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In Large WHO Survey, a Picture of Reckless Formula Milk Marketing

In Large WHO Survey, a Picture of Reckless Formula Milk Marketing

Photo: Nathan Dumlao/Unsplash

  • A new WHO report, based on interviews of more than 8,000 parents, suggested the formula-milk industry has made a habit of throwing caution to the winds.
  • The report, which the WHO has called “first-of-its-kind”, also said some healthcare professionals were also responsible for influencing mothers to adopt formula products.
  • In exchange, manufacturers offered these professionals incentives including funding for research, merchandise and gifts, and junkets.
  • Arun Gupta, a paediatrician, said the findings – while important – are not new: “We had known these things for decades now but we have failed to act.”

New Delhi: More than half of parents and pregnant women the WHO interviewed for a new report have accused formula milk companies of targeting them with false claims.

Their allegations suggest these companies have violated the ‘International Code of Marketing of Breast-milk Substitutes’, which the WHO adopted 40 years ago.

The WHO released its report on this topic on February 23. The 8,500 parents and pregnant women it interviewed were from eight countries. They are Bangladesh, China, Mexico, Morocco, Nigeria, South Africa, the UK and Vietnam. The body touted its effort as a “first-of-its-kind systematic and cross-regional research”.

And the report has found that “formula milk marketing knows no limits. It misuses and distorts information to influence decisions and practices.”

According to the WHO, the global formula milk industry is worth $55 billion. It has also said that global breastfeeding rates have increased very little in the last two decades. On the flip side, the sale of formula milk has more than doubled in the same period.

Formula-milk is a synthetic version of milk made from soybean, animal milk and vegetable oil. Companies that make it have claimed it can substitute breastmilk for infants.

However, breastmilk’s principal benefit is that it helps build the infant’s immunity – by transferring antibodies from the mother to the child.

Formula milk can’t do this. Infants who don’t receive breastmilk are known to be more prone to gastroenteritis, pneumonia, childhood obesity and diabetes.

The conventional wisdom is that babies should be exclusively breast-fed for the first six months. Complementary feeding can start after, but even then should be limited to light home-made foods and breastmilk.

Mothers who breastfeed have also reported several advantages, including reduced risk of postpartum bleeding and breast cancer.

Pseudoscientific claims

While the WHO highlights a series of malpractices in advertisements for formula milk, the chief of the Breastfeeding Promotion Network of India (BPNI) told The Wire Science that stakeholders have known of these violations for more than 50 years.

The BPNI is a 30-year-old network of civil society organisations that promote breastfeeding. “I am glad that the WHO is finally coming out with this report covering eight countries, but I am not surprised with any of the findings,” Arun Gupta, the chief and a paediatrician, said. “There is nothing new for me.”

One of the major findings of the report is that the formula-milk industry has made “pseudoscientific” claims – especially by positioning formula milk as highly similar to, or at times the same as, breast-milk in terms of its benefits.

“Ingredients, such as human milk oligosaccharides (HMOs) and docosahexaenoic acid (DHA), are advertised as ‘informed’ or ‘derived’ from breast-milk and linked to child developmental outcomes,” the report reads. “Examination of the scientific evidence cited does not support the validity of these claims.”

The report quoted a specific incident in the UK. The UK government had prohibited a brand from equating breastmilk with formula milk in 2007. But in one of its interviews, the WHO found that at least one mother from the country believed that the brand’s product was equivalent to breast milk.

The companies allegedly convince mothers that they can get rid of their child’s crying during breastfeeding if they are fed formula milk instead. The WHO cites this as an example of the sort of emotional appeals that companies resort to to sideline breastmilk.

According to Gupta, a common concern among new mothers is that they are not able to “produce” enough milk. “Physiologically, mothers can produce milk that is enough to even feed triplets at one time,” he said. But the real challenge is to have this milk flow to the nipple.

“It comes to the nipple if there is adequate muscle coordination in the breast,” Gupta added. “The latter depends on the oxytocin hormone.”

Oxytocin is associated with feelings of empathy and trust, and is popularly known as the “love hormone”. So its levels in the body are regulated by the mother’s state of mind. And according to Gupta, the formula-milk industry manipulates this state by planting fears about breastfeeding.

“It is a failure of every public health agency and government that, despite knowing this for 60 years, we couldn’t produce a marketing counter to the perceived fear,” he said.

These manipulative tactics include stressing the importance of formula milk in the first days after birth, the inadequacy of breastmilk for infant nutrition, claiming that formula milk keeps infants fuller for longer and claiming that the quality of breastmilk produced declines with time.

Marketing and advertisements

Interviewers also reported a direct correlation between the use of formula milk and exposure to advertisements. “In Bangladesh, 44% of women who were exclusively formula fed had been exposed to marketing for formula milk, compared to 27% of women who exclusively breastfed,” the report said.

The industry allegedly also used COVID-19 to its advantage. One interviewee told the WHO that a formula-milk company provided a “COVID-specific baby club, positioning itself as offering support and advice during ‘uncertain times’.” These clubs were allegedly designed to influence women’s receptivity to formula-milk companies and their products.

Marketing executives of some of these companies also told the WHO that they used digital media, especially during the pandemic. They reportedly prefer social media platforms because a) they can target women better using user data and b) social media content is subjected to less oversight.

According to the report, exposure to marketing was highest among women in urban China (97%) followed by Vietnam (92%) and the UK (84%). “In these countries, marketing is ubiquitous, aggressive and carried out through multiple channels,” it said.

A second important form of persuasion came through healthcare professionals. The WHO found that as many as 60% of the women from Bangladesh and 45% from Nigeria had received a recommendation from a qualified health worker for a formula product.

In turn, healthcare professionals – 300 of whom the WHO interviewed – said industry members frequently approached them through sales representatives. These representatives’ ‘targets’ included paediatricians, nurses, dieticians, even hospital administrators.

As a result, a pregnant woman or soon-to-be parent could be nudged towards formula milk by any number of individuals within the hospital. In return, the representatives offered funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and junkets, among others.

As the report said: (emphasis added)

“Health professionals in several countries commented that meetings with formula-milk company representatives no longer focused explicitly on brand recommendations, but instead were presented as learning opportunities where information about products – and infant feeding and nutrition more generally – is shared.”

To counter this, the WHO recommends investments in promoting breastfeeding within healthcare facilities.

According to BPNI, a hospital will need to spend only around Rs 5 lakh a year in India to have two lactation counsellors in-house. But this investment, by the government in government hospitals, is missing, Gupta said.

He also suggested that the WHO and UNICEF should set aside “10-20%” of their expenses on child nutrition for breastfeeding.

Back to breastmilk

The WHO has asked countries and donors to “divest from companies that exploit families through unethical marketing of formula milk products”.

“But are WHO and UNICEF walking the talk?” Gupta asked. He cited the example of ‘Scaling Up Nutrition’ (SUN) network, an association of agencies, chaired by UNICEF and including the WHO, and industry players involved in making nutrition products.

The SUN network approached the Indian government for a partnership in 2017. At that time, several activists and public health specialists wrote to NITI Aayog saying the government must resist the move. “While  claiming to support governments in taking the lead in policy setting, in reality, [SUN] facilitated the entry of businesses into the policy space,” they alleged.

The letter also said many countries had steered clear of SUN because they believed that the presence of multinational food corporations in the network was detrimental to the cause of nutrition, and public health more broadly.

To date, around 60 countries, of the 194 members of the WHO, have joined the SUN network. Most of them are in Africa. In India itself, SUN didn’t make headway with the Centre (but did with the governments of Maharashtra, Jharkhand, Madhya Pradesh and Uttar Pradesh).

In addition, the WHO has also asked countries to pass tough laws to keep bad claims by manufacturers of formula-products at bay. “India made its own law – the Infant Milk Substitutes Act – in 1992,” Gupta said. “It was one of the strongest laws that any country had made in this connection.”

However, he said that the Union government hasn’t acted against any complaints of violations of this Act in the last few years.

The Government of India had notified BPNI in 1994 to monitor the compliance with the Act. “We had submitted a whole bunch of complaints in 2021,” Gupta said – referring to a report the BPNI prepared in May 2021. Here, the body compiled instances in which various actors had violated the Act. For example, Section 4 of the Act says no free formula milk should be handed over to mothers as part of promotional campaigns. But Nestle and Amul allegedly engaged in just such practice in May 2021 in various parts of the country.

For another example, Section 9 of the Act says no formula milk manufacturer and/or marketer should induce healthcare professionals either through offers or through sponsorships. The BPNI report quotes numerous examples of market players having sponsored online events in 2020 in which doctors and gynaecologists participated.

“No probe has been initiated against any of these firms to the best of my knowledge,” Gupta said.

According to him, BPNI’s 2021 report, as well as complaints raised before and since have met with the same fate: the Union health ministry told him that it was the responsibility of the Union  women and child development ministry to see that the law was implemented. But the latter said this law concerned health, so it was the health ministry’s responsibility. And so they bounced the buck between themselves.

Note: This article was updated at 2:06 pm on February 24, 2022, to note that the SUN network is chaired by UNICEF.

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