India, Laos and South Africa Reject Sponsorship and Gifts from Formula Companies

Background

Exclusive breastfeeding for the first 6 months of life with continued breastfeeding and appropriate complementary foods to age 2 years could save the lives of 1.5 million children every year^1–3 However, aggressive marketing by formula companies, which create not-for-profit Nutrition Institutes sponsoring medical seminars, workshops and research, continue to undermine efforts to protect, promote and support breastfeeding.^4–9 The 1981 World Health Organization's International Code of Marketing Breast Milk Substitutes (the Code) forbids advertising to the public or gifts to health workers but permits donations of educational materials.¹⁰

Many health workers are completely unaware of any conflict of interest.⁷ Furthermore there is a fine line between a gift and a free educational event in a luxury hotel.⁷ as Wright and Waterston⁴ point out such events “convey(s) an impression of the company as being ‘health giving’ even if their products may cause net harm to children's health.”

Description of study

This commentary describes current legislation and seven instances where health professionals in three countries have rejected or attempted to reject such events. The Table lists details of the seven events and their outcome.

Table.

Summary of the seven events

#	Date	City/State	Event	Sponsor	Response	Reference
Event 1	April 2011	Hyderabad/Andra Pradesh, India	Workshop “Preterm and Low-birth weight nutrition”	NNI	Boycotted by IAP*	12
Event 2	June 2012	Surat/Gujurat, India	Workshop “Maternal and Child Nutrition: The First 1000 Days”	NNI	Boycotted by IAP*	13
Event 3	Sept 2012	Ludhiana/Punjab, India	Neonatal seminar for paediatricians	NNI	Cancelled	*
Event 4	May 2011	Vientiane, Laos	“Creating Shared Value” Prize $480,000	NNI	19 INGOs refused to apply	14
Event 5	July 2012	Vientiane, Laos	Nutrition conference at luxury hotel with expensive prizes	Danone	Complaints by WHO, UNICEF & IBFAN Danone will “improve its practices.”	15
Event 6	August 2011	Nelspruitt/Transvaal, South Africa	“Fun Event & Scientific Luncheon to launch new baby formula”	NNI	Cancelled	16
Event 7	Nov 2012	Midrand/Gauteng, South Africa	Conference “Orphans and Vulnerable Children”	None	No sponsorship, no formula advertising	†

^*Personal communication Dr Sailesh Gupta October 29, 2012

^†Personal communication Professor Anna Coutsoudis March 9, 2013

NNI = Nestlé Nutrition Institute

IAP = Indian Academy of Pediatrics

INGO = International Non-Governmental Organization

Events 1 and 2 were boycotted by the Indian Academy of Pediatrics (IAP) and event 3 cancelled. Dr Tanmay Amladi, the honorary secretary general of the IAP, strongly disagreed with the Nestlé Nutrition Institute's (NNI's) insistence that its events would be fully compliant with the Code¹⁰ and the 2003 Infant Milk Substitutes Act of India (IMS).¹⁷ He pointed out that such programs are designed with “the specific purpose of trying to find a loophole to woo medical practitioners by calling experts and organizing seminars.”¹² He added, “The IAP will continue to actively forbid its members from participating either as faculty or as delegates in such seminars.”¹² In response to the NNI's query what might make their seminars acceptable, he replied that they should cease organizing any educational programs for the 17,000 pediatricians in India.¹²

“Maternal and Child Nutrition the First 1000 Days,” Event 2, took place despite the objections of the Ministry of Women and Child Development, the Ministry of Health, and the IAP. This programme violated the IMS 2003 law, which states, “No producer, supplier or distributor…shall…give any contribution…to a health worker or any association of health workers, including funding of seminar, meeting, conferences, educational course, contest, fellowship, research work or sponsorship.”¹⁷ a neonatal seminar for pediatricians, Event 3, was abruptly cancelled one hour before commencement when the speaker, a prominent neonatologist, was made aware of the violation and declined to speak. (Personal communication Dr Sailesh Gupta October 29, 2012). India has well defined laws restricting advertising breast milk substitutes although they are not always strictly enforced.⁶

Laos

Nineteen international humanitarian organizations (INGO's) working in Laos informed Nestlé that none would apply for the $480,000 “Creating Shared Value” prize, which is awarded every two years (Event 4). Their letter stated, “Babies and children are dying in Laos because food companies such as Nestlé are weakening national regulatory frameworks and aggressively flooding the market with information that dilutes public health campaigns that promote breastfeeding.”¹⁴

Danone, a company very active in Asia, supported a nutrition workshop at a luxury hotel for over 100 health professionals (Event 5).¹⁵ Product flyers were distributed with alluring prizes for health workers with low salaries. UNICEF and the International Baby Food Action Network (IBFAN) appealed to the Lao Ministry of Health to enforce the Code and to protect health care workers from these blatant conflicts of interest. Danone finally admitted that some of its marketing practices were in violation of the Code and plans to publish the Green Book outlining their marketing guidelines in 2013.¹⁵

Legislation supporting the Code is relatively weak in Laos. In 2007, responding to pressure from the formula industry, the 2004 regulations were changed to an agreement and the section forbidding free donations, sponsorships and advertising deleted.^18,19 This led to an inevitable increase in gifts (see Figure), advertising and the use of breast milk substitutes.²⁰

Figure.

Gifts in a pediatric department in Vientiane, Laos, donated by formula representatives in violation of the WHO Code (Courtesy Dr Leila Srour)

In 2009 the government with the help of the United Nations Children's Fund's (UNICEF) Lao Country Office initiated a campaign to train health workers and mothers on the importance of exclusive breastfeeding.^19,21 IBFAN and UNICEF are working with the Lao government to develop legislation and enforcement to limit formula promotions.^18,19,21

South Africa

A “scientific luncheon,” Event 6, was planned to launch a new baby formula for nurses and dieticians.¹⁶ Concerned invitees reported this violation to the local IBFAN office. Nestlé cancelled the lunch, apologizing and stating they would carry out a “full investigation and assessment [to] make sure this is an isolated incident” and “ensure it doesn't happen again”^16,21

Event 7 is of particular interest as it is a rare occurrence. At the Conference on Orphans and Vulnerable Children in Africa the Chair insisted that unlike the previous year there be no sponsorship by formula companies, no advertising and none of their products would be present. (Personal communication Professor Anna Coutsoudis March 9, 2013)

South Africa has been slow to pass any legislation supporting the Code. Perhaps because it has the fastest growing baby food market in Africa.¹⁶ Legislation, discussed since 2003, was finally signed into law by the Minister of Health in December 2012.²² The new law supports the Code and restricts advertising of breast milk substitutes, bottles or teats, gifts to mothers or health workers or sponsorship of educational programs to advertise their products.²²

Comment

We chose the above seven examples as they illustrate the struggle facing resource challenged countries attempting to promote breastfeeding and provide education for health workers without accepting support from formula companies. There may have been others of which we were unaware. Many factors affect exclusive breastfeeding, but widespread advertising has a very negative effect and legislation restricting advertising has a positive one.^1,2,4–9,11 India with reasonably strict laws spends less than $200 million on annual formula sales whereas China, with few laws and a similar population, spends over 3 billion.¹⁶

In IBFAN's State of the Code by Country 2011, of 195 countries only 67, including India, have passed laws including most of the provisions of the Code.²³ Recently both South Africa and Kenya have passed laws making East and Southern Africa an area of the world with a high level of legislation.¹⁵ Monitoring violations and effective penalties will be critical in these countries. In contrast in East Asia marketing breast milk substitutes is increasing, legislation less effective and efforts to woo health workers more effective. ²⁴ Companies blatantly offer gifts to health workers and provide educational programs with credits for continuing medical education.

Health workers need to be more aware that any sponsorship of workshops or conferences by the formula industry invariably promotes their products. They should be prepared to monitor and report violations of the International Code. Consistent and effective regulation, rejection of seminars, gifts and incentives offered by the formula industry, which profits from the failure of breastfeeding, will save infants' lives and improve the health of children throughout the world.