Infant Formula Hawking Disaster in the the Third World For an overwhelming majority of new born babies, breast milk is the most nutritious and wholesome baby food. Unsupplemented, it is all that is required to sustain growth and good nutrition for the first six months of life in the babies of well nourished mothers. Even in poorly nourished mothers, the volume and composition of breast milk are usually surprisingly good. And breast milk contains quantities of enzymes, antibodies, and immunizing agents that protect an infant's ultra-sensitive digestive tract from a wide range of diseases. Breast-feeding has natural advantages for the mother, too. Breast-feeding helps to stimulate contractions of the womb and thus helps it return to its normal size. In addition, breastfeeding acts as a natural contraceptive. Recent studies show that if a woman does not breast-feed her baby, she begins to ovulate about two months after the birth of her baby. By breast-feeding, the woman can extend the time of the first ovulation from five months to two years. For centuries, these natural advantages allowed human breast milk to retain a monopoly in the infant food market. There was no competition because there was no need for an alternative - breast milk satisfied the needs of billions of babies and their mothers. Then came Henri Nestle. During the late 1800s, Nestle and the company he founded developed infant formula as a substitute for human milk, ostensibly to "save the life of an infant who could not be breast-fed." But the percentage of women throughout the world who bore children incapable of being breast-fed was small, and Henri Nestle, an entrepreneur, could not expect to make much money selling his substitute for human milk. So, from the beginning, Nestle's corporation made its pitch not only to mothers who couldn't breast-feed their infants but to a much larger market - mothers who were perfectly capable of breast-feeding their babies. Nestle had to convince millions of mothers that breast-feeding was not as good for the baby as bottle-feeding. And it did. Nestle became the number one manufacturer of infant formula, cornering 50 percent of what is today an estimated $2 billion market. Today, Nestle is one of the world's largest multinational corporations. And millions of mothers, perfectly capable of breast-feeding their babies, are feeding their babies infant formula out of a bottle. The promotion and sale of infant formula has had repercussions around the globe. Thirty years ago in Chile, 95 percent of the one-year-olds were being breast-fed. By 1970, only 20 percent were being breast-fed at two months. Breastfeeding in Singapore declined 30 percent between 1951-60; declined 31 percent in the Philippines between 1958-68; and 22 percent in Mexico from 1960-66. Other countries around the world experienced similar declines. Mothers, especially mothers in the Third World, were bombarded with advertisements on radio, television, and in newspapers from infant formula companies extolling the alleged benefits of infant formula. The virtues of breast-feeding were rarely noted. In August, 1974, for example, Nestle broadcast 135 30-second advertisements for its infant formula Lactogen in Sierra Leone, while in December, Unigate, another infant formula company, ran 45 30-second advertisements for its Cow and Gate brand, and Abbott ran 66 promoting Similac in the same month. A World Health Organization (WHO) study reported that between 1975 and 1977 in nine countries the "overall exposure of mothers to industrially processed and commercially marketed infant foods was extensive. Knowledge of brand names was almost universal throughout the economically advantaged populations in all nine countries." The WHO study also found that, in the Philippines, all mothers from poor communities knew infant formula products by their brand names. In Nigeria, 72 percent of the urban poor mothers knew formula products by their brand names. "The reason for the progressive decline in breast-feeding," observed WHO nutrition specialist Dr. J. Kreysler, "is the massive propaganda of the milk companies which is particularly effective in poor sectors of the population. The milk companies are creating a magic belief in the white man's milk powder." The infant formula companies also reached mothers indirectly through doctors, nurses, and other medical professionals. One Nestle representative noted, "the health services are recognized as the main intermediary between the manufacturers and the mothers." The companies greased this pipeline of intermediaries by providing free samples of infant formula to doctors, donating expensive equipment to needy hospitals, sponsoring professional symposia on infant health care, organizing conferences for pediatricians, befriending doctors and giving them gifts, and paying for their expenses to and from conferences. Dr. Leonard Barrion, chief of clinics at a hospital in the Philippines told a U.S. Senate health subcommittee that "health professionals who otherwise know the benefits of breast-feeding often succumb to the gimmicks of milk advertisements." Infant formula companies also hire "milk nurses" to visit patients in the maternity wards of hospitals to promote bottlefeeding. The business of these "so-called nurses is to sell milk, not look after the health of the children," said Dr. Cicely D. Williams, a British doctor who worked in hospitals throughout the Third World. "In Africa, I wouldn't let them in. They came to me about it, but I said no, not as long as I'm here." Williams said she found the same thing in Singapore where Nestle used women dressed as nurses to convince new mothers to use infant formula. By 1980, mothers in developing countries were paying an estimated $1 billion to Nestle, Unigate, Bristol Myers, Abbott, Wyeth, Glaxo and other infant formula companies for products which, in most instances, the mothers did not need. In the context of the developing world the marketing of infant formula through the mass media has significant ramifications. Unlike mother's breast milk, infant formula does not come ready to use. It must be prepared. And a product which requires clean water, good sanitation, adequate family income and a literate parent to follow printed instructions cannot be properly and safely used in areas where water is contaminated, sewage runs in the streets, poverty is severe and illiteracy is high. Formula requires mothers to read and understand instructions for preparing the formula, yet, in many of the developing countries where infant formula is marketed, mothers can't read. Even where the mother can read her native language, in many instances she is faced with a foreign script. In Dar es Salaam, Tanzania, for example, where Nestle's Lactogen is widely marketed, a local doctor reported that the instructions were in English even though most of the women were fluent only in Swahili. Even where a mother can read and understand printed instructions, she is ill-equipped to follow them adequately and safely. Formula preparation re quires clean water to mix with the formula. Yet boiled water is a luxury to many Third World women. Thus, Third World mothers often mix the formula with unclean water, and fail to sterilize the bottles. As a result, the babies drink the contaminated formula and become ill. The UN's Food and Agricultural Organization (FAO) reported in 1977 that "under the unfavorable economic and sanitary conditions found in low income urban groups, the consequences of bottle feeding is a high prevalence of diarrhea and gastrointestinal tract infections which, coupled with frequent over-dilution of the milk, leads to increased incidence of Protein Energy Malnutrition (PEM)." For its part, the infant formula industry has repeatedly denied that there is widespread abuse in the marketing of infant formula in the Third World. In 1978, Nestle asserted that "the formula products are usually purchased by people who can afford them. It is the working women and the women in the upper income groups who are most likely to use formula products." But health professionals throughout the world have testified otherwise. On May 23, 1978, health professionals from around the globe came to Washington to testify before the U.S. Senate Subcommittee on Health about the problems they faced with infant formula marketing in the Third World. A nurse from Yemen testified that although the country is rapidly taking to the bottle, the country does not have "an environment compatible with safe use of the bottle" since only 10 percent of the population has easy access to water. Because infant formula is a costly item in the developing world, mothers often try to stretch their supply by over diluting the product, thus increasing the potential for high malnutrition rates. It has been estimated that 15 million children under the age of five die every year, partly from malnutrition. The vast majority of these injuries occurs in the developing world and the causes are widespread, but more and more specialists within the infant nutrition and health care community are focusing their attention on infant formula use as an important causal factor in the high levels of infant diarrhea, malnutrition, and mortality. In the last decade infant formula companies have modified their marketing behavior due in large part to pressure from health care professionals. Unigate cancelled advertising of its infant formula in Africa until the ad copy was approved by local pediatricians. The company later cancelled all advertisements. Abbott adopted a code of marketing practices that prohibited the use of mass media to market its infant formula, and Nestle cancelled all radio advertisements in Nigeria. Despite these intermittent reforms, however, marketing abuse remained widespread within the industry. In response, a coalition of health, religious, labor and citizen's groups organized a worldwide boycott of Nestle, the largest infant formula company. In addition, many countries have imposed marketing restrictions on Nestle and other infant formula companies. Although Nestle claimed it abided by these laws, it refused to agree to abide by the World Health Organization/United Nations International Children's Emergency Fund (WHO/UNICEF) Code of Marketing for Infant Formula. Instead, the industry pushed the idea of "selfregulation." In May 1981, despite industry opposition, the WHO/UNICEF code was passed by 118 national governments with only the United States, at the behest of the Reagan administration, voting against it. The WHO/UNICEF code calls upon the baby formula industry to: stop giving free Formula samples, eliminate "Milk Nurses," halt direct promotion to mothers, place warning labels on their products, end commissions to sales people, and restrict promotion to the health professions. Serious application of the WHO code poses a sizable threat to infant formula company profits. The dilemma, which pits babies against shareholders, was crystallized when a group of nuns concerned about Abbott's marketing tactics in the Third World paid a call on company executives. According to one observer, one of the nuns said, "Tell me, if you stop selling to people who are too poor to use the product safely, will you still make a profit?" After a pause one of the corporate executives said: "That is the crux of the problem." In 1983, Nestle was cited by the Infant Formula Action Coalition (INFACT), a public interest group based in Minneapolis, Minnesota for disregarding key sections of the WHO code. The company had provided bulk supplies of free infant formula to a Kuala Lumpur hospital, far in excess of the special needs of infants who have to be bottle-fed and it had distributed leaflets in Taiwan in which the "for medical profession only" was in English, but the rest of the text was in Chinese and directed to mothers. INFACT urged consumers around the world to continue the boycott against Nestle's Taster's Choice coffee, chocolate, and other products until the corporation agreed to redirect its marketing priorities. The boycott, launched in 1977, had blossomed into the largest worldwide citizen's effort of its kind, mobilizing more than 100 consumer, religious, health and women's groups in 65 countries. After six years of boycott Nestle slogans, pickets, and press conferences around the world, Nestle finally gave in to INFACT"s demands in April 1984, agreeing to abide by virtually every detail of the WHO Code. The concessions by Nestle surprised boycott organizers. "If Nestle abides by the agreement," said Doug Johnson, the leader of the Nestle boycott in the United States, "it will do a lot to contribute to the lives of children. We now share with Nestle a mutual interest in seeing other infant formula companies bring their marketing practices into line with Nestle's." But three years after the boycott ended, little has changed. According to the United Nations, one million infants died in 1986 because they were bottle-fed, rather than breast-fed. Nestle had not fully implemented the policy changes it promised in 1984, and three U.S. companies, American Home Products, Bristol Meyers, and Abbott/Ross Laboratories, maintained policies that did not conform to the U.N.'s International Code. "During the past year," said Carol-Linnea Salmon, associate director of Action for Corporate Accountability, "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."