In the final part of this four-part series, David looks ahead: What can we do to achieve full implementation of the Code? And how can we otherwise promote, protect and support breastfeeding?
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By David Clark
40 years ago, the World Health Assembly adopted the Code. It’s not hard to understand why. Infant mortality rates were staggering and getting worse. It was clear that the aggressive promotion of BMS products was a major contributing factor. Gradually – and despite the BMS industry’s continued promotional efforts – breastfeeding rates have begun to improve.
We can take heart that the problem has not worsened. But we can do better – much better – and we should be emboldened by what we know today. The BMS industry is, in reality, premised on a myth: there really is no substitute for breastmilk.
That said, what do we do now?
First, we know the Code works when it is implemented effectively. Let me be very clear what that means: It is not enough for a country to pass a law. Effective implementation means a country must also set up the necessary monitoring and enforcement mechanisms – and then, when violations are reported, impose appropriate penalties. Monitoring and reporting should be on-going and ideally employ the WHO/UNICEF NetCode protocol in establishing an independent, sustainable and effective monitoring system, free from commercial influence.
Governments should release an annual report of the situation and the actions taken to address violations; they should also develop a national strategy to protect, promote and support breastfeeding.
Second, because we know that violations of the Code occur so often in the very facilities providing health care for mothers, infants and pregnant women, governments must train health workers to understand the Code and their obligations under it, recognize violations and report them to appropriate authorities. A recent study in Abidjan, Cote d’Ivoire, revealed that just 8% of health workers in health facilities knew about the Code! And in these same facilities, almost half of new mothers interviewed said they had been advised to give their infants formula. This is simply tragic, and the sight of a mother clutching her sick, malnourished child, crying as she tells you that she was advised to give her baby formula in hospital is heartbreaking.
Similarly, we must continue to train advocates on the Code. A direct line can be drawn, for example, from the training of advocates, policy makers and lawyers at IBFAN-ICDC workshops to the drafting of laws in countries to implement the Code. The workshops helped advocates understand how marketing works – and how well-drafted laws can stop a company’s lust for profit from overwhelming our basic, collective interest in infant and young child survival, growth and development.
Third, advocates need to frame violations of the Code as the violations of human rights that they most certainly are. Policy advocacy is critical to change laws – and as such advocates must leverage the clearest and most compelling arguments. Breastfeeding is a major component in every child’s right to the highest attainable standard of health, as expressed in the Convention on the Rights of the Child. Promotion of any products that discourages breastfeeding is a violation of both a mother’s right to make an informed choice about feeding her infant, as well as her child’s right to health.
This was perhaps best expressed by a former UNICEF Deputy Director, Stephen Lewis, when addressing a meeting in Geneva over 20 years ago and announced that: “Those who make claims about infant formula that intentionally undermine women’s confidence in breastfeeding are not to be regarded as clever entrepreneurs just doing their job, but as human rights violators of the worst sort.” Those words have stuck with me and inspired me over the years.
“Those who make claims about infant formula that intentionally undermine women’s confidence in breastfeeding are not to be regarded as clever entrepreneurs just doing their job, but as human rights violators of the worst sort.”
Fourth, each of us must act, as I described in Part 3, to protect, promote and support breastfeeding. Thanks to 40 years of research (many more years actually), we know that breastmilk and breastfeeding are key to good nutrition and life. Almost one million infants and mothers die annually due to inadequate breastfeeding and the world loses $1 billion a day as well. Each of us has a stake in this fight and if we all act, we can successfully implement the Code and eliminate the inappropriate, harmful marketing of BMS products.
Fifth, we must stop thinking that we can work together with the BMS industry to improve infant and young child feeding outcomes. The time has come to acknowledge once and for all that we have completely opposing goals and interests. As public health advocates our primary interest is indeed to improve health and nutrition outcomes, and the evidence shows that we can only achieve that goal by increasing breastfeeding rates. The BMS industry’s primary interest, on the other hand, is to conduct a profitable and sustainable business to benefit its shareholders. To do this they must sell more BMS, which means they have to persuade more mothers to give up breastfeeding and purchase their products.
The Global Strategy on Infant and Young Child Feeding, endorsed by the World Health Assembly in 2002, recognized this state of affairs, and specifically limited the role and of industry in the context of child nutrition to two things: they should ensure that their products meet applicable Codex Alimentarius standards; and they should comply with the Code. We should concentrate our efforts and resources on ensuring that they do so.
Finally, we must redouble efforts to implement, monitor and enforce the Code. It is one of the effective strategies to address the malnutrition and infant and maternal mortality linked to inadequate breastfeeding – and it is preventative. Should we really continue spending billions to address the consequences of inadequate breastfeeding – the myriad health problems, from diarrhea in infants to obesity that develops later to diabetes – when a way to reduce the risks of these problems is so clear and obvious?
The value of breastmilk is indisputable. Even the industry does not try to escape this simple basic truth – it incorporates the line “Breast is best” into its marketing. But that’s as far as it will go – after saying that, its ads quickly change the subject. “Breast is best, but…” – they pivot to appeals to anything but what is best for the health of baby or mother, or for that matter, society or the planet. These marketing tactics are incredibly powerful.
The data, however, do not lie. No matter what lens you might look at breastmilk through – physiological health, mental health, economic health, human rights etc. – breastmilk is uniquely beneficial. The research is as clear as it is compelling.
The Code has protected millions of mothers and babies from the exploitative and aggressive promotion of BMS, although more work is needed to strengthen that protection, particularly in countries that lack adequate national measures. On leaving UNICEF, I was given a certificate of appreciation for “making the world a safer and fairer place” for over 80 million babies from 1995 to 2020. Of course, my contribution to this effort was only a small part of the overall efforts of dedicated and courageous colleagues and partners from around the world.
I hope this series will help us redouble our efforts to implement and enforce the Code. We are at an important moment in its history. We understand better than ever that breastfeeding is vital to the health of mothers, babies, and societies.
I am so happy that UNICEF has recruited an incredibly talented public health lawyer, Kathy Shats, to continue the important work of protecting parents, caregivers and children from the harmful impacts of food and BMS marketing, and I wish her the very best and hope she enjoys the challenge every bit as much as I have over the years.