Paper Cuts: No Match for Mother’s Milk

(Illustration by POGO)

At the 71st World Health Assembly in Geneva last May, delegates drafted a routine resolution supporting a long-established restriction on marketing breast milk substitutes. The draft essentially “reaffirmed commitments” and “recognized efforts” to support the World Health Organization’s work to promote breastfeeding and the intentions of the 1981 International Code of Marketing of Breast Milk Substitutes. Expected to be approved “quickly and easily,” according to participants as reported by the New York Times this week, the resolution was ultimately withdrawn as the U.S. delegation unexpectedly “sought to wear down the other participants through procedural maneuvers in a series of meetings that stretched on for two days.” The Times suggested that the U.S. actions were taken at the behest of the multi-billion dollar formula industry, which increasingly is looking towards overseas markets to sell formula. In recent years, more mothers from economically richer regions have been deciding to nurse, on the advice of doctors.

Infant formula, as a replacement for breast milk to feed babies of women unable to nurse, can be an adequate nutritional substitute (and sometimes is the only viable option), but global public health experts universally agree that a “breast milk substitute” is measurably inferior to the home-grown original. The American Academy of Pediatrics, UNICEF, and the World Health Organization all agree that there’s no contest in nutritional value for a newborn to six-month-old child. Mother’s milk provides antibodies and nutrients that could prevent a third of infant pneumonia cases and half the cases of infant diarrhea worldwide. If contaminated water is used with formula—and many particularly poorer parts of the world lack consistent sources of safe drinking water—it has devastating impacts on babies who drink it, particularly without the protection of antibodies that they would otherwise be getting via breast milk.The World Health Organization estimates that with universal exclusive breastfeeding, 823,000 infant deaths yearly could be prevented—most of them in low- and middle-income countries.

Yet, the handful of international companies in the $70 billion breast milk substitute and baby food industry—dominated by Nestlé, Danone, RB, Abbott, FrieslandCampina, and Kraft Heinz—have continued to grow dramatically, with much of their new business in developing countries. However, their market success has not been without commercial challenges. In the 1970s, public health advocates noticed rising infant mortality rates and many more cases of respiratory illnesses, diarrhea and malnutrition in formula-fed babies.

Spurred by a 1974 exposé provocatively titled “The Baby Killer,” Nestlé became the object of a worldwide boycott over marketing practices that had led mothers to limit or abandon breastfeeding. In 1978, U.S. Senator Edward Kennedy chaired hearings to answer the question, “Can a product which requires clean water, good sanitation, adequate family income and a literate parent to follow printed instructions be properly and safely used in areas where water is contaminated, sewage runs in the streets, poverty is severe and illiteracy high?”

In 1981, the World Health Organization (WHO) drafted a resolution (below) restricting the marketing of breast milk substitutes. Calling the matter a “health issue of essential importance to all Member States, particularly to developing countries, of importance to the children of the world and thus to all future generations” the WHO board called for unanimous consensus to the nonbinding agreement. The resolution, the International Code of Marketing of Breast Milk Substitutes, passed by a vote of 118 to 1. (The one dissenting voter was the United States.)

The Code’s preamble insisted “usual marketing practices” for breastmilk substitutes were “unsuitable” given the “vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices.” WHO has reviewed and updated the Code regularly in the 37 years since its implementation. As recently as 2016, WHO found that most countries still do not adequately protect breastfeeding women from aggressive sales practices.

When U.S. procedural efforts were unsuccessful at the May meeting in Geneva, the Times reported (after interviewing “more than a dozen participants from several countries”), the American delegation used more aggressive tactics. Ecuador, the original sponsor of the measure, was told to drop the resolution, or “Washington would unleash punishing trade measures and withdraw crucial military aid.”

Health advocacy organization 1000 Days Executive Director Lucy Sullivan told, “the first rumblings of U.S. resistance to the resolution” had come in the weeks before the Geneva assembly. U.S. officials held a listening session for stakeholders to discuss the upcoming World Health meeting agenda where “companies voiced their objection to the resolution.”

There is no available transcript of the early May listening session, hosted by the Department of Health and Human Services, but a May 10 letter to Secretary Alex Azar from industry interests, including the Grocery Manufacturers Association, encourages “U.S. government efforts to use all available diplomatic tools (including activation of HHS, Department of State, Department of Commerce, Office of the U.S. Trade Representative and other agency representatives in Washington, Geneva, and key U.S. embassies) to build support among other countries to address [WHO’s] inappropriate initiatives.” Moreover, the manufacturers group wrote, “these initiatives fail to align with good regulatory practices, notably through… insufficient reliance on sound science and evidence-based approaches.”

Abbott did not comment on the Times’ report of international one-upmanship in Geneva, nor have any of the other manufacturers or industry groups weighed in. The Atlantic quotes a nutrition advocate who attended the listening session and described a Nestlé representative who spoke out against the updated resolution because he claimed it “‘restricts complementary feeding,’” the gradual introduction of solid foods along with breast milk starting at around six months of age.

After a number of other Latin American countries backed off as sponsors, fearing retaliation, the Russian Federation stepped up and introduced the proposal without most of the US changes. The small language adjustments consistent in the US public versions that remained in the final measure are in reference to “sound science” and “evidence based recommendations.” (In 2017 a report by Changing Markets found evidence that the science cited in much of the four largest manufacturers’ packaging material comes from industry marketing research, not peer-reviewed and independent nutritional studies.)

On Monday, President Trump pushed back against the idea that the United States opposes breastfeeding, but seemed to misunderstand the basic controversy over the issues in the same tweet: “We don't believe women should be denied access to formula. Many women need this option because of malnutrition and poverty.”

A State Department official told VOA that "Media reports suggesting the United States threatened a partner nation related to a World Health Assembly resolution are false," but added, the U.S. “does not shy away from expressing disagreement when necessary.”

“The United States has a long history of supporting mothers and breastfeeding around the world,” HHS spokeswoman Caitlin Oakley said. “Many women are not able to breastfeed for a variety of reasons, these women should not be stigmatized; they should be equally supported.”

Of course mothers of bottle-fed babies must be fully supported by society, and formula manufacturers offer plenty of help, but the WHO marketing restrictions don’t affect supply of formula or its individual use. What’s at stake is ensuring that new mothers of infants everywhere are getting advice from obstetricians, pediatricians, and public health advisers, not corporate advertising and promotional samples.