What would be your reaction if you were sent a case of free insulin for your healthy, nondiabetic newborn with the following pamphlet?
Babylin artificial baby insulin is the next best thing to baby’s own insulin. But baby’s little pancreas sometimes cannot produce enough insulin for his little body. That’s why we’ve developed Babylin. Doctors recommend Babylin is safe as an alternative or supplement for both diabetic babies and healthy babies. So if you’re not sure baby’s making enough insulin, you can be sure with Babylin. And when you fill out this coupon, we’ll send you a free car seat. It’s our way of saying we care.
Anyone who knows anything about the appropriate use of insulin and the dangers of giving insulin to a healthy person would be outraged at such an advertisement. If artificial insulin were injected into nondiabetic babies, they would go into insulin shock (severe hypoglycemia) and die. If you didn’t know anything about human biology (and why you would unless you had formal training in medicine or nursing) and didn’t know that a healthy pancreas makes insulin on supply and demand, you might be inclined to think that the Babylin product somehow improves on nature or is better for your child in some way. The pamphlet suggests that not by not giving supple-mental or artificial insulin, a mother puts her baby’s health at risk. If you were mother living in the Third World, you might also be influenced to think that if “Babylin” is given to First World babies, it must be better, healthier, or more scientific. What if you further discovered that the makers of Babylin were trying to buy support or endorsement from the medical establishment by regularly sponsoring medical conferences, offering research funding to scientists and medical researchers, and paying doctors substantial amounts of money for use of their names in ads and pamphlets?
The success of such an advertisement completely depends on the ignorance of its target market. The less educated the mother is about human biology; the easier it is to misinform her. The way to successfully market Babylin is to convince the public that there is a need for it. Babylin would certainly be required if a baby were not producing insulin. But the marketing campaign suggests that it’s appropriate to give artificial insulin not just to babies who have a true medical need for it, but to those who do not.
The marketing campaign I’ve outlined for the fake product Babylin is modeled after a real baby product that is unnecessary most of the time. That product is baby formula, also known as artificial baby milk or breast milk substitutes.
How it all began?
Artificial baby milk was originally intended as a lifesaving product when there was no other way to nourish the baby. It was a product designed as a last resort but never intended for routine use. If you found Babylin an absurd product to be touting to mothers—experts who already understand human biology, human history, mammal behavior, and survival instincts—then the routine feeding of artificial baby milk to infants (99 percent of women are physically capable of breastfeeding) is just as absurd.
All health authorities urge women to breastfeed for at least one year and exclusively for at least six months, if possible. Despite this, $3 billion per year is spent in the United States on artificial baby milk; 38 percent of women in the United States never even attempt breastfeeding, while only 15 percent of women in the United States breastfeed their babies for a year. Artificial baby milk also costs at least $1,000 per year.
Worldwide, the marketing of artificial baby milk is responsible for roughly 4,000 infant deaths each day. These deaths occur because the marketing of the product (especially in areas where clean water or cow’s milk is not affordable or available) entices the mother away from breastfeeding, exposing the baby to death from diarrhea or infections due to the absence of breastmilk.
The successful marketing of artificial baby milk is a socioeconomic story, not a medical or scientific one. In the social history of breastfeeding, aristocratic women would employ the services of a wet nurse. Wet nurses prior to the Industrial Revolution were usually married women whose husbands traveled. The wage was usually quite good for its day, and in cases of the very wealthy or royalty, the infants would be placed in the wet nurse’s own home. Live-in wet nurses were also considered good jobs. In these cases, the wet nurse would be well fed and kept free from undue stress since it was understood at the time that stress interfered with milk letdown. Wet nursing was also a profession unwed mothers could turn to in an effort to support themselves and to help prevent another pregnancy.
Several factors led to a decline in wet nursing as a tradition and a profession. When the childbirth industry was taken over by male physicians during the nineteenth century, the belief that wet nurses spread syphilis and diseases to their charges began to take hold within society. This coincided with the theory that disease was spread by germs, which dominated scientific thought at the time. This led to a dramatic decline in the number of wet nurses and midwives, the very people who were knowledgeable about breastfeeding. In addition, the Industrial Revolution led to urbanization, immigration, and mass employment of women as factory workers. It also led to the industrialization of dairy farming, which resulted in large surpluses of whey, the waste product created in the manufacture of cow’s milk. Artificial baby milk was first created from this one waste product, which could effectively be marketed to two distinct social groups: poor women who worked in factories (many of whom had once earned a better living wet nursing) and had no choice but to leave their babies at home; and rich women who were deprived of their wet nurses and considered themselves too delicate for breastfeeding. Thus, freedom from breastfeeding was seen as an attractive feature for both groups, and bottle-feeding emerged as a status symbol. Women who breastfed were considered “old fashioned” and not modern.
The term formula came into vogue around the turn of the nineteenth century. Various doctors began experimenting with different ingredients to try to make artificial milk closer to breastmilk. They would present their recipes as scientific formulas, and in the case of those who could afford it, babies would have an individual formula tailored to their digestive systems. In fact, in 1888, a prominent member of the American Medical Association noted that what nourishes one baby may kill the next baby. This business of tailored formulas went out of fashion quite soon because it was inconvenient, but the term was then adopted by various companies to make their product sound scientific. By the 1920s, the baby food industry was medicalized in partnership with commercial companies and doctors who invented their own special batches of artificial baby milk and benefited from royalties on sales.
As hospital births became the norm, hospital practices which discouraged breastfeeding became the norm, too. These practices included separating the mother and baby, routine bottle-feeding of artificial baby milk, or delaying introducing the baby to the breast when breastfeeding was desired by the mother. It was also routine practice to prescribe drugs that blocked the production of breast milk. Hospitals would be showered with free artificial baby milk, posters, toys, and gift baskets for mom from a myriad of manufacturers.
Not Created Equal
By the 1940s, the “equivalency position” was introduced into artificial baby milk marketing; artificial milk (evaporated, condensed, powdered, or specially formulated milk made from cow’s or goat’s milk) was sold as a substance that was “equal” in every way to breast milk, when it was not. By the late 1960s, the equivalency position evolved into the choice positioning, which coincided with the women’s rights movement. Bottle-feeding was marketed as a woman’s choice, designed to free her from her biology. While this appealed to the popular “biology is not destiny” argument made by many prominent feminist thinkers, unless a woman is truly informed about the dangers of not breastfeeding, she is not free to choose.
By the 1970s, study after study proved what breastfeeding advocates (who were considered radicals) were saying all along: breast is best. As advocacy groups began to grow, so did the “breast is best” message, and more women began to choose breastfeeding over bottle-feeding. As a result, the marketing of artificial baby milk became much more subtle. The companies produced booklets, pamphlets, and advertorials (an advertisement that looks like a regular editorial) about artificial baby milk and disguised it as “medical information” on breastfeeding, pregnancy, childbirth, and general childcare. Since these companies had more money to spend on advertising than the advocacy groups promoting breastfeeding, the literature about breastfeeding and bottle-feeding soon became controlled by the artificial baby milk companies.
Some of the common techniques used in the marketing literature includes slipping in doctors names to support distorted information about breast milk equivalency, vitamin supplementation, when to introduce solids, and charts and tables to give the literature a more scientific look. In company booklets and pamphlets, there is no mention of any particular brand, but the information on breastfeeding is inaccurate enough to discourage breastfeeding or make bottle-feeding attractive. Copy about breastfeeding is frequently accompanied by pictures of beautiful women bottle-feeding and beautiful babies being bottle-fed. Frequently, pictures of fathers bottle-feeding are used, suggesting that artificial baby milk promotes father-baby bonding. This literature is often provided to women as part of a “club pack” of other goodies: baby growth charts, posters, books, toys, games, audio tapes complete with a giant tin of free powdered artificial milk. “Pass-it-on” cards are frequently enclosed, encouraging new mothers to fill out a card so that her friends can also receive free gifts from the company.
Feeding the Nurses
The marketing of artificial baby milk also includes teaching hospital nursing staff how to discourage breastfeeding early, so that companies ensure that their product will sell. For example, maternity ward and neonatal nurses are frequently invited to events sponsored by the artificial baby milk companies. These events are then followed by a short presentation on product offerings, with lots of misinformation on scheduled feedings, lactation failure (which is highly unusual, and often caused by scheduled feedings), when to supplement a newborn, or when to discourage breastfeeding in certain women. Well-paid nutritionists, doctors, and other experts (often mothers themselves who use the company product on their own children) are frequent speakers at these events, too. Feeding newborns artificial milk or glucose water in hospitals is still routine and one of the surest ways to sabotage breastfeeding. Many studies have shown that a large percentage of women who want to breastfeed leave the hospital unable to do so as a result of hospital ward practices and staff ignorance.
Milk Marketing in the Third World
Like tobacco companies, artificial baby milk companies profit in the Third World. Because the product comes from the First World, it’s assumed that it’s more nutritious and safer for babies than breast milk. But given the fact that only one-third of the world has adequate sanitation and 99 percent of rural families and at least 50 percent of urban families in the Third World have no access to running water or uncontaminated water, artificial baby milk is often deadly to the child who is first, deprived of the immunity properties of breast milk, and second, exposed to deadly bacteria from contaminated water.
There is also the cost of the artificial milk product itself. In Nigeria, for example, the annual cost of artificial baby milk is equal to 264 percent of the minimum urban annual wage. Mothers go hungry in order to purchase this product. And this cost does not include the incidentals: clean water and fuel, or antibiotics and medical care if the baby suffers from diarrhea or infections. Of course, even if women in these regions can afford the artificial milk, they may lack the literacy skills to read the label and preparation instructions.
Even in the presence of HIV/AIDS, artificial baby milk is not a solution, but a dilemma. Unless a mother is HIV-positive, there appears to be no moral justification to sell artificial baby milk to the Third World. The situation is analogous to tobacco companies selling cigarettes to children and then denying that they are addictive.
What Does the Code Say?
The Code is designed to protect breastfeeding and control unethical or incorrect marketing practices. It’s aimed at governments and companies and is intended as a minimum guideline for marketing practices. The products that come under the Code include artificial baby milk (or formula), other artificial milks (because these are sometimes used as baby milk), all baby foods and juices, feeding bottles, and nipples. By 1996, sixteen countries had simply adopted the Code into law, while twenty-six other countries had passed portions of the Code as law.
One of the most important yet most misinterpreted parts of this code deals with information and education, specifying that objective and consistent information must be provided to families about infant and child feeding. That means mixed messages such as “breastfeeding is best, but bottle-feeding is okay too” can be harmful.
Artificial baby milk companies have then taken up the task of providing information on breastfeeding, stating that it is within their scope of duties. But it is not up to these companies to educate; this is the role of governments.
Under the Code, information and education materials must include complete information on the superiority of breast milk; proper nutrition for lactating women; how to prepare and maintain breastfeeding; the dangers of supplementation; how difficult it is to reverse the decision of not breastfeeding; and the proper instructions and use of artificial baby milk. Any information on artificial milk must include the social and financial implications of its use and health risks. No pictures or charts idealizing artificial milk can be included in the literature, either.
The Code also stipulates:
* Information or educational materials, equipment, or product can only be donated with the written approval of the appropriate government authority or within government guidelines. (Company logos can appear, but no brand name can appear.) These donations can be distributed only through the health care system.
* No company material should be given directly to mothers.
* Health authorities should take appropriate measures to encourage and protect breastfeeding and promote the principles of this Code. (This means that hospitals must stop practices that discourage breastfeeding, such as giving supplemental feedings to infants unnecessarily, or separating mothers from their babies.)
* No facility of a health care system should be used for the purpose of promoting artificial baby milk.
* Facilities of health care systems should not be used for the display of products, such as posters, booklets, leaflets, brochures, feeding bottles, cot tags, stickers, clinic cards, prescription pads, and similar materials advertising artificial feeding.
* No company-supplied staff can be allowed to work in the health care system as “professional service representatives” or “mother craft nurses.” And, no company-supplied staff is to have contact with mothers.
* Demonstrating bottle-feeding with artificial baby milk can only be done by health workers or other community workers if necessary. These demonstrations are to target only those mothers or family members who medically require artificial baby milk. The demonstration must also include information on the risks of improper use.
* No free or low-cost supplies of artificial baby milk are to be distributed in any part of the health care system. Charitable donations of artificial baby milk, feeding bottles, or other such products may only be given by companies to orphanages and similar social welfare institutions but not to hospitals and maternity wards. And, they must be given only to babies in true medical need. Finally, the donations must last for as long as the baby needs them. (Note: Companies have been ignoring this provision and have been supplying almost unlimited quantities of free product to health care facilities. They have also been interpreting babies in need as babies whose mothers are going back to work.)
* Hospitals, clinics, and maternity wards must purchase their artificial baby milk as they would any other supply. (Note: Although the code stipulates no donations to such institutions, supplies are still being delivered through “back door” channels.)
* All information provided by companies to health professionals should be restricted to scientific and factual matters and should not suggest bottle-feeding is equivalent or superior to breastfeeding.
* No promotion to health workers is allowed, and no incentives (financial or material) are to be offered to health workers. Health workers must disclose whether they’ve received funding from any of these companies for fellowships, study tours, research grants, attendance at professional conferences, and so on. The companies must also disclose to whom they’ve granted funding. To prevent conflicts of interest, professionals working in child health cannot receive money, goods, or services from any of these companies.
* Health workers should not give samples of artificial baby milk to pregnant women, mothers of infants and young children, or members of their families.
Just because this Code exists doesn’t mean everyone abides by it. In fact, there are all sorts of ways around the Code to the dismay of its authors.
For example, companies are finding ways of marketing other kinds of infant foods that can interfere with breastfeeding but are not marketed as artificial baby milk. In Europe and parts of Asia and the Middle East, one company makes herbal teas for infants from as early as the first week of life. But since these teas contain over 90 percent sugar, they are not healthy for a baby and will interfere with breastfeeding. In Asia, Africa, and Latin America, other companies are pushing cereal and vegetable-based solid foods for the first month of life. But again, introducing solids too early will not only interfere with breastfeeding, but will cause the baby to lose vital energy and nutrients and may even expose him or her to contaminants. (For the record, solids are not necessary until the sixth month of life, and even then, should be introduced as a compliment to a replacement for breast milk. Some artificial milk companies are even selling artificial milks just for mom, targeting pregnant and lactating women with special milks designed to give them special nutrients. New markets have also created opportunities for Code breaking. In Eastern Europe, for example, people are interested in anything Western so mothers are an easy market for artificial baby milk. Meanwhile, there is limited awareness about the Code by Eastern European health workers.
In Europe and the Third World, companies have begun to take the “dog food” approach, selling follow-up baby milk the way one would sell puppy food for the first six months and then regular dog food thereafter. Similarly, these follow-up milks are targeting babies four months and up; and the companies that make it deny that they’re selling the same old artificial baby milk in a new tin. Once the consumer is hooked on the follow-up milk, it is recommended for infants up to twelve months, and some brands recommend these milks for up to three years. (In many cases, the system works more subtly: the child continues to “graduate” to different tins as he or she grows older.) Be it food or drink, for the record, the World Health Assembly, along with other health authorities, such as WHO and UNICEF, maintain that any food or drink given to the baby before it is nutritionally required interferes with breastfeeding, is not necessary, and is not to be promoted.
Bottle and nipple makers (pacifiers are categorized as nipples or teats) simply market their wares as if the Code did not apply to them. They continue to advertise directly to the public (which the Code forbids). They also give free samples and promotional gimmicks to parents. Most people assume that rubber nipples are safe products, but there have been reports of nitrosamines, a toxic family of compounds, found in rubber nipples and pacifiers. Nipples made of silicone are also being marketed, even though several babies have almost choked to death from broken pieces of silicone. Although pacifiers are very popular in the developed world, nonetheless, these are considered to be unnecessary and can put the baby at risk for diarrhea due to improper washing and hygiene.