Baby Milk Companies Routinely Violate Global Pact

by Judith Perera

"The study probably underestimates the size of the problem in developing countries," said Dr Anthony Costello of the London-based Institute of Child Health, in an accompanying article for the Journal, traditional outlet for mainstream health research here.

"It will be depressing, but predictable, if manufacturers dismiss this paper. Like tobacco companies, their promotional activities may be regulated only when they face substantial claims for damages from consumers."

The code's drafters want to reduce the global use of such substitutes, which are of disputed nutritional value and lay babies open to waterborne diseases if badly prepared.

At the time only the U.S. voted against it with Argentina, Japan and Korea abstaining. However by the 1996 World Health Assembly meeting all 191 members supported the code, and by 1997, 17 countries had adopted the code's provisions into domestic legislation.

The code forbids the offering of free samples to mothers or health facilities (except for professional research), and bars the payment of bonuses to health workers to boost sales of milk substitutes.

However there has been mounting anecdotal evidence of violations.

To discover the truth, a large scale study was carried out by analyst Anna Taylor, on behalf of the Inter-agency Group on Breastfeeding Monitoring, in cities in Bangladesh, Poland, South Africa and Thailand.

Backed and funded by an alliance of 27 churches, academic institutions, and international non-governmental organizations, it was designed to measure the extent of those violations using randomly sampled groups of women health workers, and health facilities in four cities.

Some 40 health facilities were visited in Dhaka, 46 in Durban, 40 in Bangkok, and 39 in Warsaw. Some were privately run, some state-run and some were run by NGOs. In Dhaka 704 women and 111 health workers were interviewed, in Warsaw 791 women and 115 workers, in Durban 799 women and 122 workers, and in Bangkok 696 women and 104 workers.

In Bangkok 97 out of 370 mothers reported receiving free samples of a breast milk substitute, or feeding bottles or teats. Twenty out of 40 health workers in the city polled reported receiving free samples in half of the facilities. None of the samples were being used for professional evaluation or research.

The proportion of health facilities where staff reported receiving samples was highest in Bangkok, lowest in Dhaka (three out 40 polled). In all the cities except Dhaka, the health service was the main source of samples received by women.

In Poland, health workers in 22 out of 39 health facilities in Warsaw were given publicity material from manufacturers which broke the code. This was higher than in the other cities, where the figures ranged from six out of 40 facilities in Dhaka to 13 out of 40 in Bangkok.

The code requires such information to include details on the benefits of breast feeding and the risks associated with bottle feeding. However between 15 and 56 percent of health workers interviewed in the study said they had received materials that contravened these articles.

Twenty one out of 119 health workers in Warsaw and 19 out of 112 workers in Dhaka were given gifts by companies making or distributing breast milk substitutes -- including pens, notebooks, calendars, and t-shirts.

Taylor says that both the number and nature of code violations suggest systematic contravention of the code.

"It would be reasonable to believe that similar violations am occurring at similar rates in other cities and countries," she says. Of the 21 companies promoting such goods, six were trying to sell their products in more than one of the four countries.

Bangladesh was the only country studied which had laws governing the marketing of breast milk substitutes -- and it also had the smallest number of free samples.

Poland, where there is no formal or voluntary code governing this area, had the highest number of samples detected. South Africa and Thailand, which have voluntary codes in force, fell between the two extremes.

"There is little to suggest that breast feeding will be protected from commercial pressure unless there is a commitment to enforce and monitor the code nationally," Taylor concludes.

He also says doctors should be warned about the practice of sponsoring the work of prestigious national bodies, such as by funding a pediatric care conference, to try to gain "endorsement by association."

However, Costello accepts that, as with anti-smoking campaigns, legislation and monitoring are only part of the broader strategy and that a good public image for breast feeding may be even more crucial.

He suggests the training of midwives and doctors as counsellors -- also to give guidance for HIV-positive mothers -- publicity campaigns and advertising, and funding for advocacy groups, as ways to counteract manufacturers' propaganda.