Breastfeeding advocates were outraged this week after The New York Times reported that the U.S. took drastic measures to try to block an international resolution encouraging breastfeeding. Public health advocates see the dispute as yet another reminder of the enormous marketing power of the $70 billion baby formula industry.
“It’s public health versus a massive, massive industry with powerful and entrenched interests,” said Lucy Sullivan, executive director of the nonprofit 1,000 Days, which works to improve nutrition for women and children. “They’re only getting more powerful and they’re only getting more emboldened by the likes of the Trump administration.”
The resolution, which advocates expected would pass quickly at the World Health Assembly in Geneva in May, was pretty “vanilla,” Sullivan said. It contained new guidelines from the World Health Organization about supporting breastfeeding mothers in crisis situations and encouraged countries to improve breastfeeding rates. It also referred to an international marketing code the WHO adopted in 1981, which restricts unethical marketing of breast milk substitutes. That includes any direct advertising, such as giving free samples of formula at a doctor’s office. The goal of the code is to prevent new mothers from losing confidence in their ability to breastfeed.
The language has long been a sticking point for the U.S., which was the only country to vote against the International Code of Marketing of Breastmilk Substitutes when it was first introduced at the World Health Assembly in 1981. Ensuring that mothers who are able to breastfeed do so is crucial. Bringing breastfeeding rates up to near-universal levels would prevent about 820,000 child deaths each year, according to a 2016 report in the Lancet, a U.K. medical journal.
The language referencing the marketing restrictions and calling on governments to “protect, promote and support breastfeeding” was a main point of contention for U.S. officials at the assembly in May. The Department of Health and Human Services, the lead agency involved in the negotiations, said in a statement that it is just looking to protect mothers who aren’t able to breastfeed.
“Many women are not able to breastfeed for a variety of reasons, these women should not be stigmatized; they should be equally supported with information and access to alternatives for the health of themselves and their babies,” HHS spokeswoman Caitlin Oakley said in a statement released to INB.
Worldwide, five companies account for about 60 percent of the infant food market, according to Future Market Insights. In the U.S., three of those companies ― Abbott, Mead Johnson, and Nestle ― owned 98 percent of the U.S. infant formula market, as of 2008. All three companies have major lobbying presences in Washington. Abbott, which makes Similac and other infant formulas, spent $790,000 on its lobbying efforts so far this year.
Nestle, the world’s largest packaged food firm, manufactures the infant formula brand Good Start. It told INB in a statement that the company “strongly supports” the marketing code and didn’t lobby the U.S. government in May. Nestle also said it wasn’t present for any vote or decision-making that took place at the World Health Assembly this spring.
Ultimately, the resolution maintained most of its original wording, though a few references to the code were cut, Sullivan said.
Sullivan and other breastfeeding advocates noted that the goal wasn’t restricting access to baby formula, which many babies need to survive, but to reel in deceptive marketing practices that are particularly harmful to poor women. Currently, no infant formula company adheres to the WHO’s marketing restrictions, according to 1,000 Days.
Changing Markets Foundation released a report this year that found Nestle still uses marketing lingo in direct contradiction of the code, which doesn’t allow text that “may idealize the use of infant formula” or “discourage breastfeeding.” Formula labels in the U.S., for example, say that it’s “modeled after the complete nutrition and gentleness of breastmilk.” In China, its website says the product is ”inspired by human milk.”
Formula companies still push their products in offices and clinics, often without the knowledge of the health care providers who work there. While many hospitals have banned sending mothers home from the hospital with discharge bags that contain formula, companies still find ways to get their products into the hands of new moms who don’t necessarily need it before they even get home.
“There’s a physiological issue working against us: You can’t just decide to breastfeed when a baby is a month old. You have to breastfeed right away and keep doing it,” said Lia Fernald, one of the authors of a March 2018 report from the National Bureau of Economic Research on formula-related deaths. “Formula companies figured this out really quickly and that’s why they infiltrated the hospitals ― to get the babies hooked on it from the beginning.”
Aggressive and controversial formula advertising contributes to low breastfeeding rates and infant deaths, advocates say, which is of particular concern among low-income mothers with minimal education who don’t have access to clean water, as using contaminated water to mix formula can make babies sick. They are also more likely to dilute expensive formula to make it stretch to another meal, which can lead to malnutrition. Being illiterate is another risk factor, since formula comes with intricate instructions, Fernald said.
“I have a Ph.D. I teach maternal and child nutrition, and I still had trouble when I needed to use formula ― trying to figure out what’s the ratio of how much powder and how much water I use,” said Fernald, who’s also a professor at the School of Public Health at the University of California, Berkeley. “You can imagine someone who doesn’t have access to those resources.”
The NBER report found that, in 1981, formula resulted in about 66,000 infant deaths in low- and middle-income countries. This was mostly tied to women mixing formula with contaminated water, which introduced fatal illnesses. But breastfeeding also protects against diarrheal diseases and respiratory illnesses, which are a major concern in poor countries. The practice may reduce the risk of sudden infant death syndrome, which is the third leading cause of infant death in the U.S. Since the ’80s, the annual death toll related to formula has dropped to 25,000.
That year, 1981, was significant because it coincided with the peak of a scandal that rocked Nestle. In 1974, a bombshell report called “The Baby Killer,” published by the U.K. charity War on Want, accused the company of introducing formula to impoverished countries that it knew couldn’t use the products properly, just to turn a profit.
The company’s aggressive marketing in poor regions came at a time when sales were declining in the U.S. The company’s shrewd marketing scheme included sending in sales representatives dressed in nurse uniforms to hospitals to give away samples and urge mothers to give up breastfeeding.
The scandal led to an international boycott against Nestle beginning in 1977 that lasted until 1984, when the company agreed to abide by the WHO’s guidelines on marketing. (The company faced another boycott several years later when it resumed participating in banned marketing practices.)
The “milk nurse” concept is still employed today. Jesse Anttila-Hughes, a co-author of the NBER paper, told INB that one of his students held a similar position a few years ago when she was living in Nigeria.
The issue, especially in poor countries, is that there’s no one to monitor how the formula companies are marketing their products. Between 2014 and 2017, there were more than 800 violations of the World Health Organization’s guidelines for marketing breast milk substitutes in 79 countries, according to a report from the International Baby Food Action Network.
Sullivan said she’d like to see baby formula promoted just like medical products ― to those who need it, rather than to a wide consumer base. “Some babies need it, some don’t,” Sullivan said. “It’s there for whoever needs it.”
She said it should be marketed more like insulin therapy for diabetics whose bodies don’t produce the hormone.
“You don’t see cans of insulin being marketed on billboards, and on television and on social media and Facebook,” Sullivan said. “You go through aisles of Target, you don’t see giant rows of insulin brands claiming ‘these are going to make you smarter, stronger.’”