In many sub-Sahara African countries, baby formula has caused bad blood. In recent years, however, the embittered battle against AIDS has pressed the case for a re-evaluation of the importance of formula and a new role for its US$3bn manufacturing industry – if the action groups will give it a look in, that is.

From a population of 650 million, 3.8m people in sub-Saharan Africa contracted AIDS last year  and an estimated 1.1-1.7 million babies have become infected through breastmilk. This figure of infant transmission represents approximately 15% of those babies born to mothers infected with HIV. Many believe this is sufficient proof of the need to find a substitute for the milk of HIV-infected women. They have watched with growing concern as anti-infant formula activists (whose cause is often associated with Unicef) and private sector manufacturers (of which Swiss giant Nestlé is the largest) battle out the rhetoric of formula provision while people die.

Are the anti-formula activists right to refuse Nestlé a role in the AIDS crisis? And dare we hope to see the situation resolved?

The history

Unscrupulous advertising campaigns targeting developing world mothers were common during the 1960s and 70s by Nestlé and other manufacturers – the story has been told many times. Henri Nestlé laid the foundations of a US$30bn multinational in 1867 with the creation of the first commercially produced infant formula, a flour and milk concoction manufactured with high hopes for saving lives. A hundred years on, however, the formula was central to forceful marketing campaigns focused on women in developing countries.

Accustomed to creating natural breastmilk substitutes when needed, mothers were routinely plied with free samples on which to feed their babies until their own milk ran dry, at which point the formula would become a costly commodity. Ignorance compounded the problems – impoverished mothers who had not been taught how to make up the product correctly watched their babies contract diseases such as cholera or typhoid because of dirty water, or even starve as they mixed the formula too thin.

Dr Derrick B Jelliffe grabbed Western attention in his pamphlet Child Nutrition in Developing Countries (1966) with news of the “commerciogenic malnutrition” leading to countless infant deaths and perpetrated by the profit-hungry “infant formula industry, especially Nestlé.” From the mid-1970s, essays, films and interview articles throughout the US and in Europe brought the debate mainstream, and gave it a particularly anti-corporate bias.

Global protests at corporate profiteering reached a peak with organised boycotts of Nestlé products first hitting the headlines in 1977. Charities such as the United Nations’ sister agency Unicef, refused to accept cash donations from formula companies, placing them in the same category as such pariahs as landmine manufacturers. Anti-formula action groups such as Baby Milk Action (UK) and IBFAN (International Baby Food Action Network: 1979) sprung up to galvanise political and public attention, and pressure the formula manufacturers into withdrawing from developing world markets.

The birth of the Code

In a bid to prevent a reoccurrence of such ethical violations from the previous decade, a blanket prohibition on the distribution or donation of free and low-cost formula was imposed in 1981 as part of The International Code of Marketing of Breastmilk Substitutes, which focused on restricting advertising and any form of promotion. The major formula makers agreed to comply with this 14-page Code, devised by Unicef and its sister UN agency, the World Health Organisation (WHO), and governments around the world have adopted some or all of its recommendations.

Impasse continues

Not quite the solution it was intended to be however, differing interpretations of this Code have been reopening old wounds since its conception and have created an ideological impasse. In the US, an early 1980s delegation decided against the adoption of the Code arguing that because the WHO is not “an international Federal Trade Commission,” it ”

“Had no business [telling the industry] how to sell its products.”

had no business [telling the industry] how to sell its products.”  In developing countries meanwhile, important aspects of AIDS prevention have become intrinsically caught up in the power of those who support these infant formula regulations and their implementation.

Nestlé maintains that its behaviour in the developing world is dramatically different these days, a fact largely down to the Code. “In the 1970s there was some radio and billboard advertising of infant formula. There was some direct promotion to mothers in the developing world and that was stopped, some of it before the WHO Code was passed, and we’ve been implementing the WHO Code in developing countries ever since then. So there is no promotion of the infant formula to the public in those countries whatsoever,” Niels Christiansen, vice-president of corporate affairs for the company, told just-food.com.

“At this point I’m not aware of any donations,” he added.

The pressure groups are adamant that this is not the case, however. Mike Brady, of Baby Milk Action, insists: ”

“Nestlé, even today, is still violating those requirements.”

Nestlé, even today, is still violating those requirements, by, for example, giving free samples and supplies to health facilities and sometimes to mothers, and point of sale promotions on products. There are concerns about the labelling of those products in terms of the information that’s on the labels and labels not being in the appropriate language in the country where they’re being marketed.”

Does breastmilk transmit AIDS?

A highly charged argument, the issue of whether Nestlé does or does not abide by the Code still threatens to swamp the issue of HIV transmission, even more than 20 years after the Code’s inception. In the rapidly spreading AIDS epidemic, the issue of mother to baby transmission has begun to settle on the role of breastmilk.

Breastmilk is essentially a blood product; white blood cells that transmit the immune system antibodies designed to trigger the body’s responses for combating infection. As a disease that acts on the immune system, doctors have long believed that the HIV virus can therefore be transmitted through breastfeeding. In the UK, the Terrance Higgins Trust is consistent in its recommendation that HIV-infected mothers use substitutes for breastmilk. This position is echoed by doctors and medical experts throughout the developed world.

Substitutes for breastmilk as a pragmatic health option?

Others meanwhile maintain that the possibility of HIV transmission through breastmilk is not enough to recommend the provision of infant formula in sub-Saharan Africa. But could this not simply be an expression of the revulsion many feel at Nestlé’s involvement in the third word? Unicef admits that its role is not in the policing of the Code; for that “we rely on a network of groups which come under the umbrella of IBFAN,” explained press spokesman Alfred Hitchcock. Could it be that these groups are a little too fervent in their denunciation of formula, however? Is theirs an automatic response rather than a reasoned reaction?

Co-ordinator of IBFAN Africa, Pauline Kisanga is adamant: “African governments and especially mothers knew best. They have continued with breastfeeding even though health workers and policy makers were in dilemma.” Explaining the impetus behind her organisation and the latest product boycotts she added, ”

“We want them to lose some of the profits they get from killing our children.”

we want them to lose some of the profits they get from killing our children.”

In some sense, Kisanga’s hesitancy to accept formula may be justified. While essential for its make-up, safe water and adequate sanitation are not consistently available across the developing world, and ill-prepared formula causes a host of deadly illnesses in its own right. Baby Milk Action’s Brady explained: “Where water is unsafe, a bottle-fed child is up to 25 times more likely to die as a result of diarrhoea than a breastfed child. Even in this country [the UK] there’s increased risk of illnesses such as gastro enteritis. Even in the most hygienic conditions a bottle fed child is five times more likely to be hospitalised, and there’s increased risk of diabetes and allergies.”

It may be possible, however, that the risks of formula are overestimated, or even outdated. Much of the staunch anti-formula opinion is based on Jelliffe’s 1978 “guesstimate” that a reversal in the trend to avoid breastfeeding would save 10 million cases of infant malnutrition and diarrhoea. Also, somewhat problematically, Kisanga suggests formula is dangerous because at a very basic level many women do not have the firewood to boil and sterilise water. Nevertheless, she argues that HIV infected mothers can heat breastmilk to “kill the HIV virus” (but not water for formula?). The issue is undoubtedly clouded in passionate rhetoric.

Other Code-action groups point to a study of 800 babies in South Africa where the evidence suggested that where breast-feeding was exclusive the risk of transmission was no greater than in a bottle fed infant. Brady explains: “This study found that the problem of transmission came about when other substances were introduced. Water or anything else brings the increased risk because of so called mixed feeding.”

Many believe that, like IBFAN, Unicef is simply vehemently pro-breastfeeding, to the detriment of formula. The charity has received some bad press on this basis, understandable in the light of the words and letters of CEO Carol Bellamy since her appointment in 1995. In July last year, a letter from Bellamy commented: “Regardless of our soul searching on how best to navigate through the sometimes conflicting policy issues raised in part by AIDS,

“Unicef remains resolutely committed to breastfeeding.”

Unicef remains resolutely committed to breastfeeding… At the same time Unicef recognises that mothers infected with HIV face an agonising dilemma.”

Nevertheless, Hitchcock argues that the role of UNICEF is more in the investigation of formula’s role, than in a blanket denial of its positive features. In 1997, the charity joined with UNAIDS, the WHO and several governments to establish a programme that could examine the role of breastmilk in HIV transmission across nine African countries. More than 45,000 women have so far participated in this pilot study, which aimed to diagnose their HIV status and offer counselling on the different feeding options if the women tested positive. So is Unicef advising HIV-infected mothers to use formula rather than breastfeed? “Absolutely not.”

“There are lots of options for alternative feeding,” explained Hitchcock, “an entire spectrum of things women have access to.” This could mean an infant being nursed on goat’s or cow’s milk, or becoming a ward of the local wet-nurse. Unsurprisingly however, around 50% of the women on the pilot study who were found to be HIV-positive chose the free formula rather than the other options, all primitive and arguably dangerous in their own right, to babies and women. This generic formula is packaged according to Unicef specifications, in multiple local languages, after being bought at a reduced rate from the industry players. It still makes little real sense that a charity would rather buy supplies rather than receive donations, but Unicef explains this in terms of its wholehearted adherence to the Code.

This percentage may have been greater if it were not for the cultural stigma that surrounds returning from hospital with a packet of regulation formula – thus revealing the new mother is HIV-positive. Hitchcock argues, “what we do with the packaging is more or less irrelevant, the problem with stigmatising women with formula is a problem no matter what formula they’re using because breastfeeding is standard practice.” The stigma may well be eased however with a package that could just as easily have been bought from a shop as donated by an AIDS investigation programme. Either way, it says something about the deep-rooted association of infant formula in these countries with something negative, rather than the liberating force many mothers in the Western world perceive it to be.

To what extent does the refusal to accept donations of infant formula arise from a dogged suspicion of Nestlé, rather than a pragmatic health option? And are these first pilot programmes merely stalling the inevitable: Does Nestlé have a role to play in AIDS-stricken Africa?

Suspicion of the formula industry players still runs deep among many pro-breastfeeding action groups, most refusing to accept donations because they do not want to endorse those long accused of abuse in the developing world. ”

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“Please tell them [Nestlé] to stop pretending to be good boys.”

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Please tell them [Nestlé] to stop pretending to be good boys,” Kisanga asked me. “In Botswana when Nestlé South Africa saw that the government was ready to purchase formula, they became all proud and began acting funny.”

“When they were asked to translate the labels into the local language they protested and said they can just use South African labels because it is not cost-effective to them. That must be a funny way of showing caring,” she added. The motivations behind Nestlé’s involvement sometimes seem more important than the potential benefits of formula itself.

Some officials even believe that the industry will exploit the AIDS crisis in a marketing coup to boost their markets in Africa. “I honestly think Nestlé has no role to play in Africa apart from making large profits from the poor,” says Kisanga. The formula maker dismisses this, describing both current and potential sales in sub-Saharan Africa as minuscule in the light of its global markets. Nestlé’s Christiansen retorted: “Not possible. First of all

“Africa is not a fertile infant market.”

Africa is not a fertile infant market. More formula is sold in Belgium, where there are 10m people, than in the whole of sub-Sahara Africa, which has 650m people. [Furthermore] it’s a market which is not growing but going up and down with economic conditions,” he explained.

An unpredictable market, cultural stigma, action group anathema – and arguable lifesaver. So what is the future for the infant formula industry in sub-Saharan Africa?

Last October, the WHO convened a global technical meeting on HIV, AIDS and breastfeeding. Over 100 health and nutrition experts agreed with the UNAIDS/Unicef programme, but added the proviso that medical experts actually suggest the best infant feeding method to an HIV-infected mother, not just talk her through the options. This brings hope in its recommendation of decisive action. Furthermore, after a long period of broken communication, outreach efforts by Nestlé have meant that the dialogue between Unicef and the food giant has been continuing for the last 18 months. The last meeting was held less than six weeks ago. “[Nestlé] is interested to find out what can be done and talk about other areas of disagreement over interpretation of the Code,” explains Hitchcock.

And there’s the rub. The Code. At risk of playing apologist for an industry that says it is happy to play by the rules, one cannot help but wonder if the Code isn’t due for revision. In 1981, the situation was very different from today. The horror of the AIDS epidemic was still to come. Certainly, the Code has been subject to modification by the World Health Assembly resolutions, but it still contains no mention of the circumstances of AIDS or HIV infection. The issues are complex and multi-layered, but made harder when the rules are outdated and cause confusion through different interpretations.

Will there be a role for formula? “There will be. There is now and it is hard to see how there wouldn’t be,” said Hitchcock. It is imperative then that the action groups are as fluid in their ideological approach to breastfeeding and infant formula as they are dogged in their application of anti-corporate pressure. The acceptance of formula donations and their widespread provision to those who cannot otherwise afford the product is undoubtedly a controversial issue that would herald a major break with past policy. But many people are dying today, and those who charge themselves with the protection of the world’s health are running out of time to find a solution.

By Clare Harman, just-food.com journalist

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