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HEALTH MISINFORMATION

WHO publishes new report on how digital marketing lures women to breast-milk substitutes

Nestle, particularly its marketing of its breast milk substitute products, has long been the focus of criticism. (Photo: Wikipedia)

A second World Health Organisation (WHO) report on the marketing and advertising of breast-milk substitutes (formula milk) has confirmed the ‘shocking extent’ of exploitative, often tailored online marketing practices used by the $55-billion formula milk industry.

This new report, released this morning, entitled ‘Scope and impact of digital marketing strategies for promoting breast-milk substitutes,’ uncovers flagrant violations of WHO’s International Code of Marketing of Breast-milk Substitutes (“the Code”) by formula-milk manufacturers around the world — despite its adoption by WHO’s 194 member states in 1981. The report says that digital marketing is on the rise, becoming the dominant form of marketing in many countries, with more than 80% of consumers’ exposure to advertisements for formula milk occurring online.

The under-the-radar marketing techniques used by formula-milk companies include individually tailored and timed targeting of content to mothers and others who influence feeding decisions, social-media influencers, online ‘baby clubs’, ‘user-generated’ promotions (that seem to come from a trusted source) and information from formula-milk brands’ own social media accounts.

264 breast-milk-substitute brand accounts were monitored for this study and were found to post content around 90 times per day, reaching 229 million users.

“The most striking thing about these findings was not actually something new,” said Nina Chan, a WHO infant and child feeding consultant, “it was more of the same unethical marketing practices we’ve been seeing for decades. The difference is that now it’s supercharged by powerful algorithms that mine mothers’ data footprints and eavesdrop on their online conversations.”

The result of this online marketing juggernaut is a continuous acceleration in global purchases of breast-milk substitutes, as mothers are dissuaded from exclusive breastfeeding. The new forms of online marketing have been proven to have a negative impact on mothers’ intentions to breastfeed, and on the number of women who actually initiate breast-feeding, while driving the global increase in sales of formula milks.

breast milk WHO
A new WHO/Unicef report looking for the first time at the marketing of breast-milk substitutes around the world describes ‘systematic and unethical’ marketing tactics by formula-milk companies. (Photo: silverson.com / Wikipedia)

In South Africa, the sales of infant formula grew from R1-billion in 2004 to R4.2 billion in 2018, a 33% per capita increase, the South African Medical Journal reported in 2019. Sales are forecast to reach more than R6-billion in 2023.

WHO and Unicef recommend exclusive breastfeeding for at least the first six months of a baby’s life, because of clear evidence that exclusive and continued breastfeeding are major factors in improving lifelong health for children and for women who breastfeed.

Breastfeeding reduces a range of health risks for both babies and mothers: It reduces young children’s illness and death from diarrhoea, pneumonia and malnutrition, reduces their risk of obesity, enhances their cognitive development, and reduces a mother’s risk of breast and ovarian cancer, diabetes and hypertension.

The WHO has stated that far too few children are exclusively breastfed (44% of children 0-6 months, globally, and under 32% in South Africa) and that un-monitored industry marketing strategies are continuously eroding the numbers of women who have the intention to breastfeed but ultimately choose not to. This new report focuses on the techniques used by the breast-milk substitute industry to shape parents’ attitudes to infant feeding.

South Africa is one of the few countries that has taken a strong pro-breastfeeding stance, with stringent legislation against the marketing of breast-milk substitutes in the form of a regulation called R991, which was published in 2012. This followed the WHO’s establishing in 2011 that exclusive breastfeeding for at least six months was safe and preferred for the babies of women living with HIV. After this government stopped providing free formula, and breast-feeding rates started to rise. A big push for the regulations to be finalised was the Tshwane Declaration of Support for Breastfeeding in South Africa, signed by the Health Minister in 2011 following a national consultative meeting on breastfeeding (the first of its kind).

And yet, only 31.6% of babies under six months are exclusively breast-fed in South Africa, which has seen a steady growth in infant-formula sales over the past 15 years, according to an article in the South African Medical Journal in 2019.

Katie Pereira-Kotze, a PhD candidate at the University of the Western Cape’s School of Public Health, and an expert member of the steering committee for the new WHO report, told Maverick Citizen that the most striking thing about the new findings is “the fact that digital marketing is so pervasive across all of the countries, including South Africa, and so difficult to monitor.”

“The insights from this also show just how sophisticated companies are in the strategies they use to market products in the digital and online space,” Pereira-Kotze said, “and especially in social media.”

Who is behind South Africa’s xenophobic nationalism?

The perils of modern technology

Although the Code clearly prohibits all kinds of promotion of formula milk to the general public, today’s plethora of modern digital technologies were not envisioned when the Code was written in 1981, the report notes. (WHO has been clear that some mothers do need to use breast-milk substitutes, and that it is not the product that is the problem, but the marketing of it that is unethical.) Only 37 of 194 countries (19%) explicitly prohibit the promotion of formula milk products on the internet, digital channels or other electronic means.

One of the new issues that the Code does not effectively deal with is the ‘transnational’ nature of digital marketing. The Code suggests that countries ban formula-milk marketing using national legislation, without taking into account the grey area created by the internet, especially social media, in the past 20 years, which is hard to monitor and in which national legislation is hard to enforce.

The under-the-radar techniques used by the formula-milk industry are often undetectable because they are often targeted directly to individuals, and not published on broadcast media. This means that companies online ‘cross-border’ advertising can easily escape scrutiny by bodies or authorities attempting to enforce national legislation.

Data mining

The ‘data mining’ that WHO’s Nina Chan referred to is among the most insidious of these techniques, used to precisely target consumers. Data mining occurs via algorithms that drive social-media advertising: The algorithms collect users’ data — such as their purchasing preferences, behaviours, questions, topics they spend time on online, people or products or sites they interact with — and then aggregate and analyse those data.

The data is collected via a user’s ‘active’ actions (filling in forms, sharing or posting content) as well as ‘passive’ ones (the user’s interactions with other social media content, in a variety of online environments and apps). The results of the data mining enable marketers to execute “highly targeted, cross-device marketing to specific types of consumers”, reaching them not only with advertising content that has been proved to generate specific consumption behaviours, but even when users are most likely to be influenced by it, the report says. (This is how information you may have in mind but have not yet actively sought online can ‘miraculously’ materialise in your social media feeds.)

Furthermore, the report says, when mothers are online and engaging in some form of communication or discussion about feeding and caring for their babies, subtle interventions from breast-milk substitute brands create an environment where women’s attitudes to formula feeding are ‘nudged’ — gently and incrementally shifted. The result is that formula-milk products, through ‘normalised’ exposure to the brands, come to be viewed as part of the landscape of viable or even preferable feeding options.

How to legislate across the ether?

breast milk who
Only breast milk contains antibodies that protect infants and young children from diseases, such as pneumonia, diarrhoea and even asthma. (Photo: Dudu Zitha/ Gallo Images)

Because WHO codes and guidelines are not legally binding, the report calls for strengthened legislation within countries, new monitoring and enforcement strategies, and “transnational” legal frameworks to protect breastfeeding and the health of mothers and babies.

“This report demonstrates that the formula milk industry is using powerful digital marketing techniques to super-charge the marketing of breast-milk substitutes without regard for the impact of these practices on the health and well-being of infants and young children,” WHO’s Nina Chan told Maverick Citizen.

Pereira-Kotze emphasises that the much-needed regulations to restrict digital marketing are needed across sectors, not just for infant feeding products. “Some countries, like Vietnam, have quite strict rules to monitor any online advertising,” she said. “We can’t look at these issues [such as the marketing of formula milk] in isolation.”

South Africa’s Department of Communications and Digital Technologies does have a Draft White Paper on audio and audio-visual content that is open for public comment at the moment, Pereira-Kotze said, “looking at the marketing of certain unhealthy foods or other inappropriate products, and looking at how we can work together across sectors and departments to address these issues.”

Pereira-Kotze expressed wariness, though, of possible delays in implementation, referring to past delays in private sector comment ‘delaying’ health-related legislation.

The National Department of Health, and health-promotion advocates and academics work “with not much budget,” she said, “but we are up against companies that have massive budgets, with people dedicated to developing marketing strategies to sell these products.

“The power imbalance is totally in the favour of companies that make a profit from selling these products and have a lot more resources than we do in public health, to enforce and regulate the marketing.”

Industry is able to use some of its vast resources to obstruct or delay legislation, Pereira-Kotze said. “The National Department of Health and other stakeholders started working on measures to implement the Code in the 1980’s already, soon after WHO passed the 1981 Code resolution. It took almost 30 years to finalise the regulations.”

There has been talk of South Africa updating its R991 regulation restricting the marketing of formula milk products, she said, “but based on what’s happened with other food-related regulations in the past, where companies come with massive amounts of comments, and object to many provisions. To get those regulations changed or updated in any way is going to be a battle.” DM/MC

  • This latest report on formula milk marketing builds on a first report published by WHO in February 2022, which focused on women’s and health workers’ experiences of exposure to formula-milk marketing. It drew on a multi-country study built on surveys and interviews with 8,500 women and 300 health professionals in eight countries, including South Africa, Bangladesh, China, Mexico, Morocco, Nigeria, the United Kingdom, and Vietnam. It provided “the most complete picture to date” of the pervasive and burgeoning nature of formula-milk marketing globally.
  • The UN Decade of Action on Nutrition set a target of at least 50% of babies (everywhere) to be breast-fed by 2025 — at 31.6%, South Africa falls far short of that, and ranks 36 out of 51 African countries for rates of breastfeeding.
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