In Part 1, David discussed what was at stake: the lives of hundreds of thousands of children and mothers every year. In Part 2, he traces the history of the Code.
By David Clark
I spent my first year at UNICEF – and considerable time after – learning about the Code and the outrageous efforts of the baby food industry to undermine it at every turn. I had a lot to learn: Recognition of the devastation caused by the unfettered marketing of BMS has a long history.
As far back as 1939, infant health pioneer Dr. Cicely Williams raised the alarm in a speech to the Singapore Rotary Club provocatively entitled "Milk and Murder." Expressing her frustration over the number of infant deaths she was witnessing as a result of improper feeding practices, she argued that "misguided propaganda on infant feeding should be punished as the most criminal form of sedition, and those deaths should be regarded as murder."
Explore key dates in the history of the Code in this visual timeline.
Yet nothing was done to put a stop to the aggressive promotion, and almost 30 years later, Dr. Derrick Jelliffe of the Caribbean Food and Nutrition Institute in Jamaica felt the need to coin the term "commerciogenic malnutrition" to describe the terrible health outcomes that could be directly associated with the promotion of BMS products, advertising that persuaded mothers to give up the life-saving practice of breastfeeding.
But it wasn’t until the 1970s that media reports began to appear about the hazards of BMS promotion, particularly in low- and middle-income countries. Finally, in 1974, the World Health Assembly began to take notice of the general decline in breastfeeding in many parts of the world, related to sociocultural and other factors including the promotion of manufactured breast-milk substitutes, and urged member countries to “review sales promotion activities on baby foods to introduce appropriate remedial measures, including advertisement codes and legislation where necessary."
Perhaps surprisingly, the BMS industry contributed to the building momentum for action. Nestle sued advocates for libel when they translated and published “The Baby Killer” – a report that revealed how multinational milk companies were causing infant illness and death in poor communities by aggressively promoting their products and undermining breastfeeding. The suit was filed in Switzerland, where the report had been translated into German and published with the title “Nestlé kills babies.”
The lawsuit brought international attention to the issue. Nestlé won the battle; but the war was just getting started. The report and lawsuits set off boycotts of Nestlé that quickly spread from Switzerland and Britain to the U.S., where a religious order, the Sisters of the Precious Blood, filed a lawsuit charging U.S. formula manufacturer Bristol‐Myers with what the New York Times described as “in effect … lying to its stockholders about its sale of infant formula among impoverished populations.”
U.S. Senate hearings on the inappropriate marketing of BMS in developing countries further contributed to a call for a Code to regulate marketing practices.
The world acts
So, it took 40 years (and hundreds of thousands, perhaps millions of preventable child deaths) for the international public health community to finally address this tragic state of affairs. It did so at the joint WHO/UNICEF Meeting on Infant and Young Child Feeding in Geneva in 1979.
Delegates – including representatives of government, UN agencies, NGOs, technical experts and the baby food industry together – concluded: “There should be no sales promotion, including promotional advertising to the public of products to be used as breastmilk substitutes or bottle-fed supplements and feeding bottles.” Further, they recommended “an international code of marketing of infant formula and other products used as breastmilk substitutes.” WHO and UNICEF were charged with the organization of its preparation, with the involvement of all concerned parties, including the baby food industry.
Significantly, six groups at the meeting formed the International Baby Food Action Network (IBFAN), which today consists of about 200 groups in 100 countries. IBFAN became a major advocate for the implementation of the Code, organizing capacity building workshops for policymakers, often in collaboration with UNICEF and WHO, and monitoring industry violations through its periodic “Breaking the Rules” reports.
In 1981, the 34th World Health Assembly (WHA), through Resolution WHA34.22, adopted the International Code of Marketing of Breast-milk Substitutes as a "minimum requirement" to be implemented "in its entirety" by all Member States.
The political intrigue behind that vote provides some clues at the forces that drive the continued marketing of breastmilk substitutes. As Ellen Sokol describes in The Code Handbook (available in many libraries), the U.S. and other industrialized countries pushed for a weaker “recommendation” rather than a binding “regulation.” Arguing that a unanimous vote for a recommendation would result in a strong resolution, the U.S. delegation successfully lobbied other delegations and the WHO Secretariat into believing that the U.S. would vote for the Code as a Recommendation – only to do an about face at the Assembly and vote against it.
The U.S. business sector had successfully persuaded the administration that the Code would set a dangerous precedent permitting UN agencies to interfere with business interests.
Though advocates lifted the Nestle boycott in 1984 after the company agreed to abide by the Code, they relaunched it again in 1989 when IBFAN reported that baby formula companies were flooding health facilities in low- and middle-income countries with free and discounted supplies of BMS. The boycott continues to this very day.
Building on the Code
The baby food industry was involved in the drafting of the Code, along with public health experts and advocates, resulting in an instrument that reflects compromises made on both sides. So, from a legal perspective, it was not perfectly drafted and contained many ambiguities and loopholes that the BMS industry has exploited over the years as they devised new ways to promote their products.
By adopting 20 resolutions so far, however, the World Health Assembly has closed some of these loopholes, and addressed the industry’s development of new products and marketing techniques. These resolutions have the same status as the Code and should be read along with it. A 2016 resolution was particularly significant, as it called on Member States to take all necessary steps to implement the WHO Guidance on ending the inappropriate promotion of foods for infants and young children, and for manufacturers and distributors of foods for infants and young children to adhere to it. This guidance, among other things:
- Clarified that all milk products marketed for use by children up to the age of 36 months (including follow-up milks and growing up milks) are BMS and covered by the Code.
- Stated that there should be no cross-promotion of breastmilk substitutes via the promotion of foods for infants and young children.
- Called for eliminating conflict of interest in health care systems, providing a list of unacceptable practices or behaviors, such as companies donating equipment or services, giving gifts or incentives, holding events in health facilities or sponsoring scientific meetings.
The last of these deserves special attention. In countries around the world, BMS industry representatives routinely reach out to health workers – giving them gifts, offers of equipment and sponsorship, among other things.They do this “endorsement by association” and “manipulation by assistance” for a simple reason: it works.
BMS companies highly target health workers. According to a study of BMS industry practices, Mead Johnson (now RB Mead Johnson) had a global salesforce of 1,900 employees in 2010, of which 1,350 (71%) were dedicated to selling to health professionals, and the remaining 550 (29%) to pharmacy and supermarket retailers (Baker et al. 2020).
Around the world, people have learned to trust health care providers, and that is not surprising. Doctors and nurses, health volunteers in villages, medical assistants, and many others save lives every day. Of course, we trust them. This is why so many ads on TV use phrases like, “3 out of 4 doctors agree” and show actors in lab coats holding stethoscopes.
Imagine the power of a doctor in a clinic wearing a Nestle-branded lab coat advising a mother about the proper care of her new baby. Imagine a nurse giving a mother free samples of infant formula. This type of marketing happens every day around the world in health facilities.
The Code and the subsequent resolutions can be summed up relatively simply: the aim is basically to protect breastfeeding from all forms of promotion of BMS, feeding bottles and teats, while encouraging the promotion of good infant and young child feeding practices through ensuring that the public has access to unbiased, up-to-date, evidence-based information on infant and young child nutrition from which to make informed decisions about how they feed their babies. There should be no nutrition or health claims on products, no free samples to mothers, their families or health-care workers, and no promotion of products in the health care system.
This means no free or low-cost supplies of breast-milk substitutes to any part of the healthcare system, no gifts or incentives to health-care workers, no company donations of equipment or services or sponsorship of scientific meetings. All information and education materials on infant and young child feeding must explain the benefits of breastfeeding, the health hazards associated with bottle feeding and the costs of using infant formula. Product information provided to health professionals must only be factual and scientific.
To ensure that BMS are used as safely as possible when they are necessary, product labels must clearly state the superiority of breastfeeding, the need for the advice of a health-care worker and a warning about health hazards of incorrect preparation of the product. There should be no pictures of infants, other pictures, or text idealising the use of infant formula. Labels must contain the warning that powdered infant formula may contain pathogenic microorganisms and must be prepared and used appropriately. Labels on complementary foods should not cross-promote breast-milk substitutes, should not promote bottle feeding, and should state the importance of continued breastfeeding.
Countries need to pass the laws to implement the Code and then set up monitoring and enforcement mechanisms. But this is not the sole responsibility of legislators – we all have a role to play in achieving each of these. We also need to be mindful of the industry’s tactics. And those are the topics I discuss in Part 3.