Nestlé poster at a Honduras social security hospital; 1980.
IT was May, 1981. The world’s highest health authorities had gathered in Geneva for the World Health Assembly. Their purpose: to vote on an international code of ethics that would help regulate the aggressive marketing practices of the giant babymilk companies. Ten million babies suffer needlessly from malnutrition every year because their mothers have stopped breastfeeding, according to pediatrician Dr Jelliffe in UNICEF News. Hundreds of thousands die.
The debate around the Code centred on attempts to stop the misuse of infant formula. It was not about banning doctors from supplying babymilk where there was a medical need. It was not even about banning the sales of babymilk to the general public. The Code was an attempt to stop the companies publicising their dried milk powder, or subverting medical clinics into becoming unwitting sales promotion centres.
Since 1979, when the companies agreed to lower their profile, mass advertising has declined. Instead they have been concentrating on ‘point of delivery’ promotion, building up teams of ‘medical delegates’, as their sales representatives are coyly named, who visit clinics and hospitals. There, in the desperately understaffed and overworked health institutions of the Third World, they give talks to health workers and mothers, leaving behind a tempting array of free samples, free gifts, advertising posters and promotional literature. Reporting on findings in Yaounde, Cameroon ,N.R Garrett in the Journal of the National Medical Association (1981), noted that 41 per cent of mothers in his sample cited health personnel as the single most important source of information on babymilk brands: ‘It is not difficult to understand why the multinational companies agreed to restrict their publicity to furnishing “ethical information” to health personnel.’
For many countries the WHO Code would be too weak. Papua New Guinea and Sri Lanka already had far tougher national codes. Yet even this 'minimum requirement’ was being contested. The major milk producing countries could not forget their commercial interests. What would their farmers say? And what about the lobbyists from the powerful food and drug companies that produced the artificial babymilk? Underlying all the backroom politicking was a fear that the regulation of this unacceptable face of capitalism might lead to constraints in other industries.
There was even some far-fetched blustering, mostly by the US, that a Code would contravene such ideals as ‘national sovereignty’ and ‘free speech’. Since each country was free to accept, reject or adapt the Code, the first argument was spurious. The second was equally suspect The United States accepts that ‘free enterprise’ doesn’t mean ‘freedom-from-responsibility-enterprise’, and regulates other misusable products like drugs, alcohol and pornography, especially when they might hurt children. The real threat, everyone knew, was to baby-milk profits.
The rich world market had nearly reached saturation. But the Third World market, which the Code was chiefly designed to protect, was too tasty to pass up. Between one and two billion dollars are generated from sales here annually, upped by 15 per cent every year.
The companies contend that their product is for the convenience of the better-off in the Third World. Colombo’s Cinnamon Gardens set, who glide to the 100-rupee-per-head restaurants in a Mercedes, probably would prefer to let their ayahs bottle-feed their babies. They can, in cash terms, afford to. But the poor world’s government cannot afford such behaviour. For it is precisely the image of bottle-feeding as ‘up-market chic’ that makes it so lethal. If buying artificial babymilk is one of the ‘perks’ of the rich, then obviously that is what the poor will aspire to. And although a Mercedes is an impossible dream, a poor family wanting to give the very best to its newborn can own a tin of dried milk.
But there is a terrible hook hidden in the powder. Unlike the occasional Coke, or cigarettes bought in ones and twos for a treat, this symbol of the good life cannot be indulged in sporadically. Once a mother embarks on bottle-feeding, her own milk starts to fail. The vicious circle has been set in motion. But can a malnourished mother breastfeed? The answer is yes — unless she is severely malnourished, like some refugee mothers. And even in refugee camps, the Red Cross pleads that bottle-feeding be avoided: the baby should be fed with cup and spoon and the mother well cared for so that lactation can be re-established. Money spent on inadequate quantities of expensive artificial milk is money wasted. The same amount could buy an adequate diet of local foods for the mother, so helping her to breastfeed successfully — two stomachs satisfyingly filled for the price of one half-filled.
It is not just a matter of quantity, for breastmilk is custom-made to suit each baby. It varies nutritionally from country to country. A thirsty baby in hot weather will find more thirst-quenching feed at his mother’s breast, if his mother drinks more liquid, than a baby in a wintry climate. It varies with the time of day and even during the course of the feed: a baby’s equivalent of soup to a rich dessert is available at one breast, while a drink to wash it down is waiting at the other. If the baby is extra hungry, and sucks more vigorously, the breast will obligingly produce larger helpings. A dainty eater’s delicate sucking will inform the breast to dish up less.
In theory, therefore, nearly all the babies in the world could have a perfect diet That’s not all. Dr Ebrahim of London’s Tropical Child Health Unit explains: 'A baby’s nutritional status depends not only on food intake but on the illnesses a baby has suffered. Every infective illness is equivalent to the erosion of the lean tissue mass of the baby. On recovery the baby must get enough protein and energy foods to replenish this lean tissue mass, just to get back to square one. This is a highly costly process.
'The commonsense approach therefore is to prevent illness. Calculate the amount of immunising substances present in breastmilk and then go to the chemist and see just how much you would have to pay for that!’
If the doors to ill-health are nudged open by bottle-feeding in the West, they are flung wide apart in the developing world. Here gastric and respiratory diseases maim and kill An estimated five million children die of diarrhoeal disease every year, according to UNICEF.
What then is the babymilk companies’ legitimate market? A company spokesman admitted that 95 per cent of women were physically able to breastfeed. But, he added, if a woman is not breastfeeding successfully within 24 hours it was ‘legitimate’ for the companies to step in.
And that was illuminating. The point is that breastfeeding is not just a matter of physical ability; a very delicate balance of the mind and body is at work. If a mother can be made to worry enough about her adequacy as a breastfeeder, she’s halfway to failing. Often women don’t know that for a few days the breasts may produce only a small amount of odd-looking milk called colostrum. Immensely valuable for developing the baby’s immune system, it bears little resemblance to the white and gushing stuff poured on cornflakes. Three days of colostrum and a nervous mother could be reaching weepily for the nearest bottle-feed.
It is this fear that the babymilk companies play on. ‘While everyone knows that breast-feeding is best for baby,’ begins a 1981 Wyeth brochure smoothly, ‘many mothers either need to supplement the breast with the bottle or choose bottle-feeding from the start’
So mothers believe it is quite likely that they won’t have enough milk.
Infant malnutrition through a decline in breastfeeding is not one of nature’s cruel tricks, but a man-made disaster. The catch is that manmade problems too often have to be unmade by women. The evidence is clear most women can breastfeed, and society says that it wants women to breastfeed. But few women are given the right support and advice (and the early days of breastfeeding can be difficult). And most women must work to help support the rest of the family, and the more desperate the necessity for the woman’s income, the less likely she is to be in a position to demand breastfeeding facilities from her (probably male) employer.
Migrant women in the rich world , factory workers in the newly industrialising countries, women from urban slums who scavenge a living selling bangles or betel leaves— to say that such women have a free choice about enjoying motherhood’ is to add insult to oppression. The tragic twist is that these are also the women whose babies are most at risk if bottle-fed.
One answer is for governments to take action. It may seem another national expense, but if government officials — usually men — come to understand the economies of breastfeeding, the powerful financial arguments could tip the scales in its favour.
First there is that ever-present irritant, the problem of foreign exchange. The billion plus dollars that the developing world hands over to the babyfood multinational companies every year for artificial milk could be far better employed to provide clean water, train health workers or provide vaccines. The biggest savings of all would come from the plummeting hospital admission rate as bottle-related disease declines.
In the Canadian North, research by Dr Schaeffer showed that bottle-fed children were hospitalised 4-7 times more often than those fed at the breast In 1973/4, five per cent of all Inuit (Eskimo) babies born in the Baffin zone had to be flown to Montreal for treatment of intractable diarrhoea and malnutrition. Not including the costs of the air evacuation, that cost between $8,885 and $25,953 an infant
There have been hopes that if babymilk companies came face to face with the misery that they helped cause, they would stop pushing their products. Paediatrician Elizabeth Hillman tells her story: ‘Two Nestlé representatives came to visit us (at the Kenyatta National Hospital, Nairobi). I mentioned to these two gentlemen that there was a child over in our emergency ward ... who was very near death.., the mother was bottlefeeding with the Nestlé product
‘I took the two representatives over to our emergency ward, and as we walked in the door, the baby collapsed and died. And after the baby had been pronounced dead, we all watched the mother turn away from the dead baby and put the can of Nestlé ‘s milk in her bag before she left the ward. .. It was a vivid demonstration of what bottle-feeding can do — because this mother was perfectly capable of breastfeeding. The two men left that room very pale, shaken and quiet, and there was no need to say anything more... ‘But that was in 1975 and in 1981 Nestlé were still resisting the Code.
Would the national delegates at the World Health Assembly listen to the companies or to their critics? On the day of the vote the Code was a resounding success. Every country that registered a definite vote said ‘Yes’, with the solitary exception of the US.
The dramatic 118-1 vote was a historic victory for the global family. For the first time the North-South divide had been bridged at an international forum. It was one in the eye for the cynics, and a morale booster for the idealists who believed that worldwide opinion could be harnessed to resist commercial greed.
The question now is whether Nestlé really will abide by the Code. In October 1979, a meeting between the formula companies and the international health authorities produced an amicable ‘gentleman’s agreement’ to stop the public promotion of infant formula in the Third World. Since then, more than a thousand violations of this agreement have been documented. Expecting companies to apply gentlemanly self-restraint was clearly not enough to protect baby health. That recognition must have been behind the extraordinary unanimity of feeling at the World Health Assembly when it voted on the Code in 1981.
In March 1982, ten months after the WHO Code was passed, Nestlé finally announced its intention to implement the Code. Nestlé say, for example, that they will re-write and re-design their product labels and educational materials to conform to Code principles,within the next 12 months. It’s a step in the right direction, if a decade late: ten years after the New Internationalist first disclosed the connection between baby-milk promotion and malnutrition. It must be asked why the company has been so slow to move and whether there will be as many violations as with the 1979 agreement.
Nestlé’s new guidelines for company personnel also include a requirement that a qualified medical professional must request those potentially dangerous free samples of infant formula for mothers. But company personnel making contact with medical staff will have conflicting interests: their commercial interest, to gain the maximum possible number of new customers, and their humanitarian interest, to gain the minimum. Who will ensure that the humanitarian interest will triumph?
The Nestlé guidelines also promise an ‘Infant Formula Marketing Ethics Audit Committee’ to review complaints against the company. But who will appoint the members of this committee — Nestlé? ‘By themselves the company guidelines are insufficient,’ says Dr McBeath of the American Public Health Association. The APHA’s Board of Directors, representing 50,000 health professionals, has just voted unanimously to join the international Nestlé Boycott committee.
According to the New York Times, Nestlé’s new response is apparently an attempt to end the five-year Boycott If this is so, then public pressure and vigilance has proved its efficacy. That degree of vigilance must be maintained, until we are sure that rhetoric becomes reality. If you would like to help, fill in the Code-watcher questionnaire in this magazine, and join the Nestlé Boycott now.
This special report appeared in the stop the babymilk pushers... boycott nestle now! issue of New Internationalist. You can buy this magazine or, to get stories like this one through your door every month, subscribe.