The 194 member states of the World Health Organisation (WHO) met recently in Geneva for the annual United Nations-affiliated World Health Assembly. The delegation from Ecuador proposed a global public health resolution to encourage breastfeeding. The resolution stated that research evidence convincingly shows that mothers’ milk is healthiest for children, and called on governments to “protect, promote and support breastfeeding” and to strive to limit inaccurate or misleading marketing of breastmilk substitutes (infant formula).
The resolution was unsurprising. It was in keeping with many others made over the past decades supporting breastfeeding and was expected to be approved quickly and easily. What did surprise was that the delegation from the United States of America demanded the resolution be watered down. When Ecuador declined to do this, the USA threatened to unleash a punishing trade war and withdraw military assistance. Under such pressure, the Ecuadorean delegation capitulated. When another sponsor for the resolution was sought, at least a dozen poor countries from Africa and Latin America also backed away, fearing similar retaliation from the USA. In negotiations, some American delegates even suggested that the USA might cut its financial contribution to WHO.
Finally the Russian delegation came in behind the breastfeeding resolution, with one (unnamed) delegate saying it was a matter of principle to support a resolution that was so important for so much of the world. The USA did not threaten Russia and the resolution finally passed, although America did manage, through the use of tiring procedural manoeuvres, to wear down delegates and win two changes.
One change was the removal of a clause requiring WHO to provide technical support for countries trying to stop ‘inappropriate promotion of foods to infants and young children’ . Without this help, poor countries are potentially more vulnerable to aggressive marketing from infant formula corporations. The second change inserted a new requirement: that the words ‘evidence-based’ accompany any reference to long-established global initiatives promoting breastfeeding. Health advocates fear that this could be used to undermine programmes that provide feeding advice and support, since of course it is not ethically possible to have ‘gold standard evidence’ randomised-controlled trials with infants and young children randomly and blindly assigned to either breastfeeding or formula-feeding groups.
Breastmilk is the ideal food for infants, with major medical journal The Lancet in 2016 describing breastfeeding as “… nutritionally, immunologically, neurologically, endocrinologically, economically, and ecologically superior to breastmilk substitutes”, and a practice whose success is a “collective societal responsibility”. Yet a recent report indicates that the annual value of the baby formula market grew from about USD$2 billion in 1987 to $50 billion by 2017, and is predicted to grow to $69 billion in the next five years, making it one of the world’s fastest growing processed food markets.
There are clearly great profits to be made from women not breastfeeding their infants and young children. There are also costs to be paid. The Lancet’s 2016 meta-analysis indicates that increasing breastfeeding to near-universal levels globally could save over 820,000 young children’s lives a year worldwide, and prevent an extra 20,000 deaths from breast cancer each year.
These health costs of declining breastfeeding rates are particularly marked in poor and developing countries where formula may be prepared in unhygienic circumstances or with unsafe water: formula-fed infants in poor countries are four to six times more likely to die of infectious diseases than breastfed infants.
At one time, almost all newborns were breastfed. New Zealand’s lowest ever breastfeeding rates were in the late 1960s, when less than 50% of mothers breastfed. The decline was earlier and even more marked in the United States where by the late 1950s only 20% of women breastfed. Breastfeeding rates tended to remain higher for longer in poorer and developing countries simply because the cost of buying formula was prohibitive.
In 1974 the World Health Assembly noted the general decline in breastfeeding and urged its member countries to review promotional activities on baby foods and infant formula, and to introduce guidance and controls on such advertising. In 1981, WHO and UNICEF jointly adopted ‘The Code’ , a global public health strategy that aims to ensure that mothers are not discouraged from breastfeeding, and that if breastmilk substitutes are needed they are used safely (not, for example, given away as free samples in hospitals).
In 1989, WHO and UNICEF issued a joint statement called ‘Protecting, Promoting and Supporting Breastfeeding’. This outlined best practice in maternity care, and included ‘Ten Steps to Successful Breastfeeding’. Advice included now commonplace activities, such as the mother and baby ‘rooming in’ (rather than having centralised nurseries), early skin-to-skin contact, breastfeeding within the first hour, and giving newborns nothing other than breastmilk unless medically indicated.
Improved knowledge about the short and longer term benefits of breastfeeding, along with increased support, has seen global rates of breastfeeding increase (a 15% increase between 1990 and 2015). However, there are signs that infant formula companies are reacting aggressively to public health initatives like ‘The Code’ and the ‘Ten Steps’ which restrict their marketing strategies.
Corporate watchdog Changing Markets reports that parents around the world are being subject to saturation marketing by the world’s four biggest (European and American) infant formula companies. They are marketing an ever-increasing number of breastmilk substitutes – with little nutritional difference between the products – to increase their share of the profits. In some countries, the multinationals routinely ‘stretch’ laws and The Code. Some marketing strategies in some countries present formula as being better than breastfeeding, and play on parents’ desires for their children to be bigger, healthier, brighter, and more modern – more like ‘Western children’. Ironic, given that breastfeeding rates are actually increasing in the West.
It appears that the aggressive marketing approaches of the American infant formula companies might extend to aggressive lobbying of the recent American delegation to the World Health Assembly. We should question where the moral compass ought to point: in the direction of corporate wealth, or in the direction of public health, women’s health and child health?
Tricia Thompson works part time as a practising midwife and part time as a senior lecturer at the Otago Polytechnic School of Midwifery (Dunedin, New Zealand), with a subject focus on sociology, sustainability, breastfeeding, and global midwifery. Her masters thesis was based on a research project completed as part of four years working as a midwife adviser in a developing country, where she has witnessed the catastrophic effects the rapid incursion of formula feeding can have on infant health in poor countries.