Fighting the dried-milk multinationals: The bottle that kills

By Claire Brisset, Le Monde diplomatique, December 1997

One and a half million newborn babies die every year from the wrong kind of feeding. Despite the risks, and an international code designed to stamp out abusive commercial practices, the dried-milk companies continue to use their powers of persuasion to get women to give up breast-feeding and buy their products. Particularly in the third world, where this is frequently an issue of life and death.

In the 1860s, in a Germany not yet united under the iron rule of Bismarck, a chemist from Frankfurt perfected what looked like a promising product: a mixture of flour and dehydrated cow’s milk for feeding babies. His name was Henri Nestlé.

It was a time when factories were springing up throughout northern Europe and many women, eager to work, had to give up breast-feeding and entrust their babies to nurses. Could Nestlé have predicted the huge international success of his work? He had made an essential discovery which was intended, to herald a giant step forward in human nutrition.

This is the story of a misguided discovery. In 1867, when Henri Nestlé wrote, in all good faith, that the powder manufactured under scientifically correct conditions constituted a food that leaves nothing to be desired, he could hardly have thought that his discovery would eventually be harmful to children. Or that a century later, in 1974, campaigners would write a pamphlet headed Nestlé kills babies. And surely he never imagined that at the end of the 20th century the firm that bears his name (together with other large companies) would be accused of not respecting the ethics and elementary rules of infant nutrition.

But that is what is happening. It follows the recent publication in London of a document entitled Cracking the Code (1), which contains shocking data compiled over the last few years about the commercial approach of the large multinationals to infant nutrition, in contempt of the International Code on Marketing Breastmilk Substitutes signed 16 years ago.

It was in the early 1970s that the commercial strategy applied by the large multinationals to sell baby food hit the headlines. Nestlé figured large, having become one of the biggest multinationals in the world, with a turnover higher than the Swiss budget and spending more on publicity than the budget of the World Health Organisation (2).

The agro-food multinationals had discovered a major obstacle to their penetration of many third-world markets: mothers who stubbornly continued to breast-feed their babies. That was why dried milk still made up only a small fraction of their total turnover - in Nestlé’s case less than 10% - while sales of their other products were growing exponentially.

An easy code to break

The best way, of course, of getting round this obstacle was to lay siege to mothers at the places they go to before, during and after giving birth: that is, general hospitals and maternity units.

So the multinationals kited out millions of trade representatives, mainly women, in white gowns and sent them off to maternity wards all over the world to persuade mothers that artificial food was better. They used the same strategy on hospital staff, rewarding them with money and gifts. They also gave poorly equipped and outdated hospitals and maternity services various pieces of equipment, a flood of samples and even free packets of dried milk. The mothers went home provided with dried milk, feeding-bottles, teats, instructions for their use and the conviction that their child would do best on manufactured milk. It was soon to be christened the bottle-feeding culture.

The culture has spread throughout the world. Over the past 30 years, breast-feeding has continued to decline: today less than half of all third-world women (44%) breast-feed their babies. At world level, the percentage is even lower, about one third.

Yet the fact that breast-milk is better no longer needs proving. Nutritionists have known for a long time that human milk contains maternal antibodies that protect the baby from a whole range of infections. Colostrum, which mothers secrete during the early hours and days after giving birth, is a particularly powerful guard against infection. Breast-milk also contains all the nutrients babies need. Ideally, no supplements should be given during the first four to six months of life, not even water.

But artificial milk obviously needs added water, which is very rarely pure in the third world; so it has to be boiled for at least 20 minutes to eliminate all the micro-organisms. And that requires energy, such as wood or fuel, which is expensive. The family also has to have the money to buy packets of dried milk, which can make it very tempting to dilute the powder, resulting in malnutrition.

So artificial milk poses two health risks. First, it can cause a number of microbe infections, both viral and parasitic, due to dirty water, bottles that are not disinfected and the lack of proper storage facilities. Second, it can lead to severe malnutrition if the dried milk is over-diluted. Unicef believes that today one and a half million children are dying every year from the direct or indirect effects of bottle- feeding. A large majority of these children die from dehydration caused by diarrhoea or from respiratory diseases that would have been less serious if they had been breast-fed. Breast-feeding is also a good contraceptive, especially if it is the only method used, because the sucking infant stimulates the production of female hormones that delay the onset of ovulation. On top of that, breast-feeding establishes strong bonds between mother and baby which benefit the baby’s emotional development.

The facts have been known since the late 1960s. In the early 1970s the campaigners began to organise themselves. They published a brochure in 1974, first in England, then in Switzerland, Nestlé kills babies, which was to land the authors in a major libel case. The Vevey-based company succeeded in winning the case two years later and the authors were found guilty. But in fact this was only a partial success because the court appended a quite unambiguous comment to its finding: If, in future, the civil party [Nestlé] wants to spare itself the reproach of immoral conduct, it will have to totally modify its publicity methods.

The campaigners still did not lay down their arms. They formed a group called International Baby Food Action Network (IBFAN), which was very active in North America, to organise a boycott of Nestlé. But more was required: in particular, a code of conduct aimed at improving the moral approach of the milk industry.

The draft code was drawn up by WHO, Unicef, the NGOs operating in this field, and even by the industry itself, which was consulted on the wording. But the consultation was little more than a formality. That was made clear by a letter sent to the American senators in April 1981 by the Abott-Ross laboratories, major producers of baby food. It stated that the Ross laboratories and the other major American manufacturers of dried milk for babies were opposed to the code and called on the United States government to oppose it. No sooner said than done. On 21 May 1981 delegations from all over the world adopted the code at the World Health Assembly, with one exception: the United States.

But then there was the International Code on Marketing Breastmilk Substitutes. It proposed a ban on all advertising, overt or covert, of dried milk, in particular in health-care establishments; a ban on the distribution of free products, including samples; a compulsory warning on every packet of milk sold commercially that breast-milk is better. All the WHO member countries were asked to incorporate the main provisions of the code in their legislation. Even the industry, now under surveillance, signed the code, announcing right away that it would directly monitor its application. This put a check on some of the more blatant commercial practices for several years, and the boycott abated.

In 1994 the Church of England announced that it was re-examining the matter and, together with 27 other organisations, set up the Interagency Group on Breastfeeding Monitoring (IGBM). In 1996 it carried out an in-depth survey of the application of the code in four countries, South Africa, Bangladesh, Poland and Thailand, among a sample of 800 young mothers in each country and 120 health officials in 40 different establishments. It found that 32 commercial firms, including not only Nestlé and Abbott-Ross, but also BSN, Heinz, Gerber (Sandoz), Johnson and others, were all infringing the code of conduct. They were all continuing to distribute leaflets that gave a negative image of breast-feeding and presented dried milk as better for babies. They were all still distributing samples and packets of dried milk and sending staff to maternity hospitals to get their message over. More than half (56.4%) of Polish hospitals in the survey had received such visits, and 32.5% of Thai hospitals. In Thailand, more than a quarter of young mothers and half the members of staff surveyed had received dried milk samples, and one third of establishments had been given free gifts of dried milk. The practice of giving staff small gifts is widespread in Poland and Bangladesh, and in all four countries the visitors praise the benefits of their products, particularly in Thailand and Bangladesh.

In short, the survey showed that health systems and hospitals were still the preferred commercial targets of these firms, especially in Thailand and Bangladesh, the poorest of the four countries, where the maternity hospitals are under-equipped and the staff very badly paid. In Poland and South Africa, the strategy is more diversified and women are targeted both within and outside the health system.

So what will the campaigners for the cause of children do now? A few years ago Unicef and WHO devised a strategy of asking hospitals to adopt an approach that systematically encourages breast-feeding. They set out ten conditions. To begin with, breast-feeding should start immediately after birth, babies should never be given a teat or feeding-bottle, and fake nurses hired by firms should not visit the mothers. Hospitals that fulfil the ten conditions are officially declared baby-friendly. Millions of maternity hospitals in the world have now joined this network.

But clearly, more still needs to be done, such as another survey covering far more countries. In France, which has signed the code, there is a milk rota system that flagrantly breaches the provisions of the code. Firms take it in turn to distribute samples, packets of dried milk and subsidies in maternity hospitals. In exchange, during each firm’s turn, newborn babies are only given that firm’s brand of milk and every mother leaves hospital with products from that brand. A month later, or perhaps three months later, another brand will take its turn. In France, two thirds of all babies are fed on dried milk.

This practice infringes a whole number of documents, including a European directive that came into force in 1994. But everyone, except the child, benefits. The industries in this sector - dominated in France by Nestlé and BSN which control 60% of the market - take their turn in the maternity hospitals. In exchange, they may pay the establishment in question large sums of money, via a non-profitmaking association that uses the cash to pay for equipment or training schemes.

The breast-feeding campaigners do not dispute the need for dried milk or weaning food in certain specific circumstances. For instance, in the rare case where the baby is allergic to breast-milk, or in the more numerous cases where children have lost their mothers in armed conflicts. In all other cases, they say, women must be encouraged to breast-feed, in the industrialised countries too. Of course, it is a question of individual freedom. But that freedom is a matter for mothers and children only.

(1) Cracking the Code is published (in English only) by a consortium of organisations in IGBM, the Interagency Group on Breastfeeding Monitoring. The 29 participating organisations include the British Medical Association, the Catholic Church of Great Britain, the Anglican Church, Oxfam, the Ecumenical Council of Churches, Save the Children, the European offices of WHO and Unicef, and the UK Committee for Unicef.

(2) Letter from the French Committee for Unicef, Paris, February 1991.

(3) Some 750,000 babies are born in France each year, nearly all in hospitals. Excellent information on the subject can be found in Les dossiers de l’obstétrique, L’allaitement maternel en question, April 1994.