Infant Formula: WHO Mixes It Up

One ingredient has been missing from the infant formula controversy-attention to the facts.

Multinational corporations, we are told, have been killing Third World babies by selling infant formula to their mothers. The argument goes as follows: There is nothing intrinsically harmful about infant formula, but poor and ignorant mothers in underdeveloped nations mix it with polluted water or dilute it excessively, and the children die as a result. It would be much better if Third World mothers would simply breast-feed their children, but they have been deceived by the advertising and marketing practices of infant formula companies into thinking that formula is better for their children than breast milk.

In order to end these marketing practices, the argument continues, the United Nations' World Health Organization (WHO) was compelled to establish an international code governing the marketing of infant formula. By adopting the code by a vote of 118 to 1 last May, the member governments of the World Health Assembly (WHA) agreed that all advertising of infant formula should be prohibited, that health professionals should receive informational materials from formula companies only with prior government approval, and that all infant-feeding information should be either designed and disseminated or at least controlled by government.

The United States was the only member of WHA to vote against the code, precipitating the Reagan administration's first large-scale public relations disaster. Two high-level State Department officials resigned in protest, both houses of Congress passed resolutions condemning the vote, and there remained little doubt in the public mind that the American vote indicated a concern for corporate profits at the expense of the lives of little children.

Suppose, however, that the following were true:

• Most Third World mothers are already well aware that breast milk is better for their children than infant formula.

• The majority of the Third World mothers who do not breast-feed make the decision out of necessity; for various reasons, they cannot breastfeed their children.

• Poor growth rates have been detected in some Third World infants who have been fed only breast milk without some form of supplemental nourishment.

• There is no evidence that advertising by infant formula manufacturers has influenced the infant-feeding choices of Third World mothers. Although these statements may sound as if they were lifted straight out of the pamphlets and propaganda pieces of the formula manufacturers, they are based directly on findings by the World Health Organization itself. The fact is that no causal relationship has ever been established between infant formula marketing and Third World infant mortality. One must wonder, then, whether the goals of the infant formula opponents involve more than the preservation of lives.

Between 1975 and 1978, the World Health Organization undertook a study in nine countries, seven of them in the Third World. In all, nearly 23,000 mothers of infants were interviewed. The results are presented in a WHO publication released in 1981, Contemporary Patterns of Breast-Feeding. Although the report's introduction laments a worldwide decline in breastfeeding, with frequent references to the advertising and promotion of breast-milk substitutes and particularly harmful effects for the poverty-stricken areas of the Third World, the hard data presented in the body of the report tell quite a different story.

To begin with, the study found that the vast majority of mothers breast-feed at least to some extent. For most socioeconomic groups in all nine countries, the fraction was over 90 percent. Even more interesting, given the prevailing concern about the use of infant formula among the poor and uneducated, breastfeeding from birth was found to be nearly universal among the rural and urban poor groups surveyed. And it is only in these groups that breast-feeding is continued to 9 months and frequently to 18 months by at least 50 percent of the mothers.

Some mothers, it is true, do not breastfeed at all, especially among the groups classified as economically advantaged or urban middle-class. The table on p. 43, reproduced from the WHO report, shows the reasons given by mothers who never initiated breast-feeding, based on an open-ended survey question. Notice that information provided by infant formula companies is never cited as a factor.

If the companies have been trying to convince Third World mothers that formula is better than breast milk, they have certainly been doing a very poor job: according to the WHO study, the vast majority of surveyed mothers (except in Hungary) felt that breast-feeding is intrinsically better for their babies than bottle-feeding. As the table indicates, the most common reason given for not breast-feeding is that the mother does not produce enough milk to feed her child. In that context, then, infant formula may play an important role in the health and nutrition of some Third World children.

A second role for infant formula is as a food to supplement breast milk. While the report's introduction leaves little doubt that early supplementation of breast milk is an unnecessary and harmful practice, the study could find no "consistent differences in weight-for-age between breast-fed and non-breast-fed babies; similarly, within the breast-fed group, there was no difference between those receiving or not receiving supplements."

On the other hand, among rural and urban poor groups in which supplements were not provided until late in the infant's development, there was evidence of slower-than-normal growth. "While it is not possible to show a direct association between late supplementation and poor growth on the basis of existing data," states the report, "such an association is highly likely."

Although the survey found all kinds of supplements in use, milk or milk-based products are the most common during the first three to six months. Is it advertising that has convinced Third World mothers to supplement early—with formula? Once again, the WHO study fails to support what is "common knowledge" outside the Third World. When mothers were asked what influences had contributed to their decision to give supplementary food, "media" was an answer in only a tiny fraction of the cases—4 percent among economically advantaged in the Philippines being the largest response. Most of the time, the women reported that they made the decision on their own or with medical advice.

Given the nature of the data presented in the WHO report, one is hard-pressed to see why the organization that undertook the study and was privy to its results persisted in its campaign against the use of infant formula in the Third World. The answer lies partly in what the report, conveniently, leaves unsaid.

Do some mothers say that they are unable to produce enough breast milk to feed their babies? The report makes much of biological reasons to doubt this—but fails to call attention to the fact that it is only among economically advantaged and urban middle-income groups that a high percentage of mothers never breast-feed or discontinue it early. And these people are not what people have in mind when they worry about poor Third World mothers understanding and affording the proper use of infant formulas.

Do the facts indicate that supplementation of breast milk may facilitate better growth, especially among the poorest groups? The study group reports that fact, without acknowledging the role that infant formula can play in that supplementation. As Assistant Secretary of State Elliot Abrams noted in a recent address, in most developing countries if mothers do not use infant formula "their only real choice is to go to sugar water or cassava root or something even less nutritious." A frequent objection is that formula is often mixed with impure water. But as Abrams also pointed out, many of the breast-milk substitutes in use in the Third World consist of local water mixed with corn, sugar, flour, or rice. If the water is impure, they are just as likely as infant formula to be dangerous to the child's health.

Do mothers fail to report that how they feed their infants was influenced by advertising? Here, the study moves beyond sins of omission and simply asserts a connection in its conclusion.

Although the report starts off with a description of the extent of advertising and promotion in each of the countries studied, nowhere among its 75 tables and charts is there an attempt to set this information side-by-side the figures on feeding patterns to see whether intensive advertising correlates with less breastfeeding. "The study did not set out to measure in any depth the possible connection between breast-feeding prevalence and the advertising of infant formulas or the distribution of free samples to mothers," the report demurs in its conclusion. Yet, it continues, "it is interesting to note that where the level of such advertising or distribution was high, the prevalence of breast-feeding was low."

Now this alleged correlation is a pure fiction, as anyone who bothers to draw up the missing chart (see p. 44) will discover. In the Philippines, there is intensive advertising and frequent gifts of milk samples to mothers who deliver in the hospital. And sure enough, only 68 percent of economically advantaged mothers ever breast-feed. Yet Nigeria has similar advertising and milk-sample practices, and 100 percent of such mothers breast-feed. With little advertising, only 32 percent of rural Chilean mothers are still breast-feeding at 18 months; with intensive mass advertising 82 percent of Nigerian rural mothers are. Hungary, which has no advertising, and Sweden, where advertising is limited by law to professional journals, have the lowest figures of all for breast-feeding at one month and beyond. Such statistics do not a correlation make.

Scientifically sound evidence for their cause does not seem to be of much concern to the infant formula opponents. In the United States, the case against infant formula has been made to a large extent by non-nutritionists whose role in the debate has been to visit Third World countries and to report back that they saw (a) a lot of poverty, (b) a lot of sick babies, and (c) a lot of infant formula.

The one "fact" that the antiformula lobby cites again and again—that "up to one million infant deaths per year" are attributable to infant formula—is a phony statistic. The New York Times recently reported that James Grant, executive director of UNICEF, had estimated that the promotion of breast-feeding could "save one million lives per year." Grant, however, declined to provide a source for that figure, said the Times's reporter, leading the paper to comment that it "is not supported by ironclad evidence." Even Grant himself, in a 1981 report to UNICEF's executive board, noted that "infant mortality depends on many factors, and the available estimates cannot be directly related to breast-feeding and weaning."

Some infant formula opponents continue to put stock in the figure, pointing to a 1979 statement that "as many as 10 million serious cases of malnutrition or diarrhea each year may result from improper use of bottles or infant formula." These opponents then make the case that, since 10 percent of infants with these maladies typically die, the "one million deaths per year" figure is valid. What they fail to point out, however, is that the source for the "10 million serious cases" is a Dr. Derrick Jelliffe, who, according to Newsweek, "acknowledged that the number is a symbolic figure." No wonder, then, that Assistant Secretary Abrams has called the "one million lives per year" statistic "a straight-out guess, presented to us by polemicists as undeniable truth."

If the case against infant formula is so weak, how have its opponents been so successful at turning public opinion against the formula companies? To a large extent, they have been fortunate in that the quality of their opposition has ranged from inept to ineffective.

The Nestlé Corporation, which dominates the infant formula market in many Third World countries, actually supported the World Health Organization's marketing code. With the code in place,of course, Nestlé's potential competitors will be prevented from using Third World advertising in an effort to overtake its position in that market.

Yet Nestlé has not been alone among infant formula companies in going along with marketing restrictions. In a letter to the editor of the New York Times shortly after the vote on the international marketing code was taken, the chairman of another large infant formula manufacturer noted proudly that American infant formula manufacturers are not opposed to a code. Perhaps these companies hope thus to allay criticism of their product, but widespread industry support for "a" code can be interpreted as confession by the industry that the antiformula groups are right: only international-level legal action stands between formula companies and the lives of Third World children.

The Reagan administration's defense of its negative vote on the code (see end) has consisted largely of apologetic endorsements of mother's milk and vague references to antitrust principles. If the antiformula side has been unable to back up its "one million infant deaths per year" figure, the State Department has been equally silent about how a group of companies acting independently in compliance with international law could possibly be a violation of antitrust policy.

Official explanations of America's vote invariably begin with assurances that the US government is deeply committed to encouraging breast-feeding worldwide, leaving the general impression that the basic objectives of the marketing code are correct—infant formula is necessarily a net detriment to the Third World—and that the battle is only a power struggle over which government, national or international, is better suited to keeping too many mothers of the world from choosing to use infant formula.

Faced with skillfully generated public opinion on the issue and a severe shortage of ammunition to oppose the marketing code, American politicians turned against the administration. With lopsided majorities, congressmen in both houses eagerly embraced the opportunity to endorse motherhood over corporate profits.

Some of the more honest and candid of the legislators openly admitted that, where politics is concerned, perceptions are more important than reality. "Nothing could be more unfortunate than for our country to have come out against motherhood in Third World countries," said Rep. Jim Leach (R-Iowa), "and for what many perceive—rightly or wrongly—to be nothing more than child killing." Added Rep. Patricia Schroeder (D-Colo.), "Ever since I got here I have been waiting for a motherhood issue. This is it."

For code supporters in Congress, the debate seemed to revolve around two central issues. First, nearly every congressman who rose to speak in defense of the code cited the spurious "one million deaths per year" figure as though it were a certifiable statistic; the unsubstantiated figure even found its way into the House resolution supporting the marketing code.

Second, and perhaps more important, someone in the pro-code movement prepared a list of 31 editorial comments from newspapers scattered throughout the country, blasting the US government for its lone vote against the code. This barometer of public opinion had its effect on the professional opinion-watchers who make up the US Congress: the list was published twice, at the request of two different congressmen, in the issue of the Congressional Record that carried the House debate on the code, while on the Senate side one legislator's argument in support of the code consisted in part of reading and rereading from the list. Ultimately, the House declared its "dismay" and the Senate its "concern" over US opposition to the infant formula code, and with those words, the victory for the antiformula mentality was complete.

What motivates the antiformula forces? If the concern is for Third World families, why haven't their efforts been directed toward convincing appropriate organizations of the need for an educational campaign to make both health care professionals and mothers more aware of the positive case for breast milk and of the proper use of formula when it is used? Why, instead, have they devoted themselves to reducing the choices open to mothers? Why have they not sounded the alarm about the health hazard of using natural supplemental foods that are mixed with often impure water, instead of singling out manufactured formula as a danger?

Why is there no concern about the costs to Third World governments—that is, to their citizens—of implementing the WHO code? And why is there no acknowledgment of the fact that the code may well foster interference with those mothers who are unable or simply do not wish to breast-feed and could use infant formula to enable their children to survive?

In fact, concern for Third World families is not all that's behind the antiformula crusade. Observe the public statements of prominent formula opponents, and the reason for their animus becomes clear:

• Polly Mann, national organizer, Infant Formula Action Coalition (INFACT): "The root of the problem [is] the exploitation of the people in the Third World countries by those who are looking for profits and profits alone."

• Infant Formula Action Coalition: "Third World babies are starving because of the heartless, money-hungry activities of powerful multinational corporations."

• Leah Margulies, director, Interfaith Center on Corporate Responsibility: "Let us be as frank as possible. Industry is in business to make a profit." (Margulies has also coined a new phrase to describe cases where infant formula is allegedly responsible for starvation: commerciogenic malnutrition.)

• Sen. Patrick Leahy (D-Vt.): "Is it not interesting, when the figures get up into the tens of millions, the hundreds of millions, and eventually the billions of dollars, that any question of morality goes right out the window in those plush corporate headquarters?"

• Rep. Silvio Conte (R-Mass.): "With this vote, nations can say that the United States panders to narrow commercial interests."

If you are having trouble believing that the antiformula mentality is concerned more with corporate profits than with infant lives, consider this: there is little in the World Health Organization's marketing code that will affect any Communist country. In those countries, private companies do not engage in advertising and promotional practices, and the government already has control of the marketing and distribution of all products, including infant formula. So it is safe to assume that the infant formula controversy is an issue primarily where profits are involved and that the Communists have been successful in encouraging breast-feeding and preserving infant health, right?

Well, not really. In fact, infant formula use is on the increase in Communist countries, and the rate of infant mortality in the Soviet Union is triple that of the United States (and rising), despite the fact that the capitalistic evils that are blamed for "commerciogenic malnutrition" haven't existed in Communist countries for decades. Of the nine nations surveyed for the WHO report on breast-feeding, only in Hungary—the one Communist nation included in the survey—were the majority of mothers under the impression that infant formula is better than breast milk for their babies.

Of course, the WHO marketing code is right in line with a widespread general suspicion of the worst about the operations of private entities. Waiting in the wings in contemporary international law is the "New World Information Order," which is to journalism what the code is to infant formula marketing. Under the New Order, national governments would control the flow of news out of their countries to ensure that the information is "accurate and unbiased"—just as they are encouraged to do with infant feeding information.

The underlying premise here is that government knows best. Article 4.1 of the WHO code makes this point explicit: "Governments should have the responsibility to ensure that objective and consistent information is provided on infant and young child feeding for use by families and those involved in the field of infant and young child nutrition. This responsibility should cover either the planning, provision, design, and dissemination of information, or their control."

The dangers inherent in such a provision were pointed out in testimony before Congress by Dr. George Graham of the Departments of International Health and Pediatrics at Johns Hopkins University. "No matter how it is read," said Dr. Graham, "this article [4.1] is proposing prior government censorship of scientific and health information: in free countries such shackles are totally unacceptable, even where governments might have a great deal of expertise on the matter. In many developing countries no such wisdom exists in the government: the article is an open invitation to arbitrary imposition of ideas and to the denial of access by the public and health personnel to dissenting opinions or evidence."

When government control of the flow of news information was actually put on the international table this past year, there was an immediate hue and cry throughout "the free world." Some even ventured to suggest that it is not only our revered tradition of freedom of the press but the interests of the people in the Third World that counts against such a proposal. Yet the same people are perfectly willing to doubt the capacity of Third World mothers to assess the feeding alternatives available to them and make choices suitable to their situation.

One needn't be against breast-feeding to see that the WHO code is a misguided attempt to force that alternative on Third World mothers. The Human Lactation Center, for example—a Westport, Connecticut-based group devoted to research, teaching, and publishing about breast-feeding—is thoroughly opposed to the WHO code. UN delegates from both developed and developing nations want "governmental measures and community pressures to limit the choices women have in weaning food and infant feeding methods," noted the group's publication, Lactation Review, when the code was first presented in 1980. But "women need more, not less, options when it comes to infant feeding."

Unfortunately for Third World mothers, that respect for individual freedom has been rare among the powers that be.

James Hickel is a legislative and regulatory analyst for a consulting firm in Washington, D.C., and is working toward a law degree from American University. He has never been employed in any capacity by any infant formula manufacturer. This article is a project of the Reason Foundation Investigative Journalism Fund.

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DILUTING THE MESSAGE The US government's decision to cast the lone vote opposing the who infant formula marketing code started out firmly rooted in principle. The original draft of the US statement based the decision on freedom of choice, as indicated by excerpts from a May 13 draft obtained by REASON:

…But the United States cannot support the proposed Code because it would be, if enacted into national legislation, an unwarranted invasion of the freedom of men and women to engage in peaceful exchange of goods and services and a denial of the rights of consumers to make informed choices about products which appear to them to best meet their needs.

Freedom is important to Americans. Our political, economic, legal, and social systems are based on the idea of maximizing individual freedom. We believe it is not an accident that our country has achieved its present degree of prosperity, for prosperity is the result of the labor, the investment, and the confidence of free men and women in a society founded upon the ideal of freedom.

Freedom, in the economic sphere, must admittedly be regulated to some extent. Laws against fraud and misrepresentation must be enforced, so that consumers can make informed choices about the products they buy. Products potentially dangerous to human health can be restricted or banned. But if a product can be lawfully sold in the marketplace, then it is essential that those who offer the product have the right to announce its availability to customers, and to describe its merits without misrepresentation. It is essential that the sellers have the freedom to promote their product through sales incentives. And it is essential that consumers have the opportunity to exercise free and informed choice in the selection of products and services.

The proposed Code does not claim that breastmilk substitutes are harmful to infant health. They are not. unless consumers make them harmful by ignoring the instructions and adding polluted water to the powder. But the Code would deny to sellers of this nonharmful product the freedom to advertise its merits, and to make voluntary contractual arrangements for its marketing. The United States believes that these proscriptions strike at the heart of an economic system built upon free choice and voluntary exchange in the marketplace. Believing as we do that such a system offers the best hope for the increased prosperity and well-being of mankind, and recognizing the privation and grief endured by so many millions of people in countries which prohibit free choice and voluntary exchange, we are compelled to vote against the recommendation of this Code for adoption by member governments.

This forthright, informative statement was watered down by the State Department to the point of complete inefficacy. The comparable portion of the actual "US Statement on who Infant Formula Code" read as follows: On the other hand, the apparently [sic] flexibility provided to governments by paragraph 11.1 in our view does not overcome its overall effect of prescribing a rigid set of numbers applicable to companies, health workers, and health care systems in all parts of the world. The Code also contains provisions that cause serious legal and constitutional problems for the US.

Moreover, we have serious concerns about who's involvement in commercial codes and this is a central basis for our inability to support this code.

Thus, the United States ended up not only gaining the opprobrium of the other delegations and the public; it missed a golden opportunity to remind diplomats and the press of the merits of liberty.

—Robert Poole