Opinion: Stop marketing breastmilk substitutes as breastmilk

The flashy ads surged across social media just as the World Health Organization announced that COVID-19 was an international health emergency in 2020.

ColosBaby, a breast milk substitute — or BMS — formula in Vietnam, posted a picture of WHO Director-General Tedros Adhanom Ghebreyesus with a quote: “The world is entering a decisive moment when coronavirus disease is spreading more rapidly.” Next to that were health claims: “ColosBaby boosts immune system” and “prevents respiratory and digestive infections caused by viruses and bacteria.”

It was hardly an isolated example. A study by Alive & Thrive, which I co-authored, examined how companies’ marketing tactics capitalized on the pandemic, identifying examples in 14 countries by nine companies.

Apart from advertising, companies such as Abbott and FrieslandCampina in China, Danone in Indonesia, and Nestlé in Burkina Faso used cause marketing by partnering with NGOs or governments to make their donations and free services appear to be humanitarian activities.

With slogans such as “Wuhan add oil (keep it up), united with a single will strong like a fortress, we can get through the challenges together” — from FrieslandCampina in China — companies aligned themselves as a united front with the public to create a solidarity effect when providing donations.

These donations not only serve to widen markets and perpetuate a culture of dependency and reciprocity, but in emergency situations, they can also contribute to increasing rates of infant morbidity.

Even though their marketing practices undermine breastfeeding, many BMS companies, including Danone and Nestle, have made declarations to support breastfeeding. Despite the glaring conflicts of interest, companies also habitually ride on public health events to pay breastfeeding lip service to gain goodwill as a form of marketing. 

For instance, Nestlé promoted World Breastfeeding Week (WBW), which takes place annually in August, to “protect, promote, and support breastfeeding.” These declarations seem, frankly, insincere. 

The more companies pay lip service to the superiority of breastfeeding, the more they liken their products to breastmilk and ride on the benefits of breastfeeding to promote BMS. This is evidenced by examples in the Alive & Thrive study in which companies market BMS products as if they are comparable to breastmilk, especially in their nutrition claims.

Since the 1930s, public health experts have known for almost a century that there is no substitute for breastfeeding. The marketing of BMS is believed to have contributed to the deaths of millions of babies, particularly in low- and middle-income countries. Public health stakeholders everywhere know that it’s time we redouble our efforts to end this harmful marketing.

The benefits of breastfeeding literally fill books — but most significantly, it saves lives. Annually, almost 600,000 childhood deaths and nearly 100,000 maternal deaths can be prevented by improved breastfeeding.

Breastfeeding protects children against infectious diseases and long-term chronic diseases including obesity and diabetes. The human capital and socioeconomic benefits extend to entire societies. The global health system loses $1.1 billion annually due to morbidity and mortality that could have been avoided with breastfeeding.

The reality of the value of breastfeeding led the world to act against the inappropriate marketing of BMS in 1981. A near-unanimous vote led the World Health Assembly to adopt the International Code of Marketing of Breast-milk Substitutes, or BMS code, to curb this marketing, which has been updated in subsequent WHA resolutions.

And when the BMS code marked its 40th anniversary this year, marketing of BMS is more rampant than ever — the industry’s value is projected to reach $119 billion by 2025.

Something has not gone right.

Today, only 25 out of 194 WHA member states have enacted legal measures that are closely aligned with the BMS code, and 58 of them have no legal provisions. Many countries also have laws that are unable to capture the wide range of rapidly evolving marketing tactics, allowing companies to manipulate the gaps.

For instance, countries such as Myanmar and Pakistan have laws that restrict marketing of BMS products up to 24 months and 12 months of age, respectively.

Companies simply exploit loopholes to promote growing-up milks — toddler formula that has been clarified by WHO’s guidance on ending the inappropriate promotion of foods for infants and young children as BMS — as such, promotion of the product is prohibited.

Apart from it being unnecessary, the product also has excessive sugar content unsuitable for children, yet it is marketed as nutritionally suitable for children.

Enacting strong laws requires acute understanding of marketing, legal precision, and the national juridical context. Often, countries lack the technical expertise and resources. Adding to that, the formula milk industry also bands together to lobby governments to try to weaken regulatory measures.

Evidence of industry efforts to influence national maternal and child health policy has been found in several low- and middle-income countries. In 2012, the formula milk industry was behind the efforts to try to amend the implementation of the BMS code in the Philippines, which is locally known as the Milk Code. These regulations were first adopted in 1986 to restrict marketing of formula milk in the country.

Attempts were made to lift the ban on BMS donations in emergencies and distribution of samples in health facilities, as well as to allow formula company staffers to have contact with mothers.

How common are such backroom tactics? Given the enormous profits at stake, we cannot be naïve.

A large proportion of the BMS industry’s sales increase is occurring in Southeast and East Asia, where there is significant economic growth, but there are signs of increase across Africa as well, particularly in urban areas. In these parts of the world, formula feeding is often marketed as a lifestyle and status symbol.

When developing countries with growing and emerging markets muster the political will to enact stronger laws to give effect to the BMS code, countries with large formula milk manufacturing industries challenge the regulations.

According to a new study supported by WHO, trade arguments related to the World Trade Organization are often used by large dairy-producing countries, especially the United States, the EU, Australia, and New Zealand, to weaken the laws or to stop them from being adopted.

Between 1995 and 2019, 110 interventions were made by dairy-producing countries and the industry against other WTO member states regarding their BMS code-related regulations.

In 2015, Thailand began a process to expand the scope of products subject to marketing restrictions from the original zero to 12 months to 36 months, which would protect continued breastfeeding. But repeated interference through various WTO review processes ensured the scope was rolled back to zero to 12 months when the Thai National Assembly eventually adopted the law in 2018.

Celebrated in August every year, the theme of this year’s WBW was “A Shared Responsibility” and highlighted the multisectoral cooperation of governments and other key actors to create a supportive environment for breastfeeding. Many countries engage in month-long breastfeeding promotion events.

In the same month as WBW, civil society organized an online petition to condemn Nestlé’s Free Stokvel Mom and Child Forum in South Africa for violating its BMS code-related national law. Nestlé eventually canceled the event.

Such wins do not happen often and require bold activism from the grassroots, prompt enforcement action by the government, and a strong law to act as a foundation. It also demonstrates an unchanging rule: Civil society is often the driver to hold BMS industry to account.

Governments should also be held responsible as duty-bearers to hold companies accountable. Such can only be done by fully implementing the BMS code and all relevant WHA resolutions as legal measures and enforcing them. Having the political courage to call out and withstand pressure from industry — and the parties with vested interests — is the shared responsibility for all sectors working to protect breastfeeding and maternal and child health from commercial interests.

WHO, as the highest authority on international public health, should set an example for the world by withstanding undue industry influence.

The unethical and harmful behavior of the BMS industry is an old fight in this new and uncertain world. It should have ended 40 years ago when the BMS code was adopted. It’s time to end it now.