Table 3.

Actions by or on behalf of the baby food industry in relation to key multi-lateral organizations that govern the regulation of foods for infants and young children

Targeted organization	Objective (inferred)	Description
World Health Organization	Weakening the initial scope and strength of The Code	In 1980, ICIFI hired Stanislaus Flache, a former assistant director-general of WHO, in order to gain insider knowledge and lobby WHO officials during the consultation and drafting process. Flache was quoted as stating ‘We oppose the universal code and some believe it is a sign that the UN system is moving to control multinationals’ [28]. ICIFI worked to dilute language during the drafting process [29]. A letter was sent to members of the WHO Executive Board, who were meeting in January 1981 to approve a draft document, stating the ‘World Industry has found this present draft code unacceptable…highly restrictive...irrelevant and unworkable’ and that ‘various provisions…could have a negative effect on child health’ [28]. In April, ICIFI circulated another letter stating the draft was ‘too detailed, counterproductive and, in parts, incompatible with the constitutional requirements of a number of countries’ [44]. US officials were engaged to lobby other member state delegates and WHO staff on the industry’s behalf. Major dairy-producing countries rejected initial drafts, including the US, Denmark, France, Netherlands, New Zealand and Switzerland. The adoption of The Code as a recommendation, and not as a stronger regulation, was done to appease US opposition in particular, which financed ~ 25% of the WHO’s regular budget at the time. The US, under the newly elected Reagan administration, was the only member state to vote against The Code in May 1981 [28, 29, 44].
	Delaying the extension of the recommended duration of exclusive breastfeeding	In 2000, the IFM (having since replaced ICIFI) unsuccessfully attempted to lobby WHO staff, to delay the adoption of new technical guidance and a WHA resolution planned for May that year, that would extend the recommended duration of exclusive breastfeeding from ‘4–6 months’ to ‘about 6 months’, and hence conceivably impact sales [44, 101]. This lobbying was coordinated across WHO’s six regional committee meetings that year, and the Executive Board meeting and WHA the following year [101]
	Opposing guidance on ending inappropriate promotion of foods for infants & young children	In 2016, IFM and ISDI issued a statement to the Executive Board to ‘manufacture doubt’ about new technical guidance clarifying The Code covered products marketed for ages 6–36 months, including follow-up and toddler milks, categories they considered outside of scope. Nestlé claimed because the final WHA Resolution 69.9 referred to the guidance as ‘welcomed with appreciation’ rather than ‘adopted or approved’, governments were not obligated to implement it [44, 102]. The resolution also called for an end to all forms of inappropriate promotion, as set out in the guidance, including cross-promotion. The International Dairy Foods Association (IDFA) endorsed the IFM and ISDI position, and engaged US officials to oppose the guidance, stating it was ‘alarmed by the non-transparent, flawed process by which the WHO has developed this guidance’ and called upon officials to ‘work aggressively toward improving the WHO’s processes and procedures to ensure the organization builds and maintains greater trust’ [44].
		In 2018, Trump Administration officials, aggressively opposed a new WHA resolution that included, among other provisions, the contested 2016 technical guidance. US Government delegates worked to water-down wording, questioned the supporting evidence, and threatened to remove military support and enact trade measures against Ecuador, the proponent of the resolution. This had a ‘chilling’ effect on others, with at least 10 member states declining to support the resolution, although it was eventually adopted by the WHA, through the leadership of Russia [44, 103].
	Challenging the WHO initiative on conflicts of interest in nutrition	In 2018, ISDI, the International Dairy Federation (IDF) and Global Dairy Platform, among others, provided submissions to a WHO consultation on a new tool for ‘Safeguarding against possible conflicts of interest in nutrition programmes’. The ISDI submission argued that managing such conflicts was best left to country governments. The IDF submission called into question the consultation process itself, requesting a postponement and wider consultation [104].
Codex Alimentarius Commission	Contesting revisions to Codex standards on infant, specialised and follow-up formulas	Contestations of the Codex Standard for Infant Formula and Formulas for Special Medical Purposes Intended for Infants, have included how The Code is referenced in the Standard, whether in the main text or as a lesser footnote; allowable ingredients, and minimum and maximum nutrient ranges; and the allowable nitrogen conversion factor for determining infant formula protein levels, with the IDF, supported by some dairy-producing member states, advocating for a higher value than the one proposed by leading expert groups [105, 106].
		Contestations of the Codex Standard for Follow-Up Formula have included the definition of products for ages 12–36 months, with pro-industry stakeholders arguing these are not BMS; advocating the use of the term ‘formula’ for products for young children, hence implying nutritional adequacy; whether to reference The Code and resolutions (like WHA 69.9) in the Preamble, with pro-industry stakeholders arguing sources ‘external to Codex’ should not be referenced; that neither additives with sweet taste, types of sweeteners, or sugar content should be restricted in the Standard; and that ‘cross-promotion’ is not clearly defined and should be excluded [105].
World Trade Organization	Countering country-level implementation of The Code, and fostering regulatory chill	Between 1995 and 2019, there were 110 interventions α made in the WTO concerning existing or proposed BMS marketing, labelling or safety testing regulations of a member state. The majority of these interventions occurred in the TBT Committee, mainly concerning whether regulations were more restrictive than international standards (including Codex standards), and considered scientifically justified. Interventions also occurred during periodic trade policy reviews, where member state policies were assessed for compliance with WTO agreements. An even greater number of interventions occurred during the screening of new members for accession to the WTO, with the large majority of countries undergoing the accession process experiencing either exploratory questions and/or issue-specific negotiations (Initial Negotiation Rights) [Russ K, Baker P, Byrd M, Kang M, Siregar RN, Zahid H, McCoy D: Understanding the global trade and public health regime complex: a case study on breastfeeding and commercial breastmilk substitutes. Forthcoming].

Notes: α = here the term ‘intervention’ does not refer to trade arbitration; rather, it is defined as questions or comments relating to BMS regulations or proposed regulations in one member state, registered to a WTO committee or council, or raised during a trade policy review, by another member state [Russ K, Baker P, Byrd M, Kang M, Siregar RN, Zahid H, McCoy D: Understanding the global trade and public health regime complex: a case study on breastfeeding and commercial breastmilk substitutes. Forthcoming]