is at least one case where that happened). What a problematic whack job I am! [Holding my sides with laughter at the idiocy of Jessica Martucci and Anne Barnhill who authored this piece of crap.]

Also the conflation of breastfeeding and the anti-vax movement is patently absurd. To assume that women are such idiots that they cannot think through multiple separate issues but must take one with the others is insulting in the extreme. YES, USING THE FEEDING METHOD THAT YOU AND YOUR BABY WERE *DESIGNED* TO USE IS BEST! OBVIOUSLY!!! ***NO***, that does NOT mean that other ways of feeding babies are not sometimes TOTALLY NECESSARY AND WONDERFULLY HELPFUL! AND YES! VACCINATING BABIES IS A GREAT IDEA AND SHOULD BE DONE IN MOST CASES.

You can say that one is natural without saying the other is unnatural. You can say that one is good without saying that the other is bad. Look, I love having legs. But if my legs didn't work, I would ABSOLUTELY LOVE prosthesis. And I would NOT assume that if I said that having legs is natural that I must therefore always wear daisy chains in my hair or joint he anti-teethbrushing movement. HOW ARE THESE PEOPLE EVEN CALLING THEMSELVES RESEARCH SCIENTISTS WHEN THEY SEEM INCAPABLE OF LOGICAL THOUGHT?

I'm so sorry, but I am sick of everyone talking about and to mothers as though we are morons. I have advanced degrees and am capable of reasoning, thank you very much. Ok, I stopped laughing. Now I'm mad.

More evidence that mainstream medical journals like Pediatrics are full of pc nonsense and that they should never be trusted or taken seriously by thinking people.

This is the most absurd article I've ever read. Shame on you for trying to downplay the importance of the most NATURAL human act. If it provokes home birth, home school and a natural lifestyle without the toxic scam AKA, vaccines, then that's outstanding!!! I'm not sure if this was a test to see if anyone actually reads this drivel or if you're completely incompetent.

Natural practices are often best for our children and ourselves. The authors of this paper are researchers who purport to specialize in medical ethics. To suggest that we should campaign to vilify all natural practices in an attempt to influence parents to accept vaccines or GMOs is the epitome of unethical advice."

The Academy of Breastfeeding Medicine’s (ABM’s) Comment on “Unintended Consequences of Invoking the ‘Natural’ in Breastfeeding Promotion” authored by Jessica Martucci, PhD, Anne Barnhill, PhD
Published March 4th, 2016 in Pediatrics

Food for thought: Unintended, potential, or intended consequences of invoking the “natural” in breastfeeding promotion?

On behalf of the Academy of Breastfeeding Medicine (ABM), a global organization of physicians with expertise in breastfeeding medicine, I am writing to comment on Martucci and Barnhill's recent article.

Yes, the language used to describe breastfeeding is critical for public health, especially because breastfeeding profoundly impacts the immediate and long-term health of mothers and children. It is troubling, therefore, that the authors begin their essay by asserting that "a spate of recent work" challenges the extent of breastfeeding's impact; in fact, the evidence for breastfeeding's importance has never been stronger. Even the reference the authors cite to support their assertion concludes, "It is unquestionable that breastfeeding is important for both baby and mother." The importance of breastfeeding was affirmed resoundingly in a recent systematic review, which found that scaling up breastfeeding would prevent 823,000 child deaths each year.1

Perhaps the problem with using the term “natural” to define breastfeeding is that it implies an alternative. In fact, breastfeeding is the physiologic standard and a normal human function that has no equivalent alternatives, so there are no “advantages” per se. After all, we don't talk about breathing or eating as “natural” comparisons to ventilator support or parenteral nutrition. Breast milk contains antibodies, innate immune factors, bacteria and living cells that protect infants from infection and orchestrate development of the immune system.2 Despite the extensive marketing campaigns of the formula industry, additives to formula do not replicate the myriad physiologic functions provided by breastfeeding.

That's exactly why the AAP 2012 Policy Statement on breastfeeding does not use the word “natural.” 3 Instead, breastfeeding is described as the "normative standard for infant feeding”; the statement emphasizes that breastfeeding is a health issue and not a lifestyle choice.

Martucci and Barnhill's argument rests on the assertion that referring to breastfeeding as "natural" will inevitably lead families to reject vaccines as "unnatural." Using “natural” and “unnatural” to compare breastfeeding and formula feeding is simply not the same context as the discussion around food, vaccines, medicine / herbal products and the implications of their benefits or harm.

The authors provide no evidence to link promoting breastfeeding with avoiding vaccines. And their argument is a slippery slope that presumes families will develop a zombie-like allegiance to the word "natural," lacking the capacity to differentiate evidence-based public health recommendations from pseudoscience. We feel the term “natural” is best conceptualized as a marketing issue, not one of science, ethics or anything to do with any controversy regarding vaccinations or one's feminist perspective.

According to Webster Dictionary, natural means “existing in nature and not made or caused by people.” The word is persuasive, but perhaps in a positive and not a negative way. Note the successful “It’s Only Natural” breastfeeding campaign which was grounded in extensive focus group research .4

More important than the unintended, potential, or intended consequences of using the word “natural” to promote breastfeeding, physicians and parents should understand that there is extensive evidence to show that both breastfeeding and vaccines are healthy choices for families.

Julie Taylor, MD, MSc
President, Academy of Breastfeeding Medicine

The AAP Section on Breastfeeding Leadership read with interest the Perspectives in Pediatrics article, “Unintended Consequences of Invoking the ‘Natural’ in Breastfeeding Promotion” by Martucci and Barnhill. While we agree that the words we choose to encourage healthy behaviors certainly matter, equating breastfeeding as “natural” with the supposed “natural” of the anti-vaccine movement is neither logical, nor appropriate. Furthermore, this direct link is not substantiated in the literature.

Breastfeeding is the normative standard for infant feeding, and the standard by which all other feeding methods should be compared. Infant formulas are inferior to this standard, as documented in multiple evidenced-based studies, including the recent Lancet series on breastfeeding, which concludes that the evidence supporting breastfeeding benefits for mothers and babies is now “stronger than ever.” Accordingly, we disagree that higher risks of formula feeding to mothers and babies are being oversold.

The Nuffield Council on Bioethics Analysis Paper states that public agencies, governments and organizations “should avoid using the terms natural, unnatural and nature” unless they make transparent the “values or beliefs that underlie them.” The US DHHS Office on Women’s Health 2013 campaign entitled “It’s only natural, mother’s love, mother’s milk” specifically targets African American families, the demographic least likely to breastfeed, yet facing the greatest burden of adverse health outcomes. Among mothers giving birth in 2012, 83.0% of white women (non-Hispanic) and 82.4% of Hispanic women initiated breastfeeding, while only 66.4% of non-Hispanic black women initiated breastfeeding, a concerning disparity. For the targeted population of the “It’s only natural” campaign, breastfeeding initiation is not “natural.” The language of the campaign was chosen to convey that breastfeeding is achievable when African American mothers receive culturally sensitive education, help and support, using a multi-pronged approach.

AAP policy states that infant feeding should be considered a public health issue and not a lifestyle choice.2 Breastfeeding is indeed at the core of public health promotion and primary prevention. Additional important preventive measures advocated by the AAP and other health organizations include routine immunizations, which protect against preventable childhood diseases, based on centuries of proven benefits. The ideal way to connect breastfeeding with vaccinations is to highlight breastfeeding as the “first immunization” recognizing the abundant immune protective factors present in breastmilk, and especially in colostrum.

Choosing our words carefully in health promotion is important, but even more important is the effect our words have on the desired health outcomes. Just as the authors are concerned about a theoretical effect of breastfeeding promotion on vaccine rates, we are concerned about the effect of their article, and other similar articles, on breastfeeding promotion and rates. Let us state clearly that breastfeeding is the normative standard for infant feeding, and other feeding methods put mothers and children at risk for both short and long-term adverse health outcomes. It is our responsibility, as pediatricians and children’s advocates, to inform parents of these facts, just as we explain the importance of immunizations.

Acknowledgements

Thank you to the Leadership Team of the American Academy of Pediatrics Section on Breastfeeding for their contributions and review of this comment.

References

1. Eidelman AI, Schanler RJ, American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841
2. Victora CG, Bahl R, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475-490
3. Nuffield Center on Bioethics. Ideas about naturalness in public and political debates about science, technology and medicine. November 2015. Available at http://nuffieldbioethics.org/wp-content/uploads/NCOB_naturalness-analysi.... Accessed March 8, 2016
4. U.S. Department of Health and Human Services, Office on Women’s Health. It’s only natural, mother’s milk, mother’s love. April 2013. Available at http://womenshealth.gov/itsonlynatural/. Accessed March 8, 2016
5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2012 National Immunization Survey. July 2015. Available at http://www.cdc.gov/breastfeeding/data/nis_data/index.htm. Accessed March 8, 2016