World Breastfeeding Week: Conflicts of interest in infant and young child feeding

In the aftermath of World Breastfeeding Week, leading academics in infant nutrition from the Australian National University, Julie Smith, Libby Salmon and Phillip Baker, examine the challenges that remain in keeping breastfeeding on the global agenda.

Cognitive losses from formula feeding cost the world economy $300 billion a year, according to a major study earlier this year.[1] Relatedly, a review of evidence on reproductive cancers calculates that 20,000 women a year – most in high income countries such as the United States and the United Kingdom – die of breast cancer avoidable by extending breastfeeding duration [2]. For children lack of breastfeeding also means increased risk of death, infectious disease, and chronic disease including asthma, obesity and type-2 diabetes.

Infant and young child feeding matters for wealthy as well as poor countries. This year's theme for World Breastfeeding Week, 'breastfeeding … the foundation of a country's development', [3] should remind governments in high income countries that aggressive infant formula marketing isn't just a problem for deprived populations in faraway export markets.

The consequences of current marketing practices by the baby food industry are clearly evident in our recent study [4]. We demonstrated that a boom in global milk-based formula sales is underway, with 41% growth between 2008 and 2013. Growth was particularly rapid in China, Indonesia, Malaysia, Vietnam and Thailand, as well as South Africa, Iran, Turkey, Brazil and Peru. This raises serious concerns for the health and development of children and mothers deprived of the protective effects of breastfeeding. Available evidence is that fewer than one third of infants worldwide are now exclusively breastfed and only a minority continue breastfeeding to 2 years or beyond as the World Health Organization (WHO) recommends. We describe this as a global 'infant and young child feeding transition', as a population-level shift from lower to higher formula diets. This presents a costly and potentially unsustainable burden on future development.

In the context of World Breastfeeding Week it is important to reflect on how far we have come, and how far we have to go, with regulating the unethical marketing of formula companies. During the 1970s, a strong public backlash against aggressive formula marketing in 'Third World' countries delivered the pioneering 1981 WHO International Code of Marketing of Breast-milk Substitutes and several subsequent relevant World Health Assembly resolutions (the Code)[5]. The Code placed obligations on industry to behave, and on governments to monitor and enforce compliance.

In practice, such monitoring has until now been left largely to NGOs with compliance in high-income countries depending mainly on the reputational self-interest of industry [6]. Assurances from the baby food industry that its members comply with individual country's Code requirements are belied by demonstrated breaches [6, 7]. In the Asia Pacific region the industry association's stated aims are to 'ensure that the infant and young child nutrition industry adopts standards that are reflective of the requirements of each country where we operate, through collective action' [8].

This ignores major imbalances of power that shape how 'country requirements' are decided. A few large companies dominate a global infant formula market worth over US$44 billion in sales in 2014, and protect their profitability collectively, including through promoting trade agreements [9] or lobbying and 'consultation' with individual governments [10].

Viewing a world map of countries which have implemented legal protections against aggressive marketing of infant formula highlights the dilemma [11]. Of the 194 WHO Member States, only 32 had systems of formal monitoring and only six of these were budgeted [11]. As a new report on Code implementation notes mildly, many monitoring arrangements are not 'free of commercial interference' [11].

High-income countries have the weakest implementation of the WHO International Code. Importantly, several are major dairy exporters (Australia, Canada, European Union, New Zealand and USA) and house the head offices of transnational formula companies. It is not surprising that New Zealand's monitoring system is reported in the WHO report as 'not free of commercial influence'. Likewise, in Australia, government relies on industry's own arrangements to restrain inappropriate formula marketing [12, 13], giving free rein to exporters generating new markets in Asia.[14, 15]

There are emerging signs of more coordinated global action to counter weak and fragmented national infant feeding policies and industry influence. In 2014 a coalition of global stakeholders was established to strengthen civil capacity to implement and monitor the WHO Code (NetCode),[11] and in 2015 the Breastfeeding Advocacy Initiative partnered NGOs with international health agencies [16]. Integrated strategies based on the WHO/UNICEF Global Strategy on Infant and Young Child Feeding are known to be effective [17], and individual country studies have clearly documented the factors for successful breastfeeding promotion policies and programs, central to which is the implementation of the Code.[18-20] In May 2016, the World Health Assembly welcomed a report which noted 'government obligations to establish monitoring and enforcement mechanisms that are independent and transparent, free from commercial influence' and clarified that the WHO Code covered toddler milks for children up to 36 months [21].

There are also signs that 'business as usual' for the formula industry may be changing in high-income countries. In April 2016 the UK Royal College of Paediatrics and Child Health voted to reject sponsorship of health professional meetings and education from formula manufacturers [22], citing evidence of the health impacts of low breastfeeding rates in high income countries and the reputational risks to the profession [23].

It remains to be seen whether such actions translate to a strengthening of policy in high-income countries, especially those with a substantial economic stake in the global dairy industry. The half-hearted global political commitment to protecting breastfeeding has burdened low-income countries with the cost of legislating, administering and monitoring the Code within their borders. As noted by Judith Galtry, it takes considerable moral fibre for major exporter countries to require Code compliance in destination markets [24].

In truth, the boom in milk formula sales lays bare the potential economic conflicts between public health and unfettered global food trade and marketing, through its links with the accumulating evidence of formula feeding's economic and financial costs. For cash strapped governments of stagnating economies, productivity losses of $300 billion a year are not to be sneezed at. Neither are the human and health treatment costs of chronic disease, which, for the present, are most strongly evidenced for the world's most affluent populations and countries [25-27].

As World Breastfeeding Week looks to a sustainable economic future, it is to be hoped that the political will to protect breastfeeding's contribution to human and economic potential continues to gather momentum globally.