In 1974 War on Want's publication The Baby Killer led to widespread condemnation of businesses that aggressively market breastmilk substitutes in the developing world. In response WHO isssued guidelines five years later, the International code of marketing of breastmilk substitutes.
More than 30 years on however, adherence to the code remains mixed. Annelies Allain, director of the International Code Documentation Centre at the International Baby Food Action Network (Ibfan) says that it is now rare to find promotion of formula milk aimed at infants under the age of six months, the age to which the WHO recommends exclusive breastfeeding. The code is also law in 37 countries and another 47 have adopted laws that encompass many of the code's provisions.
The trouble, says Allain, is that "there is a big step between implementing and enforcing a law, and that's where many countries are slow or hesitant to act, because companies are very powerful". Between 2011 and 2013, Ibfan documented more than 800 violations of the code in 81 countries, ranging from bribery of health officials to price-fixing, promotions to mothers and health professionals, sponsorship and non-compliant labelling.
Save The Children reported evidence of industry lobbies working to weaken legislation. Violations remain extensive because the rewards are so attractive: the baby food business was estimated to be worth $25 billion in 2013 and set to grow by 31% by 2015, with much of that growth in Asia.
Stefan Germann, director for partnership, innovations and accountability at the global sustainable health cluster at World Vision, says that it is disappointing that violations still take place but he argues that the debate has become so entrenched – "almost religious" – that no resolution can come out of it. "Civil society and the business community need to find more meaningful ways to engage," he says.
There have been efforts to include breastmilk substitute marketing practices in the FTSE4Good series, an index measuring the performance of companies in corporate responsibility standards. A good idea, says Germann, although the methodology (which uses a dumbed-down version of the WHO's code) and execution (companies are in or out rather than included and ranked, which would provide more incentive for improvement) are flawed. Nestlé is, for the time being, the only breastmilk substitute manufacturer to feature in the index.
For the past two years, Germann has therefore been trying to set up a new platform that would involve, and be recognised by, all stakeholders in the infant food debate – NGOs, UN agencies, businesses, national governments. The platform would foster greater dialogue and transparency and play an important role in investigating and resolving violations of the code. His efforts have ground to a halt however because of the unwillingness of some quarters to engage.
Germann says that the infant food debate would have much to learn from environmentalists or sweatshop activists who successfully managed to open a dialogue with the private sector despite strongly opposed views.
Many agree. "There is definitely room for more collaboration," a spokesperson for Nestlé said. "Interested stakeholders could build on the FTSE4Good breastmilk substitutes assessment to establish a transparent process."
NGOs are also keenly aware that more must be done to actively encourage breastfeeding. In East Java, Indonesia, the Global Alliance for Improved Nutrition (Gain) and the London School of Hygiene and Tropical Medicine recently found that although women knew about the benefits of breastfeeding, many lacked the confidence to actually do it and ended up using formula instead (the study will be published soon). Gain is putting together a campaign to educate women through TV commercials, community-outreach programmes and better training of health workers (all the while keeping an eye on the application of the code).
"There is a lot of lip service being paid to breastfeeding, but I don't see it in budget allocations," says Dr Arun Gupta, regional coordinator for Ibfan Asia. "We need to start valuing what women do, the time they invest." This means a whole raft of measures, including maternity leave, facilities to encourage breastfeeding at work, training of health care workers etc. This, he argues, is why Bangladesh has seen an increase in exclusive breastfeeding while India, despite having an excellent law restricting the promotion of breastmilk substitutes since 1992, hasn't. "As long as policymakers and doctors believe that women breastfeed anyway and that you don't need interventions, the struggle will continue," he says.
