Despite the many policies, interventions and efforts to promote the uptake of breastfeeding, South Africa, like many other countries, lags far behind the global target of 50% of infants under age six months being exclusively breastfed. The opposition to breastmilk is infant formula and, where mothers cannot afford sufficient infant formula, other fluids that displace and replace breast milk are sweetened water, sweetened teas and watered-down infant cereal fed from a bottle.
Given the widely known benefits of breastmilk, why is infant formula feeding so desired?
One may turn to the glamorous and attractive adverts for infant formula of beautiful bouncing babies with big eyes and happy looking mothers. Then there are the intelligent, scientific-looking health professionals endorsing this “clinically approved formula milk” for children or perhaps the allure lies with the status that formula feeding signals. All of these above-the-line marketing strategies are in play.
But there are other, more underhanded ways that infant formula companies have engaged to secure their long-term market base.
The first misrepresentation is that infant formula is like breastmilk. As society, we must accept that to sell more infant formula means less breastfeeding. And less breastfeeding means more ill-health, in all settings, in developed and developing countries. Without significant and purposeful interventions to protect, promote and support breastfeeding, many countries, particularly in Africa, are on a trajectory for less breastfeeding with rising levels of malnutrition, more pronounced childhood obesity and its associated health conditions of non-communicable diseases.
The infant formula industry has earmarked low- and middle-income countries for market expansion.
In South Africa, one in four infants under the age of six months has never received breastmilk (25%), while one in three is exclusively receiving breast milk (32%), the larger portion of 43% is mixed fed, receiving breastmilk and other feeds, predominantly infant formula. This means that 68% of infants under six months, who should be receiving breast milk only as recommended by the national Department of Health and global health organisations, are receiving suboptimal infant feeding.
While many health researchers have focused on the barriers to and challenges of mothers to breastfeed, the true depth and grip of power of the infant formula industry must be analysed from a strategic marketing perspective.
It’s a war to destroy breastfeeding.
The formula industry is dominated by a small number of extremely powerful multinational corporations with the resources to deploy the best global marketing expertise. Like all corporations the infant formula industry is governed by the fiduciary imperative to pursue profits ahead of all other concerns, including children’s health. This mix of fiscal power, sophisticated marketing and single-mindedness is causing great harm to public health, in child nutrition and in future adult health.
Infant formula companies have positioned themselves as credible and helpful partners in infant feeding that many mothers have turned to in their time of breastfeeding difficulties. The website of one of the companies with the largest market share in South Africa reads “your trusted partner, guiding you and your baby on your journey of the critical first 1,000 days, from conception to your baby’s second birthday. We can’t wait to share this exciting journey with you.”
You would be forgiven for thinking of them as a trusted healthcare professional interested in your child’s wellbeing. It is easy to forget that this is a company interested primarily in making profits.
So how has the infant formula industry become so personalised and trusted?
It has and still relies on people of influence, most notably health professionals. To begin with, infant formula companies only distributed infant formula through medical doctors. Later infant formula became part of the health system as mothers and babies were separated and babies were cared for by a nurse in a nursery feeding babies infant formula.
Baby-Friendly Hospital Initiative
This became the norm until 1991 when the World Health Organization and Unicef initiated the Baby-Friendly Hospital Initiative (BFHI) to protect and support breastfeeding. The “BFHI 10 steps” included initiation of breastfeeding within one hour after birth, no prelacteal feeds to interrupt breastfeeding, rooming in of babies with their mothers and prohibiting infant formula unless clinically indicated.
South Africa initiated its first BFHI-accredited hospital in 1994. Mowbray Maternity Hospital in Cape Town has retained its BFHI status and to date, more than 80% of all public health facilities with maternity services implement the BFHI principles.
Why is it that despite this enormous effort, South Africa is still struggling with low breastfeeding rates?
In 2012 South Africa gazetted Regulations Relating to Infant and Young Child Feeding, R991 that prohibit the advertising and promotion of infant formula in any form and on all media platforms. But since then, infant formula companies have engaged in different strategies to promote and market their product.
Under the guise of promoting and supporting optimal infant feeding these include sponsorship of educational opportunities like Continuous Professional Development activities for medical and allied health professionals, sponsorship of conferences and symposiums specifically linked to infant and young child nutrition, funding for students and researchers through industry-affiliated entities like the Nestlé Nutrition Institute Africa and sponsorship of lecturer positions to specifically teach infant and child nutrition.
Without diligent monitoring and reporting, the infant formula companies continue to push the envelope and test the strength of R991. The most recent Nestlé-funded mom & child events are but some of the many violations committed by the infant formula company. Nestlé’s Baby & Me website and its “Start Strong, Stay Strong” programme continue to offer parents infant and child-feeding information which is in contravention of R991.
In 2018, Nestlé South Africa commemorated World Breastfeeding Week by setting up a branded breastfeeding station at the Baragwanath Taxi Rank in Soweto. While many breastfeeding women welcomed the safe space the breastfeeding station offered, they also expected to receive free products. After complaints from civil society, the provincial Department of Health was swift to remove the breastfeeding station as a violation of R991.
In 2017, Nestlé offered sponsorship for the Preemie & Me conference, which is dedicated to premature newborn care. The organisers, unaware of the conflict of interest and the provisions of R991, initially accepted the Nestlé funding but had to decline after eminent guest speakers Dr Nils Bergman and Dr Jack Newman threatened to withdraw after Nestlé “accidently” circulated a Nestlé-branded programme bearing the names of the guest speakers. This caused much consternation and anger in the speakers and the broader child health fraternity. Nestlé offered no apology to the conference organisers nor the speakers.
Not only has Nestlé funded a number of eminent South African academics, researchers and professional associations, but now a prominent South African academic serves on the Nestlé board of directors. Surely this flags a serious conflict of interest for the Director and Chairperson of the African Research Universities Alliance Centre of Excellence in Sustainable Food Systems at the University of Pretoria?
This modus operandi of “sorry, not sorry” has been a trademark of Nestlé. After 40 years of the International Code of Marketing of Breastmilk Substitutes and almost 10 years of South Africa’s Regulation R991, it is welcomed that South Africa’s food justice fraternity has embraced R991 and recently has successfully challenged Nestlé to disengage in the child nutrition space.
But more needs to be done.
If the National Department of Health is to assert South Africa as a breastfeeding country with zero-tolerance for R991 violations, then the department should seriously consider strategic litigation. Following the precedent of the Health Promotion Levy on Sugary Beverages (known as the “sugar tax”), based on the astronomical cost of child morbidity and mortality from inappropriate infant feeding practices, South Africa should seriously consider formula tax. By doing so, South Africa would send a strong message to the infant formula industry that children’s lives are more important than profits and that children deserve the protection afforded them in our Bill of Rights and our Constitution. DM/MC