Babies At Risk

If your lives were embittered as mine is, by seeing day after day this massacre of the innocents by unsuitable feeding, then I believe you would feel as I do that misguided propaganda on infant feeding should be punished as the most criminal form of sedition, and that those deaths should be regarded as murder."

-Dr. Cicely Williams, M.D., MRCP
"Milk and Murder," Singapore 1939

Dr. Cicely Williams, the eminent British pediatrician who worked for years in poverty-stricken areas of Asia and Africa, was one of the first physicians to identify corporate promotion of artificial baby milk as a source of infant illness and death. Fortyseven years later, and despite a decade-long campaign to limit the damage done by improper promotion of baby foods, the problem has worsened. Today, one million infants die annually because they are bottle-fed, rather than breastfed, according to the United Nations.

"We have definitely won a battle," says Carol-Linnea Salmon, Associate Director of Action for Corporate Accountability-an organization continuing the work of INFACT. "But the war against the illegal and unethical promotion of artificial infant milk has yet to be won."

Despite the enactment of the United Nations-World Health Organization (WHO) Code of Marketing of Breastmilk Substitutes in 1981, the agreement by the three U.S.-based infant formula companies to abide by the terms of the WHO Code in developing countries, and the successful conclusion of the Nestle Boycott in 1984, infant formula promotion remains a critical problem for the health of the world's infants.

Over $4 billion of artificial infant milk is sold every year to mothers worldwide, many of whom are convinced by promotion that bottle-feeding their infants is modern, scientific, and better for their babies than breastfeeding. But mothers-particularly in the developing countries-who don't have clean water and high incomes are not able to prepare feeding bottles safely. Mixed with bacteria-laden water and over-diluted to make it last longer, the expensive artificial milk becomes a daily dose of disease and malnutrition.

The World Health Assembles landmark Code, on which the United States cast the lone no vote, proscribed certain sales tactics and urged health professionals to support breast feeding through hospitals.

But only four countries-Sri Lanka, Tonga, Guatemala, and Peru-have enacted the U.N. Code provisions into law. Throughout much of the rest of the world, babies are still becoming ill and dying from the unethical and illegal promotion of infant formula. Nestle has not fully implemented the policy changes it promised in 1984. And three U.S. companies-American Home Products, Bristol Meyers, and Abbott/Ross Laboratories, targets of shareholder and legal pressure since the mid-1970s, maintain policies that do not conform to the United Nation's International Code.

In the last year, all four companies have taken some positive steps, but in a large part, these steps have been overshadowed by new, equally aggressive marketing practices which violate both the spirit and the letter of the Code.

A Giant Surrenders

In the early 1970s, concerned health workers, citizens' groups, and churches began to lobby the infant milk makers to halt their aggressive promotion of bottlefeeding. By the end of the decade, most companies had agreed to stop the most blatant forms of marketing, especially mass media advertising, but continued their more subtle and most effective promotional tactics-distributing free product samples to mothers of newborns and encouraging the automatic bottle feeding of babies by medical personnel in hospitals.

The Nestle Boycott, begun in 1977 by the Infant Formula Action (INFACT) Coalition and other organizations, was the major tactic used to pressure the Swiss corporation, the largest seller of infant formula, to comply with the WHO/UNICEF Code. In 1984, after a seven-year boycott, Nestle caved in.

When Nestle signed an agreement with the boycott committee, critics of the infant formula industry adopted a wait-and-see policy, carefully monitoring the marketing practices of Nestle and its major competitors.

"During the past year," says Salmon, "we have found that while some life-saving changes have been made, the corporate onslaught of baby milk promotion continues, particularly through deliveries of massive quantities of free infant formula supplies to maternity wards."

There are thirty companies in the international baby milk industry, selling roughly $2 billion of baby milk a year to the developing world, $1 billion in Europe, and $1 billion in the United States. Nestle and American Home Products (Wyeth) are the two largest sellers in the Third World. Although Bristol-Myers (Mead Laboratories) and Abbott/Ross sell internationally at significant but much smaller levels, in some major markets, like the Philippines, these four companies split the market fairly evenly.

Marketing was once consumer-oriented (via massmedia and direct consumer contact) but is now conducted by manipulating the health care system-free infant formula samples on discharge from the hospital, free supplies during maternity stay, and funding to doctors.

"Baby milk manufacturers like Nestle, American Home Products, Bristol-Myers, Abbott/Ross and others create a market for themselves by giving vast quantities of free milk to hospitals and inducing nurses and doctors to , bottle-feed babies during the short maternity stay," explained Salmon. "When mother and baby leave the hospital, they're ready-made purchasers of baby milk, hooked on the product from birth." ,

Although the Code prohibits companies from providing large quantities of free supplies of infant formula to hospitals, it has been weakened by an ongoing debate over what constitutes "large." Nestle, which agreed to change its policy of supplying "large amounts" of free samples, and its competitors frequently provide enough free formula to Third World hospitals for every baby to be bottle-fed and every mother to get free samples to take home. Unless a mother requests otherwise, her baby is bottle-fed from birth in the hospital. When the mother leaves the hospital two or three days later, her milk is dried up and she is forced to feed her baby expensive infant formula. And industry research shows, she will probably buy the brand her baby was fed in the hospital.

"As long as the formula companies continue to supply hospitals with free cans of formula," says Douglas Clement, Action's Executive Director, "they are not in compliance with the International Code."

According to J.M. Rashidi, Senior Nursing Officer for the Malawi Ministry of Health, "The breastmilk substitute companies know that they can encourage bottlefeeding by giving our health care facilities vast supplies of free milk so that health workers are persuaded to feed newborn children on them. This is detrimental to breastfeeding and must not be allowed."

Companies vie for this lucrative market in both the developing and developed world. In 1985, American Home Products paid $1 million to New York City for the privilege of being able to supply the city's hospitals with ' formula.

The companies claim that free supplies do not violate the International Code. The language of the original section of the Code governing supplies was, the companies claim, very ambiguous. The section provided that "supplies should only be used or distributed for infants who have to be fed on breast-milk substitutes." The companies claim that their practice was exactly that, to supply hospitals with enough formula to feed those babies that had to be fed on infant formula. Health and consumer activists argue that a very small number of babies actually have to be fed on infant formula and that the practice of free supplies should be halted to be in compliance with the Code and to preserve a mother's free choice of feeding methods. I

Delegates to the World Health Assembly in 1985 called for a clarification of the Code's wording to restrict the quantity of supplies allowed. In December 1985, infant health experts from around the world met in Geneva to take on the task of clarifying the Code. They issued a comprehensive report recommending that hospitals stop j the practice of allowing companies to donate supplies of infant formula. However, when the WHO later issued its ' own guidelines, its language was much weaker.

In a May 1986 meeting of the World Health Assembly, Professor Ransome-Kuti, the Health Minister of Nigeria, proposed a resolution which strengthened the Code's language about supplies. Caught by surprise, the industry relied heavily on the delegations of the three countries housing the most powerful of the formula companies-Switzerland, the United States, and the Netherlands-to effect their positions. The United States delegation began an intense eleventh-hour lobbying effort to water down the language of the resolution. Two industry representatives, Steven Bauer and Thomas Christie of American Home Products, were even observed sitting in on a "closed session" of the drafting committee meeting.

"At the WHO, a very high value is placed on achieving consensus," said Clement. "This gives the United States an enormous amount of power. Their posture towards the Supplies Resolution is a good example: The U.S. delegation began by implying that they would vote- for the resolution if only some changes were made. Several drafting sessions took place during which the U.S. exerted a great deal of influence by implying that the Assembly could enjoy a unanimous vote if only the resolution were altered to suit the U.S." Many critics say the United States had no intention of voting in favor of the resolution, no matter what changes were made to it.

Despite long hours of redrafting and watering down the resolution, in the end the United States voted against the resolution, casting the only "no" vote. Ninety-two countries joined in support of the proposal.

"Regrettably, the text of the resolution was heavily compromised under extreme pressure from the U.S. and European delegations, who were lobbied by the infant formula industry," said an IBFAN representative. "It is shameful that the United States again stands alone against infant health."

Click here to view :Companies and the Code: Industry Compliance to the International Marketing of Breast Milk Substitutes

Nancy Gaschott is a staff attorney with Action for Corporate Accountability.