The 2016 Lancet report states that if almost every woman breastfed their baby, 800,000 thousand deaths per year could be prevented (Victora et al, 2016). Not only could better breastfeeding rates have an enormous effect on health and well-being in terms of lower mortality and morbidity but it could impact on the environment (both ecologically and in terms of savings to health services ( IBFAN Asia, 2014 and Brown 2016), educational attainment (Victora et al, 2015) and even social levelling (Sacker, 2013).
“Breastfeeding is a natural safety net against the worst effects of poverty…It is almost as if breastfeeding takes the infant out of poverty for those first few months in order to give the child a fairer start in life and compensate for the injustice of the world into which it was born. (James P Grant, cited in Clark, 2011)
Yet the barriers to breastfeeding are many. In the UK, they include low education around breastfeeding, among mothers and health professionals, lack of support, psychological stress and physiological problems (Brown, 2016). Elsewhere, they include harmful traditional beliefs such as the devaluing of colostrum (Rogers, 2010) or short maternity leaves (Huang, 2015). In recent years, though, one of the biggest global threats has been the well-documented and systematic misinforming of the public by baby milk companies.
‘The International code of marketing of breast milk substitutes’ is a health policy ratified by the World Health Assembly in 1981. It puts restrictions on how breast milk substitutes are marketed (i.e. prohibiting the marketing of milks and foods for babies under 6 months of age) and also covers the marketing of bottles and teats. It protects both mothers and health workers from the unsolicited, direct influence of formula companies, and bans free-gifts and other financial inducements. It also relates to the labelling of breast milk substitutes, insisting that information is accurate and contains information about safe preparation, the superiority of breast milk and the risks of not breastfeeding. (WHO, 1981) Individual countries may sign up to all, or some of its recommendation and tailor their country laws accordingly. For example, while Ghana has fully implemented the code, the US (the only country to vote in the WHA against the adoption of the code) has made almost no progress towards its recommendations (WHO, 2016).
Although the code is often “toothless” in the face of the enormous wealth and ingenuity of formula companies, where it’s enacted effectively, where health workers are trained to understand its ethos, and where it is written into country law, it has been shown to have a huge impact on breastfeeding rates. The remarkable difference in sales of formula in China and India is an example of this (Save the Children, 2013, p.38). The Chinese, who do not subscribe to the code saw their formula market grow by $12 billion in 2012 and it is estimated to keep growing by around 14% every year (Brown, 2016). In India formula sales have stayed relatively low.
Yet some have raised the argument that by prescribing what is ‘good’ for people in terms of their health (ie breastfeeding rather than formula feeding), health promotion may be being high-jacked by ‘governments who wish to propagandize and manipulate, to even ‘force’ people to live in healthier ways’ (Dixey, 2013, p.5). An extreme example of this is the totalitarian state of Turkmenistan which has recently banned cigarettes (BBC, 2016). In the UK cries of ‘Nanny State!’ often accompany government attempts to create legislation to curtail unhealthy behaviour by individuals or corporations. (http://nannystateindex.org/, 2016). Larsen and Mandlesen (2009, p.608) write that “another way of seeing health promotion is as an ‘extended arm of the ‘neo-liberal’ discourse…health promotion is one way of ‘governing the masses’, and health education is explicit in this task: people are directed to eat healthy foods, not to smoke cigarettes or use drugs, consume alcohol moderately, exercise regularly, participate in community life, and be responsible for their own life.”
However, the expectation of personal responsibility for health creates a tension, because “Freedom becomes redefined as the capacity to exercise discrete consumption choices, with scant attention to how poverty and powerlessness constrain those choices.” (Larsen, 2015) A government that did nothing to ameliorate those external factors could be accused of negligence and failing to act according to the original definition of politics, “of, for, or relating to citizens”.
Some have equated the code with a prohibition of choice, or a penalisation of mothers, (Mailonline, 11th Nov, 2016). However, the code, while it curtails the activities of those that aggressively market formula is actually both protective and permissive. In conjunction with other health promotion interventions aimed at removing the social barriers to breastfeeding, it is one of a number of political tools that can facilitate the achievement of biological, social, and educational potential among the wider populace and their children. It does this by giving them access to accurate information on which to make their choice rather than commercially biased advice. “Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored.” (Palmer, 2009, p.7).
The UN have recently called breastfeeding to be acknowledged as a human right and asked for all countries to uphold the Code. The right to health as declared in the Universal Declaration of Human Rights 1948 raises the question of who has the responsibility to deliver on this right, the individual or the government?
In the unregulated environment that preceded the code, baby milk companies showed themselves capable of gross misconduct in the name of market share and profit. Perhaps the most shocking example was the Nestle ‘nurses’ (saleswomen) that the company deployed in developing-world hospitals to persuade women to give up breastfeeding (Muller, 1974) Today, misinformation, such as spurious, unsubstantiated health claims, and incentives to health workers are regularly reported by those who monitor the code (Allain, 2008). Loopholes around the marketing of the unnecessary and invented product ‘Follow-On Milk’ have been exploited by formula companies in order to advertise first milks (UNICEF, A Weak Formula for Legislation). Globally, formula milk sales are expanding faster than any product in the world, with sales between 1987- 2013 rising by $38 billion. While sales in high-income countries have plateaued, in developing countries formula use is rising fast, putting the health of poor children at great risk. In 2009 sales of formula milk in Nigeria and Vietnam both increased by 18% (Brown, 2016).
The increasing globalisation of trade has opened up new markets to companies like Danone, Abbott and Nestle. While some dream that freeing up trade regulations may lead to a reduction in poverty in the developing world others worry that trade de-regulation will lead to legal limitations placed on individual states that frustrate their efforts to stop corporations marketing unhealthy products. In 2003, when Mexico tried to increase a sugar tax, US agribusiness sued them for $100 million (claiming discrimination) (Provost, 2016). It has been argued (Fooks, 2013) that the proposed Transatlantic Trade and Investment Partnership (TTIP) would allow tobacco company Phillip Morris to sue the UK for its introduction of plain packaging. It could therefore be envisaged that such a legal precedent could endanger protective legislation around breastfeeding.
Similarly, while some see linking up with private food production companies in partnerships for health as the practical way forward, IBFAN expresses concern; “These Platforms can give businesses and their front groups unprecedented opportunities to influence the setting and shaping of nutrition strategies and policies.” (IBFAN, 2012) McMichael (2009) reminds us that corporate responsibility is often “little more than cosmetic” and suggests that “corporate accountability” may be more appropriate. The International code is a measure created specifically in order to hold formula companies to account.
The formula industry is a many headed, multi-billion-dollar industry. According to Brown (2016) they spend $6 billion a year in advertising, many times more than country budgets to promote breastfeeding. The battle to keep them at bay can sometimes seem overwhelming. In the face of such challenges, promoting breastfeeding means taking a stance against the commercialisation of society, and where individuals and organisations cannot succeed, politicians may need to enter the fray.
“Politicians don’t breastfeed our babies, but they have significant influence on whether our babies are breastfed or not.” (Brown, 2016, ch.7)
The ‘Feeding Products for Babies and Children (Advertising and Promotion) Bill’ put forward by Alison Thewliss MP, which aims to put in place legislation to curb the ways formula companies market their products, will have its second hearing in the UK House of Commons later this week. The bill wants a crack-down on adverts on social media and in parenting clubs, prohibition on advertising in health journals, and a ban on advertising for ‘follow-on milk’.
The MP said:
“I absolutely understand and respect that some families will choose to use formula milk; this is absolutely not about breastfeeding versus bottle feeding. I want to make sure parents are protected from misleading advertising and can access impartial, trusted information when making feeding decisions.”
In the face of the many challenges facing health promoters Dixey (2013, p.71) advises “practicing optimism as an act of political resistance.”
If passed, this optimistic bill would give the code some teeth. It is very welcome.
Allain A, Kean YJ. The Youngest market: babyfood peddlers undermine breastfeeding. Multinational Monitor: 2008 July 1;29 (1):17.
Brown, A, 2016, Breastfeeding Uncovered: Who really decides how we feed our babies? Pinter and Martin, London (Chapter 7)
BBC, 11th Dec. 2016, Turkmenistan: The regime that throws cigarettes on bonfires http://www.bbc.co.uk/news/magazine-38266078
David L. Clark, Christiane Rudert, and Nune Mangasaryan BREASTFEEDING MEDICINE Volume 6, Number 5, 2011, Breastfeeding: A Priority for UNICEF
Dixey, R., Health Promotion-Global Principles and Practice, CABI, Oxfordshire, UK p.5
Fooks, G, Gilmore, A,(2013) International trade law, plain packaging and tobacco industry political activity: the Trans-Pacific Partnership, Department for Health, University of Bath, Bath, UK http://tobaccocontrol.bmj.com
Huang R, Yang, M., Paid maternity leave and breastfeeding practice before and after California’s implementation of the nation’s first paid family leave program Economics and Human Biology 16 (2015) 45–59
IBFAN DISCUSSION PAPER November 2012, The Scaling Up Nutrition (SUN) initiative IBFAN’s concern about the role of businesses. ( ibfan.org/ips/SUN-IBFAN-Nov-2012.pdf)
Larsen, E.L., Mandlesen E., (2009) “A good spot”: Health promotion discourse, healthy cities and heterogeneity in contemporary Denmark. Health and place 15 . 2009 Jun;15, 606-13.
Larsen, L, Stone, D., Govern in g H e a lth Care through Free Choice: Neo liberal Reforms in Denmark and the United States Journal of Health Politics, Policy and Law, Vol. 40, No. 5, October 2015, Duke University Press
Linnecar, A, Gupta, A., Dadhichand JP, Bidla, N., (2014) A Formula for Disaster: Weighing the Impact of Formula Feeding Vs Breastfeeding on Environment, Ibfan Asia http://ibfan.org/docs/FormulaForDisaster.pdf
McMichael, A., Beaglehole R., in Global Public Health: A New Era, eds. Beaglehole, R., and Bonita R., 2009 Published to Oxford Scholarship Online: September 2009, Chapter 1.
Palmer, G, The Politics of Breastfeeding: when breasts are bad for business, Pinter and Martin, London, 2009, p.7Muller, M, The Baby Killer, 1974, War on Want, London, p.5
Provost, C., Taxes on trial How trade deals threaten tax justice February 2016 Transnational institute, Provost, C. http://www.globaljustice.org.uk/sites/default/files/files/resources/taxes-on-trial-how-trade-deals-threaten-tax-justice-global-justice-now.pdf
Rogers, N, Abdi, J , Moore, D , Nd’iangui, S , Smith, L , Carlson, A, Carlson, D. , Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in rural Northern Ethiopia Public Health Nutrition: 14(11), 2029–2036 (2010)
Save the Children, Superfood for Babies. How overcoming barriers to breastfeeding will save children’s lives. (2013) http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0df91d2eba74a%7D/SUPERFOOD%20FOR%20BABIES%20ASIA%20LOW%20RES%282%29.PDF
UNICEF, A weak formula for legislation: how loopholes in the law are putting babies at risk http://www.crin.org/en/docs/Weakformula.pdf
Victora Cesar G et al (2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health, 3: e199–205
Victora, Cesar G et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect, The Lancet , Volume 387 , Issue 10017 , 475 – 490
World Health Organization, UNICEF, IBFAN, Marketing of breast-milk substitutes: National implementation of the international code Status Report 2016, http://www.who.int/nutrition/publications/infantfeeding/code_report2016/en/