As we reach the end of the decade, child malnutrition, obesity and stunting are at higher levels than they were in 2015. As we commemorate World Food Day, hunger and food insecurity have increased among households.

In the fight against malnutrition, government and the public turn to academia as the think tank of solutions. So, when academia fraternises with big food and accepts seats at the tables of industry — whose main aim is product sales and profits — what is the real cost academia is paying for these industry engagements? 

There is no such thing as a free lunch. This is no more apparent than in the longstanding and deeply intertwined relationship between big business and academia in which academia becomes the extension of big business marketing. Look no further than the alcohol industry, tobacco and sugar industries. As child malnutrition increases, the magnifying glass is focused on the role of the formula industry and inadvertently on its relationship with researchers and academia. Especially academia that trains health professionals. Health professionals who influence, and counsel mothers on their infant feeding choices.

The impact of formula feeding on children casts a long shadow over the duration of their lives as they pay now with rising rates of malnutrition — obesity and stunting — but also in future due to their predisposition to non-communicable diseases like diabetes and cardiovascular disease. Yet the formula industry takes no responsibility for this public health nutrition crisis nor do they see their marketing of their products as aggressive displacement of breastfeeding. Rather, they see it as a business strategy to increase market share. This is at the cost of children’s health, well-being and futures.

In South Africa, the percentage of exclusively breastfed infants is stagnating compared to the formula industry’s increased market shares. National data from 2016 reported then that for infants 0-3 months 24% have never been breastfed, for infants 6-9 months this increased to 40% and by 20-23 months an overwhelming 87% no longer breastfeed. This is despite the global and national recommendation for all children to breastfeed for the first two years of life. Evidently, the majority of children in South Africa are missing out on the health-promoting and immune-boosting benefits of breastmilk, and mothers are missing out on the protective benefits of breastfeeding in reducing the risk for breast and ovarian cancer. Both conditions are of public health concern for women globally. Is the formula industry not costing children, mothers, the state and the planet more than what their products promise of convenience and better sleep?

These statistics prove that the formula displaces breast milk. While we recognise that formula has a purpose in the continuum of feeding patterns.  It cannot be the norm for feeding infants. It cannot be that breastfeeding is the alternative to formula feeding. More importantly, we should ask how did this situation come into being? In South Africa, we have the legacy of HIV and the mark it left on the child-feeding landscape. 

But after more than a decade of discontinuation of free formula distribution as part of the prevention of mother-to-child-transmission of HIV programme, and a decade of the Regulations of Foodstuff for Infants and Young Child Feeding — the R991 — to regulate the inappropriate marketing of foods that displace breastmilk, how is it that formula feeding is the norm in a country that supports breastfeeding as the optimal choice for child health and development?

Earlier this year, a report was published by the World Health Organization (WHO) and United Nations Children’s Fund (Unicef) following a multi-country study, in which South Africa was included as a study site, How the marketing of formula milk influences our decisions on infant feeding. The report highlights how the formula industry exploits mothers and cleverly uses convincing, sophisticated and misleading advertising that promotes false scientific claims that formula is equivalent to breastmilk. Formula companies engage mothers on social media platforms and through influencers, building very personal and intimate relationships with mothers, offering advice, support and companionship through their motherhood journey. These tactics build mothers’ trust and confidence in the formula industry. To the point that mothers perceive any negative response to the formula industry as a personal attack on them. The formula industry has manipulated mothers by positioning the industry as a friend of mothers. In fact, the industry is a wolf in sheep’s clothing. Breastmilk is the undisputed optimal feeding choice for infants and the formula industry has intentionally displaced breastmilk.

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How has the formula industry crept into mothers’ psyches to this extent? Formula companies have free access to the most trusted sources of child health — doctors and nurses — who have direct contact with mothers through antenatal and postnatal care, immunisation contact, and when children are sick. In the WHO-Unicef report, doctors and nurses admitted that their interactions with these companies had led them to recommend particular formula-feeding brands to women. This report makes it clear that medical professionals are not unwittingly engaged with the infant formula industry but have knowingly become an extension of the formula industry’s marketing strategy.

A 2012 stakeholder mapping report compiled by Sahara Salt Consulting for Nestlé confirmed that the formula industry recognised and utilised academia as a channel to influence government and broader society — the consumers. The mapping report identified academics/researchers, professional scientific organisations, and donor organisations by name and categorised these as ‘retain and reward’. Not only is the formula industry influencing health practice, but they are also re-enforcing their products through professional development opportunities and events. This is done through scientific organisations that serve as educational conduits and influence healthcare professionals — and subsequently consumers — through sponsored conferences, symposiums, and continuous professional development events and learning opportunities. The industry has a free extension to practicing health professionals now and into the future through its engagements with academia. We should be extremely concerned that formula companies are engaged with high-ranking academia in leadership positions. This has to stop if we are to give breastfeeding a fighting chance.

We are in this situation due to a lack of conscious and ethical leadership in academia, and political will by the South African government to tackle the hold that the infant formula industry has on the public health nutrition agenda in South Africa. In 1987 already, an academic article focused on the Interaction of the infant formula industry with the academic community indicated that “the infant formula industry and the academic community have developed and maintained significant educational and research interactions over the past four decades”. It named governments as the “third partner in the enterprise”. At the time that article was published, the International Code for the Marketing of Breastmilk Substitutes which “protects and promotes appropriate infant and young child feeding” was already in place. 

Internationally, guidelines regarding research integrity in academia exist in the form of the Singapore Statement on Research Integrity of 2010, which is “the first international effort to encourage the development of unified policies, guidelines and codes of conduct, with the long-range goal of fostering greater integrity in research worldwide”. 

While South Africa has had legislation in place since 2012 to regulate the inappropriate marketing and promotion of formula milk, efforts to systematically address the engagement of academia with the formula industry were not prioritised. Regulation R991 has laid out very systematically all the elements that prohibit the formula industry from engaging with health personnel, which includes academia in the health sciences. Sponsorships and meetings targeting healthcare personnel and gifting of branded and unbranded giveaways to health personnel and health establishments, including the catering for those monthly clinical meetings, the student information sessions, and the sponsored guest lectures, are all prohibited. They are also mechanisms for the formula industry to build relationships with academia and influence health professional training and practice.

While the focus has been on healthcare professionals, formula manufacturers have turned their attention to their academics working on the fringes of child development and food security. The raised profile of early child development has seen increased attention in this space from the formula industry investing in gardening projects and child well-being, such as the offerings of mother and ‘toddler stokvels’. Through addressing the misinformation and misrepresentation in the marketing of the formula industry, the Infant and Young Child Feeding (IYCF) Advocacy project based at the DSI-NRF Centre of Excellence in Food Security (CoE-FS) at the University of the Western Cape is publicly calling on academia and universities of South Africa to take a stance against the industry’s influence in the training and capacity development of health professionals.

Everything comes at a price — that price shouldn’t be our children’s health and well-being. DM/MC

16 October is World Food Day and Maverick Citizen will be publishing articles throughout the week in commemoration of this which will culminate in a special newsletter on Friday 14 October.

Dr Chantell Witten has been engaged in the field of food and nutrition for children for 25 years and is passionate about infant and young child food and nutrition with a particular focus on the normalisation of breastfeeding. She is the Project Lead for the Infant and Young Child Feeding Advocacy Project at the DSI/NRF Centre of Excellence for Food Security co-hosted by the University of the Western Cape and Pretoria University. She also serves on the National Department of Health, Ministerial Committee for the Morbidity and Mortality of Children under 5 years (CoMMiC). For more articles on the work of the IYCF, visit the CoE-FS news page at https://foodsecurity.ac.za/news/.