Pushing commercial infantfoods in Pakistan

FeedingFiasco

Report of company compliance in Pakistan with theInternational Code of Marketing of Breastmilk Substitutesand the SAARC Code for the Protection of Breastfeeding

and Young Child Nutrition

The NETWORKAssociation for Rational Use of Medication in Pakistan

...(The manufacturers of breastmilk substitutes) seem to be solely guided by profit motives and are, there-fore, likely to violate the International Code and the SAARC Code to increase their sales, if theycan get away with it. The Network report amply demonstrates the various direct and subtle ways in whichthe manufacturers of breastmilk substitutes and infant foods are violating the Codes whilepromoting their products in Pakistan....It is, therefore, very important that medical professionals, NGOs and consumers pressure the governmentnot only to introduce appropriate legislation in this regard at the earliest but also to take effective measureto ensure its compliance....Prof. Akhlaque un Nabi KhanChairman, The Network � Association for Rational Use of Medications in Pakistan

The report compiled by The Network reveals a disturbing situation. Sixteen years after the International CodeSubstitutes was overwhelmingly adopted by the World Health Assembly, setting out the minimum standardswhich every baby food manufacturer and distributor should operate by, there should not be such blatantviolations of the Code in a country like Pakistan. Independently of any other steps taken by the Government ofPakistan to legislate, all the companies have a moral obligation to stop violating internationally agreedstandards in Pakistan.Urban JonssonRegional Director UNICEF, Regional Office for South Asia

The Network�s monitoring report is a reminder of what all the sectors of Pakistan society - political leaders,government, civil society and the private sector - need to do to protect children and women�s breastfeedingrights. UNICEF is committed to the promotion, protection and support of breastfeeding and urges commitmentand action from everyone.Stephen UmemotoUNICEF Representative for Pakistan

The report is ... an eye opener for many of us who are committed to the promotion of breastfeeding and childnutrition in Pakistan.... It clearly points to the need for expediting all efforts to regulate this area. The Ministry ofHealth has taken up the draft legislation for enforcement of the Code with renewed commitment on prioritybasis. In recent months, the dialogue between Ministry of Health, Pakistan Medical Association, infant formulaindustry and other stakeholders have been reinitiated to finalize the legislation.... We hope to continue to workwith other partners for the promotion of breastfeeding and child nutrition in Pakistan and offer our support andassistance to all sincere efforts to achieve this objective.Dr. Mubbashar Riaz Sheikh Deputy Director General Health, Federal Ministry of Health, Islamabad

Reviews

�If you think this is bad, go see what is happening in Pakistan,� I was told by a Nestlé executive whowas attending the same pediatric conference in Singapore more than ten years ago.... �Cut-throatcompetition� were his words. �Why?� I asked. �Look at the birth rate,� he said. At that time IBFAN hadno contacts in Pakistan but as soon as we could, we sent a monitor on a fact-finding tour. He foundthe whole gamut of Code violations: posters, gifts, samples and supplies in hospitals and clinics,labels with baby pictures, billboards and media advertising. It is sad to read in 1998 that so little haschanged in more than a decade. Yet, some progress has been made: The Network has been able totrain and mobilize dozens of monitors.... Moreover, Pakistan adopted the SAARC Code as well as theInternational Code and its subsequent Resolutions. Draft legislation is now under discussion. May wehope that the nation�s babies will be better protected by the year 2000? May we be confident that theJapanese, European and American multinationals who came to make money off the poor and theinnocent will finally give up? It won�t be so easy.... Annelies AllainDirector, International Code Documentation Centre, Penang, Malaysia

...Having conducted the first exercise to monitor the International Code in association with Dr. K. A.Abbas, I have no hesitation in saying that it is a very difficult work demanding a high degree ofdevotion, hard work and tactfulness. The Network has done a commendable job. The monitoringseems to be thorough and monitors seem to have been meticulous in their survey and interviewing....The Network is to be congratulated on the exposure of the new tactics used by the industry and thearray of so-called breastmilk substitutes which they are now promoting instead of infant formula tobypass the Codes.The report exposes the mercenary attitude of the milk and infant food industry and clearly shows thattheir only motive is to make money, no matter at whose expense. The report also highlights theexploitation of doctors by the industry for their war against breastfeeding and the unfortunate willing orunintentional cooperation extended by many doctors....In the end, I feel that the report makes it amply clear that if any loophole is left in a code or a legislation,one can be sure that the companies will exploit it the full and even that they will create loopholes if there isany possibility of doing it. It is therefore only sensible that codes of marketing and the legislation based onthem should have unambiguous and clear-cut guidelines purely in the interest of the infants.Dr. M. A. ArifProfessor of Pediatrics, Current General Secretary of Childcare Association, Past GeneralSecretary of Pakistan Pediatric Association (Center), Past President of PPA (Sindh), Convener andChairman of the PPA Committee on Code of Ethics (1978 -94)

...This book sets out to examine and expose through a systematic study throughout Pakistan, thestate of compliance with the International Code and SAARC Code. And the results are clear. In cityafter city, the study found that the Codes were being violated. The Network, through a painstakingresearch process, has made a strong case for the authorities in Pakistan to ensure Code complianceand tightened legislation. The unconscionable practices of multinational companies have to bestopped.... The future of this generation and generations to come will be shaped by actions we takenow. This laudable effort by The Network is a major step in protecting infant health everywhere.Josie FernandezRegional Director, Consumers International, Regional Office for Asia and the Pacific

This brave new report about the impact of baby food promotion in one of the poorest regions of the worldcannot be ignored. In a very readable and compelling way, it exposes the companies� marketing strategies,their relationships with doctors and retailers and the influence this has on women�s decisions about feeding. Itprovides indisputable evidence that baby food marketing must be controlled by the strictest legislation.While reading it I tried to place myself in the shoes of the company representatives that I saw at the recentWHO Executive Board meeting Geneva. Twenty-five of them - including familiar faces from Switzerland, theNetherlands, the UK, Italy, France and the USA - were there. And once again they collectively claimed supportto the International Code.... Arguing that they should be accepted as �collaborative partners� they offer�humanitarian� assistance for many projects. (But) along with the offers come demands that governments passlegislation only when it has been agreed by the industry.... In this report we read that the Pakistan Government- after listening to the concerns of the companies - feels under no obligation to accommodate the industry�srecommendations. It must not. Seventeen years after the International Code was first passed the intolerableabuses of human rights outlined in this report cannot be allowed to continue. As we all await the proposed law,the Protection of Breastfeeding and Young Child Nutrition Act, I wonder if a single one of the men and women Isaw in Geneva will feel the slightest twinge of guilt or responsibility for the activities of their company�semployees in Pakistan. Will any of them ensure that these practices never happen again?Patti RundallInternational Coordinator, Baby Milk Action, UK.

The report produced by The Network should be required reading for every health-worker in Pakistan, and everysales person working for a baby food company. The well written report calls for moral reflection by each ofthese workers on how their activities contribute to children�s ill health and maternal morbidity.Margaret Kyenkya-IsabiryeChief Health & Nutrition, UNICEF Pakistan

The Network ought to be commended for carrying out an exhaustive study on the misleading information andlabeling of the infant formula including the following-on products of different brands. This report will be a verygood tool to monitor the infant formula industry after the Government of Pakistan enacts the legislationimplementing the International Code. While implementing the legislation, serious note should be taken of therecommendations made in this report.Dr. Noorjahan SamadChairperson, Breastfeeding Steering Committee (Sindh), Professor Gynae & Obst, Dow MedicalCollege

The Network makes strong case for the Government of Pakistan to enact effective legislation whichimplements the International Code and the SAARC Code. Painstakingly documenting the promotional andmarketing practices of multinational baby food manufacturers, this well researched and well documentedpublication is a strong reminder to both government and industry that consumers will not accept harmfulproducts that produce unhealthy dependencies and promote ill health. Reading the text I found myself thinking�How many more babies will have to die or live in ill health through such unconscionable practices before ourauthorities state very loudly and very emphatically, �No, we shall not take this anymore�?�Shila Rani KaurProject Officer, Health and Pharmaceuticals Program, Consumers International, Regional Office forAsia and Pacific, Malaysia

The Network has done a meticulous job of monitoring infant formula manufacturers� compliance with theInternational Code. The study has uncovered serious and blatant violations of the Code, and has found that nota single company marketing infant food or infant feeding products in Pakistan is abiding by the Code in itsentirety.Marketing strategies circumventing the Code have evolved, and many medical practitioners unfortunately havebecome allies of these multinationals.... It has become clear that an effective and binding legislation is needednot only to control the marketing of these infant feeding products but to promote the best possible food for theinfant: breastmilk.Anees JillaniSPARC (Society for the Protection of the Rights of the Child), Islamabad, Pakistan

According to a recent report, Pakistan has the highest infant mortality rates (IMR) in Southeast Asianregion. Out of ten babies born in our country, one is unable to celebrate his or her first birthday. This highIMR is attributed mainly to diarrheal diseases, the ever-increasing incidence of which is due to a growingtrend of bottle-feeding. For this, the baby food manufacturers are the main culprits as they make use of allkinds of unethical marketing practice to convince mothers to initiate artificial feeding.I, as a former employee of Nestlé Milkpak Ltd., have been a part of this malpractice, but a stage camewhere I could not bear it any more and ultimately decided to quit this company.Whereas as an individual, I felt the need to highlight this malpractice at a national level, I am very muchpleased to know that other agencies like The Network are also taking this issue seriously.This publication is a very encouraging step towards generating a general awareness about the unethicalmarketing strategies of baby food manufacturers. I wish and hope that this effort will help to save the livesof thousands of children of my nation.Syed Aamer RazaEx-employee, Nestlé Milkpak Ltd., Sialkot

Feeding Fiasco - Pushing commercial infant foods in Pakistan: the report documenting company compliance with the International Codeof Marketing of Breastmilk Substitutes (1981) and the SAARC Code for Protection of Breastfeeding and Young Child Nutrition (1996) andother relevant violations in Pakistan, is published byThe Network - Association for Rational Use of Medication in Pakistan60-A, St: 39, F-10/4, Islamabad, Pakistan.Ph: +92-51-281755 Fax: +92-51-291552, E-mail: zafar@arump.sdnpk.undp.org

Written and compiled byTahir Mehdi and Tracey Wagner-Rizvi.

The information has been collected by: Abdul Karim, Afshan Jaleel, Aisha Gazdar, Ayyaz Gul Kiani, Azher Abbas, Dr Azra Talat Saeed, Cassandra Balchin, Farhat Perveen,Farjad Nabi, Feroze Ali Sathio, Ghazala Khizar, Ghazala Perveen Syed, Gul Sharif Khan, Imrana Shamim, Kosar Perveen, Mazher Zaidi, Mehboob Alam, Dr Mohammad Tanveer, Mumtaz Ali Shiekh, Dr Munir Ekbal, Noreen Ikram, Rashid Naeem, Rehana Mirjat, Sadaf Iqbal, Samina Zafar, Sardar Sarfraz Khan, Shamim Bano, Tahir Anjum, Tahir Mehdi, Tayyaba Khanum, Tracey Wagner Rizvi,Wahab Pandrani, Wareed Khan and Ziaur Rehman.During their work they were assisted byAsghar Zaidi, Fatima Sardar, Iffat Zaidi, Kishwar Sultana, Nadia Anjum and Shama Shiekh

Edited by D. Shah Khan

Design and layout by Tahir Mehdi

ISBN 969-8411-00-3Islamabad, March 1998

Also available from:Baby Milk Action23 St. Andrew�s Street, Cambridge CB2 3AX, UKPh: +44-1223-464420 Fax: +44-1223-464417andInternational Code Documentation Centrec/o IBFAN Penang, PO Box 19, 10700 Penang, Malaysia.Ph: +60-4-656 9799 Fax: +60-4-657 2655

Any part of this report may be reproduced on the condition that the source is mentioned. No part of this report, however, can bereproduced, quoted or used in any way for direct or indirect commercial purposes.

Price: Rs 150, overseas US$ 15 (including handling and postage)

Acknowledgements

The Network would like to thank the monitors and everyone who assisted them for their hard work and dedication. Without theircontribution this report would not have been possible. Thanks also go to Annelies Allain, Ellen Sokol, David Clark, Patti Rundall andMargaret Kyenkya-Isabirye for their expert advise in fine tuning the content of the report. Their encouragement at every stage wasmuch appreciated. Much gratitude goes to UNICEF Islamabad for continuing support for this report and the campaign to ProtectBreastfeeding and Young Child Nutrition in Pakistan.

Foreword .................................................. 8

Undermining the Code .......................... 10

International and SAARC CodesA tale of two Codes .............................. 11South Asia: Progressing poverty ........ 14

Monitoring in Pakistan .......................... 15

Health sector in PakistanThe baby and the beast ........................ 16Conduct unbecoming ............................ 20

Products available in PakistanFormula potpourri .................................. 22Price wars .............................................. 23

Visuals on food packingPainting it red ........................................ 24Too late the hero! .................................. 26

Text of labelsMincing words ........................................ 27Tragedy of errors .................................. 29

Promotion through mass mediaLoud lies ................................................ 31

Promotion to mothers in health facilitiesCautious whispers ................................ 33

What do mothers say?Under a demon�s shadow .................... 37An act of shame?.................................... 39

Visuals displayed in health facilitiesWriting on the wall ................................ 41

Gifts for health professionalsA marriage of convenience .................. 45The party that wasn�t over! .................. 47Soother chains ...................................... 48

Info brochures for health professionalsAdvertisements in disguise .................. 49Whose cows are more human? .......... 52

Samples and suppliesCovert operations ..................................53An interview with conscience .............. 56

Winning legitimacy for illegitimate productsTrojan horses ........................................ 57The twin paradox .................................. 60Never say No ..........................................61

Special formulasMountains out of molehill .................... 62Promotion at points of saleForefront of the brand war .................. 65RecommendationsWhat is to be done? .............................. 68

AppendicesText of SAARC Code.............................. 73Text of International Code .................... 76Related WHA Resolutions ....................80

Contents

Cover photo:Stacks of formula in a Quetta shop.By Tahir Mehdi

Top photo:Women at a medical store in Chakwal.By Ziaur Rehman

8

Nearly all women are able to breastfeedtheir babies. Why, then, do we see moreand more women artificially feeding theirbabies? More babies being bottle fedmeans fewer babies breastfeeding.

Why are women doubting their natu-ral ability to provide their children with themost nutritious, anti-infective food avail-able? Why do mothers believe they can-not produce enough milk to satisfy theirbabies hunger, when their mothers andtheir mothers� mothers knew no other wayof feeding babies? Why are their doctorsquick to recommend infant formula to�supplement� breastfeeding, rather thanhelping mothers to breastfeed with easeand success.? Why are mothers delayingthe initiation of breatfeeding by hours andeven days rather than feeding their babiescolostrum - baby�s energy packed firstvaccination?

There are a number of factorsresponsible for all these misconceptionsand malpractices. Largely to blame arethe unethical promotional practices of thebaby food industry. It was this same con-cern which prompted the World HealthAssembly, of which Pakistan is a member,to adopt the International Code ofMarketing of Breastmilk Substitutes inMay 1981 as a recommendation to mem-ber states. Resolutions on infant feedingwere adopted every two years thereafterto improve on the articles in the Code andclarify meanings, and to respond to newmarketing gimmicks. The InternationalCode and the subsequent, relevant reso-lutions adopted since provide basis foraction at the country level.

Article 11.4 of the International Codestipulates, �Non-governmental organiza-tions, professional groups, institutions,and individuals concerned should havethe responsibility of drawing the attentionof manufacturers or distributors to activi-ties which are incompatible with the princi-ples and aim of this Code, so that appro-priate action can be taken. The appropri-ate governmental authority should also beinformed.�

In the spirit of the above article, mon-itoring of manufacturers� compliance withthe International Code has been conduct-ed in many countries since it was adopt-ed. These studies have consistentlyrevealed promotional practices, both bla-tant and subtle, in violation of the Code.The infant food industry has modified mar-keting strategies, created new productsand found loopholes to get around theCode, as well as blatantly ignoring manyprovisions.

Concern that breastfeeding andyoung child nutrition were not being ade-quately protected in South Asia prompteddelegates from the seven member coun-tries of the South Asian Association forRegional cooperation to review theInternational Code and subsequent WHAresolutions on infant feeding and developan instrument adapted to the region�s cir-cumstances. The SAARC Code for theProtection of Breastfeeding and YoungChild Nutrition was this instrument. TheSAARC Code is much broader in scopeand closes many loopholes of theInternational Code. It was adopted by theSAARC Ministerial Conference on

ForewordFeeding Fiascoa

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aFeeding Fiasco

Children of South Asia, held inRawalpindi, Pakistan from 20-22 August1996.

The Network, along with its work topromote the rational use of medicationand the essential drugs concept, in 1997started a campaign for the protection ofbreastfeeding and young child nutrition inPakistan. In March 1997, we decided toconduct a countrywide study to recordcompany compliance with both theInternational Code and the SAARC Code.

The study was conducted over a peri-od of three weeks in 33 cities and towns,with the help of 11 survey teams compris-ing 34 monitors. The teams visited publicand private hospitals, clinics and shopsand interviewed mothers, nurses, doctors,pediatricians and company representa-tives. In over 2,500 one-to-one encoun-ters, questions were asked, views weresought and evidence was gathered. Backin the office, analysis of data and materi-als collected turned out to be much moretelling than our own expectations: not asingle company marketing infant food orfeeding products in Pakistan was abidingby the International Code in its entirety;also, of the 662 mothers interviewed near-ly every fourth mother was buying milkmade by the infant food industry.

The monitoring teams visited cities,towns and villages of varying profiles, andthe findings can be considered represen-tative of the whole country due to the geo-graphic breadth and number of encountersin the survey. Still, as with all surveys to

monitor Code compliance, these findingsare only the tip of the iceberg.

The Network�s interest is in the pro-tection of breastfeeding. This report,therefore, is primarily a qualitative exami-nation of the infant food industry�s promo-tional practices which undermine breast-feeding and/or promote artificial feeding,especially bottle feeding, as the norm. Inthe analysis of the results, violations ofvarious articles of both the InternationalCode and the SAARC Code are present-ed. In addition, any finding which wasfound to have a negative influence onbreastfeeding is also examined.

The findings of the study made itclear that if Pakistan wishes truly to pro-tect breastfeeding and young child nutri-tion, legislation must go beyond the provi-sions of these two Codes, which regulateonly the marketing of infant foods andfeeding products, to cover all practiceswhich undermine the initiation and contin-uation of breastfeeding.

The Network vows to continue tomonitor the excesses of the baby foodindustry with regard to their unethical pro-motion of so-called �breastmilk substi-tutes�. We hope that in the next monitoringexercise our point of reference will be anational law, and not just Codes.

Dr Zafar MirzaExecutive CoordinatorThe Network

First it was cracked and then broken. Nowit has been decimated into small, prof-itable pieces. They have invented newproducts and changed old strategies toget around the International Code. Theirapproach has become more vicious andoperations more clandestine.

They are using science to scaremothers and coerce doctors. They areexploiting women�s penchant for theirrights and men�s desire to adapt to newfamily realities. They shut up governmentsby flooding investments and hush worldbodies by threatening to withdraw theirmillions.

They never felt obligated to abide bytheir commitments. They picked andchose from the Code. Selected some ofits parts to use as feathers in their hat andmolded some into more useful things.They took the teeth out of the dangeroussections and murdered its spirit.

Yes, they have curtailed promotion tomothers and on the mass media. But onlyto invest more on their ultimate ally - thedoctor. Yes, they have taken baby facesoff their formula tins. But only to put themon other products they themselves havedeemed legitimate. Yes, they havereduced free supplies and made samplingdeceptive. But have they lost a singlepenny in sales?

The market is thriving. Companiesare growing. Profits are mounting. Moreand more babies are sucking rubber in a

vain search for the juice of life.In an age when capital has con-

quered nation states, corporations haveovershadowed governments and profit hasbecome a supra territorial reality, theCode as a global instrument, as humani-ty�s promise to its children, seems too lit-tle, too late.

It took us generations to ask profit torespect life. But has the Code been suc-cessful in stopping more babies being puton artificial feeds? The companies are stillhaving a field day with the Code with anopportunistic drive.

Shall we as a generation be defen-sive, apologetic about our contributiontowards the future of humanity? Can welook into the eyes of our children and saythat this is all we could do? No. We shallnot be cowed down by the sheer size ofthe mega houses of profit. We shall not beoverwhelmed by the strength of globalizedcapital and the extent of sprawling market-ing networks.

We need to renew our commitment tolife on Earth. We need a new system thatstands up to current realities. We need asystem that does not offer the greedyroom to manipulate. We do not need aCode that only burdens the pawns in thenew global game, governments, with themoral responsibility of implementing it. Weneed instead regulations that are bindingon the corporations themselves. We needa system that serves its purpose.

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Feeding Fiascoa

Underminingthe Code

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aFeeding Fiasco

The International Code of Marketing ofBreastmilk Substitutes was adoptedthrough a resolution of the World HealthAssembly (WHA 34.22) in May 1981 by avote of 118 votes to 1, with only the USAvoting against it. Subsequent WHA resolu-tions on infant and young child feedingclarified and reaffirmed the contents of theoriginal Code document.

The Code seeks to encourage and

protect breastfeeding by regulating the mar-keting practices used to sell products forartificial feeding. It is a compromise, not theideal. It is the result of negotiations betweenNGOs, governments, industry and expertsfrom related fields. It should be used as atool to develop national measures that arestronger and adapted to include new prod-ucts and changed marketing practices.

The International Code includes these

International Code and SAARC Code:Similarities and differences

A tale oftwo Codes

27 million babies are born in South Asiaevery year - more than the totalpopulation of all the Scandinaviancountries.A girl waiting for her mother outside thepediatric out-patient ward of a hospitalin Quetta. By Tahir Mehdi

10 important provisions:l No advertising to the public of any prod-uct within the scope of the Code.

The Code covers infant formula, othermilk products, cereals, teas and juiceswhen they are marketed for use in a feed-ing bottle or for babies under six months ofage, as well as bottles and teats (but notpacifiers).l No free samples to mothers.

Baby food manufacturers and distribu-tors may try to convince health workers thatsamples are charity, that mothers will behappy with the sample. This kind of charitymothers can do without. Samples get moth-ers and babies hooked on unnecessary,expensive and potentially dangerous prod-ucts that appear to come with the healthworkers� endorsement.l No promotion of products in health carefacilities, including the distribution of free orlow-cost supplies.

Booklets, leaflets, posters, feedingbottles, stickers, prescription pads and sim-ilar materials that advertise infant feedingproducts should not be permitted in healthcare facilities, nor should artificial infantfoods or feeding products be displayed.Donated equipment may bear a company�sname or logo, but should not refer to anybrand name.

In May 1994 the World HealthAssembly reinforced the ban on free orlow-cost supplies, saying �no donations ...in any part of the health care system.�l No company sales representatives toadvise mothers.

Company marketing personnel, nomatter what they are called, should not bepermitted to have contact with mothers.l No gifts or personal samples to healthworkers.

Gifts include money, goods or services(such as printing letterheads/prescription

pads, financing parties, etc.). These shouldnot be offered to, nor accepted by healthworkers. For only two reasons shouldhealth workers receive samples: a) forresearch at the institution level, or b) forprofessional evaluation. This means routineand regular distribution of samples is notpermitted.l No words or pictures idealizing artificialfeeding, or pictures of infants on labels ofinfant milk containers.

This provision is open to interpreta-tion. While most manufacturers haveremoved, for example, baby pictures fromtheir product labels, many still includeillustrations of stuffed animals, feedingbottles and other images which breast-feeding advocates argue also idealize arti-ficial feeding.l Information to health workers should bescientific and factual.

Besides being scientific and factual, allinformation should include the points setout in Article 4.2 (listed below). This infor-mation should emphasize that breastfeed-ing is superior to artificial infant feeding.

All information on artificial infant feed-ing should explain the benefits of breast-feeding, and the costs and hazards associ-ated with artificial feeding.l Information to mothers should include allthese points:

a) the benefits and superiority ofbreastfeedingb) how to prepare for and continuebreastfeedingc) that adding bottle feeds will causeless breastfeedingd) how hard it is to return to breast-feeding once bottle feeding is estab-lishedIf the materials talk about the use of

infant formula, the following informationmust be included:

a) the cost of using artificial infantfoods b) the social implicationsc) the possible risks to the baby�shealth

Companies should only supply materials atthe request of and with the written approvalof the appropriate government healthauthority.

None of the material should refer tobrand name products covered by the Code.None of the material should be givendirectly to mothers by the companies.l Unsuitable products, such as sweetenedcondensed milk, should not be promotedfor babies.

Other unsuitable products areskimmed milk, standardized partiallyskimmed milk and whole milk.l Manufacturers and distributors shouldcomply with the Code�s provisions even ifcountries have not adopted laws or othermeasures.

The SAARC (South Asian Associationfor Regional Cooperation) Code for the

Protection of Breastfeeding and YoungChild Nutrition was adopted by over 100delegates attending the 3rd SAARCMinisterial Conference on Children of SouthAsia in Rawalpindi, Pakistan from 20 to 22August 1996. It uses the International Codeas a minimum standard and adjusts its pro-visions to the nutrition realities of all sevenSouth Asian countries. Developed 15 yearsafter the International Code, the SAARCCode closes loopholes and removes ambi-guity by incorporating subsequent WorldHealth Assembly resolutions on infant feed-ing and adjusting to new marketing tactics.The purpose of the SAARC Code is �to pro-tect breastfeeding and child nutrition byeducating health workers and the publicabout the benefits of breastfeeding and by

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Feeding Fiascoa

13

aFeeding Fiascoregulating the marketing and promotion ofinfant and complementary foods and relat-ed products.�

The SAARC Code includes theseeight important provisions:l No promotion of any product covered bythe SAARC Code.

Products covered by the SAARCCode are called �designated products.� Thedefinition of designated products uses lan-guage clearer than that of the InternationalCode�s scope by removing the vaguephrase �represented or marketed as areplacement for breastmilk� and includingany milk food, packaged food or drink forthe use of a child below the age of twoyears. Feeding bottles, teats, valves forfeeding bottles and pacifiers are alsoincluded as designated products.l Labels must not contain anything thatmay discourage breastfeeding nor showphotographs, drawings or graphics, otherthan graphics to illustrate correct prepara-tion.

Whereas the International Code per-mits illustrations which do not �idealize�artificial feeding, the SAARC Coderemoves any ambiguity and room for inter-pretation by disallowing all photographs,drawings and graphics. Label content is tobe measured against its ability to �discour-age breastfeeding�, unlike the InternationalCode, where its ability to �idealize artificialfeeding� is considered.l Labels must include notices in accor-dance with Article 3 and be written in thespecified (local) language.

The SAARC Code goes beyond theInternational Code, which stipulates theinformation to be included in product labelsbut leaves the wording and presentation forthe manufacturer to determine. TheSAARC Code specifies the wording ofwarnings and notices and the size of print

in which they must appear. This is impor-tant given the ways in which manufacturershave been known to manipulate the word-ing and presentation of informationrequired by the International Code.l Condensed milk, evaporated milk, andskimmed milk must contain a notice statingthat it should not be fed to babies belowone year.

Again, the International Code saysunsuitable products should not be promot-ed for infant feeding; the SAARC Codetakes it a step further to stipulate the warn-ing that must appear on such products.l No company-produced or distributed edu-cational or information materials relating toinfant and young child feeding.

Companies are forbidden to produceor distribute any educational or information-al materials relating to infant and youngchild feeding, while the International Codepermits such materials as long as theymeet certain criteria.l Samples, gifts, services or other benefitsshould not be given to health workers orhealth care facilities.

This provision is almost identical tothat in the International Code.l Health workers should not accept norgive samples of products covered by theSAARC Code.

Notwithstanding prohibitions placed oncompanies regarding samples, health work-ers have a responsibility not to accept orpass on samples of designated products.l No company-funded research unlessapproved by the government. Publicationof findings must disclose source of funding.

This provision is in recognition of thedanger of grants causing conflict of interest.

See full text of SAARC Code,International Code and the related WHAresolution on pages 73-87.

South Asia comprises seven countries, namely India, Pakistan,Bangladesh, Sri Lanka, Nepal, Maldives and Bhutan. More thanone-fifth of the world�s population and nearly 40 per cent of theworld�s absolute poor reside in this region. More babies are bornin South Asia every year (27 million) than the total population ofall the Scandinavian countries.

The extent of human deprivation in South Asia is colossal.The sheer magnitude of human distress numbs the mind: over500 million people living in absolute poverty; 260 million peoplelacking access to rudimentary health facilities; 337 million peoplewithout safe drinking water; 830 million people people with noaccess to basic sanitation; 396 million adults unable to read andwrite; over 400 million people go hungry every day.

According to a recent UNICEF study, the region worstaffected with malnutrition among children is South Asia. Half thechildren in South Asia are underweight, compared to 30 per centin Sub-Saharan Africa. The infant mortality rate of the region is82 per 1,000 live births. Diarrhea and acute respiratory infectionsare the main culprits and are responsible for more than half ofthe infant deaths.

The per capita GNP of South Asia ($309 in 1993) is lowerthan any other region in the world.

The adult literacy rate in South Asia (48 per cent) is nowlowest in the world. Its share of the world's total illiterate popula-tion (46 per cent) is twice as high its share of world's population.There are more children out of school in South Asia than in therest of the world; two-thirds of this wasted generation is female.

All SAARC countries with the exception of Sri Lanka havesimilar disease patterns and almost identical health, educationand water and sanitation conditions, besides sharing a commoncolonial past and a number of linguistic, social and cultural simi-larities. Still, Pakistan�s health indicators lag behind others inSouth Asia. (Source: Human Development in South Asia, 1997,Mahbub ul Haq)

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Feeding Fiascoa

South Asia: Progressing poverty

Photo: LESSER CITIZENS OF THE GLOBAL VILLAGE: Thenew waves of globalization and opening up of marketsoffer little hope for ailing the masses of South Asia. Peoplewatching television at a tea stall near Shahdad Kot, aremote town of Sindh. By Tahir Mehdi

The monitoring exercise was carried out inthe first half of March 1997 by 11 teams of34 monitors. It covered 33 cities, townsand small towns in the whole of Pakistanexcept the mountainous Northern Areasand the coastal belt of Balochistan, whichare far flung and difficult to reach.

The monitors visited 66 public andprivate hospitals, 151 private clinics (217health facilities) and 562 medical storesand interviewed 662 mothers. A conserva-tive estimate of total one-to-one encoun-ters in the monitoring exercise is morethan 2,500. Besides this, the exerciseincluded an extensive study and analysisof product labels and 400 specimens ofpromotional and information materials andother objects submitted by the monitors.

Monitoring took place in the followingareas: Jamrud, Peshawar, Charsadda,Abbottabad, Bannu, Mansehra,Rawalpindi, Islamabad, Taxila, Jhelum,Chakwal, Sargodha, Faisalabad, Bhalwal,Wazirabad, Lahore, Kasur, Okara, Multan,Bahawalpur, Zahir Pir, Rahim Yar Khan,Dera Ghazi Khan, Larkana, Sukkur, Dadu,Sanghar, Tando Mohammad Khan, Thatta,Hyderabad, Karachi, Quetta and Kalat.

The monitoring exercise in Pakistanwas designed for a qualitative assessmentof the marketing practices of artificial babyfood companies and their potential effectson breastfeeding practices. Qualitativeresearch methods employed were: non-participant observation; structured, semi-structured and in-depth interviews andsurvey questionnaires (using purposiveand convenience sampling). Apart fromproviding understanding about the depth

of the issues through purely qualitativemethods, the survey questionnaires didgenerate useful data to quantitatively sig-nify the issues. Many specimens werealso collected during the monitoring. Theanalysis and interpretations of these arepresented in the next chapters.

The International Code of Marketingof Breastmilk Substitutes, 1981 and theSAARC Code for the Protection ofBreastfeeding and Young Child Nutrition,1996 were used as references to defineviolations. In addition, the monitoringsought to document any act perceived to

undermine the initiation or continuation ofbreastfeeding. Such acts are violations ofa child�s basic right to enjoy the highestattainable standard of health and theState�s responsibility to provide basicknowledge of child health and nutritionand the advantages of breastfeeding(Convention on the Rights of the Child,Articles 24.1 and 24.2(a) and (e)). Ourintent in documenting practices outsidethe purview of either of the two Codes wasto ensure that any law in Pakistan wouldincorporate clauses to prohibit all actswhich undermine breastfeeding.

15

aFeeding Fiasco

Monitoring in Pakistan

Ch ar sad da

Pe sh awa r

M an se hr aA bb ott ab ad

Isla m ab adRa wa lpin diTaxila

J he lumCha kwa l

Sa rg od h aWa zira b adBha lwa l

Fa isa lab adKa su r

O ka ra

M ulta nQ u ett a

Kala t

BALO CHI STAN

SINDH

PU NJAB

NW FP

N ORTHER NAR EAS

Ba ha walp u r

La rk an a Sukk ur

Da du

Sa n gh ar

Ta nd o M o ha mm a d Kha n Mon ito ring po in ts

Th at ta

Kar ach i

Hy de ra ba d

Der aGh aziKha n

Ra him Ya r Kha n

La ho re

Jam r ud

Ba nn u

Pakistan

PAKISTAN

INDIA

SRI LANKA

MALDIVES

BANGLADESH

NEPAL BHUTAN

China

Myanmar

Afghanistan

SouthAsia

Kath mand uDhaka

Colo mbo

Delhi

Islam abad

16

Pakistan is a country of 140 million people.(This is a UNFPA estimate. The last censuswas conducted in 1981.) The country com-prises four provinces: Punjab, Sindh,Balochistan and the North-West FrontierProvince (NWFP) and a federally controlledtribal belt along the Afghanistan border and

the mountainous Northern Areas.Every year 5.5 million babies are born

in Pakistan. The country�s population isgrowing at a rapid rate of 3.3 per cent.

The infant mortality rate is high - 95 perthousand live births. This is second highestin the region, ahead of only Afghanistan and

higher than even Bangladesh, which ismuch poorer a country. The under-five mor-tality rate is also high at 135 per thousandlive births. This means 755,000 childrenunder five years of age die every year.Every tenth baby dies before his/her firstbirthday and every fourth baby is born

Introduction to Pakistan and its health sector

The baby and the beast

Pakistan has failed to improve the public healthinfrastructure it inherited from its colonial past.A man from rural Balochistan waits for the doc-tors outside the pediatric ward of SandemanHospital, Quetta. By TM

underweight. Diarrhea and acute respiratoryinfections cause more than half of infantdeaths. Every woman bears six children onaverage and the maternal mortality rate is340 per 100,000 live births.

Pakistan scores poorly in education.The literacy rate is a meagre 38 per centand the number of literate women is half(24 per cent) that of literate men (50 percent). This means that three out of fourwomen cannot read and write, reflecting abias against enrolling girls in school.

The average per capita income isUS$430 per annum. Even more disturbingis the fact that 60 per cent of the populationearns less than the average per capitaincome.

Breastfeeding: a dying culture

Pakistan is as yet a breastfeeding culture.Mention of the need to protect, promote andsupport breastfeeding invites a dismissive,�But everybody breastfeeds.� True, themajority of mothers in Pakistan do initiatebreastfeeding; also true that many recog-nize the importance of continued breast-feeding.

But the reality is that in Pakistan today,the breastfeeding culture is a dying one.Bottle-feeding is being accepted as the rule,rather than the exception. Mothers unneces-sarily �supplement� their own milk with othermilks, water and foods before it is nutritional-ly required by the baby. Women are beingwrongly convinced that for any number ofreasons - not enough milk, poor quality milk,weakness, delivery by caesarean section,premature baby, mother returning to work -they are �unable� to breastfeed their baby.

According to UNICEF�s State of theWorld�s Children 1998 report the exclusivebreastfeeding rate from birth to three monthsin Pakistan is 16 per cent, and 56 per cent

of mothers breastfeed their babies for 20-23months. Largely to blame for these low fig-ures, The Network believes, are the promo-tional practices of the artificial baby foodindustry, which undermine breastfeedingand promote a bottle feeding culture.

The strong presence of the artificialbaby food industry in Pakistan can bejudged by the fact that Cerelac was listedas the 42nd best selling �pharmaceutical�product in Pakistan in 1995 with a sale ofRs 84 million. The list of top selling 100products, published by Pharma Bureau ofOverseas Investors Chamber of Commerceand Industry in Pakistan, also includesLactogen 1 and Morinaga BF. Lactogen 1ranked 66th with sales worth 67.53 millionwhile Morinaga BF stood 91st with 50.33million worth of sales in 1995. The sales ofthese three products alone constituted twoper cent of the top hundred pharmaceuticalmarket or 0.8 per cent of the total market.

Retail shops of health

A survey carried out in 1993 by WHO andthe Government of Pakistan revealed that

17

aFeeding Fiasco

Top: The private health sector has nomorals when it comes to acceptingsponsorships. A 7-Up sponsored frontsignboard of a medical complex inMultan. By TMBottom: The general hygienic conditionof government hospitals is appalling.Doctors' washroom in Lyari Hospital,Karachi. By Farhat Perveen

18

Feeding Fiascoa

only around 20 per cent of Pakistan�s totalpatients attend public sector hospitals; therest go to private hospitals and clinics. Themajority of doctors working in governmenthospitals have their own private clinics aswell. They work in hospitals in the morningand sit in their clinics in the evening. A goodposition in the hospital positively affectstheir evening practice, both in terms ofpatient turnout and the fee that the doctorcan charge. Consultants generally see richpatients or serious cases. They prescribebut do not dispense drugs.

The bulk of patients, however, seekhealth care from general practitioners in pri-vate clinics. These clinics are mostly smallshops owned by MBBS doctors. Almost

every clinic has either a dispensary of itsown or a medical store/pharmacy attachedto it. The GPs may charge separately aconsultation fee and the price of the dis-pensed generic medicines, or they mayoffer a package deal covering both butexcluding �necessary� patent medicines tobe bought by the patient separately.

The attached medical stores are some-times owned by a brother or another rela-tive of the doctor. In other cases these aresecretly owned by the doctors themselvesand run by hired staff. At the very least, thedoctor and store-owner have a mutuallybeneficial understanding. For example, if acompany is offering a discount on the bulkpurchase of a cough syrup, the store-ownerwill avail this and inform the doctor. Thedoctor will respond by increasing prescrip-tions of that product. Similarly, if the doctorwants to favor a particular company, he canask the store-owner to purchase its prod-ucts on the guarantee that he will be pre-scribing that medicine frequently. Thepatients are not bound to buy medicinesfrom the attached store, though they tend todo so. In some cases, the doctor may sug-gest that the patient fill his prescription fromthat particular store.

Anything and everything

Pakistan is a virtual pharmaceutical jungle.It�s a bizarre situation and a marketing para-dise. Anything and everything is availableopenly to anybody with the requisite pur-chasing power. In the words of an unpub-lished UNIDO report (1993), the pharma-ceutical sector in Pakistan is �characterizedby inadequacies, irrationalities, imbalancesand a lack of direction and implementationof operational guidelines.�

Literally any medicine can be boughtwithout prescription from any medical store.

Infant formulas in Pakistan are justanother consumer item availableanywhere and everywhere. A kiosknear Quetta's biggest hospital. By TM

Some 30 multinational pharmaceutical com-panies hold sway. Their market share is 60per cent while the remaining 40 per cent isdivided among over 250 local manufactur-ers, importers and distributors. According toNetwork analysis, the multinational compa-nies in Pakistan enjoy over 90 per cent ofthe prime value and volume market com-prising the top selling 100 drugs, (which is40 per cent of the total market).

As mentioned already, the PharmaBureau of the International Chamber ofCommerce and Investors includes baby foodproducts in its list of 100 top-selling drugs.

In Breaking the Rules 1991 and 1994,the IBFAN global reports on Code compli-ance, Pakistan has the �distinction� of beingquoted most often as a country allowingCode violations.

Welcome visitors

Company representatives are welcome visi-tors to health facilities. The majority of doc-tors interviewed remark that the efficacyand quality of different brands are largelythe same, the only difference is which com-pany pays them more attention and visits.

A doctor in Multan who prescribes onlyMeiji, when asked why, replied, �Actually,the Meiji rep. has become a very goodfriend of mine.� Another doctor in Sindhsaid, �The Morinaga guy is a very nicechap. He treats me like his sister.� AFaisalabad gynecologist told a monitor thatshe was prescribing P-7A these daysbecause the rep. had complained that shewas not prescribing his product enough.When asked why they suggest a particularbrand, many doctors simply respond, �Itsrep. visits me more often.� But a womangynecologist in Iqbal Town, Lahore had amore vivid and bold answer. She told amonitor: �I believe that all brands of formula

are same. It really does not make any differ-ence whether you prescribe �formula x� or�formula y�. I can accept favors from onecompany and respond by supporting itsproduct. I don�t think there is anythingwrong with it.� When asked whether shereceives samples of formula, the doctorsaid, �Cartons and cartons.� But sherefused to name the company and product,saying, �I don�t want to put the poor rep. introuble.�

Hoards of company reps. carryingloads of free samples can be seen daily inhospitals. Very few hospitals have formulat-ed a policy about the company visitors.Indeed, neither the International Code northe Baby Friendly Hospital Initiative rulesrestrict in any way the entry of sales reps. aslong as the information conveyed is scientificand factual. Many Baby Friendly hospitals inPakistan, however, allow formula companyrepresentatives only if they come withoutcarrying their bags containing literature andsamples. But their bags are usually heavierthan normal when they visit these �babyfriendly� doctors at their private clinics in theevening. Moreover, the majority of company

reps. get around restrictions by pleading thatthey are there only to inform doctors of their�medicated� or lactose-free formulas. A moni-tor from Bahawalpur reported a campaignagainst Snow Brand being run in a BabyFriendly hospital by Abbott and Wyeth. Thetwo companies were lobbying the hospitaladministration to ban Snow Brand represen-tative�s entry on the pretext that this compa-ny has no �special� formula to promote andthus its entry violates the hospital�s commit-ments under the Baby Friendly HospitalInitiative - an invalid argument.

Unholy alliance

The companies exploit the doctor-pharmacynexus in more than one way. A typical �call�of a company representative in Pakistanstarts with a brief visit to the medical storeattached with the doctor he intends to see. Arep. usually has good and frank terms withstore-owners. At times the rep. can help thestore-owner keep up his stock, especiallywhen an item is in short supply, or he canpass on tips about a possible price rise oran inevitable shortage of any item or any

19

aFeeding Fiasco

Private clinics generally look more like the sales points of pharmaceutical compa-nies. A general practitioner in his clinic in Kasur. By Mahboob Alam

t

Pakistan was among 118 countries that inMay 1981 voted in favor of adopting theInternational Code of Marketing ofBreastmilk Substitutes through a WorldHealth Assembly resolution. Pakistan hasalso supported subsequent WHA resolu-tions on infant feeding. Its ministers wereamong 100 delegates from seven SAARCcountries that adopted in August 1996 theSAARC Code for the Protection ofBreastfeeding and Young Child Nutrition.Most other SAARC countries and all ofPakistan�s neighbors (with the understand-able exception of Afghanistan) have legis-lation implementing the International Code.But in Pakistan, legislation has yet to bepassed.It is hoped, however, that the Protection ofBreastfeeding and Young Child NutritionAct will be adopted in early 1998. In hisspeech as chief guest at the launch ofUNICEF�s State of the World�s Children1998 report on December 18, 1997,Minister for Health Javed Hashmi referredtwice to the proposed law and said thegovernment would be going ahead with thelaw within a few months.In August 1997 the Ministry of Law gavethe go-ahead for federal legislation to pro-tect breastfeeding and young child nutri-tion. Since then, final revisions have beenmade to the latest draft of the proposedlaw. The National Breastfeeding SteeringCommittee met on November 21, 1997 toreview the bill. Certain expert bodies,

including The Network, were asked to sub-mit their comments and recommendationsregarding the draft by December 31, 1997.Industry representatives were also invitedto attend the meeting to present their viewson the draft law. Senior Nestlé lobbyistsfrom outside Pakistan were also present.The government, however, made it clearthat it was under no obligation to accom-modate the industry�s recommendations.The draft of the proposed law currentlyunder consideration was prepared by theMinistry of Health in mid-1995 and wasbased on the then in the works SAARCCode. Legislation in this regard was firstdrafted in 1989 by the Pakistan PediatricAssociation.The Ministry of Health commissioned adraft which was submitted for governmentconsideration in the summer of 1992.Immediately thereafter, on August 11, 1992the Ministry of Health notified infant formulaas a drug for the purposes of the Drugs Act1976. However, certain provisions of theCode, such as information and educationalmaterials for health workers, quality andlabeling are not covered by the Drugs Act.Though this notification could not be con-sidered legislation and there was noattempt to implement even this �stop-gapmeasure�, it was promoted by the govern-ment as its determination to implement theInternational Code.The comments of the infant food industryin Pakistan were sought. While there was

no formal response, industry representa-tives frequently met with UNICEF (whichwas providing technical support) and thegovernment to express reservations overthe proposed law. In fact, one senior offi-cial from Nestlé few into Pakistan in lateOctober 1992 to meet with UNICEF andgovernment officials, including the DrugsController.On November 5, 1992, the Ministry ofHealth modified its notification on thegrounds of �public interest� and exemptedinfant formula and infant food from all pro-visions of the Drugs Act except those con-cerning advertising and sampling. As aresult, there is no monitoring mechanism,no prosecution and judicial set-up and nopenalty provisions, nor can any rules beenacted to implement the notification.Infant formula and infant food were notdefined in the notification, its modification,the Drugs Act or any other law in Pakistan.Feeding bottles, teats and pacifiers werealso not covered. A 1996 amendment tothe Drugs Act included in its definitions�infant formulas, follow up milks, milk sub-stitutes, baby foods, baby gruels, baby teasand juices, bottles and teats and any otherproduct used as infant formula as such�.The Ministry of Health is to be commendedfor the strength of the current draft of thelaw, and it is encouraged to resist the pres-sures of the infant food industry in havingthe proposed law enacted and effectivelyimplemented without further delay.

20

Feeding Fiascoa

The legal position in Pakistan

Conduct unbecoming

21

aFeeding Fiascogossip from company circles which the

store-owner might find interesting. Reps.also occasionally, if not regularly, givestore-owners their due share in small giftslike notepads, which companies distribute inbulk. Sometimes the store-owners canrequest samples for their personal use. Inreturn, the store-owners keep their friendsup-to-date about market trends in theirarea. They can give surprisingly detailedaccounts of who is prescribing what, whichbrand has what position in its category, whois paying how many visits, which doctor hasstopped prescribing what brand andswitched to what other brand. Reps. use allthis information quickly to formulate in amatter of seconds their strategy for the nextcall as well as for the weeks and months tofollow. Store-owners generally have nofavorites and are friends with every rep.

The Network�s monitoring strategyincluded this important source of informa-tion. Monitors were briefed about it andasked to look for doctor-specific informationfrom stores as well and to write it separatelyas additional notes. It proved very interest-ing; monitors told the coordinators that in anumber of cases the stores presented astory absolutely opposite from what thedoctors narrated. For example, the store-owner would tell the monitor that he sellsten tins a week or more of formula and con-firm that it is sold on a particular doctor�sparchee (prescription) while the doctorwould claim that he never or seldom pre-scribes formula. Most monitors reportedsimilar experiences. However, this informa-tion was treated as supplementary and notincluded in the statistical analysis. Forexample, if the doctor denied ever receivingsamples, it was counted as a �no� even ifother evidence suggested otherwise.

General practitioners usually sell thesamples of baby food products at their dis-

pensaries or supply it to the attached med-ical store. Sometimes doctors give these ascharity to poor patients - the last peoplewho should be introduced to these expen-sive and unnecessary products - or to their�important� patients. People generallybelieve samples to be more potent, pureand effective than the medicine itself andthus value them more.

67 million people in Pakistan have noaccess to safe drinking water. A scenefrom near Kambar, a remote town ofSindh. By Tahir Mehdi

t

At present, infant formula, other breastmilksubstitutes and cereals do not require reg-istration in order to be sold. Infant formulais normally imported as ordinary milk, so itis difficult to distinguish the quantity ofspecifically infant formula from the totalimported milk. Additionally, many productssmuggled into the country are readily avail-able in the market.

According to the Ministry of Healththere are �more than 160 brands of breast-milk substitutes currently being marketedby both local and foreign companies�.

However, the Drug Index (a localcommercial drug compendium) providesthe details of 50 brands of infant formula(including follow-on and growing up milks)and 6 brands of infant cereals manufac-tured by 16 companies. Many other brandsof infant formula, cereals and other infantfood products are smuggled into the coun-try and are readily available in the market.

Nestlé, Morinaga, Meiji, Snow Brand,Mead Johnson, Nutricia, Cow & Gate,Abbott, Knoll Pharmaceuticals (formerlyBoots Pharmaceuticals), Wyeth and Celia

Feeding Fiascoa

22

Baby food products available in Pakistan

Formulapotpourri

Abundance is the name of the game:A milk and tea shop in Quetta.By TM

are more visible than other small share-holders in Pakistan�s booming baby foodmarket. Almost all of them have a wholerange of formulas for babies of differentages and those suffering from different ail-ments. Typically, the range consists of aninfant formula, a follow-on formula, a lac-tose-free formula and a special �high nutri-tion� formula for babies born underweightor those suffering from diarrhea or �weak-ness�.

Among the formulas that are certainlysmuggled is a tin manufactured by Nutriciabut packaged with generic labeling accord-ing to Iran�s specifications and in thePersian language.

Also available in Quetta is a formulathat was manufactured in Switzerland byRapaks International of Australia for importby Uzbekistan and smuggled intoPakistan, possibly through Afghanistan.The label of this well-travelled brand iswritten in Russian, with the exception ofthe English words: �Infant Milk Formula;and �For the Infant�s First Months�.

A whole range of assorted baby fooditems are also regularly smuggled intoPakistan from the Far East and the MiddleEast and sold at posh markets in all thebig cities. Heinz complementary foodsoccupy permanent space in many shelvesin Karachi and Lahore.

Feeding bottles come in all shapesand sizes. Shield and Kidco feeding bot-tles, teats and pacifiers, and Twinkle andKid�s Kare pacifiers are manufacturedlocally. Imported and smuggled brandscome from Japan, Korea, Germany andelsewhere. Each brand attempts to distin-guish itself from its competitors throughtheir design and colorful animation andwith this or that �new and improved fea-ture�.

Besides these products, The Network

aFeeding Fiasco

23

Price warsThe Network has determined the aver-age per month cost of different brandsof formula and the cost of feeding ababy these formulas from birth to sixmonths of age according to the feedingtable provided by the manufacturer.

The average per month cost of for-mula comes out to Rs 1,480, which isequal to the average monthly income inPakistan!

The number of tins required to feeda baby varied according to three factors:tin size; scoop size and number of feedsper day.

Among the brands examined, thenumber of tins ranged from 41 tins ofAbbott�s Similac to 67 tins of Maeil�sBabycare, and a whopping 107 boxes inthe case of the Nestlé�s Lactogen 1200g soft pack. The prices ranged fromRs. 102 (Nestlé Lactogen 1, 400g softpack) to Rs. 234 (Abbott Sensimil)among the 17 brands whose prices (of375g/ 400g/ 450g tins) were examined.

Once again, Nestlé is first in adopt-ing the latest in a long line of pro-

motional tactics. This time the line ofattack is the 200g and 400g �soft packs�of Lactogen 1 and Lactogen 2.

The cost of six months� worth offormula in soft packs is significantlylower than the same in tins. Nestlé has

Abbott Isomil 46 231 1,771 10,626Abbott Sensimil (400g) 46 234 1,794 10,764Abbott Similac 41 176 1,203 7,216

Meiji FMT 55 155 1,421 8,525Morinaga Morinaga BF 61 145 1,474 8,845Morinaga NL-33 61 197 2,003 12,017

Nestlé al-110 48 215 1,720 10,320Nestlé Lactogen 1 107 53 945 5,671

(200g box)Nestlé Lactogen 1 54 102 918 5,508

(400g box)Nestlé Lactogen 1 48 180 1,440 8,640

(450g tin)Nestlé Nan 48 187 1,496 8,976

Nutricia Almiron 49 185 1,511 9,065Cow & GateNutricia Nutrilon Premium49 140 1,143 6,860Nutricia Nutrilon Soya 49 195 1,593 9,555

Snow Brand P7A 60 155 1,550 9,300Wyeth S-26 50 200 1,667 10,000

Following statistics are tabulated as Company;Brand; Number of tins needed to feed babyfrom birth to six months following feeding tableprovided; Cost per tin (Rs.); Cost per month(Rs.); Total cost (from birth to six months) (Rs.)

found a number of other things that it con-siders harmful for the protection and pro-motion of breastfeeding. Many dolls comewith a feeding bottle and/or pacifier; storybooks are often illustrated with feeding

bottles or babies being bottle fed. TheNetwork has even found pencil sharpen-ers, candy dispensers, money banks andbaby�s �squeak toys� in the shape of feed-ing bottles!

exploited this fact by widely promoting Lactogen1 soft packs on colorfully illustrated leaflets �forthe medical profession only� as �the most eco-nomical infant formula in the market�, surround-ed by a pink starburst. Indeed, many doctorsprescribing Lactogen 1, the only brand availablein soft packs, do so because �it is the cheapest�.Hence, product packaging has become yetanother promotional ploy.

Feeding Fiascoa

Most companies no longer show pictures ofbabies on the labels of infant formula,though there are several exceptions. Maeil�s(a Korean company) Babycare and a brandmanufactured by Rapaks for import byUzbekistan and smuggled into Pakistan,both show photographs of babies� faces, incontravention of both the International Codeand the SAARC Code. The Rapaks tin alsobears a photo of feeding bottles.

Great liberties are taken, however, inplacing baby photos on cereals and otherinfant food labels marketed for use under 6months of age. World Health Assembly res-olution 47.5 recommends complementaryfeeding �from about six months�. Cerealsmarketed for use below that age are, there-fore, covered by the International Code aswell as by the SAARC Code. Nestlé�s rangeof Cerelac flavors all feature baby photos,as does the Nestlé Rice (formerly Nestum)label. On the label of Farley�s Farex, amother gazes lovingly at her baby. TheFarex label also bears the slogan �SoFarley�s, So Good� on building blocks.

Other illustrations and graphics arewidely used on infant formulas, follow-onformula and cereals to undermine and dis-courage breastfeeding more subtly -- in vio-lation of Articles 3.1(a) and 3.1(g) of theSAARC Code, if not the International Code,which prohibits in Article 9.1 the idealizationof the use of infant formula. All Nutricialabels carry illustrations of the same teddybear, flowers and feeding bottle (feedingcup in the case of Nutrilon follow-on).Newer labels of Nutrilon premium no longerinclude the feeding bottle following a policychange in order to �follow latest rules andregulations set by PPA/WHO.� (See box onpage 22.)

Abbott, too, adorns its labels of Isomiland Similac with an illustration of a teddybear, a feeding bottle and a cup, whileSensimil labels show an illustration of a sim-ilar bear, holding a comfort blanket beside apillow and apparently giggling behind itspaw. Wyeth�s Wysoy bears an illustration ofa fuzzy, stuffed rabbit sitting on a blanketwith butterflies on it. On Celia�s Celia 1 a

24

Visuals on baby food packing

Painting it red

Right: A Farex bunting that the companygives for shopkeepers to decorate theirshops.Bottom: Two brands of formula withbaby faces on the tins. Babycare isimported from South Korea while theother is smuggled from Central Asia.

Facing page: TOYING WITH THE CODE: Formula tinswith visuals on the packs. The majorityof companies use toys and other itemsof babies' use to associate theirproducts with health, happiness andinfants.

What do the two Codes say?

No idealizing of bottle feeding;No baby picturesInternational Code, Article 9

Nothing to discourage breastfeeding;No photos, graphics or drawingsSAARC Code, Article 3

non-specific cartoon animal carrying afeeding bottle appears three times. Farley�sFarlac shows a bunny riding a bicycle with aboy and girl watching and a bird in a tree.

Morinaga is widely recognized by thecow face in the company logo, which�graces� more than half of the front of theMorinaga BF tin. The cow is associated withthis product to such an extent that manymothers refer to it as �gaey wallay dabbayka dudh� (the milk tin with the cow on it).

Nestlé places a feeding cup on thelabel of locally made soft packs of Lactogen2, though not on the imported 450g tin.Cartoon illustrations of a smiling sun, a bee,flowers, rolling hills and the blue sky appearon Neslac labels.

The labels of some products enticemothers to use them unnecessarily and per-haps prematurely through images of immac-ulate ingredients that are supposedly superi-or to the blemished but otherwise identicalitem she may buy fresh from her local mar-ket. Nestlé�s range of Cerelac flavors all fea-ture a perfect bowl of cereal surrounded byperfect wheat stalks and perfect honey-combs, bananas or other fruit, depending onthe flavor. Similarly, Nestlé Rice(formerly Nestum) uses perfectrice stalks around a perfect bowlof cereal to idealize the product.

An arrangement of flawlessfruit is the centerpiece ofthe Heinz Fruit Dessertlabel, while Heinz AppleJuice features an illustra-tion of apples andblossoms, alongwith graphics of afeeding bottle anda feeding cup.

Many labels offeeding bottles,teats, nipple shields

and pacifiers contain photos, drawings andother graphics. Especially popular are pho-tos and illustrations of babies with theirmothers, in an attempt to associate theproduct with a loving and caring mother andthe strong bond between her and her baby.This idealizes the use of the product andultimately discourages breastfeeding, whichis forbidden by Article 9.1 of theInternational Code and Articles 3.1(a) and3.1(g) of the SAARC Code.

Twinkle adorns its teat labels with aphoto of mother and her baby, a photo ofthe teat, as well as graphics illustrating howthe teat design supposedly helps the milkflow by allowing air to escape before themilk enters the baby�s mouth. A photo of amother with her baby is featured on thelabels of Kidco feeding bottles, along with aphoto of the bottle (full of milk) and its com-ponents. The window panel shows the bot-

tle is decorated withfluffy teddy bears -

what the labeldescribes as a �color-ful design.�

Camera pacifiersalso showan illustra-tion of ababy face.

The labelof

Camera feeding bottles shows a drawing ofa bottle decorated with a cartoon child,blocks, toffee, ice cream and a puppy.There are also drawings of lambs riding uni-corns, stars, moons, houses, a lace design,as well as an illustration of the teat.

The label of Kid�s Kare pacifier con-tains photos of a baby and the pacifier, aswell as the brand name in a banner. BabyBeginnings feeding bottle has on its labels agraphic of the bottle and its components.Labels of Shield evenflow feeder containphotos of the bottle (assembled and disas-sembled), and a graphic of a child using abottle, while a window panel shows that thebottle is decorated with balloons and stars.

A photo of a mother and baby appearon the labels of Farlin feeding bottles, aswell as a graphic of the bottle parts. Also,two window panels allow mothers to see thebottle, which is decorated with a rainbow,trees, water, crabs and birds. A baby photois also included on the label of Pigeon paci-fiers, as well as a photo of the pacifier cov-ered with a cap. The pacifier is visiblethrough a window panel. Púr feeding bottlelabels have an illustration of a baby and acartoon elephant, and the bottle is decoratedwith cartoon animals riding carousel horses.

Article 9.1 of the International Codesays, �labels should be designed to

provide the necessary information about theappropriate use of the product.� Productconfusion can arise, however, when compa-nies play with the colour and design of thepacking to create an association betweenseveral products. This can prove very harm-ful for babies: if a so-called follow-on formu-la is given to a baby under six months, itshigher protein and mineral content increas-es the risk of dehydration during diarrhea.

The infant formula and the follow-onmilk are especially easy to confuse when

aFeeding Fiasco

25

Feeding Fiascoa

the label designs are similar, with onlyminor differences. Nestlé�s Lactogen 1 & 2labels, for example, are very similar - thenames are the same, the only differencebeing �1� and �2�, and Lactogen 2 packs arelighter blue while Lactogen 1 packs aredarker. The label is also comparable to thatof Nan, which follows the same design in ashade of green.

The labels of Meiji�s follow-on formulaMeiji Fu are very similar in design to that ofMeiji FMT. About the top half of the Meiji Fulabel is red, the bottom white, with a gold

ribbon dividing. Meiji FMT is white on thetop and red on the bottom with gold andorange bands dividing.

The labels of Nutrilon Follow-on andNutrilon Soya Plus resemble the labels ofall Nutricia formulas. The root name�Nutrilon� is the same as in other Nutriciabrands only the suffix is different. All thelabels contain the same teddy bear andflowers and the feeding bottle is replacedwith a feeding cup. Nutrilon Soya Pluslabels are a darker shade of the samecolour as the Nutrilon Soya labels.

26

Doctors in Pakistan have been notifiedby a Nutricia circular that the companyhas modified the packaging of itsNutrilon range, in an effort to showNutricia�s commitment to follow the lat-est rules and regulations set byPPA/WHO.

The changes include giving theaverage analysis data in the format of atable to make it more readable by med-ical professionals and consumers andremoving the picture of a feeding bottlefrom the packaging of Nutrilon Soya,Nutrilon premium, Almiron and Nenatal.

These �latest rules and regula-tions� mentioned in the circular referapparently to the International Code ofMarketing of Breastmilk Substitutes,adopted in 1981! The InternationalCode in Article 9.2 prohibits labels ofinfant formula from bearing pictures ofinfants or other pictures or text whichmay idealize the use of infant formula.This restriction, in place since 1981,

includes not only the feeding bottlewhich Nutricia has belatedly removedfrom its Nutrilon range labels, but alsothe fluffy teddy bear - easily associatedwith happy, healthy babies, thereby ide-alizing the use of the product - whichthe company failed to remove from itsproduct labels.

The doctors are asked to informmothers of this modification should theyseek their advice.

Too latethe hero!

Feeding bottle companies considerthemselves outside the purview of theCodes and take full liberty with all typesof marketing tactics. Almost all of themhave a baby picture on their pack labels.Shelves filled with feeding bottles at aBahawalpur store. By Ayyaz Kiani

27

aFeeding Fiasco

In contravention of Article 9.1 of theInternational Code and Article 3.1(a) of theSAARC Code, infant food manufacturersmanipulate the text of their product labelsto discourage breastfeeding. One of theeasiest and most effective way to discour-age breastfeeding is to undermine a moth-er�s confidence in her ability to producemilk. This is done through statementswhich suggest that many women areunable to produce enough milk and mustsupplement their milk with formula, or thatunhealthy women can�t breastfeed, or that�sometimes it just doesn�t work out.�

Many labels blatantly suggest thatbreastfeeding may not be possible or that amother�s milk may be insufficient. Wyeth�sS-26 reports that it �is intended to replace

or supplement breastmilk when breastfeed-ing is not possible or is insufficient....� Thelabel of Meiji FMT indicates that this prod-uct is meant for times �when mother�s milkis not available in sufficient quantity.� Onthe label of Abbott�s Similac, mothers aretold: �If breastfeeding is not possible con-sult your medical advisor about usingSimilac as the replacement.�

O-Lac, Mead Johnson would havemothers believe, is the answer to any andall difficulties. �Sometimes doctors adviseto use O-Lac,� the label asserts, �if moth-er�s milk is unavailable or prohibited or ifmore milk is required or infant doesn�t toler-ate lactose.� Likewise, Celia 1 can be used,the label tells us, �when breast-feeding isimpossible.� The corresponding statement

Text of labels

Mincing wordsWhat do the two Codes say?

No idealizing of bottle feeding;Superiority of breastfeedingstatement; Warning of healthhazards and other specifiedinformation, Local languageInternational Code, Article 9

Nothing to discourage breastfeeding;Labels must contain specificwarnings; Local languageSAARC Code, Article 3

Shelves of a baby food shop in Quetta.By TM

in Urdu says the product is suitable �whenmother is not able to providesufficient milk forbaby.� Underthe heading�ImportantAdvice�, itsays itsproductCelia 1 �isused to replace thebreastmilk ...� and that it �supplies thebaby�s requirements and gives him all thenutrients necessary for his development.�In Urdu, too, it says: �Celia 1 is a completesubstitute.�

Several companies were found negli-gent of their responsibility under Article 9.2of the International Code to have on theirinfant formula labels a statement of thesuperiority of breastfeeding. No productcarried the relevant notice that Article3.1(b) of the SAARC Code stipulates mustappear on all designated products. OnMaeil�s Babycare the statement is absent,as it is on labels of Mead Johnson�sEnfalac.

On labels of Enfalac PrematureFormula, Mead Johnson dismisses eventhe possibility of breastfeeding a prematurebaby, making not so much as a mention ofbreastfeeding - much less a statement ofthe superiority of breastfeeding. There is,however, plenty of reference to hospital useof the product and special feeding. �Useaccording to doctor�s advice,� reinforces theimpression of medical endorsement of theproduct.

Breastfeeding continues to be vital toyoung child nutrition up to two years andbeyond. Abbott�s PediaSure, intended foruse by children as young as one year ofage, makes no mention of breastfeeding.Indeed, the product is marketed as a �total

diet replacement or supplement.�Nestlé�s Neslac, marketed for use

from 1 year of age, necessarily replacesthe breastmilk portion of a breastfed youngchild�s diet. Yet its label offers the self-con-tradictory statement: �Neslac is not abreastmilk substitute, but a growing-up milkspecially suited to healthy children from 1year of age.�

Nutricia takes a similar cop-out onlabels of Nutrilon Follow-on: NutrilonFollow-on �is not intended to be used as apartial or total replacement of breastmilkbut should be used exclusively as a part ofthe progressively diversifying menu of yourchild, notwithstanding the prolonged use ofbreastmilk or infant formula.�

The required statement of the superiori-ty of breastfeeding is frequently twisted.References to a �healthy mother�s milk� leavethe false impression in a mother�s mind thatshe should not breastfeed if her diet is lessthan perfect or if she is �weak� or ill.

On Snow Brand�s P7A the statementreads: �Healthy mother�s milk is recognizedas the best for babies.� The very next sen-tence again refers to �well-nourished,healthy mother�s milk.� Meiji FMT makes asubtle presentation: �The milk from a healthymother is the best nutrition for a baby.� Thisstatement, however, does not appear inUrdu. Celia�s version of the required state-ment on its Prep 1 label reads: �Healthy

mother�s milk is the best food for infants�, asit also appears on Morinaga�s Chilmil and

NL-33.The required

statement of thesuperiority of breast-feeding is weak-

ened on both Similacand Sensimil to read:

�Breastfeeding is best forinfants and is recommend-

ed for as long as possible duringinfancy.� The phrase �for as long as possi-ble� informs a mother that inevitably a timewill come when she will no longer be able tobreastfeed her baby. By adding �duringinfancy�, Abbott discourages breastfeedingbeyond one-year, the period which is widelyunderstood as infancy. On labels of Al-110,Nestlé makes the confusing statement:�Breastfeeding is still best for babies.�

Another popular ploy used by infantfood manufacturers is to promote theirproduct as �nutritionally complete�, or �clos-est to mother�s milk.� Inflated claims aboutthe nutritional content or special formula-tions/modifications, or associating the prod-uct with healthy growth or doctor�s endorse-ment create doubts in mothers� mindsabout the quality of their own milk. This ulti-mately discourages breastfeeding and is,therefore, in contravention of Article 9.1 ofthe International Code and Article3.1(a) ofthe SAARC Code.

Nutricia�s Almiron and NutrilonPremium are promoted as being �nutrition-ally complete�, while Nutrilon Soya istermed �complete infant formula.� NutrilonFollow-on suggests that it can complete thenutritional requirements not being metwhen breastmilk is supplemented by solidfoods, implying that breastmilk somehowbecomes inferior after the introduction ofsolids. It

Feeding Fiascoa

28

aFeeding Fiascoalso refers to a �weaning period� - whichindicates the cessation of breastfeeding -between 6 and 12 months of age. Labels ofCelia�s Celia 1 boast that the product hasbeen �Polyvitaminized�.

Farley�s Farex discourages sustainedbreastfeeding by recommending Farex fol-lowed by milk from breast or bottle, where-as breastmilk continues to be the primarysource of nutrition for the first year of lifeand should be given to baby before theirsolid meal. Breastfeeding a baby full ofFarex will result in less stimulation of thebreast, leading to less milk production andan early cessation of breastfeeding. Thissuits Farley�s just fine, as the label says:�When weaning is completed, Farex cancontinue to form the basis of the daily diet.�

The labels of feeding bottles, teats,nipple shields and pacifiers discouragebreastfeeding in contravention of Article 9.1of the International Code and Article 3.1(a)of the SAARC Code by creating theimpression that bottle-feeding is convenientand easy. Manufacturers present safety astheir number one concern and promotetheir products as specially designed withbaby�s health and well being in mind. Kidcofeeders, too, claim to be �non-toxic andtotally safe to use� while Shield productsare labeled �the choice of wise mothers.�

The World Health Assembly takes theposition that most babies need nothingother than breastmilk for about the first sixmonths (WHA 47.5). Most manufacturers,however, suggest mothers introduce com-plementary foods when their babies arefour to six months.

Among the manufacturers and brandsrecommending a premature introduction ofcomplementary foods are Meiji Fu (fromfour to five months), Nestlé�s Lactogen 1(from four months), Nutricia�s Almiron,Nutrilon Premium and Nutrilon Soya (from

four months).Other products themselves are recom-

mended from too early an age, such asFarley�s Farex (from four months, but thelabel also says Farex may be given to babyas early as the fourth month, i.e. from threemonths of age), Farex-veg (from fifthmonth, i.e. from four months), Farley�sFarlac (from four months), Nestlé�s Nestum(from about four months), Nestlé�s Cerelac(from four months, except honey flavorwhich is to be used from six months),Heinz Apple Juice (�strained for infantsfrom four months�, �May also be diluted foryounger infants�), Hero Baby fruit juice(from third month, i.e. from two months).The package design of Heinz Apple Juiceis such that a teat may be attached directlyon the bottleneck for easy serving.

Some companies use the term �wean-ing� to refer to the introduction of comple-mentary foods. While neither theInternational Code nor the SAARC Codeexplicitly forbid the term, it does discouragecontinued breastfeeding by implying thecessation of breastfeeding, not merely theintroduction of semi-solid foods. Nestlé�sLactogen 2 is recommended for use �dur-ing and after weaning� on soft pack labels�from the 6th month� and on 450 gm tins�from the 5th month�, indicating the prema-ture cessation of breastfeeding. Curiously,the label alleges that the product is �not abreastmilk substitute�, but goes on to say itis �designed ... as the liquid part of the diet�- necessarily the breastmilk part of the dietof a breastfed infant or young child.

Labels of Wyeth�s Wysoy are inEnglish only as are the labels of Farley�sFarex. The only Urdu on Maeil�s Babycareand Nestlé�s Al-110 is found on lid inserts,although Al-110 labels find space to includeinstructions in Filipino. The InternationalCode specifies that all required information

29

Tragedyof errorsThe labels of at least one batch ofLactogen 2 were found to carryerroneous information.

Nestlé and other infant formulamanufacturers present the nutrition-al information of their productsunder two headings: �Per 100 g ofpowder� and �Per liter of preparedformula.� Network has come across200g soft packs of Lactogen 2(expiry February 1998, batch #OS6BBS) which carry values for100 ml of prepared formula underthe heading �Per liter of preparedformula.� That is to say, the nutri-tional value provided is actually1/10 the real value.

This error is confirmed fromother 200g soft packs of Lactogen 2manufactured before (expiry August1997) and after (expiry March 1998)the defective packages. These twopackages carry the correct head-ings, and therefore the accuratenutritional value.

Facing page: The four brands that do not havepreparation instructions in Urduproperly placed on tins.

must appear on a label or sticker not easilydetached from the product unit. It is only�additional� product information that may beincluded on package inserts. Similarly,though Celia 1 labels managed to accom-modate English, French and Arabic, onlyminimal information in Urdu is provided --and that, too, on the bottom of the tin!

On many labels, the ingredients, analy-sis and composition are provided in Englishonly. Such is the case with Wyeth�s S-26,Meiji FMT, Meiji FU, Meiji Lactoless,Nutricia�s Nutrilon Premium, Morinaga�sMorinaga BF, NL-33 and Chilmil, Abbott�sIsomil, Sensimil and PediaSure, Nestlé�s Al-110, Lactogen 1, Lactogen 2 and Neslac,Mead Johnson�s Enfalac and O-Lac, Celia�sCelia 1 and Prep-1. Analysis is in Englishonly also on Nestlé�s Nestum and Cerelac.

Maeil�s Babycare provides no list ofingredients. Celia�s Prep-1 fails also to indi-cate the required storage conditions.

Not a single Urdu word appears on thelabels of any feeding bottles, teats andpacifiers except Twinkle. Smuggled babyfoods - the Iranian tin of Nutricia, Rapaksformula from Uzbekistan and Heinz prod-ucts - obviously bear no instructions orwarning in Urdu.

The International Code requires thatthe labels of infant formula contain a warn-ing of the health hazards of inappropriatepreparation. Some products that do carrythe required warning down play the severityof the hazard. Morinaga BF labels, forexample, state: �Misuse may lead to alower level of infant health and nutrition.�

Information for the appropriate use of

the product as required by Article 9.1 of theInternational Code and Article 3.1(c) of theSAARC Code is in many cases insufficientor unclear. Morinaga�s Chilmil, Abbott�sPediaSure and Maeil�s Babycare do nothave any graphics to demonstrate use ofproduct. There are no graphics on thelabels of Farley�s Farlac and Farex orNestlé�s Nestum, while the preparation ofCerelac is demonstrated with photographs.

The SAARC Code requires in Article3.2 that labels of infant formula �indicatethe number of containers of the sameweight required to properly feed an infantfor the first six months of life.� None of thelabels examined provided such information,although several indicated the yield of onetin or how many days one tin may last.

The SAARC Code also requires inArticle 3.1(h) that all labels must �containthe name and address of the manufacturerand of the wholesale distributor if the desig-nated product is an imported item.�

The complete name and address ofneither the manufacturer nor the distributorwas provided on the labels of Wyeth�s S-26,Meiji FMT, Meiji Fu, Meiji Lactoless,Abbott�s Isomil, Nestlé�s Lactogen 2 (450gtin) and Maeil�s Babycare. On Celia�s Prep1, the manufacturers name and address aregiven as is the name but not the address ofthe local distributor (International Brands(Pvt.) Ltd.). Many more manufacturers alsomake no mention of the wholesale distribu-tor. This was the case with Snow Brand�sP7A, Nutricia�s Almiron, Nutrilon Soya,Nutrilon Premium and Nutrilon Follow-on,Morinaga�s Morinaga BF, NL-33, andChilmil, Abbott�s Similac, Sensimil andPediaSure, Mead Johnson�s O-Lac andEnfalac, Celia�s Celia 1.

The addresses of the local manufac-turers of Twinkle teats and Shield evenflowfeeding bottles are incomplete.

Feeding Fiascoa

30

A number of mothers were reported by monitors to be feeding Nestlé�s Nido totheir infants. Even some doctors admitted to prescribing this powder milk, pleadingthat it is cheap and nutritious and that their poor patients could not afford to buyexpensive formulas. Though Nestlé promotes Nido as regular milk for older chil-dren and adults, the company�s warning against its use for younger child readssimply: �However, like liquid fresh milk, it has not been modified for infant feeding.�

Photo: A Nido sponsored sign board of a medical store inside a medicalcomplex in Peshawar. By Dr Mohammad Tanveer

aFeeding Fiasco

Nestlé uses the mass media to promote itsproducts, going against Article 5.1 of theInternational Code and Article 5.1 of theSAARC Code. Television advertisements ofCerelac and Neslac are aired regularly.

One Cerelac advertisement shows amother preparing home foods for her babywhile a modern looking woman tells herthat these foods may not fulfill her baby�s

protein, carbohydrate and vitamin require-ments and that her baby needs a bal-anced diet. �How could I know whether thediet is balanced or not�, asks mother. �Youneed not worry, just start using Cerelac,�is the reply.

The Neslac TV ad emphasizes thatone year of age is some sort of a turningpoint in a baby�s life, and that this is

31

Promotion to mothers through mass media

Loud lies

Left: Kidco's illuminated pole signsalongside a busy road in Karachi.By Tahir MehdiTop: Nestlé Cerelac's newspaperadvertisement offering a free photo framewith every pack.

What do the two Codes say?

No advertising or promotionNo discount coupons, special sales,point-of sale promotionInternational Code, Article 5;SAARC Code, Article 5

Feeding Fiascoa

exactly the time the baby should be put onNeslac.

Nestlé some time ago produced achildcare talk show that was broadcast ona local private channel, NTM. The show,titled �Nestlé sitaron kay chand� (Nestlé:Moons of the stars), invited popular show-biz personalities with their spouses andleading pediatricians to share their per-sonal experiences about childcare. Thediscussion made no direct reference toNestlé products, but short breaks duringthe program were loaded with Nestlé ads.It is another example of companies usingproducts not covered by the InternationalCode to establish a link between childcareand the company name.

Both Cerelac and Neslac are massive-ly advertised in the print media as well. Theads appear in family, fashion and politicalmagazines and daily newspapers.

Nestlé has recently offered one freephoto frame with every 400 gm pack ofCerelac and this is also advertised on TVand in the print media.

A Neslac advertisement in the printmedia compares the product with �ordi-nary� milk and says ordinary milk cannotfulfill the nutritional requirements of 1 to 4years old children. It does not specifywhat is meant by ordinary milk and has no

breastfeeding related warning/importantnotice on it. Neslac ads include a couponthat says, �For free sample fill out thecoupon and mail.�

Nestlé also spends hefty amounts onsponsoring different public events. InRawalpindi Nestlé has been supporting apuppet show for children while it spon-sored the program card of a musical func-tion in Lahore titled �Living Traditions ofMusic in Asia and the Muslim World� heldon April 2-5, 1997. UNESCO supportedthe program, held under the auspices ofPakistan National Council of the Arts.Teams of Nestlé marketing personnelhave been visiting schools promoting thecompany image in general and someproducts like Nido in particular.

Knoll Pharmaceutical�s (formerlyBoots) Farex is also advertised on televi-sion. Some monitors have spotted Farexbillboards as well.

Shield and Kidco run very aggressivepromotional campaigns for their feedingbottles, pacifiers and teats and use everymarketing tactic for the purpose, includingmass media advertising. Both companiesrun ads in local newspapers and journalsand use billboards and illuminated polesigns. Shield also advertises its sootherson the electronic media.

32

Top right: A Shield soothers banner inKarachi. By TMTop left: Neslac advertisement in ajournal with a coupon offering a freesample by post.Bottom: A Farex billboard in Karachi.By TM

aFeeding Fiasco

Direct promotion to mothers is not central tothe formula companies� selling strategies.That is not to say that the companies havestopped approaching mothers altogether.The business potential of talking to mothersface-to-face is too tempting for many com-panies, especially in areas where competi-tion is stiff. They covertly seek contact withmothers (in violation of Article 5.5 of theInternational Code) or camouflage formulapromotion campaigns by putting up frontproducts not covered by the InternationalCode. The companies are very cautious notto leave any footprints.

Boots Pharmaceuticals (now KnollPharmaceuticals) has held healthy babyshows for the promotion of its cereal, Farex.

This was reported from Quetta, Sukkur andDG Khan. The company has printed stan-dard posters with blank spaces for the date,time and place of the show. The companyrepresentative decides the schedule in con-sultation with the hospital administration.The completed poster is pasted at aprominent place in the hospital. Thejury consists of hospital doc-tors whom the companywants to please. Small giftsand samples of baby foodproducts are showered onthe participating mothersat the end of the showwhile the fatter gifts goto the jury (in violation of

33

Promotion to mothers in health facilities

Cautiouswhispers

Left: A mother with the prescribed'treatment' for her ailing little baby in thepediatric ward of District HeadquarterHospital, Sargodha. By Aisha GazdarBottom: COMPANY'S EYE VIEW: Thecaricature of a breastfeeding motherand a photo of a bottle feeding motherin a Meiji information brochure formothers.

What do the two Codes say?

Marketing personnel not to seekdirect contact with mothers; No pro-motion of breastmilk substitutes; Noproduct displays, advertising posters;No gifts, samples to mothers;Information or educational materialsmust contain required informationInternational Code, Articles 5, 6 and 4.2

No promotion of designated prod-ucts; No product displays, advertis-ing posters; No gifts, samples tomothers; Companies not to produceinformation or educational materialsSAARC Code, Article 5

Feeding FiascoaArticles 5.2, 5.4 and 7.3 of the InternationalCode and Articles 4.3, 5.4 and 5.6 of theSAARC Code). The company also hands out(in violation of Article 4.3 of the InternationalCode and Article 5.3 of the SAARC Code)information leaflets and booklets about child-care to mothers.

Similarly, one monitor reported thatCMH (Combined Military Hospital),Bahawalpur had in the recent past organizeda meeting for mothers on preventive health-care. Nestlé donated samples of Cerelac andNestlé Rice in a large quantity for distributionon the occasion, and a doctor demonstratedthe preparation and use of these products tomothers on behalf of Nestlé.

A leading pediatrician of Multan told amonitor that formula company representa-tives had requested that he let them spendten minutes with mothers in his private clinicbut he refused.

Representatives of Nestlé directlyapproach mothers in hospitals and clinics. Amonitor in Quetta witnessed a Nestlé repre-sentative distributing a carload of Cerelacsamples to mothers inside the waiting area ofa private clinic. A former Nestlé representa-tive told Network in an interview that they areasked by the company to approach mothersin the waiting areas of children�s wards, gyne-cology wards and immunization centers andto give them free samples of Cerelac andNestlé Rice. �We are asked to pay extraattention to a mother breastfeeding her childand tell her about Lactogen,� said the formerNestlé rep. �We even wrote �prescriptions� forLactogen 1 or 2 on plain slips of paper andsigned them ourselves.�

The International Code permits informa-tional and educational materials only at therequest and with the written approval of theappropriate government authority (Article 4.3)and stipulates that such materials dealing withinfant feeding and intended to reach mothers

must contain certain information (Article 4.2).It may bear the company�s name or logo, butnot refer to a proprietary product within thescope of the Code. Article 7.2 says informa-tion provided to health professionals regard-ing products within the scope of the Codeshould be restricted to scientific and factualmatters and include the information specifiedin Article 4.2. The SAARC Code in Article 5.3prohibits manufacturers and distributors fromproducing or distributing educational or infor-mation materials relating to infant and youngchild feeding. However, companies producematerials in contravention of these provisions.

Boots (now Knoll) distributes a 24-pageUrdu booklet to mothers titled �Your child�sgrowth: first year with Farex.� It contains noneof the information required by Article 4.2 ofthe International Code and its very existenceis in violation of Article 5.3 of the SAARCCode. The text of the booklet and the packshot on the inside cover specify three monthsas the complementary food age. (Boots sometime ago changed the age to four months onits product labels but has not carried thechange to its promotional literature.) Thoughthe booklet is seemingly a part of the Farexpromotion campaign, careful reading revealsthat the cereal is a mere cover-up, and thebooklet is part of an integrated campaign topromote bottle feeding. Some translatedexcerpts are as follows.

�Father and childTo participate in a child�s upbringing is

also a father�s duty. This duty starts fromyour wife�s pregnancy and continues after-wards. The father should practically partici-pate in changing baby�s clothes, feeding(milk/foods) to him/her on time and bathingthe baby.� (Emphasis added.Ed.) Page 3

�SoothersFormerly it had been a controversy

whether or not to give the baby a soother. Butnow pediatricians and psychologists permit its

34

Top: A Farex baby show poster on thewall of a maternity home in Sukkur.By Azra Talat SaeedBottom: Cover and page 8 of the Farexinformation booklet for mothers.

aFeeding Fiascouse. It gives babies contentment and happi-ness. Soothers have been termed as �secondmother� and �little gymnastic toy�. While usingsoothers keep them clean and never putsugar or honey on them. If possible use twosoothers alternately. The benefit of a sootheris that the children use this little toy for physi-cal exercise and business (or pastime,hobby: Ed). It helps in the growth of cheekmuscles.� Page 6 (A number of studies haveestablished that soothers undermine breast-feeding.)

�Breastfeeding or bottle feedingBreastmilk is best for babies. This is the

natural way. If you are breastfeeding, followthe following simple instructions:

Keep breast clean. Feeding times arenot fixed. The baby sets the timing accordingto his/her need.

Lactating mothers should use fewermedicines, and doctor�s advice must besought before using any medicine.

If for any reason you do not breastfeed,consult doctor to decide which powder milk isbetter for your baby. If you are not breast-feeding your baby, do not harbor any nega-tive feelings in your heart.

The important thing is that the child�shealth is connected to the mother�s content-ment and satisfaction. If, God forbid, you areunhappy and worried, the child will also havesimilar feelings.� Page 8

�Stopping breastfeeding and child�s firstsolid food

The second step in relation to child�sfoods is stopping breastfeeding. The impor-tant thing is it should be done at an appropri-ate and right time. You should neither hurry,nor delay it. This change is essential sincemilk is not a complete diet. Milk lacks iron,which is an important nutrient. Iron makesred blood cells. It has been a custom to stopbreastfeeding when the child is one year orolder (and in this way) there was a possibility

of the child having a shortage of blood andlacking growth.

The age for stopping breastfeeding can-not be fixed as the same for every child. Innormal conditions three, four months is anappropriate age, when the child weighs 7.5kg (15 lbs.).� Page 9

�Mothers should not ignore themselvesMothers have to ignore themselves in

first three months of childcare. If you arebreastfeeding, you have to pay even moreattention and sacrifice a lot more. But slowlyyou can again start paying attention to yourroutine pursuits according to your personalneeds and interests and financial capacity.�(Emphasis added: Ed) Page 21

Though the booklet is ostensibly about acomplementary food, it misguides mothersabout breastfeeding and promotes bottlefeeding and the use of pacifiers/soothers. Itsays that breastfeeding is best but also tellsmothers that bottle feeding isn�t harmfuleither. If mothers are breastfeeding, it asksthem to stop it at three, four months of ageand frightens them by saying their childwould otherwise be deficient in iron andblood. Posing as a neutral adviser the book-let mentions only on the last page that moth-ers should give their babies Farex, but it isvery open about its preference for bottlefeeding. The food schedule for six-month-oldsuggests home prepared foods and �milk inbottle made from 200 gm milk powder.�

Nestlé gives stacks of leaflets of Neslacand Cerelac to doctors in hospitals and pri-vate clinics for distribution to mothers. ANeslac brochure in Urdu directly addressingmothers does not mention the age from whichmothers could start giving this milk product totheir babies. It starts by informing them thatthe first four years in the life of their child arevery important and then lists all the greatnutrients that Neslac has. The leaflet has agrowth chart printed on the back and says it

35

Top: Nestlé Lactogen 1 informationleaflet for mothers with a packshot. Bottom: Cover of a single-fold leafletof Neslac for mothers that does notmention the age from which mothersshould start giving their babies theproduct.

Feeding Fiascoahas the approval of the Pakistan PediatricAssociation, which is not the appropriate gov-ernment authority referred to in Article 4.3.

Another Neslac leaflet asks parents togive their child this wonderful gift on his/herfirst birthday. It does not contain the informa-tion required by Article 4.2 of the InternationalCode and compares Neslac with fresh animalmilk as if at one year of age, breastfeedinghas long since ceased. The promotionalmaterials of Neslac suggest that a one-year-old child is too old to be breastfed or thatbreastfeeding is only suitable for infants a fewmonths of age.

The promotional brochures of Cerelac,which has been sub-titled by the company�Infant Milk Cereal� (emphasis added: Ed), donot contain the information required by Article4.2 and promote the use of the product frombelow six months of age. They also directlyattack home-made foods and create doubtsabout the protein, vitamin and other nutrition-al contents of these foods.

Nestlé leaflets containing informationabout using infant formulas Lactogen 1 andAl-110 are distributed to mothers through hos-pitals and clinics. These brochures are alsodistributed by company representatives direct-ly to mothers and all of these clearly refer totheir products and contain pack-shots, in vio-lation of Article 4.3 of the International Codeand Article 5.3 of the SAARC Code.

A Meiji FMT brochure is vicious inapproach and is a cruel joke with breast-feeding mothers. The eight-page brochure inEnglish is promotional in all regards. On thecover it says: �Meiji FMT Quick dissolving,Taurine enriched infant formula.� It offersmothers six simple indicators to determinewhether or not their breastmilk is sufficientfor their babies, such as �Breast not full� and�Baby is cranky.� The brochure lists tensalient features of Meiji FMT that includeFMT�s comparison with mother�s and cow�s

milks. The brochure contains formula prepa-ration details, cautions and feeding scheduletitled: �Smart ways to feed baby�. It has apictorial section that boasts of Meiji�sresearch and development excellence andindustrial superiority.

The inside cover has two paragraphsarranged side by side. The first one titled�Babies love mother�s breast milk. Healthybreast milk gives baby the ideal nutrition�,praises the breastfeeding practice. The fac-ing paragraph is titled: �A mother�s �peace ofmind� is the most important thing� and readsas follows: �Sometimes breast-feeding justdoesn�t go the way you want. You want tobreast-feed your baby, you try to start butyou just can�t get any milk. The baby is cry-ing and the mother is flustered. She�s reallyworried because she doesn�t know whetherthe milk will come out sufficiently. Infant for-mula was made for those times. One ofthese infant formulas is Meiji FMT Soft CurdPowdered Milk. It�s manufactured accordingto the latest findings in the composition ofmother�s milk, so you can rest assured. Ababy loves its mother�s smile.�

Wyeth distributes a �child growth recordcard� to mothers through doctors and direct-ly. This single-fold card has a baby picturewith a Promil tin image on the back. TheUrdu text of the card is addressed to moth-ers, saying: �Promil, Milk full of protein forchildren of six months of age and older.�Inside, the card says: �Your child�s care - tothe road to better health.� The card hasspaces for writing dates for a child�s firsts.One section of the card titled �Food card�has From and To blanks to be filled in forbreastfeeding, infant formula, follow-on for-mula and cereals.Unlike Europe or America,people in Pakistan do not keep date recordsof their child�s firsts. As such, this card hasno gift value for any mother, but it does havepromotional value for the company.

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Nestlé Al 110's information leaflet formothers with a packshot on thecover.

aFeeding Fiasco

Six hundred and sixty-two mothers wereinterviewed in hospitals and private clinics in33 cities and towns during the monitoring.Their babies ranged in age from one day toaround two years. Though the exercise wasdesigned primarily as a qualitative and notquantitative assessment, it did generatesome data that could help understand thestatus of breastfeeding and the effects ofpromotion of artificial baby foods in Pakistan.

Eighty mothers (13.3 per cent) saidtheir babies were receiving breastmilk sub-stitutes only and were not being breastfed atall. Not all of them had been given breast-

milk substitutes since birth. Another 66mothers (10 per cent) told monitors that theywere giving their babies both breastmilk sub-stitutes and breastmilk.

This means that 23.3 per cent (154) oraround every fourth mother was giving herbaby breastmilk substitutes either exclusive-ly or partially.

Many monitors reported that a numberof mothers were giving their babies freshmilk of cows, buffaloes or goats either exclu-sively or in addition to breastmilk. The moni-toring forms did not specifically ask aboutthe use of fresh milk, yet 62 mothers said

they were giving fresh animal milk in addi-tion to breastmilk while 16 told monitors thattheir babies were receiving animal milk only.Another five said their doctors had pre-scribed formulas but they had switched tofresh animal milk for economic reasons. Thisillustrates the real problem: unethical mar-keting of breastmilk substitutes has encour-aged mothers to stop breastfeeding in thefirst place, and when they find they can�tafford the formula, they use fresh animalmilk. Additionally, the promotion of milk for-mula encourages a bottle feeding culture inwhich the use of fresh animal milk is also

37

What do mothers say?

Under a demon�s shadow

Three out of every four mothers inPakistan cannot read or write. Motherswith sick babies queue at a children'sclinic in Multan.By Samina Zafar

Feeding Fiascoaacceptable. Many monitors felt that ifthe animal milk option had beenincluded in the forms these figureswould have been much higher.

�Not enough milk� was the rea-son for not breastfeeding given by65 (42.2 per cent) of 154 mothersusing formula milk exclusively or par-tially. But this reason held true morefor mothers giving both formula andbreastmilk than for mothers relyingentirely on formula - 29 of 88 infantformula-only mothers said either theydidn�t have breastmilk at all (11) orthat the supply was not enough (18),while 36 of 66 mothers giving bothfeeds complained of insufficient milk.

Twenty-eight of a total 154mothers (18.2 per cent) using infantformula said they had been asked bydoctors to do so and did not furtherelaborate on any personal reasonsfor using infant formulas.

Besides the myth of not-enough-milk, another concept seemsto be quite common and an importantfactor in deciding the type of feed thebaby would be given: that a mother�smilk does not suit her baby. This rea-son is cited in exactly these words bysome mothers, while others wouldsay that their milk is not good, it usedto upset the baby�s stomach or thebaby used to cry �a lot� and so theystopped breastfeeding or started giv-ing supplementary formula feeds. Atotal of 16 mothers (10.4 per cent) of154 mentioned the doesn�t-suit-babyfactor for their decision to use formu-las. Two mothers even said that theirmilk was poisonous.

But perhaps more astonishingis the fact that any type of sicknessof either mother or child increases

the chances of a mother resorting toformulas. Thirty-three of 154 mothers(21.4 per cent) fell in this category.Out of these, 16 said they startedgiving their baby formula milkbecause the baby got sick and thedoctor prescribed formula feeding.(In two of these cases because thebaby had diarrhea). Five (of 33)mothers put their babies on artificialfeeding on a doctor�s suggestionsince they themselves were weak.Eight mothers stopped breastfeedingafter getting sick and being asked bya doctor to do so. Another six justi-fied their decisions by saying theirbabies had been born through oper-ations. It was the common observa-tion of many monitors that doctorsand families consider breastfeedingimpossible if mothers have deliveredby caesarean section.

Six (3.9 per cent) of 154 moth-ers using formulas were doing sobecause they were pregnant again orhad two babies of breastfeeding age.Two babies were not receivingbreastmilk because their mothershad died. Another two mothers saidthey were working women and foundit hard to manage breastfeeding andwork. One mother flatly said she wasnot interested in breastfeeding, whileanother said she was giving her babyformula because it was available toher free. She did not elaborate.Some women from NWFP said theycannot breastfeed their babies asthey are under a demon�s shadow.

The medical profession plays avital role in directing the family aboutthe brand of formula they should feedtheir babies. The majority mothers,76 per cent (117 of 154), said they

38

eign concepts of development and is anact that even poorer classes havelearned to follow. The bottle is used tofeed animal milk, water, tea or any otherliquid food.

were using a particular brand of formula ontheir doctor�s recommendation. 7.1 per cent(11) accepted a brand on a relative�s sug-gestion and 5.8 per cent (9) were loyal to abrand since it �suited� their baby. Two saidthey chose the brand because it was cheap,

while one said she did so because it isexpensive and must be very good. Themother of a five-and-a-half-month-old babysaid she was giving her baby Nido (wholemilk powder) as she had been impressed byits TV advertisement. Thirteen others gave

different reasons for their brand selection.Four hundred and twenty-five mothers

responded to the question about when theywould/did start feeding their babies some-thing other than breastmilk. Out of these 360could give answers in terms of months, while

aFeeding Fiasco

39

An actof shame?Over the past few decades breastfeedinghas become an act of embarrassment, evenshame, for the women of middle-class inPakistan. In the words of a gynecologist ofa posh private hospital in Lahore, �It�s amatter of common decency (not to breast-feed in public). It�s something like you coveryour mouth with your hand while using atoothpick.� Even inside homes mothers aresupposed to breastfeed while covered witha big piece of cloth - a �chaddar� - if they arenot breastfeeding behind closed doors.

But this sense of shame is still not verystrong in women of poorer classes, espe-cially of rural areas. A male doctor workingin the pediatrics ward of a government hos-pital in Quetta, which is considered a rela-tively more conservative area of Pakistan,says, �The women from rural areas some-times do things that make us blush. Once Iwent to the gynecology ward to ask a moth-er admitted there to express her milk andsend it to the ward for her baby. She imme-diately pulled up her shirt in the presence ofher male family members and handed me acup full in a few minutes.�

The feeding bottle, however, hasbecome one of the many symbols of statusthat the society has imported with the for-

AGAINST ALL ODDS: A dry fruit ven-dor breastfeeds her baby on a busyKarachi sidewalk. By Tahir Mehdi

65 used phrases like �when the baby getsbigger� or �when the baby demands foods�.An overwhelming 74.7 per cent of women(269) said they had started or planned tostart giving their babies semi-solids at four tosix months of age. A further break down isas under:After four months 161 44.7%After five months 41 11.4%At around six months 67 18.6%

Thirty-five (9.7 per cent) of 360 motherstold monitors that they had (or would) puttheir babies on semi-solids before the age offour months while 56 (15.6 per cent) saidthey had done (or would do) so after the ageof six months. Of these 56, 32 (8.9 per centof total 360) said they would start giving theirbabies complementary foods after one yearof age. The majority of these mothersbelonged to rural areas of Sindh.

A total of 378 mothers replied to thequestion about what they would feed theirbabies as complementary food. Of these,245 (64.8 per cent) named only traditionalbaby foods like kichhery, halwa, kheer, cus-

tard or fruits like banana. While 112 mothers(29.6 per cent) named packaged foods(Cerelac and Farex) either along the tradi-tional foods or alone, 21 mothers (5.6 percent) named cow, buffalo or goat milk as acomplementary food.

The question about how long theywould breastfeed was answered by 348mothers. Of these, 62 (17.8 per cent) saidthey would breastfeed their babies for lessthan two years. Except two, all of the moth-ers planned to breastfeed at least for a year.The majority, 215 mothers (61.8 per cent)planned to continue breastfeeding for twoyears, and 46 (13.2 per cent) wanted to con-tinue beyond the two-year mark. Two moth-ers said they would breastfeed until the babywas five years old.

Twenty-five mothers (7.2 per cent) didnot have a clear idea about how long theywould breastfeed and responded in terms of�as long as possible�, �as long as the childwants to� or �as long as I have the breast-milk.�

Reasons for breastfeeding (exclusively

or partially) were offered by 429 mothers. Ofthese, 224 (52.2 per cent) were convincedthat breastfeeding was the best way to feedtheir baby or that breastmilk is good for chil-dren. Seventy out of 224 (31.25 per cent)believed breastmilk was good for theirbaby�s health, that it was very nutritious orthat it was very energizing/powerful. Twoothers believed that breastmilk helped babyfight disease and four valued it for beinggerm-free. Two mothers cited the conven-ience of breastfeeding as the reason fortheir choice while two others said the breast-milk suits their babies.

One hundred and four of 429 (24.2 percent) did not directly refer to any benefit ofbreastmilk and said they were breastfeedingbecause it was a custom. Some made state-ments like: �all women in our family breast-feed� or �I breastfed my other children aswell.� Thirty responded as if they were sur-prised by the question and simply said,�because we do so.� A few quipped, �If notbreastmilk what else can we give?� Onemonitor reported a woman replying: �Can wemake our children eat grass?�

Thirteen women said they were breast-feeding their baby on the advice of theirmothers/mothers-in-law. Another three saidit was their duty as mothers and three morewere obliged since it was their child�s right.Eight women told monitors they were breast-feeding because it was in their religion.

Fifty-six of 429 (13 per cent) motherswere breastfeeding following their doctors�advice. The majority of these mothers wasfrom northern Sindh. Three mothers wereconvinced by television advertisementsabout breastfeeding.

Nine said they were breastfeeding theirbabies because they were poor and couldn�tafford to buy formulas, while one mothersaid she was breastfeeding to ensure thather baby remained hers.

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Any type of sickness of either mother or child increases the chances of a motherresorting to formulas. Two mothers 'suffering from not-enough-milk syndrome' andprescribed Lactogen 1 and Meiji FMT by doctors at Nishtar Hospital, Multan. BySamina Zafar

aFeeding Fiasco

Almost every company marketing its prod-ucts in Pakistan has posters, wall calen-dars and wall clocks displayed in hospitalsand clinics. All of them have companynames and, or logos, product names orproduct pictures.

Monitors visited 151 private clinicsand 66 private and government hospitals(217 health facilities). They spotted 185posters and wall calendars from formulacompanies in 91 health facilities. This

means two health facilities in five have onaverage two publicly displayed visualsassociated with formula companies. Or,there were 17 formula company postersfor every 20 clinics/hospitals.

An assistant professor in Balochistanhad eleven posters and wall calendars offormula companies in his 10�X12� inspec-tion room at his private clinic.

Posters and other company associat-ed visuals can be found anywhere inside a

41

Promotion in health facilities:Posters, wall clocks and other displayed visuals

Writing on the wall

Left: CORPORATE CORRIDORS:Mothers in the waiting area of one ofMultan's popular pediatrician's clinic.By Samina ZafarTop: Nestlé growth chart with Cerelacand Neslac logos 'decorates' manywalls in health facilities.

What do the two Codes say?

No promotion of breastmilksubstitutesNo product displaysNo advertising postersNo gifts to health workersInternational Code, Articles 6 and 7.3;SAARC Code, Article 5

Feeding Fiascoa

health facility: in waiting areas, in lobbies,in inspection rooms, in pediatric wards,gynecology wards, doctors rooms, nursescounters and even in dispensaries.

All bear company names. Meiji doesnot need to put anything other than itsname on posters since the company nameis also part of its brand names, i.e. MeijiFMT and Meiji Fu. Some Meiji posters alsohave the name and logo of the distributor,

Geofman, suggesting that Geofman arethe manufacturers and Meiji is the product.Meiji and Snow Brand specialize in pro-ducing posters and wall calendars showinghealthy and happy, chubby Japanesebabies. Doctors cherish these visualssince babies with Chinese or Japanesefeatures are generally considered cute inPakistan. Many doctors mount pages fromthese calendars for permanent

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NestléYour four-month-old baby needs protein, carbohydrates, fats, vitaminsand mineralsso that s/he triples her/his weight in thefirst year.

S/he needs a balanced, rich and solidmeal every time so that she/he remainsactive.It is impossible to achieve this balancewith traditional foods.

A Pakistani motherBut I have been giving him/her only por-ridge, bananas, eggs, bread and fruits.

Triple his/her weight? I have no idea aboutthat, but s/he is sure not as healthy as Iwant him/her to be.That is exactly what I want.

Oh, my God!

Start giving your baby the rich food Cerelac from today.

Right: A Chilmil poster marks the pedi-atric ward of a government hospital inDadu. By Azra Talat SaeedTop: THE IRONY: Mead Johnson makesa hoax call to scare mothers frombreastfeeding - and that, too, 'as ahealth service to community'.

aFeeding Fiascodisplay in their clinics.

Mead Johnson posters were mostspotted by the monitors. One of theseposters, which was accepted by evenstaunch supporters of breastfeeding,shows a mother breastfeeding with thecaption: �A gift of love. Every babydeserves the best. Mead Johnson. Aworld leader in nutrition.�

Another Mead Johnson poster, how-ever, takes a more direct approach. Itsays on top: �An important message formothers. Iron: an important element forthe proper nutrition of infants and chil-dren.� The first two paragraphs tell moth-ers that iron deficiency at levels less thanobvious anemia can have long termadverse effects on learning ability andscholastic achievement. Then it says thatbreastfed babies could develop iron defi-ciency after four months and suggestsmothers consult their doctors on �suitablesupplements.� It advises mothers feedingtheir babies formula to switch to an ironfortified formula after four months in con-sultation with doctors. It also warns moth-ers that cow or buffalo milk can causeiron deficiency too and quotes theAmerican Academy of Pediatrics as say-ing, �The only acceptable alternative tobreastmilk is iron-fortified infant formula.�

The message of the poster is confus-ing: first it says breastmilk cannot fulfill ababy�s iron requirement, but then it saysonly an iron-fortified formula could be asuitable substitute for (iron rich?) breast-milk. Moreover, this is sheer scare mon-gering. If mothers were simply told to startgiving their babies complementary homefoods from six months of age, there wouldbe no need for wholesale, medicalizediron supplementation. There certainlywould be no need for a formula companyto provide this type of �educational

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Clockwise from bottom:Meiji provides clinics the much indemand happy, chubby looks. AMeiji poster in a Rahim Yar Khanhospital. By Shamim Bano

Nestlé Neslac's Ninja Turtle standsguard in the pediatric ward ofCombined Military Hospital,Bahawalpur. By Ayyaz Kiani

A Morinaga height measuringscale in a mission hospital inQuetta. By Tahir Mehdi

Sowing doubts, reaping profits. ANeslac poster asks mothersquestions about their children'snutritional needs.

A Snow Brand wall calendar.

material as a service to the community.�The messages in these posters are

subliminal. They associate �gifts of love�and �quality of life� with �a world leader innutrition� and not with the world leader inchild nutrition - mothers.

Mead Johnson also distributes for dis-play in health facilities four cardboardcutouts with cartoons and pack shots ofSustagen Junior. The colorful cutouts to bestuck on walls and windows also bear a�community health message by courtesy ofMead Johnson nutritionals�, like �Early tosleep. Early to rise.� Through these cutouts,which appeal to children in their design,Mead Johnson has taken its marketing strat-egy a step further. The company is targetingchildren directly to promote its product. Itrecommends Sustagen for children agedone to four years, which discourages breast-feeding up to two years of age and beyond.

Neslac posters in Urdu tell mothersthat this Nestlé product is ideally suited tochildren of one to four years of age andthat �ordinary milk� lacks iron, which isvital to the health of child of this age. Thesuggestion to put one-year-old child onNeslac discourages breastfeeding up tothe age of two years or beyond.

Nestlé has adopted a double-edgedmarketing strategy for Neslac. It pretendsthat Neslac has nothing to do with any ofthe marketing Codes and that it�s a sim-ple, non-medical consumer item. Thus, itis promoted at points of sale and throughmass media. But, on the other hand,Neslac is promoted in health facilities as amedically indicated product, and doctorsare asked to prescribe it to mothers.Neslac posters are displayed in children�sand gynecology wards and waiting areasfor mothers. Nestlé has also produced aheight-measuring meter shaped as a bigNinja Turtle cardboard cut-out holding a

Neslac flag. Neslac wall clocks were alsoreported by a number of monitors.

Even doctors who have otherwise highclaims about being �baby-friendly� acceptCerelac posters. These have a clock in onecorner as well. The Urdu version of theposter is malicious. Between the lines it tellsa mother that there is no way she can giveher child a balanced diet, if she doesn�t givehim/her Cerelac. It uses thick scientific jar-gon to impress mothers.

The background of the Cerelac posterhas a stethoscope in watermark that sug-gests the message is endorsed by medicalscience.

Nestlé has widely distributed growthcharts with the Neslac and Cerelac logos.Many doctors receive these charts alreadyframed.

Morinaga�s poster of Chilmil has apack shot beside a photo of a happymother and healthy baby. The poster alsohas a Morinaga logo printed on the topcorner. Many illiterate mothers describeMorinaga products by its logo, calling it�the tin with a cow face on it�. Morinagahas also distributed height-measuringmeters with images of the Chilmil tin andthe company logo. Some doctors get themmounted.

Feeding Fiascoa

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Clocks are ideal eye-catchers. Whether or not a poster gets the attention of a viewerdepends upon its design, yet clocks can catch your sight even if they are unattrac-tive. You may need to look at the clock many times while waiting in a queue at a clin-ic or a hospital. Every time you check the time, the company name, logo or productname sneaks into your mind along with a brisk and subtle message.

Photos: Neslac wall clock in a private clinic in Lahore. (By Ghazala Khizar)Inset: Meiji and Mead Johnson wall clocks.

aFeeding Fiasco

In Pakistan it is a custom that the bride�sfamily gifts everything a bridegroom wearson his wedding day. The more caring (andrich) the bride�s family, the more preciousthings the bridegroom receives. It seems thatformula companies in Pakistan have takenextra care of this custom in their marriage ofconvenience with the health professionals.

From cufflinks to lipstick cases, fromtableware to refrigerators and dish antennas,from birthday bashes to joyrides to Japanand from funding daily tea clubs to sponsor-ing �scientific seminars�, formula companiesare ready to heap any favor upon the health

professionals. Most doctors happily acceptanything and everything. Some feel guilty orshy when questioned about this arrange-ment, while others defend it as their right.Some are famous among company circlesas �extortionists�, while others are annoyedat being ignored by the companies.

A doctor in Faisalabad who failed tograsp the idea of monitoring asked the mon-itor to inform the formula company reps. tonow visit him in that hospital, saying: �I havelost contact with them since I joined thishospital six months back.�

A lady doctor in Quetta informed a

45

Gifts for health professionals

A marriage ofconvenience

Left: COOL FAVORS: A doctor's room ina big private hospital of Multan with arefrigerator donated by Meiji.By Samina ZafarBottom: A Mead Johnson Enfalac book-mark.

What do the two Codes say?

No gifts to health workersInternational Code, Article 7.3SAARC Code, Article 5.4

Feeding Fiascoamonitor that for the last three years, the firstthing she receives on the morning of herbirthday is a gift from Morinaga deliveredpersonally by its representative. �Once I gota bathroom set, once a decoration time-piece, and last time I received two decora-tive trays with some Japanese written onthem. A Japanese nun working in our hospi-tal read it for me and said it was reallyexpensive stuff�, the lady doctor said.

Other doctors, however, were not soopen. But it�s not easy for doctors to hidesuch things either. Nurses and other staffmembers generally spill the beans as theyfeel left out of this great gift game.

While the International Code does per-mit donations of equipment and materialsbearing a company�s name or logo (Article6.8), the SAARC Code does not (Article5.5). In any case, doctors or health carefacilities receiving such donations then feelobliged to pay back the company in theshape of prescriptions or promotion for thatcompany�s products. In some cases, thecompany name is similar to the productname, which is not permitted to appear ondonated equipment.

Monitors in Multan found a refrigeratorin a doctor�s room in Medicare Hospitallabeled, �With compliments from Meiji.� Thestaff of a government maternity hospital inPeshawar informed monitors they hadreceived a refrigerator from Morinaga buthad later removed the company name fromthe gift. A monitor in Khyber Agency discov-ered that a doctor had received a refrigera-tor, a TV and a dish antenna from a compa-ny. Meiji has funded clinic signboards inMultan. A weighing machine donated byMeiji was reported from Multan and anotherby Morinaga from Peshawar. Two maternityhomes in Bahawalpur admitted they hadreceived surgical equipment like scissorsfrom Mead Johnson.

46

Clockwise from top left:THE BOOTY: A Farex tea coaster; aPeshawar doctor�s table with threeMorinaga prescription pads (By Dr MTanveer); a Morinaga weighing scale; aCerelac table clock; a Snow Brand tis-sue paper pocket pack; an Ostermilkobstetric calendar and an O-Lac keyring; Nestum tongue depressors.

aFeeding Fiasco

47

The party thatwasn�t over!The monitoring team in Multan came backwith an interesting story. One team mem-ber narrates:

�On the morning of March sixth, wevisited Nishtar Hospital. As decided, one ofus went into the doctors� room, and theother two started roaming around to inter-view mothers and staff members and tolook for posters and other things. Severalstaff members told these two monitors thatthere was going to be a tea party in a hospi-tal room in a few minutes and that Meiji hadthrown it. (These employees were not invit-ed.) So the two monitors decided to stopinterviews until after the party started so thatnobody would get conscious about monitor-ing and we could witness the party first-hand. We saw the party venue with tablesfull of snacks, but we were unable to com-municate our decision to our third partner inthe doctors� room. Meanwhile, during theinterview the doctors realized it was not thebest day to boast of their pro-breastfeedingdeeds. We witnessed a flurry of activity,doctors whispering in each other�s ears andgoing out and coming back in. Finally, theytold us it was the birthday of one of their col-leagues and they had arranged a party.They invited us as guests. One of the doc-tors pretended he was celebrating his birth-day and cut the cake. They kept exchangingsecret smiles during the party. Other staffmembers later confirmed it had been a Meijiparty and that the company rep. whoarranged the party had been asked by thedoctors at the last moment to slip out quick-ly through a back door.�

Nestlé distributes scores of dispos-able tongue depressors to all doctors,regardless of their speciality. The wrap-per announces that Nestum has beenrenamed Nestlé Rice. This gimmick, withone of their most benign baby food prod-ucts as the cover, places the Nestléname at the front of the doctor�s mind(and on the tip of the patient�s tongue!). Itis a goodwill gesture to the doctors andpart of the larger strategy of makinginroads into the doctors� community.

Health workers also receive as giftspromotional Farex coasters as well asOstermilk obstetric calculators. Farexstickers with the slogan, �You are my littledarling, so I should help you grow well�adorn many a health facility in the plainview of mothers.

Health workers receive as gifts O-Lac key chains, Mead Johnson desk cal-endars and Enfalac bookmarks whichsay, �Enfalac ... When Growth andDevelopment Really matter�, as if therewere times when growth and develop-ment didn�t matter.

Prescription pads, tissue papers,pens, torches and key chains are consid-ered cheap and are showered on doctorsduring every visit. The largess is alsoextended to nurses and other staff mem-bers. Junior doctors, medical studentsand doctors on house jobs as well areoffered a share of the booty.

There are numerous reports of com-panies providing office supplies and print-ing services to resource starved hospi-tals. For example, a pediatrician posted ina government hospital in Kalat, a veryremote part of Balochistan, claims hesees almost 250 to 300 patients a day. �Ineed almost 7,000 prescription slipsevery month. It is impossible to get thesefrom the (health) department alone,� said

the doctor. Companies do not hesitate tofill the gap.

The covers of Morinaga prescriptionpads are dedicated to the promotion ofone of its products. But each of the insidepages, which go to mothers, bears thename, logo and catch line of one of fourdifferent products. One prescription padcover claims that Morinaga BF infant for-mula is humanized and gentle on theimmature kidneys of a baby. Anotherrings alarm bells for babies with diarrhea.It highlights five �realities� that are oftenignored. The first is that �carbohydrateintolerance was found in 78% of infantswith acute gastro-enteritis�, quoted from astudy conducted in 1970!

A number of monitors reported for-mula companies arranging different typesof gatherings for doctors. Meiji is notori-ous with regard to this form of promotionto health professionals. Besides routinetea parties, the company also arrangesIftar parties to break the fast during theIslamic month of Ramazan and Eid par-ties to celebrate the conclusion of fasting.

There are also numerous reports offormula companies holding seminars forhealth professionals or sponsoring travel,boarding, lodging and registration in othernational and international conferences.Nestlé held a seminar on �general updateon child diseases� in November 1996,reported doctors in Dadu. Nestlé alsoorganized a training workshop on diar-rhea in Islamabad for pediatricians.Morinaga and Meiji are also well into thiskind of sponsorship. Morinaga flew a doc-tor from Peshawar to Japan on a leisuretrip. Meiji is also keen to make this kindof �investment� and has taken a numberof doctors to Japan.

Meiji�s Japanese official visitedSargodha around Eid and spoke Urdu.

Doctors welcomed him as a guest who hadcome from a distant country.

The International Code does not pro-hibit companies from sponsoring confer-ences and so on, however, doctors on thereceiving end feel obligated to repay thecompany�s generosity. Leisure travel andother financial or material inducementsare not permitted under theInternational Code (Article 7.3). TheSAARC Code prohibits in Article 5.6 allbenefits including but not limited to fellow-ships and funding for attendance of meet-ings, seminars and conferences.

Formula companies also make it easyfor lower ranking health workers to prescribetheir products. A monitor from Peshawarreported that vaccinators in big hospitals aregiven stacks of small slips printed with for-mula prescriptions for distribution to moth-ers. A doctor at the Lactation ManagementCentre of Hayat Shaheed TeachingHospital, Peshawar was disturbed by thecompanies� attempts to make inroadsthrough juniors. She was especially critical

of Morinaga for unethical promotional prac-tices and accused formula companies ofheaping gifts on junior doctors and even

vaccinatorsin order to

pushtheir products.

Monitors submitted four slips with print-ed prescriptions. Cerelac and Farex slipsbear only the product names and a slogan,i.e. �First step in solid food� and �Baby�s firstsolid food�, respectively. Morinaga slips,however, had more details provided in Urdu.�Mix one spoon of NL-33 in an ounce of

water and give it your child suffering fromdiarrhea and wash the bottle with hot water,�says the NL-33 slip. This is the height of cal-lousness and an example of extremely irre-sponsible marketing. Morinaga is promotingits lactose-free formula as if it is a cure fordiarrhea. The instructions for preparation areso vague that they can only further spoil thehealth of an innocent child who is alreadyengaged in a tough battle against diarrhea.More than a quarter of infant mortality in

Pakistan is caused by diarrhea. ProbablyDr. Cicely Williams had witnessed sucha situation in 1939 when she said, � ...

misguided propaganda on infant feedingshould be punished as the most criminalform of sedition and these deaths should beregarded as murder.�

Morinaga�s printed slips for Chilmil addinsult to injury. They suggests in Urdu: �Mixfour spoons in a glass of water and give topregnant women, before and after pregnan-cy, three times a day�! One can�t help butconclude that the companies value profit,and only profit, whatever way it comes.

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In hospital after hospital, clinic after clinic, doctors are confiscat-ing pacifiers from the mouths of their young patients. The paci-fiers are then linked together in chains and displayed on the wall,a powerful visual of a filthy and potentially deadly practice.

These pacifier chains are also a reminder that without con-stant marketing pressure, doctors can and will do what is in thebest interest of their patients. Without the pressures of sales rep-resentatives and their promotional tactics, doctors are free to actagainst the wishes of pacifier manufacturers by instructing theirpatients not to use pacifiers.

When the representatives of artificial baby milk manufactur-ers are allowed access to health care facilities and health careprofessionals, doctors become marketing tools - puppets, if youwill - in the hands of the baby food industry. Incentives offered to

doctors do nothing to better infant and child health, but plenty tocompromise professional judgement.

Denying infant formula companies access to the health caresystem allows doctors to serve the best interests of their patients.

Photo: A soother chain in a Quetta hospital washroom. TM

Soother chains

aFeeding Fiasco

Information brochures for health workersor detailing materials use science as acover-up. In total disregard of both theInternational Code and the SAARC Code,they are used to promote and idealize arti-ficial feeding. Few carry the informationrequired by Article 4.2 of the International

Code. None are restricted to scientific andfactual matters and many make compar-isons between the product and mother�smilk (forbidden under Article 7.2). Theirvery existence in contravention of Article5.3 of the SAARC Code.

The detailing materials for Nutricia

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Information brochures for health workers

Advertisementsin disguise

Left: Meiji detailing material displayed ina private hospital's pharmacy in Quetta.By TMRight: THE SCIENCE OF MARKETING:Cover of a Mead Johnson informationbrochure for health professionals that issupposed to contain only scientificinformation.

What do the two Codes say?

Information must be restricted toscientific and factual matters;Must not create a belief that bottlefeeding is equivalent to breastfeed-ing.International Code, Articles 7.2, 4.2

Companies not to produce informa-tion or educational materials.SAARC Code, Article 5.3

Feeding Fiascoa

Cow & Gate products feature large infantphotos and pack shots - far from scientificand factual. The required information iseither absent or incomplete. The material forNutrilon Follow-on recommends weaningfrom four months of age and the use ofNutrilon follow-on from six months. It alsocontains pack shots and a comparison ofthe product to breastmilk. The company alsoproduces a �Nutritional Newsletter� series,which is nothing short of an advertisement indisguise. Each �newsletter� promotes a dif-ferent product with regard to a specifiedtopic; for example, weaning is discussedalongside promotion of Nutrilon Follow-on.For the busy professional, Nutricia offers �aquarterly literature review of recent researchas an updating-aid�, in the shape of an�Abstract Service.� Nutricia warns its read-ers, �Every professional must reach his/herown conclusions, and in a dynamic sciencesuch as nutrition, continuing controversy is asign of continuing progress.�

Detailing material for Snow Brand�sP7A compares breastfed infants with P7Ainfants and P7A with colostrum and maturemother�s milk. A Meiji-FMT brochure setsthe record by making nine comparisons to

breastmilk and breastfed infants on onepage. The last page of the brochure pro-vides, among others, these cautions:�Infant formula Meiji-FMT is made for sup-plementing shortages when the motherdoesn�t have enough milk or when she can-not breastfeed the baby.�

Morinaga prescription pads providedto doctors come with various covers, eachhighlighting an indication for a Morinagaproduct and making numerous claims. Forexample, �Avoid renal hazard with human-ized Morinaga BF�, �where top-feeding ismedically indicated�, �NL-33 breaks thevicious cycle of diarrhea-malnutrition-diar-rhea�, �... can be used as a replacement forinfant formula.�

The cover of a brochure about Chilmilasks, �In cases of infant malnutrition whichis a better choice?� The options are�Vitamin supplement or ... complete nutri-tion with all the essential vitamins andminerals through Morinaga Chilmil.�

A pamphlet about Morinaga BF-Pcompares the product with colostrum andbreastmilk. Drawings of an infant and aninfant with its parents adorn the covers of

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Left: Nutrilon tailors scientificinformation to suit its marketingstrategy. Centre: NO KIDDING: Covers ofMorinaga's story books for children?No. Covers of folders having scientificand 'professional information' aboutMorinaga products. Right: HUE AND CRY: Nestlé's detailingmaterial for Lactogen 1 tells doctors itprevents 'iron deficiency and is themost economical formula in the market.

aFeeding Fiasco

�Morinaga infant care product line� cards.Inside, pack shots take up half of eachpage, while the text makes comparisonswith breastmilk.

�Nutri-News�, published �through aneducational grant from BootsPharmaceuticals Ltd.�, carries on one-thirdof the cover an ad for Farex which showsa mother with her baby. Another ad forFarex plus two each for Complan andSupplement 32 are found inside, completewith pack shots. The back cover is takenup by an ad for a �Farex Baby Show�which reads, �Community orientation andparticipation.� The publication�s moniker is:�A clinical nutrition service for medicalpractitioners.�

�If lactose is the problem, O-Lac isthe solution� announces the product detail-ing material. The formula is recommendedif baby demonstrates �colicky behavior.�As colic is virtually unknown amongbreastfed babies, could it be that �colickybabies� are merely protesting at beingdeprived of their right and proper sourceof nutrition - mother�s milk? Incidentally,O-Lac is also compared with breastmilk.

�Mother�s milk is best for infant� read

Abbott�s detailing materials for Similac,�BUT when mother�s milk is not availableor supplement is required ... recommendSIMILAC.� What little text there is, com-pares Similac with breastmilk - �simulatingmother�s milk� and �close equivalent tomother�s milk� - and the attempt at theinformation required by Article 4.2 appearsin small print. Similac is touted in a detail-ing material as being �next best to moth-er�s milk.� Another brochure calls it the�closest to breastmilk in composition andperformance�, adding �the closer you look,the closer it stands to breastmilk.� Thecover contains only a photo.

The front cover of the detailing mate-rial for Sensimil is only a photo and a slo-gan - hardly scientific and factual. Thematerial examines �various aspects oflooking at infant diarrhea, irrespective ofcause.� Perhaps the material dares notexplore the cause of diarrhea, as it mayturn out to have been an Abbott product oranother milk formula.

Abbott�s Pedialyte, an unnecessaryand expensive ready-to-serve ORS, andIsomil are promoted as �reliable partnersin complete nutritional management of

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Left: Detailing literature of Snow Brand'sSnow F does not mention the superiori-ty of breastfeeding and compares itscontents with 'recommended values ofFAO/WHO'Centre: Abbott claims Similac's caloriccontribution and digestibility simulatesthat of mother's milk.Right: Nestlé Nan's information sheetmakes 9 comparisons with breastmilk.

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diarrhea.� Isomil is compared withhuman milk, which of course is the mostreliable and effective prevention of diar-rhea.

The detailing materials for Nan arefilled with charts and graphs, illustrationsand pack shots. What little text they docontain is devoted to comparing the prod-uct to human milk - �virtually the same asbreastmilk�, �same as breastmilk�, �likebreastmilk�, and �mirrors the constituentsof breastmilk.� The information required byArticle 4.2 of the International Codeappears in very small print.

In a leaflet highlighting Nan, Lactogen1 and Lactogen 2, the indications for Nanare given as: �for routine feeding of healthyinfants from birth onwards as a supplementto breastfeeding or when breastfeeding isnot adopted or discontinued.�

Detailing material for Pre-Nan recom-mends breastfeeding low-birth weightinfants but goes on to say, �If breastmilk isnot available, or must be supplemented�.Material for Lactogen 1 is anything but sci-entific and factual, containing an illustra-tion on the cover, two pack shots and thedeclaration that it is �the most economicalformula in the market.� The focus is onpreventing iron deficiency - somethingbreastfeeding is more capable of accom-plishing.

Several doctors were found to havethe booklet titled �Diarrheal Disease�resulting from the 38th Nestlé NutritionWorkshop, held in Islamabad, Pakistan,22-26 October 1995.

Only two papers mention breastfeed-ing - one while referring to history taking inmaking the diagnosis; the other, �Nutritionin Acute Diarrhea�, devotes one section tothe �Role of Human Milk.� Another paperblames diarrhea on inadequate supplies ofdrinking water and poor sanitation - two

problems easily overcome by breastfeed-ing. Interestingly, the paper �Nutrition inAcute Diarrhea� was written by a pediatri-cian who is also the chairman of thePunjab Breastfeeding Steering Committee.

A misleading and inaccurate state-ment opens the detailing material forEnsure, a nutritional supplement promotedfor use by pregnant and lactating women:�Poorly nourished mothers produce lessmilk than well-nourished mothers.� It goeson to say: �The mother�s diet shouldinclude sufficient sources of energy, pro-tein, minerals and vitamins to ensure ade-quate milk production and composition.�

Mothers in many health facilities aregiven printed chits as hand-written �pre-scriptions� for Supplement 32. Detailingmaterial for Supplement 32 places undueemphasis on mother�s diet during lactationand claims, �Supplement 32 facilitatesbreastfeeding.�

Mead Johnson manufactures a simi-larly damaging product for mothers calledMaMa Sustagen. Again, detailing materialover emphasizes maternal nutrition and isnot limited to scientific and factual informa-tion.

Maternal diet during pregnancy andlactation is important, but even malnour-ished women can and do successfullybreastfeed their children without the �aid�of expensive and unnecessary productslike Ensure or Supplement 32. Motherswho can ill afford such products mayassume they will consequently be unableto breastfeed and give up or not bothereven to try.

While such products do not comeunder the scope of either the InternationalCode or the SAARC Code, the marketing ofproducts of this sort must come underscrutiny considering their impact on a moth-er�s confidence in her ability to breastfeed.

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Morinaga has circulated an �anonymous�letter to doctors with �subject:Modification in formulation of Lactogen 1Soft Packs� dated January 15, 1997.The letter alleges that Nestlé has recent-ly incorporated alterations in the formula-tion of Lactogen 1 Soft Packs. It saysthat while the older formulation used fullcream milk, the new one uses skim milk.The letter says Nestlé has includedTaurine in the new formulation andincreased the amount of phosphorouswhile keeping the amount of calcium thesame. It claims that the new phospho-rous, calcium ratio makes the formulaeven less human-like than its older ver-sion and BF (Morinaga BF) beatsLactogen 1 by a great margin in the raceto simulate human milk. A table compar-ing the formulations of the old and thenew Lactogen 1 is attached to the letter.Photo:Cover of a Morinaga BF prescription paduses the term humanized and claims theformula is gentle on young kidneys.

Whose cows aremore human?

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aFeeding Fiasco

Doctors in 96 (44.2 per cent) of 217 healthfacilities visited during monitoring said theydo receive samples of baby food (includinginfant formula, follow-on and milk cereals).One hundred and eight (49.8 per cent)denied receiving any samples while 13 (6.0per cent) gave vague answers.

Many doctors told monitors that theyused to receive samples of formula, but nowthe companies had stopped distributingthem. In a number of cases, however, doc-tors� claims were contradicted by lower rank-ing staff of the health facility or the dispenserin their clinic. In some instances, monitorseither were shown samples by these per-sons or they spotted some in shelves andcupboards. In the majority of private clinics,doctors sell samples to their patients at theirin-house dispensaries. This information,however, was treated as supplementary and

not included in the statistical analysis. Adoctor denying having received sampleswas counted as a �no� even if other evi-dence suggested otherwise.

There were hardly any doctors whohad no idea about the International Code�srestrictions about samples, though mosthad an inaccurate understanding. Mostwere defensive and secretive - some wouldoutright deny receiving anysamples, while otherswould hidebehindgeneraliza-tions like,�Everycompanygives sam-ples.� A few,however, asserted that

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Samples and supplies

Covert operations

Left: Kitchen near the children�s ward ofa Social Security hospital in Karachi.By Farhat PerveenBottom: Samples of baby food productsdistributed among mothers throughdoctors.

What do the two Codes say?

No free samples to mothers (directlyor indirectly) or health care facilitiesInternational Code, Articles 5.2, 7.4;SAARC Code, Articles 4.4, 5.5

Feeding Fiascoaasking such questions was against theirright to privacy.

Many doctors admitted having receivedsamples from formula companies butrefused to elaborate; these were counted asvague/not clear answers. Some named oneor more companies that offered samples butdid not give the names of the products theyhad received as samples.

Of 96 doctors, 71 said they receivedsamples from Nestlé. Thirty-seven of thesehad received Cerelac samples, six NestléRice (Nestum) and five Neslac. Fourteendoctors said they had received Lactogensamples during last three months. Five toldmonitors they were given samples of Pre-Nan, and there were four claims each ofreceiving Nan and AL-110 samples.

Of the 96 doctors 28 were receivingMorinaga samples. Ten named MorinagaBF as the brand, while 12 said they got NL-33 samples.

Twenty doctors reported receiving sam-ples from Abbott and 16 from Meiji. Therewere another 20 claims of receiving samplesfrom Nutricia, Mead Johnson, Snow Brandand Wyeth. There were 43 claims by doctorsof receiving samples of either one or more ofSimilac, Isomil, Farex, P7A, PediaSure,Enfalac, Meiji FMT, O-Lac, Chilmil, Sensimil,S-26, Almiron and Nutrilon.

Frequent sampling of formula byNestlé, Morinaga, Meiji and others is nosecret. They may not give formula samplesto each doctor during every visit, but makeopen offers and invite and oblige requests.Nestlé representatives as a rule do not carrysamples to distribute to doctors. These areinstead kept in the custody of the area man-agers, who regularly accompany represen-tatives on important calls and or fill doctors�requests via the representatives.

Nestlé�s representatives, called med-ical delegates by the company, have to fill a

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Top: THE CACHE: A Dadu doctor'scollection of offerings from variouscompanies. By Azra Talat SaeedCentre: A load of samples donated byNestlé to a government hospital inRawalpindi. By Rashid NaeemBottom: Farlac and Farex samplesachets with no information about theirpreparation or use.Facing pageTop: Four formula tins and theirreduced pack samples beingdistributed to mothers through healthprofessionals.Centre and bottom: Nestlé medicaldelegates� daily report forms which askthem to notify daily stocks of samplesincluding those of Lactogen 1 & 2.(Portion circled)

daily report form at the end of every workingday. In a separate section on thefirst page of the report sheetthe representatives arerequired to recordopening balance,received, total, sup-plied and closing bal-ance of their stocks of samples of AL-110,Cerelac, Neslac and four other unspecifiedproducts. On the other side of the sheetthere is another separate section under thehead Balance in Office for the area man-agers to fill. It requires them to notify open-ing balance, received and closing balance ofsamples of L-1 and L-2 (Lactogen-1 andLactogen-2), tins and soft packs separately,AL-110, Nan, Cerelac, Neslac and threeother unspecified products. The form washanded over to The Network by a formerNestlé employee and is clear evidence thatthe company distributes samples of babyfood products as a daily and routine market-ing practice.

It has also been reported that compa-nies supply these restricted items and otherproducts to doctors at home. A monitor inBahawalpur waiting to talk to a doctor in agovernment hospital overheard a rep. prom-ising the doctor a home delivery of formulasamples.

Samples of Nutrilon Premium ofNutricia Cow & Gate, NL-33 of Morinaga, O-Lac of Mead Johnson and Isomil of Abbottare given to doctors in special tins that aresmaller than the commercial packs. Toevade suspicion, most companies, however,give commercial packs as samples writing�sample� on the label with a marker beforegiving them to doctors.

Nestlé samples of Cerelac and NestléRice (for use before 6 months of age) comein sachets and are distributed in bulk. Amonitor from Peshawar got a Cerelac sachet

with an expiry date of March1997 being distributedthe same month. Hereported these sachetswere being practicallythrown at mothers.

Boots distributesFarex commercial

packs overprinted with �Physician�s sample,Not for sale� as samples and also smallsachets of Farex and Farlac. The sachetscarry no preparation instructions.

Supplies haven�t dried up either. Elevenof the 66 government and private hospitalsvisited during monitoring said they receive�samples in bulk� and quite regularly. Doctorsin hospitals in Peshawar and in Charsaddasaid Morinaga has at least once in the lastthree months given the hospitals a tin of NL-33 for every patient in the gynecology andpediatric wards. Most of the hospitals saidthey only get supplies of �special formulas�like O-Lac, Enfalac, NL-33, Pre-Nan andNutricia, but one admitted having receivedLactogen 1 and another Morinaga BF.

Cantonment Military Hospital (CMH),Multan was reported to be receiving three tofive cartons of Morinaga NL-33 on the fifth ofevery month and to have recently received20 cartons of Nestlé products. CMH,Bahawalpur was reported to have been buy-ing Nestlé AL- 110 at a discount of 25 percent until six months earlier. �Now it is onlyoccasionally bought from the LP (local pur-chase) fund�, a doctor informed the monitor.Nestlé was reported to have donated to thishospital 15 cartons of �special formula� as a�drug�. A former Nestlé representative said inan interview with The Network that he wit-nessed cartons of Lactogen 1 being deliv-ered to at least two hospitals, including thePakistan Institute of Medical Sciences inIslamabad, and had knowledge of area man-agers making other such donations.

aFeeding Fiasco

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Monitors spoke to five marketing personnel of formulacompanies. These were mainly brief encounters and infor-mal chats while three former employees of formula com-panies agreed to speak at length on the condition ofanonymity. Following are excerpts of an interview with aformer area manager of an infant formula company.

�A marketing consultant company in Karachi hasdone a survey of infant formula market in Pakistan.According to this survey Lactogen has 70 per cent of thelocal market. Morinaga is placed second and Meiji third.

�Sales figures for Multan for infant formula are 7,000to 7,300 tins per month. The promotion of �special formu-las� has jacked up their use to over half (4,000 to 4,500)the total sales.

�Lucrative hospitals and doctors are known as JKs orjackpots among company circles. These are �purchased�by companies for up to Rs. 200,000 ($5,000), after whichthe doctor or hospital is bound to recommend the compa-ny�s formula for six months or one year, depending uponthe deal.

�Mission Hospital, Multan is �a Lactogen hub.� Thedeal is a 20 per cent cut to doctors for every tin recom-mended. Morinaga dominates CMH (Combined MilitaryHospital) Multan. The hospital requests donations, whichare documented in its registers. Three to five cartons ofMorinaga are donated to CMH on the fifth of every month.Recently Nestlé also donated 20 cartons of its products tothe same hospital. The company also donated to CMH,Bahawalpur 15 cartons of special formula as a �drug�.

�Medicare and Sial Clinic have practically been builtby the companies. Nestlé has paid for three air condition-ers while a company has also donated an X-ray machine.

�Area managers (of formula companies) are allowed

to spend Rs. 50,000 ($1,250) per quarter on doctors.Some companies set aside even bigger amounts for thispurpose. This is called a �standby� amount.

�Area managers can buy doctors or their families airtickets for any kind of tours to other cities. Companieshave also carried expenditure for Hajj for some doctors. Ifdoctors or their families are to be picked up or dropped atthe airport in the area managers� personal car, he canclaim fuel expenses from the company.

�Nestlé reps. do home deliveries. Cartons of Milkpak(standardized whole milk in cartons - a product of NestléPakistan), Frost (fruit drinks, another Nestlé Pakistanproduct), Everyday tea whitener and Milo are dropped atdoctors� residences regularly.

�Free commercial packs are given to doctors withfake bills. Doctors are also given stamped slips so thatthey don�t have to write the formula�s name in their ownhandwriting. They are also asked to recommend theseproducts verbally.

�Quacks and hakims (traditional unani/ayurvedichealers) are also �bought� by companies. Lactogen has�hit� three dawakhanas (medicinal herbs stores).

�Mothers are not directly �hit� by the reps. The mar-keting strategy usually has two major targets - professorsand LHVs (Lady Health Visitors, home birth attendants). Ifa professor starts recommending a brand, the productbecomes prestigious and the juniors also start prescribingit.

�Business is not as it used to be. A company isreported to have spent Rs. 1,750,000 (approximately$43,750) in one year on buying doctors and so on, but thereturns have not been as good. The doctors� demandshave gone too high.�

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A former area manager of a formula company speaks out

An interview with conscience

aFeeding Fiasco

In Pakistan and probably in many othercountries too, free samples of baby foodproducts serve two purposes. One is inter-nationally recognized: they help companieshook babies (and mothers) on these prod-ucts and ensure enduring sales. A formerNestlé representative told The Network inan interview that they were told repeatedlyby the management that one prescription ofLactogen 1 ensures the company a profit ofRs 50,000.

The second aspect of sampling ismore complicated and needs more study.

Doctors, especially general practitioners,see their relationship with the companies asa commercial contract and consider freesamples their due share of the company�searnings. They realize that, amid cut-throatcompetition, companies are dependent onthem for sales and that a stroke of their penor even a verbal suggestion means moneyto these companies. They don�t hesitate touse the situation to their benefit. Doctorswant companies to return their favor andare not particular about the form the pay-back should take. Usually, samples are a

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Winning legitimacy for illegitimate products

Trojan Horses

At the gates of one of Pakistan's biggesthospitals: Nestlé regularly providesdoctors' tea clubs with Everyday teawhitener and keeps reminding them ofits largess. By Tahir Mehdi

Feeding Fiascoagood bargain for both company anddoctor, since the doctor can easilycash in samples at the dispensary,while the doctor�s promotion of theproduct guarantees the companymore sales and popularity.

Except Snow Brand, all for-mula companies in Pakistan havea whole range of baby food prod-ucts. Typically, the range consistsof an infant formula, a follow-onformula, a lactose-free formulaand a special �high nutrition� for-mula for babies born underweightor those suffering from diarrhea or�weakness�. Companies act as ifall products other than infant for-mula are outside the purview ofthe International Code.

They are using all marketingtactics with full force to pushdemand for these productsbeyond the actual need (see sep-

arate section on special formulas, page 58).Mead Johnson, Nutricia, Abbott andMorinaga have special reduced-sized sam-ples of their lactose-free formulas. By offer-ing doctors loads of samples and giftsassociated with these, in their view, �legiti-mate� products, companies also compen-sate the doctor�s favors with regard to the�illegitimate� products (infant formulas). Inthis way samples of special formulas servethe dual purpose of creating a market of

their own and helping to keepformula sales afloat.

Besides promotion withhealth care facilities, the

advertising campaign forCerelac alone is a massiveundertaking. It is advertised onboth the national TV channels,

in all major newspapers andjournals, at points of sales and even

through free coupons and gifts to con-sumers. The product is already a house-hold name in the country. The huge expen-diture on the campaign solely for this prod-uct can only be justified if it is considered apromotional campaign for the company�sfull infant feeding product line.

In a major market move in early 1997Nestlé changed the brand name of one ofits better-known infant cereal products,Nestum. But it was a calculated risk, con-sidering the replacement name was thecompany name itself: Nestlé with a sub-name Rice printed in a much smaller pointsize on the product label and elsewhere.The change in no way could be seen as aproduct face-lift. Nestlé has rather sacri-ficed the product�s individual identity bynaming it simply Nestlé Rice. The producthas in fact been converted into a decoy.Since Nestlé considers this product mostlegitimate and �Code-resistant�, it can nowsafely put Nestlé Rice up-front and associ-ate its gifts to doctors, be these dispos-able tongue depressors or prescriptionpads, with this product (September 25,1997 saw the launch of a new product,Nestlé Wheat: Ed)

This phenomenon of using one prod-uct to promote another is not specific toNestlé, however. It is an intrinsic companydesire to use one success to build or sus-tain another. Abbott uses Similac, Isomiland PediaSure to promote its nappy rashcream, Rashnil, by placing a sticker of theproduct on the lids of formula tins. ButNestlé is best placed to play this marketinggame. No other formula company has sucha big and diverse product line offeringcountless �formulas� to win over the market.

From Frost fruit drinks (a product ofNestlé Pakistan) to Polo, Nestlé�s marketingpersonnel can deliver anything to the doc-tor�s doorstep. A former Nestlé rep.

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Top: HITTING WHERE IT HURTS:Nestlé Rice tongue depressors in theLactation Management Centre of HyatShaheed Hospital, Peshawar.By Dr M TanveerBottom: Abbott uses its formula tins topromote its Rashnil nappy rash cream.

aFeeding Fiasco

revealed that doctors could ask Nestlé tosupply these products for their child�s birth-day party. Nestlé is not allowed by thePakistan Pediatric Association to put stallspromoting its infant feeding product line atits annual or biennial meetings, but aNescafé vending machine offering free cof-fee to the participants is, nevertheless, wel-come. Everyday tea whitener �donations�are in great demand at all the doctors� teaclubs in government hospitals. Nestlé rep-resentatives keep a separate record ofEveryday supplies to tea clubs and take

extra care to keep the clubs� stocks full. Ata number of places Everyday billboards areplaced near hospitals, probably to reminddoctors of the company�s hospitality. Nestléalso gives Nescafé coffee donations tothese clubs in the winter.

Formula samples might be reachingfewer mothers now, but this has notreduced formula prescriptions and sales inany way. The companies have built a giantTrojan Horse of �legitimate� products andused deception to gain access to the healthcare facilities.

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Top: Owing to its diverse product line,Nestlé is best positioned to entice theshops that do not generally sellformulas, to do so. A bakery in Quettathat sells only Nestlé's baby foodproducts. By TMLeft: HAND IN HAND: Nestlé' s Milo andCerelac posters in a Faisalabad shop(Top: By Noreen Ikram) and Nescafé andCerelac displays in a Multan store(Bottom: By Azher Abbas).

Lactogen 2 and Neslac. Two milk productsmanufactured by Nestlé. But that�s wherethe similarity ends, right? One is meant forinfants from the sixth month onwards, theother for 1-4 year olds - two different prod-ucts. Think again. The two products are asmuch different from each other as are twobatches of Lactogen 2 or Neslac. It�s a trickyriddle - Nestlé�s nutritional brain teaser.

During the monitoring The Networkbought two packs of Lactogen 2 - one,batch number OMVABS with March 98 asexpiry date (Column d of table) and theother, batch number WEBBBS with October98 as expiry date (Col. a). The averagecomposition of the two batches of the sameproduct is notably different. Similarly, TheNetwork bought two packs of Neslac - one,batch number OCNABS with November 97as expiry date (Col. c) and the other, batchnumber WP4BBS with July 98 as expirydate (Col. b). The average composition ofthe two batches of this product, too, arenotably different from each other. Evenmore surprising is the fact that the averagecomposition of a batch of Neslac (Col. b) isalmost identical to that of a batch ofLactogen 2 (Col. a) and different from theother batch of Neslac (Col. c). The same istrue for the other batch of Neslac (Col. d) - itis similar to a batch of Lactogen 2 (Col. c)and different from the other batch of Neslac(Col. b).

Feeding Fiascoa

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Lactogen 2 and Neslac

The twinparadox

Diff. Lactogen 2 Neslac Diff. Neslac Lactogen 2 Diff.a-b a b b-c c d c-d

Energy, kcal 0.0 464.0 464.0 0.0 464.0 464.0 0.0

Fat, gm 0.0 19.0 19.0 0.0 19.0 19.0 0.0Linoleate gm 0.2 2.4 2.6 0.1 2.5 2.4 0.1Protein gm 0.0 21.6 21.6 0.0 21.6 21.6 0.0

Carbohydrate gm 0.0 51.6 51.6 0.0 51.6 51.6 0.0Minerals (ash) gm 0.0 4.8 4.8 0.0 4.8 4.8 0.0Sodium mg 5.0 310.0 305.0 15.0 320.0 320.0 0.0

Potassium mg 0.0 1010.0 1010.0 40.0 970.0 970.0 0.0Chloride mg 5.0 730.0 725.0 5.0 730.0 730.0 0.0Calcium mg 0.0 780.0 780.0 10.0 770.0 770.0 0.0

Phosphorous mg 5.0 630.0 635.0 35.0 600.0 600.0 0.0Magnesium mg 0.0 70.0 70.0 0.0 70.0 70.0 0.0Manganese ug 2.0 30.0 32.0 0.0 32.0 33.0 1.0

Moisture gm 0.0 3.0 3.0 0.0 3.0 3.0 0.0Vitamin A IU 0.0 1900.0 1900.0 510.0 1390.0 1390.0 0.0Vitamin D IU 40.0 420.0 460.0 180.0 280.0 280.0 0.0

Vitamin E IU 2.7 5.6 8.3 2.7 5.6 6.0 0.4Vitamin K1 ug 0.0 21.0 21.0 17.0 38.0 38.0 0.0Vitamin C mg 10.0 46.0 56.0 19.0 37.0 37.0 0.0

Vitamin B1 mg 0.27 0.7 0.97 0.69 0.28 0.3 0.02Vitamin B2 mg 0.0 1.1 1.1 0.45 0.65 0.6 0.05Niacin (PP) mg 0.0 13.0 13.0 9.5 3.5 3.5 0.0

Vitamin B6 mg 0.47 0.93 1.4 1.05 0.35 0.3 0.05Folic acid ug 0.0 140.0 140.0 98.0 42.0 42.0 0.0Pantothenic acid mg 1.0 3.2 4.2 2.1 2.1 2.1 0.0

Vitamin B12 ug 0.0 0.93 0.93 0.07 1.0 1.0 0.0Biotin ug 12.0 16.0 28.0 18.0 10.0 10.0 0.0Choline mg 46.0 46.0 0.0 35.0 35.0 35.0 0.0

Inositol mg 23.0 23.0 0.0 21.0 21.0 21.0 0.0Iron mg 0.4 7.9 8.3 0.1 8.4 8.0 0.4Iodine ug 0.0 97.0 97.0 74.0 23.0 24.0 1.0

Copper mg 0.56 0.56 0.0 0.28 0.28 0.3 0.02Zinc mg 8.4 5.6 14.0 10.5 3.5 3.5 0.0s

The situation cannot be interpreted asa swapping of the average compositioncharts, since all the four being more or lessthe same, have some differences anyway.There can be only one explanation of thesituation: that Lactogen 2 and Neslac are infact two different names of the same prod-uct.

Even if we compare the two batches ofLactogen 2 and Neslac that have differentcomposition, the difference is not significant.Both the products provide 464 kcal energyper 100 grams of powder. Both contain thesame quantities of 15 nutrients while thequantity of the rest varies by a meagre 4.3per cent. (Nestlé should better renameNeslac as Lactogen 2.043!) The 200 grampack of Neslac has half gram (0.450908gram and 42.7 IUs) more of 12 nutrientsthan a similar pack of Lactogen 2 and one-sixth gram (0.15912 gram) less of five othernutrients.

Has the company made these micro-scopic calculations based on scientific evi-dence of the different nutritional require-ments of babies at sixth months and oneyear of age? The feeding regimen of Neslacsuggests two or three servings a day andLactogen 2 three or four. Moreover, both theproducts suggest that mothers supplementthis milk with complementary foods, whichcontain nutrients in unspecified and practi-cally incalculable quantities. Does, then, thedifference between Neslac and Lactogen 2have any meaning for its users?

The difference, however, is vital forNestlé. While Nestlé hesitates to promoteLactogen 2 publicly, it has no qualms aboutusing even the electronic media for pushingNeslac.

The little variation in the contents of thetwo products has been doctored to create a�new� product that could help the companyevade Code related criticism.

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An important tactic to deal with clientslearned by all marketing personnel inany industry is the �Yes, but� tech-nique. For example, if a client hassome doubts about a product andasks questions, reps. are never torespond with �no� if this hurts theproduct image and goes against thecompany�s interests. Instead, reps.are first to say �yes�, even if the realanswer is a blunt no, then add a �but�and create doubts in the questioner�smind by quoting any study or merelyby using thick scientific jargon orwhatever other trick that can workwell. Then, add another �but� andshake the doctor�s confidence evenmore. In the end the reps. achievetheir objective without saying either ablunt �no� or a clear �yes�.

This is exactly what the formulacompanies have done with the Code.The following is an account of some ofthe �yes, buts� they are using to avoidreal answers.

Is breastfeeding best for babies?

Yes a healthy mother�s milk isbest for babies up to 3 or

4 months of age.

But some mothers don�t haveenough milk. You can sup-

plement, if not replace, breastmilk withformula so that the poor baby doesn�tgo hungry.

But mothers who are in seri-ous condition after deliv-

ery, like after caesarean sectiondelivery, can�t breastfeed. They are inpain for at least a week, during whichtime our formula suits babiemost.

But breastmilk lacks iron,which is extremely impor-

tant for a child�s growth. Especiallyafter four months of age, �iron supple-mentation� becomes crucial. Ourinfant formula and follow-on milk areboth iron fortified.

But pre-mature, underweightand �weak� babies need

special doses of concentrated nutri-tion. (Every fourth baby in Pakistan isborn underweight.) Mother�s milk can-not fulfill this extra demand; our spe-cial formula can.

But a majority of babies suf-fering from diarrhea

develop lactose intolerance. To be onthe safe side, give our special formulato all diarrhea patients - regardless ofwhether or not they are breastfed.

But cranky babies who cry allthe time may be lactose-

intolerant. Our special formula will putthem at ease.

But babies one-year and olderhave special nutritional

needs. Anyway, at this age they aretoo old to be breastfed. Give them ourspecial formula.

Never say No

s

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Formula companies have created a newmarket in the name of �special formulas� andare trying hard to expand it far beyond itsreal legitimacy. There is some evidence sug-gesting that the market for so-called specialformulas might have already become com-parable in size to that for regular formulas.

Statistics provided by the PharmaBureau of Overseas Investors Chamber ofCommerce and Industry, Pakistan showCerelac as the country�s 42nd best selling�pharmaceutical� product in 1995 whileLactogen 1 ranked 66th and Morinaga BFstood 91st. In less than two years (by the

end of the third quarter of 1997), the rankinghas changed significantly, however, withMorinaga BF jumping to 40th and Lactogento 53rd position. (The new list does not dif-ferentiate between Lactogen 1 and 2.) Nanranks 92nd in the new list and NL-33 93rd.

The biggest attraction for companiesin pushing these special formulas is thatthey think they are not obliged to abide byeither the International Code or the SAARCCode. Hence, they fearlessly indulge in allof their favorite marketing practices. Thecompanies freely distribute samples ofthese

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Promotion of special formulas

Mountains outof molehill

Right: A baby born prematurely at a wel-fare hospital in Hyderabad being fedEnfalac Premature Formula. By Tahir MehdiLeft: Detailing material for MeadJohnson�s Enfalac Premature Formula.

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formulas, many of them using specialreduced size packs as samples (also seepage 49). A monitor reported Morinaga dis-tributing a pack of NL-33, the company-suggested cure for diarrhea, to everypatient in the children�s ward. There werealso reports of bulk donations to hospitalsof Mead Johnson�s O-Lac.

A monitor reported two formula compa-nies demanding that the administration of aBaby Friendly Hospital disallow a SnowBrand representative�s entry to the hospitalon the pretext that the company did notmanufacture a special formula and hence itsrepresentative�s visit to the hospital violatedthe hospital�s commitments under the BFHInitiative. Neither the International Code northe Baby Friendly Hospital Initiative rulesprohibit sales representatives from enteringhospitals, provided the information conveyedis scientific and factual.

The companies are sounding falsealarms and blowing facts out of proportionto expand the market for special formulas.A number of doctors interviewed duringmonitoring believed that lactose-free formu-las must be prescribed to almost every

baby suffering from diarrhea, and manyconsidered that low birthweight babiesneed something �more than breastmilk�.

The companies are concocting base-less stories and presenting them as scien-tific evidence.

A Morinaga NL-33 prescription padcover says: �Diarrhea is a leading cause ofdeath in children under 4 years of age and asubstantial cause of malnutrition. MorinagaNL-33, milk protein based lactose free for-mula comprehensively meets the essentialsof dietary realimentation in diarrhea.� It sup-ports the claims with 14 studies - all datingfrom 1964 to 1978. Another pad coverclaims that �carbohydrate intolerance wasfound in 78 per cent of infants with acutegastroenteritis... NL-33 breaks the viciouscycle of diarrhea-malnutrition-diarrhea.�

Abbott promotes its product Pedialyte,an unnecessary and expensive ready-to-serve ORS, along with Isomil as �reliablepartners in complete nutritional manage-ment of diarrhea.� Isomil is compared withhuman milk, which of course is the mostreliable and effective prevention of diar-rhea.

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Left: A mother cares for her babysuffering from diarrhea at a Hyderabadhospital. The baby was prescribed NL-33as part of treatment of diarrhea. By TMRight: Cover of Nestlé Al-110�s detailingmaterial that boasts of helping to controldiarrhea.

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Nestlé also promotes AL-110 as �anutrition that helps control diarrhea�. Itsdetailing literature says: �Early diagnosis,prompt rehydration and feeding with nutri-tionally complete lactose free formula canstop diarrhea and reverse the cataboliceffects before they lead to more debilitatingillness�. The assertion is not supported byany reference to scientific studies and theonly two references made in the four-pageleaflet are in support of the inclusion ofmaltodextrin in AL-110.

Though the leaflet contains anImportant Notice about breastfeeding print-ed in a small font size, it does not say any-where that breastfed babies are less likelyto develop diarrhea that leads to lactose-intolerance and that continued breastfeed-ing during diarrhea is preferred over lac-tose-free formula.

The companies are instead trying topromote lactose-free formulas as a cure fordiarrhea. Morinaga distributes amonghealth workers printed prescription slips fordistribution to mothers. The slips say inUrdu: �Mix one spoon of NL-33 in an ounce

of water and give it your child sufferingfrom diarrhea and wash the bottle with hotwater�.

Mead Johnson, however, appears tobe more creative in marketing its lactose-free formula O-Lac. Mead Johnson�s cre-ative product managers decided to invent adisease named �colicky behavior� after hav-ing invented its cure: O-Lac.

A four page detailing brochure for O-Lac explains to doctors how it can treat�colicky behavior� in infants. The coverdilates on the mechanism of pain transmis-sion in infants and tries to give a complete-ly �scientific look�. It quotes two studies toconclude that �Infants lack fully developedpain inhibitory processes.� Then it tells doc-tors that the enzyme production in aninfant�s stomach is insufficient to digest thefull lactose load. Undigested lactose caus-es fermentation which in turn causesgaseous distension of the colon.Unexplained crying could come from paincaused by this gaseous distention.

The whole sequence including thelinkage of gaseous distention with �colicky

behavior� is not supported by any scientificstudy. It goes further to diagnose �lactoseload-exceeding-lactase production� as theunderlying causes of loose stools, nappyrashes, diarrhea, restlessness and generalfussiness without providing any scientificevidence.

Of course, the prescription for all theabove mentioned fatal diseases is O-Lac,which the company calls a �routine� formu-la. The brochure mentions nowherewhether the problems caused by the over-loading of infant�s stomach with lactose arerelated to babies on formula or those beingbreastfed, leading doctors to prescribe O-Lac to any crying baby - whether bottle fedor breastfed. The literature nonethelesscompares O-Lac with breastmilk saying ithas a �new fat blend which has been clear-ly shown to promote neuro-development atthe same rate as breastfed infants�.

With few laboratory facilities to diag-nose lactose intolerance, most doctors sus-pect it in all babies whose mothers com-plain of restlessness or crying and pre-scribe lactose free formulas.

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Top: Mead Johnson�s O-Lac detailing material that tries to convince doctors that O-Lac is a trouble-free �routine� formula.

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Monitors visited 562 medical stores andother shops. Seventy-eight of the shopkeep-ers (13.9 per cent), or every seventh shop-keeper, admitted having benefited from dis-count, gift or credit schemes offered by for-mula companies.

Usually bigger shops benefit more fromthese schemes as they have the capital toavail the offers. The nature of offers variesfrom time to time and from city to city.Morinaga offered a three per cent discounton trade price to shopkeepers in Peshawarbuying Rs. 10,000 worth of its products. InMultan, Meiji was reported to be offering fivepercent and Snow Brand seven per cent dis-count on purchases of the same value;Nestlé offered a two per cent discount in

Karachi. These schemes are not alwaysproduct specific; the company only wants thebuyer to spend a certain amount on any ofits products and generally doesn�t botherwhether it is formula or follow-on or lactose-free milk. There were, however, a fewinstances where a company offered productspecific incentives. Morinaga in Sargodhaoffered a three per cent discount on the pur-chase of only NL-33 worth Rs. 10,000.

Many companies offer one or moretins/packs free on the purchase of 12 or 24.There were reports of Abbott and Meiji offer-ing 12+1-free schemes and Snow Brandoffering 7+1-free. Nestlé has been reported tooffer a cash discount of Rs. 15 to Rs. 45 indifferent cities on the purchase of one carton

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Promotion at points of sale

Forefront ofthe brand war

Left: PHARMACEUTICAL JUNGLE:Laws related to sale and purchase ofmedicines are practically non-existentin Pakistan. Medicine stores in front ofNishtar Hospital, Multan. By TMBottom: A shop boy unloads cartons offormula from the delivery van inLahore's medicine market. By TM

What do the two Codes say?

No advertising or promotionInternational Code Article 5.1,SAARC Code, Article 5.1

No special displays, special sales,discount coupons or gifts to mothersInternational Code, Article 5.3

of Lactogen 1. Shield and Kidco also offerone bottle free on the purchase of 12. A fewshopkeepers also told monitors that Nestléhad offered them a 15-day credit facility.

Nestlé announced at the end of 1996 ascheme in which it gave shopkeepers serial-ized yellow coupons on the purchase of twocartons of Cerelac and green coupons onthe purchase of five cartons. Later, separatedraws were held from these two types ofcoupons, and the winners were awardedprizes which included a pilgrimage toMakkah, colour TV, deep freezer, dishantenna, tape recorder and many smallprizes. A shopkeeper in Quetta claimed tohave won a tape recorder under thisscheme. Though on paper the schemeinvolved only purchases of Cerelac, in reali-ty, many shopkeepers said, the companypersonnel would give coupons on purchaseof any product worth a certain amount.

Shopkeepers who buy more of a prod-uct than they routinely need come underpressure to sell it as quickly as possible torecover their money. They unwittinglybecome company salesmen and make anextra effort to push that particular brand. InPakistan the medical store-owners� recom-mendation of a particular brand carries a lotof weight for common buyers. Many con-sumers expect guidance from store-owners�in light of their vast experience in the field.�Companies manipulate and enhance thisadvisory role of shopkeepers.

Nestlé has also organized product dis-play competitions. They ask shopkeepers todisplay the company�s products in theirshops in the most prominent manner. Theygive buntings and posters of their productsto help shopkeepers �decorate� their shops.Then company judges visit all the shops andaward prizes to the best-decorated shop.The majority of shopkeepers participating inthese competitions do not differentiate

between formula and other company prod-ucts. In their attempt to appease the judgesand win prizes, they prominently display allof the company�s products, including formu-las. Moreover, through these kinds of com-petitions the company sensitizes the shop-keeper, for the long run, about the impor-tance that the company gives to the displayof its product inside his shop.

In the majority of shops, baby foodproducts are displayed prominently. This is�requested� by company distributors as afavor. A shopkeeper in Islamabad alwaysshelves Nestlé AL-110 at eye-level butrefuses to give reasons.

Baby food products, infant follow-onand special formulas are sold in Pakistan atmedical stores, general grocery stores, bak-eries, sweet shops and even small kiosksselling cold drinks or cigarettes. The sheerpresence of these products next to oil picklesand cream pastries conveys to the publicthat these, too, are just benign food prod-ucts, which helps to promote their use. SinceNestlé has a very large and diverse productline, it has something for every shop. Somebakeries and sweets shops have only Nestléformulas because they are basically Nestlémilk or fruit juice clients but are enticed tosell Lactogen, Neslac and Cerelac as well.

The omnipresence of formulas, espe-cially Nestlé�s, and prominent displays com-bined have become the most powerful pub-lic advertisements of these products.

Artificial baby food products are adver-tised at points of sale in Pakistan. Manyshops have posters of Neslac, Cerelac andFarex. Nestlé also has mobile cardboardcutouts for Neslac, Cerelac and Nestlé Rice.They generally carry messages and visualssimilar to thoes on posters of these prod-ucts. Boots also distributes to shopkeepersa colored bunting printed with Farex imagesand slogans.

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aFeeding Fiasco

Shield and Kidco have cardboard cut-out mobiles to be hung inside shops.Moreover, most of the packing of thesecompanies� pacifiers, teats and bottles aredesigned in such a way that on openingthey become product displays. Shield andKidco teats and pacifiers are also promotedat points of sale with posters, which read�reasonable price� and �insist on quality, beconfident with Kidco.� �Orthodontic shape,does not harm natural development of jawand teeth,� Kidco cartons say. A poster forShield teats shows a photo of the teat and ababy and mother saying the teat is �for new-born babies.� Twinkle teat cartons, whichcarry a photo of a mother and baby, are also

designed to be used as a display unit.Snow Brand distributes among shop-

keepers packshot stickers of its formula andfollow-on. Boots has stickers of Farex forshops. Some monitors also reported Meijirepresentatives giving detailing literature toshopkeepers as a display item. A few alsospotted Nutricia literature displayed in shopwindows on representatives� suggestion.

Formula companies are also reportedto be handing out gifts like notepads, pens,key chains and calendars to shopkeepers.Some also admitted having received formu-la samples on request and for use in theirown homes. Neslac and Shield wall clockswere found in some shops as well.

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Clockwise from top: Prominent displayof milk formula at a busy general storeof Quetta (By TM). Kidco's illuminatedsign board hoisted at a Lahoremedicine store (By Mehboob Alam).Shield soothers' cardboard mobiledisplay and Shield feeding bottlenipple carton.

Facing pageTop: Nestlé handout announcingdetails of lucky draw scheme forshopkeepers.Centre and bottom: Nestlé Rice andFarex cardboard mobiles for shops.

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Introduction of legislationNearly 17 years have passed since theadoption of the International Code andmore than a year since the adoption of theSAARC Code. As a signatory to theInternational Code, Pakistan is obligatedto enact legislation implementing the Codein its entirety. Such legislation is also inline with its obligations under other agree-ments, most notably the Convention onthe Rights of the Child.

The Network supports the currentgovernment initiative to enact strong andeffective legislation implementing theInternational Code and based on theSAARC Code, which was adopted at theministerial level as the minimum require-ment for this region. The following recom-mendations based on the findings of thismonitoring exercise are intended as acontribution to such legislation.

Generic labelingSeventy-six per cent of mothers and 50per cent of fathers in Pakistan cannot reador write. A detailed analysis of the labelsof baby foods marketed in Pakistan showsthat labels are tricky and incomprehensi-ble, even for those who can read, albeitbeautiful and attractive. The packing ofartificial baby food products can be entic-ing, leading parents to be wrongly con-vinced that they are providing their babythe best possible food.

The Network, therefore, recommendsgeneric labels and colors for all baby foodproducts sold in Pakistan. There shouldbe no visuals, brand names and companylogos. Instead a label conforming to thetwo Codes shall be designed and all thecompanies should be allowed to use thatonly. Iran has set a good example in thisregard.

Controlled availabilityEasy availability of baby food products inPakistan is also a reason for theirincreased use. Baby food products shouldnot be considered ordinary consumeritems and thus not be made available atgeneral stores, bakeries and sweet shops.Instead all baby food products should bemade available only at special, registeredpharmacies. The companies should bebarred from supplying their products toany points of sale other than the regis-tered pharmacies. Similarly all other shopsexcept registered pharmacies should bebarred from selling these products.

Prescription/permit only itemsA system should be adopted of issuingpermits to mothers/family members ofbabies whose need for artificial feeding isscientifically justified. Iran has developedand had success with such a system, andit should be examined.

The authority to issue artificial baby

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Recommendations

What is to bedone?

PLAIN TRUTH: Iran makes it simple andstraight. A formula tin manufactured byNutricia for Iran with the mandatorygeneric label and color.

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food permits should rest with qualified pedia-tricians only. The pediatricians must also berequired to follow a laid down procedure toassess and justify the baby�s need for artifi-cial foods before issuing permit. The proce-dure should also be able to hold prescribersaccountable for their decisions.

Detailed guidelines for the prescrip-tion/issuance of a permit for any baby foodproduct should be evolved in light ofPakistan�s child health situation and in con-sultation with UNICEF and WHO expertson the subject, referring as well to theWHO/UNICEF guidelines of 1985 oninfants who must be fed on breastmilk sub-stitutes. Prescribing guidelines for infantformulas, any follow-on, lactose-free, non-allergic or any other special formulasshould be included.

Baby Food AuthorityNetwork recommends the formation of aBaby Food Authority with powers to regulatethis sector. Some details are as follows:n Any company intending to mar-

ket a food product meant for children ofbreastfeeding age (birth to two years ofage) or any other product that could influ-ence breastfeeding in any way must seek

permission to do so from the Authority.n The Authority should have the

power to register, disallow, de-register, orban with immediate effect any food orother item meant for children of breastfeed-ing age. It should also have the power tolimit a product�s sale to permit holdersonly.n The Authority should have the

power to set the age of children for whomthe product could be marketed and takecare of other labeling issues, keeping inmind the objective that the product shouldnot in any way become a hurdle to the initi-ation of breastfeeding or its continuation upto the age of two years and beyond.n The Authority should have the

power to approve or disapprove of anymarketing practice of a company withregard to its baby food products. Thisincludes the use of electronic or printmedia, publicity, any gift schemes, babyshows or sponsorship or any other form ofadvertising.n The Authority should have the

power to disapprove of any practice of com-panies or institutions not directly having acommercial interest in the promotion of babyfood if the authority finds these practices

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Emerging trendsThe following are a number of marketing trends emerging inPakistan that should be checked. Some are in contravention ofthe International Code and the SAARC Code, while others areefforts to get around their provisions and to create confusion:

1. Promotion of so-called �specialty formulas� (lactose-free, soya, etc.) is expanding the demand for these products farbeyond their legitimate need.

2. Many manufacturers use their company name as theirproduct name or as the root of their product name.

3. Label designs and product names within a company lineare often very similar, creating potential for confusion amongconsumers.

4. Products not covered by the International Code or theSAARC Code (such as foods, drinks, candies, etc.) are beingused as a front to gain access to health workers and mothersand as incentives.

5. Cereals are intensely promoted for use from fourmonths of age.

6. Milks for pregnant and lactating mothers are being usedto gain access to mothers and to associate the company namewith infants and feeding.

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Though most monitors found the BabyFriendly Hospitals far better with regardto breastfeeding practices than otherhealth facilities, they still found room forimprovement and raised some points.

Female employees of BabyFriendly Hospitals are unable to breast-feed their babies because these hospi-tals have no creche facilities. Enablinghospital staff to breastfeed their babies,aside from the many benefits for moth-er, baby and employer, would set apowerful example for mothers attendingthe facility. A mother successfully com-

bining breastfeeding and work would bethe best advocate for breastfeeding.

Conversely, at present hospitalstaff seem to recommend breastfeedingonly as a job requirement and do notspeak from their hearts. They are leastconvincing and the contradiction in theiract and advice is counter-productive.

Most hospitals are not well trainedon the subject of �special formulas� andfall prey to the companies� concoctedscientific evidence in favor of prescrib-ing these to every child with diarrhea orsuspecting lactose intolerance as the

reason for every baby �crying toomuch.� These hospitals accept all thegifts associated with �speciality� prod-ucts - even samples and supplies - yetbelieve they are baby friendly.

The majority of the doctors workingin Baby Friendly Hospitals are leastbaby friendly in their evening clinic prac-tices. In some cases they are found tobe the biggest formula fans of the city!Assessment of a hospital seeking BabyFriendly status should also include thepractices of its doctors in their privateevening clinics.

About Baby Friendly Hospitals

harmful for breastfeeding.n The Authority should have the

responsibility, and the requisite power, toundertake or to suggest/recommend tosome other institution/ministry any activitythat it deems helpful for the promotion andprotection of a breastfeeding culture or thediscouragement of a bottle feeding culture.n The Authority should consist of

mothers, consumer groups, NGOs workingin the field of mother and child health,pediatricians, gynecologists andnutritionists. It should be a blend ofprofessionals and common people, and allmembers must declare that they will notaccept any kind of favors from formulacompanies. At least half the membersshould be women.n The Authority should be

financially autonomous and raise funds bylevying a tax on the annual sales of theartificial baby food companies.

Campaign to counter feeding bot-tles as instruments of feeding

Aside from its effects on breastfeeding,the bottle as an instrument of feeding is amajor health problem in Pakistan. Theyare used to feed babies (and children asold as 3, 4 and 5 years old) formulas,fresh animal milk, water, juices, tea, sher-bet, or any liquid food. The hazards of thebottle need to be addressed separatelyfrom the breastfeeding issue throughmass awareness campaigns.

Feeding bottles and pacifiers havebeen made a symbol of infancy and inno-cence. Anything marketed for childrenuses these images to make the productmore appealing and specific to babies.Even children�s playthings include feedingbottles. These are manifestations of thegrowing bottle-feeding culture that needsto be checked.

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AppendicesSAARC Model Code

for Protection of Breastfeeding and Young Child Nutrition

International Codeof Marketing of Breastmilk Substitutes

And the related resolutions of the World Health Assembly

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The text of this Model Code was first drafted by a RegionalTraining Workshop held in Nepal in February 1995. The SAARCWorkshop on Formulation, Monitoring and Implementation ofLegislation on Infant Milk Substitutes and Related Mattersamended the text in February 1996 and forwarded it to theSAARC Technical Committee. This Committee met in April 1996and endorsed the Code as worded.

The 3rd SAARC Ministerial Conference on Children of SouthAsia took place in Rawalpindi, Pakistan from 20 to 22 August1996. Over 100 delegates from the seven South Asian countriesattended and, among others, they adopted the �SAARC ModelCode For Protection Of Breastfeeding And Young ChildNutrition�.

Following is the text of the Code.

SAARC Model Code For Protection Of Breastfeeding AndYoung Child Nutrition

WHEREAS infant and young child malnutrition is widespreadin SAARC countries;

WHEREAS the WHO/UNICEF Meeting on Infant and YoungChild Nutrition (1979) affirmed the right of every child and everypregnant and lactating mother to be adequately nourished as ameans of attaining and maintaining physical and psychologicalhealth;

WHEREAS the World Health Assembly adopted theInternational Code of Marketing of Breastmilk Substitutes in 1981with the approval of all SAARC countries;

WHEREAS the Innocenti Declaration of August 1990 calls onall governments to have implemented the International Code ofMarketing of Breastmilk Substitutes and subsequent relevant WorldHealth Assembly resolutions in their entirety by the end of 1995;

WHEREAS the Colombo Declaration, adopted by SAARCcountries in September 1992, expressed alarm at the decliningtrends of breastfeeding and increasing trends in use of breastmilksubstitutes;

WHEREAS World Health Assembly Resolution 47.5 of May1994 recommends exclusive breastfeeding for about six months;

WE THE PARTICIPANTS at the SAARC Workshop onFormulation, Monitoring and Implementation of Legislation onInfant Milk Substitutes and Related Matters held in Kathmandu,Nepal, from 09-11 February 1996 hereby recommend the follow-

ing to SAARC Technical Committee for consideration:Code for Protection of Breastfeeding and Young Child

NutritionThe purpose of this Code is to protect breastfeeding and child

nutrition by educating health workers and the public about the ben-efits of breastfeeding and by regulating the marketing and promo-tion of infant and complementary foods and related products;

The Government shall direct its policy towards educatinghealth workers, students and members of the public about thebenefits of breastfeeding and appropriate child feeding practicesand the hazards of using infant milk foods and related products.

1.0 DefinitionsFor the purposes of this Code:

1.1 �Advertising� means to make any representation by anymeans whatsoever of a designated product.

1.2 �Complementary food� means any food suitable as anaddition to breastmilk or as a substitute for breastmilk whenbreastmilk becomes insufficient to satisfy the nutritional require-ments of an infant.

1.3 �Container� means any form of packaging of a designat-ed product, including wrappers.

1.4 �Designated products� means1.4 (a) any milk food manufactured or marketed or promoted

for the use of a child below the age of two years;1.4 (b) any packaged food or drink, feeding bottles, teats,

valves for feeding, bottles and pacifiers, nipple shields, manufac-tured or marketed or promoted for the use of a child below theage of two years, or which is commonly used for the feeding ofsuch child;

1.4 (c) such other products as the Government may, by noti-fication in the Official Gazette, declare to be designated productsfor the purposes of this Code.

1.5 �Distributor� means any person engaged in the busi-ness of marketing, whether wholesale or retail, any designatedproduct and includes persons providing product public relationsand information services.

1.6 �Feeding bottle� means any bottle or receptacle for thepurpose of feeding an infant or a young child.

1.7 �Follow-up formula� means an animal or vegetable basedmilk product marketed for infants and young children older than sixmonths and formulated industrially in accordance with the

SAARC Model Codefor Protection of Breastfeeding and Young Child Nutrition

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standards of ..... [Country] (or in the absence of such standardswith the standards of the Codex Alimentarius).

1.8 �Health care facility� means any public or private institu-tion or organization or private practice directly or indirectly provid-ing health care to infants, young children, pregnant women ormothers, including pharmacies, day-care centers, nurseries andother child-care facilities.

1.9 �Health worker� means any person providing services toinfants, young children, pregnant women or mothers as a medicalpractitioner, nurse, midwife, traditional birth attendant, pharmacistor dispensing chemist, nutritionist, hospital administrator oremployee, whether professional or not, paid or not, and any otherperson providing such services.

1.10 �Infant� means a child up to the age of twelve months.1.11 �Infant formula� means an animal or vegetable based

milk product manufactured in accordance with the relevant stan-dards of ..... [Country] (or in the absence of such. standards withthe standards of the Codex Alimentarius) adapted to meet thenutritional requirements of an infant.

1.12 �Importer� means any person or organization engagedin the business of importing, directly or indirectly, any designatedproduct.

1.13 �Label� means any tag, mark, pictorial or other descrip-tive matter, written, printed, stencilled, marked, embossed,attached or otherwise appearing on a container of a designatedproduct.

1.14 �Manufacturer� means any person engaged in the busi-ness of manufacturing, directly or indirectly, a designated product.

1.15 �Marketing� means any method of introducing or sellinga designated product, including, but not limited to promotion, dis-tribution, advertising, distribution of samples or free or low-costsupplies.

1.16 �Nipple shield� means an appliance with a teat for babyto suck from the breast.

1.17 �Pacifier� means a teat for babies to suck, also referredto as a �dummy�.

1.18 �Promoter� means any person or organization engagedin the promotion of any designated product.

1.19 �Promotion� means any method of directly or indirectlyintroducing a person to a product or inducing a person to buy orto use a designated product, including but not limited to advertis-ing, donation of samples, supplies or gifts, discounts, distributionof literature, product public relations and information services.

1.20 �Professional bodies� means any society or associationor groups of persons, private or otherwise.

1.21 �Sample� means any quantity of a designated productprovided at no cost.

1.22 �Young child� means a person from the age of 12months up to the age of two years.

2.0 Information and Education2.1 Information and education material of any kind regardingyoung child feeding shall:

2.1(a) clearly and conspicuously explain:(i) the benefits and superiority of breastfeeding;(ii) how to prepare for and maintain breastfeeding;(iii) how the introduction of bottle feeding or inappropriate

complementary feeding interferes with breastfeeding;(iv) why it is difficult to return to breastfeeding even after a

short period of bottle feeding;(v) the importance of mother�s and young, child nutrition;(vi) hazards of artificial feeding;(vii) economic implications of artificial feeding.2.1(b) contain only correct and current information and not

use pictures or text that encourage bottle feeding or discouragebreastfeeding;

2.1(c) be written in [insert desired language(s)].

3.0 Labeling3.1 The label of a designated product shall:

3.1(a) not contain anything that may discourage breastfeed-ing;

3.1(b) contain a conspicuous notice in bold characters noless than 5 mm in height stating only:

MOTHER�S MILK IS BEST FOR YOUR BABY AND PREVENTS DIARRHEA AND OTHER ILLNESSES;

3.1(c) contain instructions for the correct preparation in easi-ly understandable words and graphics;

3.1(d) indicate the age in months before which the productshould not be used; provided that this clause shall not apply toinfant formula, bottles, teats and pacifiers; and provided that inthe case of follow-up formula such age shall not be less than sixmonths, and in the case of complementary foods, not less thanfive months;

3.1(e) except for bottles, teats, pacifiers and nipple shields,indicate the ingredients, the composition and analysis of the des-ignated product, the required storage conditions and batch num-ber and the expiry date;

3.1(f) not use terms such as �maternalized� or �humanized�or the equivalent nor contain any comparison with mother�s milk;

3.1(g) not show photographs, drawings or graphics; exceptthat graphics may be used to illustrate the correct method ofpreparation;

3.1(h) contain the name and address of the manufacturerand of the wholesale distributor if the designated product is animported item;

3.1(i) except for bottles, teats, pacifiers and nipple shieldscontain the following conspicuous warning in bold characters noless than 3mm in height:

WARNING!IF YOU USE THIS PRODUCT EVEN ONCE, YOUR BABY

MAY NO LONGER WANT TO BREASTFEED. THIS PRODUCTSHOULD ONLY BE USED UPON MEDICAL ADVICE;

3.1(j) be written in ..... (language).3.2 In the case of infant formula, the label shall indicate the

number of containers of the same weight required to properly

feed an infant for the first six months of life.3.3 The label of every container of condensed milk, evapo-

rated milk or skimmed milk shall contain a conspicuous notice inbold characters no less than 3mm in height stating:

THIS PRODUCT SHOULD NOT BE FED TO BABIES BELOW ONE YEAR;

3.4(a) The label on every feeding bottle, teat, pacifier or nip-ple shield shall contain instructions for proper cleaning and sterili-zation in easily understandable words and graphics;

3.4(b) The label of every feeding bottle shall contain the fol-lowing conspicuous warning in bold characters no less than 3mmin height:

WARNING!FOLLOW THE INSTRUCTIONS CAREFULLY TO ENSURE

THAT YOUR BABY DOES NOT BECOME ILL;IF YOU USE A FEEDING BOTTLE THIS WILL HAMPER

YOUR BABY�S BREASTFEEDING.FEEDING WITH A CUP IS SAFER

THAN BOTTLE FEEDING;3.5 The label of every teat, pacifier or nipple shield shall

contain the following conspicuous notice in bold characters noless than 1.5mm in height:

USE OF THIS PRODUCT INTERFERES WITH BREASTFEEDING.

4.0 Health Workers� Responsibilities4.1 Health workers should encourage, support and protectbreastfeeding and promote appropriate infant and young childnutrition. Those who are concerned in particular with maternal,infant and young child nutrition should make themselves familiarwith the provisions of this Code.

4.2 Health workers should work to eliminate practices thatdirectly or indirectly retard the early initiation and continuation ofbreastfeeding, such as prelacteal feeds.

4.3 Health workers should not accept any gift or benefit,either personally or in the name of their health care facility, finan-cial or otherwise, of whatever value from a manufacturer,importer, promoter or distributor, that would interfere with theirprofessional conduct.

4.4 Health workers should not accept nor give samples ofdesignated products to any person.

5.0 Prohibitions5.1 No person shall promote any designated product, except asprovided under this Code.

5.2 No person shall in any manner state or imply that desig-nated products are a substitute for mother�s milk, nor that theyare equivalent to or comparable with or superior to mother�s milk;except that such a prohibition shall not curtail the expression ofviews in scientific research.

5.3 Manufacturers, importers, distributors and promotersshall neither produce nor distribute any educational or informa-tion materials relating to infant and young child feeding.

5.4 Manufacturers, importers, distributors and promotersshall not make gifts or contributions of any kind to health workersor their families.

5.5 Manufacturers, importers, distributors and promotersshall neither donate equipment or services nor provide designat-ed products free of charge or at low cost to a health worker, ahealth care facility or a professional body.

5.6 No manufacturer, importer, distributor or promoter shalloffer or give any gift nor offer or give any benefit to health work-ers or their associations, including but not limited to fellowships,training, study grants and funding for attendance of meetings,seminars, continuing education courses or conferences.

5.7 No manufacturer, importer, distributor or promoter shall,directly or indirectly, fund research on designated products,unless such research has been approved by a designatedauthority of the government. Any publication resulting from suchresearch shall include a statement disclosing the source of fund-ing.

Further Recommendations for Implementationby theSAARC Workshop on Formulation, Monitoring, andImplementation of Legislation on Infant Milk Substitutes andRelated Matters

1. There should be a �freeze� on installed production capaci-ties of breastmilk substitutes, and that member States shouldmove towards a reduction in these installed production capaci-ties.

2. There should be a freeze on present levels of import andexport of the designated products as defined in the Code andmember States should work towards a reduction in the existingimport and export levels.

3. NGOs should be encouraged to play a �watch-dog� role inthe implementation of the Code. They should also be involved inthe implementation of the Code and related legislation.

4. The Code and related legislation should receive thewidest possible publicity in the respective countries. Specialfocus should be on informing and educating adolescent girlsabout the provisions of the Code.

5. SAARC Secretariat should initiate a mechanism for coor-dinating the implementation of the model Code in the memberStates.

6. Effective monitoring systems should be established/strengthened in each member State.

7. All member States should report on monitoring and evalu-ation to SAARC Secretariat annually.

8. Those member States who have not enacted legislationshould do so by the end of 1996.

Kathmandu, 9-11 February 1996

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The Member States of the World Health Organization:

Affirming the right of every child and every pregnant and lactatingwoman to be adequately nourished as a means of attaining andmaintaining health;Recognizing that infant malnutrition is part of the wider problems oflack of education, poverty, and social injustice;Recognizing that the health of infants and young children cannot beisolated from the health and nutrition of women, their socioeconom-ic status and their roles as mothers;Conscious that breast-feeding is an unequalled way of providingideal food for the healthy growth and development of infants; that itforms a unique biological and emotional basis for the health of bothmother and child; that the anti-infective properties of breast milkhelp to protect infants against disease; and that there is an impor-tant relationship between breast-feeding and child spacing;Recognizing that the encouragement and protection of breast-feed-ing is an important part of the health, nutrition and other socialmeasures required to promote healthy growth and development ofinfants and young children; and that breast-feeding is an importantaspect of primary health care;Considering that when mothers do not breast-feed, or only do sopartially, there is a legitimate market for infant formula and for suit-able ingredients from which to prepare it; that all these productsshould accordingly be made accessible to those who need themthrough commercial or non-commercial distribution systems; andthat they should not be marketed or distributed in ways that mayinterfere with the protection and promotion of breast-feeding;Recognizing further that inappropriate feeding practices lead toinfant malnutrition, morbidity and mortality in all countries, and thatimproper practices in the marketing of breast-milk substitutes andrelated products can contribute to these major public health prob-lems;Convinced that it is important for infants to receive appropriate com-plementary foods, usually when the infant reaches four to sixmonths of age, and that every effort should be made to use locallyavailable foods; and convinced, nevertheless, that such comple-mentary foods should not be used as breast-milk substitutes; Appreciating that there are a number of social and economic factorsaffecting breast-feeding, and that, accordingly, governments shoulddevelop social support systems to protect, facilitate and encourageit, and that they should create an environment that fosters breast-feeding, provide appropriate family and community support, andprotects mothers from factors that inhibit breast-feeding;

Affirming that health care systems, and the heath professionals andother health workers serving in them, have an essential role to playin guiding infant feeding practices, encouraging and facilitatingbreast-feeding, and providing objective and consistent advice tomothers and families about the superior value of breast-feeding, orwhere needed, on the proper use of infant formula, whether manu-factured industrially or home-prepared;Affirming further that educational systems and other social servicesshould be involved in the protection and promotion of breast-feed-ing, and in the appropriate use of complementary foods;Aware that families, communities, women�s organizations and othernon-governmental organizations have a special role to play in theprotection and promotion of breast-feeding and in ensuring the sup-port needed by pregnant women and mothers of infants and youngchildren, whether breast-feeding or not;Affirming the need for governments, organizations of the UnitedNations system, non-governmental organizations, experts in variousrelated disciplines, consumer groups and industry to cooperate inactivities aimed at the improvement of maternal, infant and youngchild health and nutrition;Recognizing that governments should undertake a variety of health,nutrition and other social measures to promote healthy growth anddevelopment of infants and young children, and that this Code con-cerns only one aspect of these measures;Considering that manufacturers and distributors of breast-milk sub-stitutes have an important and constructive role to play in relation toinfant feeding, and in the promotion of the aim of this Code and itsproper implementation;Affirming that governments are called upon to take action appropri-ate to their social and legislative framework and their overall devel-opment objectives to give effect to the principles and aim of thisCode, including the enactment of legislation, regulations or othersuitable measures;Believing that, in the light of the foregoing considerations, and inview of the vulnerability of infants in the early months of life andthe risks involved in inappropriate feeding practices, including theunnecessary and improper use of breast-milk substitutes, the mar-keting of breast milk substitutes requires special treatment, whichmakes usual marketing practices unsuitable for these products;

THEREFORE:The Member States hereby agree the following articles which arerecommended as a basis for action.

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International Codeof Marketing of Breastmilk Substitutes

Article 1. Aim of the CodeThe aim of this Code is to contribute to the provision of safe andadequate nutrition for infants, by the protection and promotion ofbreast-feeding, and by ensuring the proper use of breast-milk sub-stitutes, when these are necessary, on the basis of adequate infor-mation and through appropriate marketing and distribution.

Article 2. Scope of the CodeThe Code applies to the marketing, and practices related thereto,of the following products: breast-milk substitutes, including infantformula; other milk products, foods and beverages, including bot-tle-fed complementary foods, when marketed or otherwise repre-sented to be suitable, with or without modification, for use as apartial or total replacement of breast milk; feeding bottle and teats.It also applies to their quality and availability, and to informationconcerning their use.

Article 3. DefinitionsFor the purposes of this Code:�Breast-milk substitute� means any food being marketed or other-wise represented as a partial or total replacement for breast milk,whether or not for that purpose.�Complementary food� means any food, whether manufactured orlocally prepared, suitable as a complement to breast milk or toinfant formula, when either becomes insufficient to satisfy thenutritional requirements of the infant. Such food is also commonlycalled �weaning food� or �breast-milk supplement�.�Container� means any form of packaging of products for sale asa normal retail unit, including wrappers.�Distributor� means a person, corporation or any other entity in thepublic or private sector engaged in the business (whether directlyor indirectly) of marketing at the wholesale or retail level of a prod-uct within the scope of this Code. A �primary distributor� is a man-ufacturer�s sales agent, representative, national distributor or bro-ker.�Health care system� means governmental, non-governmental orprivate institutions� or organizations engaged, directly or indirect-ly, in health care for mothers, infants and pregnant women; andnurseries or child-care institutions. It also includes health workersin private practice. For the purposes of this Code, the health caresystem does not include pharmacies or other established salesoutlets.�Heath worker� means a person working in a component of such ahealth care system, whether professional or non-professional,including voluntary, unpaid workers.�Infant formula� means a breast-milk substitute formulated indus-trially in accordance with applicable Codex Alimentarius stan-dards, to satisfy the normal nutritional requirements of infants upto between four and six months of age, and adapted to their phys-iological characteristics. Infant formula may also be prepared athome, in which case it is described as �home-prepared�.

�Label� mean any tag, brand, mark, pictorial or other descriptivematter, written, printed, stencilled, marked, embossed orimpressed on, or attached to, a container (see above) of any prod-uct within the scope of this Code.�Manufacturer� means a corporation or other entity in the public orprivate sector engaged in the business or function (whether direct-ly or through an agent or through an entity controlled by or undercontract with it) of manufacturing a product within the scope of thisCode.�Marketing� means product promotion, distribution, selling, adver-tising, product public relations, and information services.�Marketing personnel� means any persons whose functionsinvolve the marketing of a product or products coming within thescope of this Code.�Samples� means single or small quantities of a product providedwithout cost.�Supplies� means quantities of a product provided for use over anextended period, free or at a low price, for social purposes, includ-ing those provided to families in need.

Article 4. Information and education4.1 Governments should have the responsibility to ensure thatobjective and consistent information is provided on infant andyoung child feeding for use by families and those involved in thefield of infant and young child nutrition. This responsibility shouldcover either the planning, provision, design and dissemination ofinformation, or their control.4.2 Informational and educational materials, whether written,audio, or visual, dealing with the feeding of infants and intended toreach pregnant women and mothers of infants and young children,should include information on all the following points: (a) the ben-efits and superiority of breast-feeding; (b) maternal nutrition, andthe preparation for and maintenance of breast-feeding; (c) thenegative effect on breast-feeding of introducing partial bottle-feed-ing; (d) the difficulty of reversing the decision not to breast-feed;and (e) where needed, the proper use of infant formula, whethermanufactured industrially or home-prepared. When such materialscontain information about the use of infant formula, they shouldinclude the social and financial implications of its use; the healthhazards of inappropriate foods or feeding methods, and, in partic-ular, the health hazards of unnecessary or improper use of infantformula and other breast-milk substitutes. Such materials shouldnot use any pictures or text which may idealize the use of breast-milk substitutes.4.3 Donations of informational or educational equipment ormaterials by manufacturers or distributors should be made only atthe request and with the written approval of the appropriate govern-ment authority or within guidelines given by governments for thispurpose. Such equipment or materials may bear the donating com-pany�s name or logo, but should not refer to a proprietary product

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that is within the scope of this Code, and should be distributed onlythrough the health care system.

Article 5. The general public and mothers5.1 There should be no advertising or other form of promotion tothe general public of products within the scope of this Code.5.2 Manufacturers and distributors should not provide, directly orindirectly, to pregnant women, mothers or members of their families,samples of products within the scope of this Code.5.3 In conformity with paragraphs 1 and 2 of this Article, thereshould be no point-of-sale advertising, giving of samples, or anyother promotion device to induce sales directly to the consumer atthe retail level, such as special displays, discount coupons, premi-ums, special sales, loss-leaders and tie-in sales, for products withinthe scope of this Code. This provision should not restrict the estab-lishment of pricing policies and practices intended to provide prod-ucts at lower prices on a long-term basis.5.4 Manufacturers and distributors should not distribute to preg-nant women or mothers of infants and young children any gifts ofarticles or utensils which may promote the use of breast-milk substi-tutes or bottle-feeding.5.5 Marketing personnel, in their business capacity, should notseek direct or indirect contact of any kind with pregnant women orwith mothers of infants and young children.

Article 6. Health care systems6.1 The health authorities in Member States should take appro-priate measures to encourage and protect breast-feeding and pro-mote the principles of this Code, and should give appropriate infor-mation and advice to health workers in regard to their responsibili-ties, including the information specified in Article 4.2.6.2 No facility of a health care system should be used for thepurpose of promoting infant formula or other products within thescope of this Code. This Code does not, however, preclude the dis-semination of information to health professionals as provided inArticle 7.2.6.3 Facilities of health care systems should not be used for thedisplay of products within the scope of this Code, for placards orposters concerning such products, or for the distribution of materialprovided by a manufacturer or distributor other than that specified inArticle 4.3.6.4 The use by the health care system of �professional servicerepresentatives�, �mothercraft nurses� or similar personnel, provid-ed or paid for by manufacturers or distributors, should not be permit-ted.6.5 Feeding with infant formula, whether manufactured or home-prepared, should be demonstrated only by health workers, or othercommunity workers if necessary; and only to the mothers or familymembers who need to use it; and the information given shouldinclude a clear explanation of the hazards of improper use.6.6 Donations or low-price sales to institutions or organizationsof supplies of infant formula or other products within the scope ofthis Code, whether for use in the institutions or for distribution out-

side them, may be made. Such supplies should only be used or dis-tributed for infants who have to be fed on breast-milk substitutes. Ifthese supplies are distributed for use outside the institutions, thisshould be done only by the institutions or organizations concerned.Such donations or low-price sales should not be used by manufac-turers or distributors as a sales inducement.6.7 Where donated supplies of infant formula or other productswithin the scope of this Code are distributed outside an institution,the institution or organization should take steps to ensure that sup-plies can be continued as long as the infants concerned need them.Donors, as well as institutions or organizations concerned, shouldbear in mind this responsibility.6.8 Equipment and materials, in addition to those referred to inArticle 4.3, donated to a health care system may bear a company�sname or logo, but should not refer to any proprietary product withinthe scope of this Code.

Article 7. Health workers7.1 Health workers should encourage and protect breast-feed-ing; and those who are concerned in particular with maternal andinfant nutrition should make themselves familiar with their responsi-bilities under this Code, including the information specified in Article4.2.7.2 Information provided by manufacturers and distributors tohealth professionals regarding products within the scope of thisCode should be restricted to scientific and factual matters, and suchinformation should not imply or create a belief that bottle-feeding isequivalent or superior to breast-feeding. It should also include theinformation specified in Article 4.2.7.3 No financial or material inducements to promote productswithin the scope of this Code should be offered by manufacturers ordistributors to health workers or members of their families, norshould these be accepted by health workers or members of theirfamilies.7.4 Samples of infant formula or other products within the scopeof this Code, or of equipment or utensils for their preparation or use,should not be provided to health workers except when necessary forthe purpose of professional evaluation or research at the institution-al level. Health workers should not give samples of infant formula topregnant women, mothers of infants and young children, or mem-bers of their families.7.5 Manufacturers and distributors of products within the scopeof this Code should disclose to the institution to which a recipienthealth worker is affiliated any contribution made to him or on hisbehalf for fellowships, study tours, research grants, attendance atprofessional conferences, or the like. Similar disclosures should bemade by the recipient.

Article 8. Persons employed by manufacturers and distributors8.1 In systems of sales incentives for marketing personnel, thevolume of sales of products within the scope of this Code should notbe included in the calculation of bonuses, nor should quotas be setspecifically for sales of these products. This should not be

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understood to prevent the payment of bonuses based on the over-all sales by a company of other products marketed by it.8.2 Personnel employed in marketing products within thescope of this Code should not, as part of their job responsibilities,perform educational functions in relation to pregnant women ormothers of infants and young children. This should not be under-stood as preventing such personnel from being used for otherfunctions by the health care system at the request and with thewritten approval of the appropriate authority of the governmentconcerned.

Article 9. Labeling9.1 Labels should be designed to provide the necessary infor-mation about the appropriate use of the product, and so as not todiscourage breast-feeding. 9.2 Manufacturers and distributors of infant formula shouldensure that each container has a clear, conspicuous, and easilyreadable and understandable message printed on it, or on a labelwhich cannot readily become separated from it, in an appropriatelanguage, which includes all the following points: (a) the words�Important Notice� or their equivalent; (b) a statement of the superi-ority of breast-feeding; (c) a statement that the product should beused only on the advice of a health worker as to the need for its useand the proper method of use; (d) instructions for appropriate prepa-ration, and a warning against the health hazards of inappropriatepreparation. Neither the container nor the label should have picturesof infants, nor should they have other pictures or text which may ide-alize the use of infant formula. They may, however, have graphicsfor easy identification of the product as a breast-milk substitute andfor illustrating methods of preparation. The terms �humanized�,�materialized� or similar terms should not be used. Inserts givingadditional information about the product and its proper use, subjectto the above conditions, may be included in the package or retailunit. When labels give instructions for modifying a product into infantformula, the above should apply.9.3 Food products within the scope of this Code, marketed forinfant feeding, which do not meet all the requirements of an infantformula, but which can be modified to do so, should carry on thelabel a warning that the unmodified product should not be the solesource of nourishment of an infant. Since sweetened condensedmilk is not suitable for infant feeding, nor for use as a main ingredi-ent of infant formula, its label should not contain purported instruc-tions on how to modify it for that purpose.9.4 The label of food products within the scope of this Codeshould also state all the following points: (a) the ingredients used;(b) the composition/analysis of the product; (c) the storage condi-tions required; and (d) the batch number and the date before whichthe product is to be consumed, taking into account the climatic andstorage conditions of the country concerned.

Article 10. Quality10.1 The quality of products is an essential element for the pro-tection of the health of infants and therefore should be of a high rec-

ognized standard.10.2 Food products within the scope of this Code should, whensold or otherwise distributed, meet applicable standards recom-mended by the Codex Alimentarius Commission and also the CodexCode of Hygienic Practice for Foods for Infants and Children.

Article 11 . Implementation and monitoring

11.1 Governments should take action to give effect to the princi-ples and aim of this Code, as appropriate to their social and legisla-tive framework, including the adoption of national legislation, regu-lations or other suitable measures. For this purpose, governmentsshould seek, when necessary, the cooperation of WHO, UNICEFand other agencies of the United Nations system. National policiesand measures, including laws and regulations, which are adopted togive effect to the principles and aim of this Code should be publiclystated, and should apply on the same basis to all those involved inthe manufacture and marketing of products within the scope of thisCode.11.2 Monitoring the application of this Code lies with governmentsacting individually, and collectively through the World HealthOrganization as provided in paragraphs 6 and 7 of this Article. Themanufacturers and distributors of products within the scope of thisCode, and appropriate non-governmental organizations, profession-al groups, and consumer organizations should collaborate with gov-ernments to this end.11.3 Independently of any other measures taken for implementa-tion of this Code, manufacturers and distributors of products withinthe scope of this Code should regard themselves as responsible formonitoring their marketing practices according to the principles andaim of this Code, and for taking steps to ensure that their conduct atevery level conforms to them.11.4 Non-governmental organizations, professional groups, insti-tutions, and individuals concerned should have the responsibility ofdrawing the attention of manufacturers or distributors to activitieswhich are incompatible with the principles and aim of this Code, sothat appropriate action can be taken. The appropriate governmentalauthority should also be informed.11.5 Manufacturers and primary distributors of products within thescope of this Code should apprise each member of their marketingpersonnel of the Code and of their responsibilities under it.11.6 In accordance with Article 62 of the Constitution of the WorldHealth Organization, Member States shall communicate annually tothe Director-General information on action taken to give effect to theprinciples and aim of this Code.11.7 The Director-General shall report in even years to the WorldHealth Assembly on the status of implementation of the Code; andshall, on request, provide technical support to Member Statespreparing national legislation or regulations, or taking other appro-priate measures in implementation and furtherance of the principlesand aim of this Code.

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WHA 31.47 (1978)The Thirty-first World Health Assembly, 1978

Recommends that Member States give the highest priority to ...preventing malnutrition in infants and young children by supportingand promoting breastfeeding; ... (by taking) legislative and socialaction to facilitate breastfeeding by working mothers ....and ... regulating inappropriate sale and promotion of infant foodsthat can be used to replace breastmilk;......

WHA 33.32 (1980)The Thirty-third World Health Assembly, 1980

Recalling resolutions WHA27.43 and WHA31.47 which in particu-lar reaffirmed that breastfeeding is ideal for the harmonious phys-ical and psycho-social development of the child, that urgent actionis called for by governments and the Director-General in order tointensify activities for the promotion of breastfeeding and develop-ment of actions related to the preparation and use of weaningfoods based on local products, and that there is an urgent need forcountries to review sales promotion activities on baby foods and tointroduce appropriate remedial measures, including advertisementcodes and legislation, as well as to take appropriate supportivesocial measures for mothers working away from their homes dur-ing the lactation period;Recalling further resolutions WHA31.55 and WHA32.42 whichemphasized maternal and child health as an essential componentof primary health care, vital to the attainment of health for all by theyear 2000;Recognizing that there is a close interrelationship between infantand young child feeding and social and economic development,and that urgent action by governments is required to promote thehealth and nutrition of infants, young children and mothers, interalia through education, training and information in this field;Noting that a joint WHA/UNICEF Meeting 011 Infant and YoungChild Feeding was held from 9 to 12 October 1979, and wasattended by representatives of governments, the United Nationssystem and technical agencies, non-governmental organizationsactive in the area, the infant food industry and other scientistsworking in this field;1. ENDORSES in their entirety the statement and recommenda-tions made by the joint WHO/UNICEF Meeting, namely on theencouragement and support of breastfeeding; the promotion and

support of appropriate weaning practices; the strengthening ofeducation training and information; the promotion of the health andsocial status of women in relation to infant and young child feed-ing; and the appropriate marketing and distribution of breastmilksubstitutes. This statement and these recommendations alsomake clear the responsibility in this field incumbent on the healthservices, health personnel, national authorities, women�s andother non-governmental organizations, the United Nations agen-cies and the infant-food industry, and stress the importance forcountries to have a coherent food and nutrition policy and the needfor pregnant and lactating women to be adequately nourished; thejoint Meeting also recommended that �There should be an interna-tional code of marketing of infant formula and other products usedas breastmilk substitutes. This should be supported by bothexporting and importing countries and observed by all manufactur-ers. WHO and UNICEF are requested to organize the process forits preparation, with the involvement of all concerned parties, inorder to reach a conclusion as soon as possible�;2. RECOGNIZES the important work already carried out by theWorld Health Organization and UNICEF with a view to implement-ing these recommendations and the preparatory work done on theformulation of a draft international code of marketing of breastmilksubstitutes;3. URGES countries which have not already done so to review andimplement resolutions WHA27.43 and WHA32.42;4. URGES women�s organizations to organize extensive informa-tion dissemination campaigns in support of breastfeeding andhealthy habits;5. REQUESTS the Director-General:

(1) to cooperate with Member States on request in supervisingor arranging for the supervision of the quality of infant foods dur-ing their production in the country concerned, as well as duringtheir importation and marketing;

(2) to promote and support the exchange of information on laws,regulations, and other measures concerning marketing of breast-milk substitutes;6. FURTHER REQUESTS the Director-General to intensify hisactivities for promoting the application of the recommendations ofthe joint WHO/UNICEF Meeting and, in particular:(1) to continue efforts to promote breastfeeding as well as sound

supplementary feeding and weaning practices as a prerequisite tohealthy child growth and development;

(2) to intensify coordination with other international and bilateralagencies for the mobilization of the necessary resources for thepromotion and support of activities related to the preparation of

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Related WHA Resolutions

weaning foods based on local products in countries in need ofsuch support and to collate and disseminate information on meth-ods of supplementary feeding and weaning practices successfullyused in different cultural settings;

(3) to intensify activities in the field of health education, trainingand information on infant and young child feeding, in particularthrough the preparation of training and other manuals for primaryhealth care workers in different regions and countries;

(4) to prepare an international code of marketing of breastmilksubstitutes in close consultation with Member States and with allother parties concerned including such scientific and other expertswhose collaboration may be deemed appropriate, bearing in mindthat:

(a) the marketing of breastmilk substitutes and weaning foodsmust be viewed within the framework of the problems of infant andyoung child feeding as a whole;

(b) the aim of the code should be to contribute to the provisionof safe and adequate nutrition for infants and young children, andin particular to promote breastfeeding and ensure, on the basis ofadequate information, the proper use of breastmilk substitutes, ifnecessary;

(c) the code should be based on existing knowledge of infantnutrition;

(d) the code should be governed inter alia by the following prin-ciples:

(i) the production, storage and distribution, as well as adver-tising, of infant feeding products should be subject to national leg-islation or regulations, or other measures as appropriate to thecountry concerned;

(ii) relevant information on infant feeding .should be provid-ed by the health care system of the country in which the product isconsumed;

(iii) products should meet international standards of qualityand presentation, in particular those developed by the CodexAlimentarius Commission, and their labels should clearly informthe public of the superiority of breastfeeding;

(5) to submit the code to the Executive Board for considerationat its sixty-seventh session and for forwarding with its recommen-dations to the Thirty-fourth World Health Assembly, together withproposals regarding its promotion and implementation, either as aregulation in the sense of Articles 21 and 22 of the Constitution ofthe World Health Organization or as a recommendation in thesense of Article 23, outlining the legal and other implications ofeach choice;

(6) to review the existing legislation in different countries forenabling and supporting breastfeeding, especially by workingmothers, and to strengthen the Organization�s capacity to cooper-ate on the request of Member States in developing such legisla-tion;(7) to submit to the Thirty-fourth World Health Assembly, in 1981,

and thereafter in even years, a report on the steps taken by WHOto promote breastfeeding and to improve infant and young childfeeding, together with an evaluation of the effect of all measures

taken by WHO and its Member States.

MAY 1980 WHA 33/1980/REC/1,32(emphasis added)

WHA34.22 (1981)The Thirty-fourth World Health Assembly, 1981

Recognizing the importance of sound infant and young child nutri-tion for the future health and development of the child and adult;Recalling that breastfeeding is the only natural method of infantfeeding and that it must be actively protected and promoted in allcountries;Convinced that governments of Member States have importantresponsibilities and a prime role to play in the protection and pro-motion of breastfeeding as a means of improving infant and youngchild health;Aware of the direct and indirect effects of marketing practices forbreastmilk substitutes on infant feeding practices;Convinced that the protection and promotion of infant feeding,including the regulation of the marketing of breastmilk substitutes,affect infant and young child health directly and profoundly, andare a problem of direct concern to WHO;Having considered the draft International Code of Marketing ofBreastmilk Substitutes prepared by the Director-General and for-warded to it by the Executive Board;Expressing its gratitude to the Director-General and to theExecutive Director of the United Nations Children�s Fund for thesteps they have taken in ensuring close consultation with MemberStates and with all other parties concerned in the process ofpreparing the draft International Code;Having considered the recommendation made thereon by theExecutive Board at its sixty-seventh session;Confirming resolution WHA33.32, including the endorsement intheir entirety of the statement and recommendations made by thejoint WHO/UNICEF Meeting on Infant and Young Child Feedingheld from 9 to 12 October 1979;Stressing that the adoption of and adherence to the InternationalCode of Marketing of Breastmilk Substitutes is a minimum require-ment and only one of several important actions required in orderto protect healthy practices in respect of infant and young childfeeding;1. ADOPTS, in the sense of Article 23 of the Constitution, theInternational Code of Marketing of Breastmilk Substitutes annexedto the present resolution;2. URGES all Member States:

(1) to give full and unanimous support to the implementation ofthe recommendations made by the joint WHO/UNICEF Meeting onInfant and Young Child Feeding and of the provisions of theInternational Code in its entirety as an expression of the collectivewill of the membership of the World Health Organization;

(2) to translate the International Code into national legislation,

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regulations or other suitable measures;(3) to involve all concerned social and economic sectors and all

other concerned parties in the implementation of the InternationalCode and in the observance of the provisions thereof;

(4) to monitor the compliance with the Code;3. DECIDES that the follow-up to and review of the implementa-tion of this resolution shall be undertaken by regional committees,the Executive Board and the Health Assembly in the spirit of reso-lution WHA33.17;4. REQUESTS the FAO/WHO Codex Alimentarius Commission togive full consideration, within the framework of its operationalmandate, to action it might take to improve the quality standardsof infant foods, and to support and promote the implementation ofthe International Code;5. REQUESTS the Director-General:

(1) to give all possible support to Member States, as and whenrequested, for the implementation of the International Code, and inparticular in the preparation of national legislation and other meas-ures related thereto in accordance with operative subparagraph6(6) of resolution WHA33.32;

(2) to use his good offices for the continued cooperation with allparties concerned in the implementation and monitoring of theInternational Code at country, regional and global levels;(3) to report to the Thirty-sixth World Health Assembly on the sta-

tus of compliance with and implementation of the Code at country,regional and global levels;

(4) based on the conclusions of the status report, to make pro-posals, if necessary, for revision of the text of the Code and for themeasures needed for its effective application.

21 May 1981 WHA34/1981/REC/1(emphasis added)

WHA35.26 (1982)The Thirty-fifth World Health Assembly, 1982

Recalling resolution WHA33.32 on infant and young child feedingand resolution WHA34 22 adopting the International Code ofMarketing of Breastmilk Substitutes;Conscious that breastfeeding is the ideal method of infant feedingand should be promoted and protected in all countries;Concerned that inappropriate infant feeding practices result ingreater incidence of infant mortality, malnutrition and disease,especially in conditions of poverty and lack of hygiene;Recognizing that commercial marketing of breastmilk substitutesfor infants has contributed to an increase in artificial feeding;Recalling that the Thirty-fourth World health Assembly adopted aninternational code intended, inter alia, to deal with these marketingpractices;Noting that, while many Member States have taken some meas-ures related to improving infant and young child feeding, few haveadopted and adhered to the International Code as a �minimum

requirement� and implemented it �in its entirety�, as called for inresolution WHA34.22;1. URGES Member States to give renewed attention to the needto adopt national legislation, regulations or other suitable meas-ures to give effect to the International Code;2. REQUESTS the Director-General:

(1) to design and coordinate a comprehensive program of actionto support Member States in their efforts to implement and moni-tor the Code and its effectiveness;

(2) to provide support and guidance to Member States as andwhen requested to ensure that the measures they adopt are con-sistent with the letter and spirit of the International Code;

(3) to undertake, in collaboration with Member States, prospec-tive surveys, including statistical data of infant and young childfeeding practices in the various countries, particularly with regardto the incidence and duration of breastfeeding.

May 1982 WHA35/19821REC/ 1, 20(emphasis added)

WHA37.30 (1984)The Thirty-seventh World Health Assembly, 1984

Recalling resolutions WHA27.43, WHA31.47, WHA33.32, WHA34.22 and WHA35.26, which dealt with infant and young childfeeding;Recognizing that the implementation of the International Code ofMarketing of Breastmilk Substitutes is one of the important actionsrequired in order to promote healthy infant and young child feed-ing;Recalling the discussion on infant and young child feeding at theThirty-sixth World Health Assembly, which concluded that it waspremature to revise the International Code at that time;Having considered the Director-General�s report, and noting withinterest its contents;Aware that many products unsuitable for infant feeding are beingpromoted for this purpose in many part of the world, and that someinfant foods are being promoted for use at too early an age, whichcan be detrimental to infant and young child health;1. ENDORSES the Director-General�s report;2. URGES continued action by Member States, WHO, non-gov-ernmental organizations and all other interested parties to put intoeffect measures to improve infant and young child feeding, withparticular emphasis on the use of foods of local origin;3. REQUESTS the Director-General:

(1) to continue and intensify collaboration with Member States intheir efforts to implement and monitor the International Code ofMarketing of Breastmilk Substitutes as an important measure atthe national level;

(2) to support Member States in examining the problem of thepromotion and use of foods unsuitable for infant and young childfeeding, and ways of promoting the appropriate use of infant

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foods;(3) to submit to the Thirty-ninth World Health Assembly a report

on the progress in implementing this resolution, together with rec-ommendations for any other measures needed to further improvesound infant and young child feeding practices.

May 1984 WHA3711984/REC/1, 19(emphasis added)

WHA39.28 (1986)The Thirty-ninth World Health Assembly, 1986

Recalling resolutions WHA27.43, WHA31.47, WHA33.32,WHA34.221 WHA35.26 and WHA37.30 which dealt with infantand young child feeding;Having considered the progress and evaluation report by theDirector-General on infant and young child nutrition;1Recognizing that the implementation of the International Code ofMarketing of Breastmilk Substitutes is an important contribution tohealthy infant and young child feeding in all countries;Aware that today, five years after the adoption of the InternationalCode, many Member States have made substantial efforts toimplement it, but that many products unsuitable for infant feedingare nonetheless being promoted and used for this purpose; andthat sustained and concerted efforts will therefore continue to benecessary to achieve full implementation of and compliance withthe International Code as well as the cessation of the marketing ofunsuitable products and the improper promotion of breastmilk sub-stitutes;Noting with great satisfaction the guidelines concerning the mainhealth and socioeconomic circumstances in which infants have tobe fed on breastmilk substitutes,2 in the context of Article 6, para-graph 6, of the International Code;Noting further the statement in the guidelines, paragraph 47:�Since the large majority of infants born in maternity wards andhospitals are full term, they require no nourishment other thancolostrum during their first 24-48 hours of life - the amount of timeoften spent by a mother and her infant in such an institutional set-ting. Only small quantities of breastmilk substitutes are ordinarilyrequired to meet the needs of a minority of infants in these facili-ties, and they should only be available in ways that do not interferewith the protection and promotion of breastfeeding for the majori-ty�;1. ENDORSES the report of the Director-General;12. URGES Member States:

(1) to implement the Code if they have not yet done so;(2) to ensure that the practices and procedures of their health

care systems are consistent with the principles and aim of theInternational Code;

(3) to make the fullest use of all concerned parties - health pro-fessional bodies, non-governmental organizations, consumerorganizations, manufacturers and distributors generally, in pro-

tecting and promoting breastfeeding and, specifically, in imple-menting the Code and monitoring its implementation and compli-ance with its provisions;

(4) to seek the cooperation of manufacturers and distributors ofproducts within the scope of Article 2 of the Code, in providing allinformation considered necessary for monitoring the implementa-tion of the Code;

(5) to provide the Director-General with complete and detailedinformation on the implementation of the Code;

(6) to ensure that the small amounts of breastmilk substitutesneeded for the minority of infants who require them in maternitywards and hospitals are made available through the normal pro-curement channels and not through free or subsidized supplies;3. REQUESTS the Director-General:

(1) to propose a simplified and standardized form for use byMember States to facilitate the monitoring and evaluation by themof their implementation of the Code and reporting thereon to WHO,as well as the preparation by WHO of a consolidated report cover-ing each of the articles of the Code;(2) to specifically direct the attention of Member States and other

interested parties to the following:(a) any food or drink given before complementary feeding is

nutritionally required may interfere with the initiation or mainte-nance of breastfeeding and therefore should neither be promotednor encouraged for use by infants during this period;

(b) the practice being introduced in some countries of provid-ing infants with specially formulated milks (so-called �follow-upmilks�) is not necessary.

16 May 1986 A39/VR/15(emphasis added)

1: Document WHA39/1986/REC/1, or Document A39/82: Document WHA39/1986/REC/1, or Document A39/8 Add.1

WHA41.11 (1988)The Forty-first World Health Assembly, 1988

Having considered the report by the Director-General on infantand young child nutrition;Recalling resolutions WHA33.32, WHA34.22 and WHA39.28 oninfant and young child feeding and nutrition, and resolutionsWHA37.18 and WHA39.31 on the prevention and control of vita-min A deficiency and xerophthalmia, and of iodine deficiency dis-orders;Concerned at continuing decreasing breastfeeding trends in manycountries, and committed to the identification and elimination ofobstacles to breastfeeding;Aware that appropriate infant and young child nutrition could ben-efit from further broad national, community and family interven-tions;1. COMMENDS governments, women�s organizations,

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professional associations, consumer and other non-governmentalgroups, and the food industry for their efforts to promote appropri-ate infant and young child nutrition, and encourages them, incooperation with WHO, to support national efforts for coordinatednutrition programs and practical action at country level to improvethe health and nutrition of women and children; 2. URGES Member States:

(1) to develop or enhance national nutrition programs, includ-ing multisectoral approaches, with the objective of improving thehealth and nutritional status of their populations, especially that ofinfants and young children;

(2) to ensure practices and procedures that are consistentwith the aim and principles of the International Code of Marketingof Breastmilk Substitutes, if they have not already done so;3. REQUESTS the Director-General to continue to collaboratewith Member States, through WHO regional offices and in collab-oration with other agencies of the United Nations system, espe-cially FAO and UNICEF:

(1) in identifying and assessing the main nutrient and dietaryproblems, developing national strategies to deal with them, apply-ing these strategies, and monitoring and evaluating their effective-ness;

(2) in establishing effective nutritional status surveillance sys-tems in order to ensure that all the main variables which collective-ly determine nutritional status are properly addressed;

(3) in compiling, analyzing, managing and applying informa-tion that they have gathered on the nutritional status of their pop-ulations;

(4) in monitoring, together with other maternal and child healthindicators, change in the prevalence and duration of full and sup-plemented breastfeeding with a view to improving breastfeedingrates;

(5) in developing recommendations regarding diet, includingtimely complementary feeding and appropriate weaning practices,which are appropriate to national circumstances;

(6) in providing legal and technical assistance, upon requestfrom Member States, in the drafting and/or the implementation ofnational codes of marketing of breastmilk substitutes, or other sim-ilar instruments;

(7) in designing and implementing collaborative studies toassess the impact of measures taken to promote breastfeedingand child nutrition in Member States.

May 1988 WHA41/ 1988/REC/1, 9(emphasis added)

WHA43.3 (1990)The Forty-third World Health Assembly, 1990

Recalling resolutions WHA33.32, WHA 34.22, WHA35.26,WHA37.30, WHA39.28 and WHA41.11 on infant and young childfeeding and nutrition;

Having considered the report of the Director-General on infant andyoung child nutrition;1Reaffirming the unique biological properties of breastmilk in pro-tecting against infections, in stimulating the development of theinfant�s own immune system, and in limiting the development ofsome allergies;Recalling the positive impact of breastfeeding on the physical andemotional health of the mother, including its important contributionto child-spacing;Convinced of the importance of protecting breastfeeding amonggroups and populations where it remains the infant-feeding norm,and promoting it where it is not, through appropriate informationand support, as well as recognizing the special needs of workingwomen;Recognizing the key role in protecting and promoting breastfeed-ing played by health workers, particularly nurses, midwives andthose in child health/family planning programs, and the signifi-cance of the counselling and support provided by mothers� groups;Recognizing that, in spite of resolution WHA39.28, free or low-costsupplies of infant formula continue to be available to hospitals andmaternities, with adverse consequences for breastfeeding;Reiterating its concern over the decreasing prevalence and dura-tion of breastfeeding in many countries;1. THANKS the Director-General for his report;2. URGES Member States:

(1) to protect and promote breastfeeding, as an essential com-ponent of their- overall food and nutrition policies and programs onbehalf of women and children, so as to enable all infants to beexclusively breastfed during the first four to six months of life;

(2) to promote breastfeeding, with due attention to the nutri-tional and emotional needs of mothers;

(3) to continue monitoring breastfeeding patterns, includingtraditional attitudes and practices in this regard;

(4) to enforce existing, or adopt new, maternity protection leg-islation or other suitable measures that will promote and facilitatebreastfeeding among working women;

(5) to draw the attention of all who are concerned with plan-ning and providing maternity services to the universal principlesaffirmed in the joint WHO/UNICEF statement2 on breastfeedingand maternity services that was issued in 1989;

(6) to ensure that the principles and aim of the InternationalCode of Marketing of Breastmilk Substitutes and the recommenda-tions contained in resolution WHA39.28 are given full expressionin national health and nutrition policy and action, in cooperationwith professional associations, women�s organizations, consumerand other non-governmental groups, and the food industry;

(7) to ensure that families make the most appropriate choicewith regard to infant feeding, and that the health system providesthe necessary support;3. REQUESTS the Director-General, in collaboration with

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UNICEF and other international and bilateral agencies concerned:(1) to urge Member States to take effective measures to

implement the recommendations included in resolutionWHA39.28;

(2) to continue to review regional and global trends in breast-feeding patterns, including the relationship between breastfeedingand child-spacing;

(3) to support Member States, on request, in adopting meas-ures to improve infant and young child nutrition, inter alia by col-lecting and disseminating information on relevant national actionof interest to all Member States; and to mobilize technical andfinancial resources to this end.

14 May 1990 A43/VR/12(emphasis added)

1: Document WHA43/1990/REC/1,p.352: Protecting, promoting and supporting breastfeeding: the specialrole of maternity services. A joint WHO/UNICEF statement,Geneva, World Health Organization, 1989

WHA45.34 (1992)The Forty-fifth World Health Assembly, 1992

Having considered the report of the Director-General on infantand young child nutrition;Recalling resolutions WHA33.32, WHA34.22, WHA35.26,WHA37.30, WHA39.28, WHA41.11 and WHA43.3 concerninginfant and young child nutrition, appropriate feeding practices andrelated questions;Reaffirming that the International Code of Marketing of BreastmilkSubstitutes is a minimum requirement and only one of severalimportant actions required in order to protect healthy practices inrespect of infant and young child feeding;Recalling that products that may be promoted as a partial or totalreplacement for breastmilk, especially when these are presentedas suitable for bottle feeding, are subject to the provisions of theInternational Code;Reaffirming that during the first four to six months of life no foodor liquid other than breastmilk not even water, is required to meetthe normal infant�s nutritional requirements, and that from the ageof about six months infants should begin to receive a variety oflocally available and safely prepared foods rich in energy, in addi-tion to breastmilk, to meet their changing nutritional requirements;Welcoming the leadership of the Executive Heads of WHO andUNICEF in organizing the �baby-friendly� hospital initiative, with itssimultaneous focus on the role of health services in protecting,promoting and supporting breastfeeding and on the use of breast-feeding as a means of strengthening the contribution of healthservices to safe motherhood, child survival, and primary healthcare in general, and endorsing this initiative as a most promising

means of increasing the prevalence and duration of breastfeed-ing;Expressing once again its concern about the need to protect andsupport women in the workplace, for their own sakes but also inthe light of their multiple roles as mothers and care-providers,inter alia by applying existing legislation fully for maternity protec-tion, expanding it to cover any women at present excluded or,where appropriate, adopting new measures to protect breastfeed-ing;Encouraged by the steps being taken by infant-food manufactur-ers towards ending the donation or low-price sale of supplies ofinfant formula to maternity wards and hospitals, which would con-stitute a step towards full implementation of the InternationalCode;Being convinced that charitable and other donor agencies shouldexert great care in initiating, or responding to, requests for freesupplies of infant foods;Noting that the advertising and promotion of infant formula and thepresentation of other products as breastmilk substitutes, as wellas feeding-bottles and teats, may compete unfairly with breast-feeding which is the safest and lowest-cost method of nourishingan infant, and may exacerbate such competition and favor unin-formed decision-making by interfering with the advice and guid-ance to be provided by the mother�s physician or health worker;Welcoming the generous financial and other contributions from anumber of Member States that enabled WHO to provide technicalsupport to countries wishing to review and evaluate their ownexperiences in giving effect to the International Code,1. THANKS the Director-General for his report;2. URGES, Member States:

(1) to give full expression at national level to the operationaltargets contained in the Innocenti Declaration, namely:

(a) by appointing a national breastfeeding coordinator andestablishing a multisectoral breastfeeding committee;

(b) by ensuring that every facility providing maternity servic-es applies the principles laid down in the joint WHO/UNICEFstatement on the role of maternity services in protecting, promot-ing and supporting breastfeeding;

(c) by taking action to give effect to the principles and aim ofthe International Code of Marketing of Breastmilk Substitutes andsubsequent relevant Health Assembly resolutions in their entirety;

(d) by enacting legislation and adopting means for itsenforcement to protect the breastfeeding rights of workingwomen;

(2) to encourage and support all public and private health facil-ities providing maternity services so that they become �baby-friendly�:

(a) by providing the necessary training in the application ofthe principles laid down in the joint WHO/UNICEF statement;

(b) by encouraging the collaboration of professional associ-ations, women�s organizations, consumer and other non-govern-mental groups, the food industry, and other competent sectors in

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this endeavor;(3) to take measures appropriate to national circumstances

aimed at ending the donation or low-priced sale of supplies ofbreastmilk substitutes to health-care facilities providing maternityservices;

(4) to use the common breastfeeding indicators developed byWHO, with the collaboration of UNICEF and other interestedorganizations and agencies, in evaluating the progress of theirbreastfeeding programs;

(5) to draw upon the experiences of other Member States in giv-ing effect to the International Code;3. REQUESTS the Director-General:

(1) to continue WHO�s productive collaboration with its tradition-al international partners, in particular UNICEF, as well as otherconcerned parties including professional associations, women�sorganizations, consumer groups and other non-governmentalorganizations and the food industry, with a view to attaining theOrganization�s goals and objectives in infant and young child nutri-tion;(2) to strengthen the Organization�s network of collaborating cen-

ters, institutions and organizations in support of appropriatenational action;

(3) to support Member States, on request, in elaborating andadapting guidelines on infant nutrition, including complementaryfeeding practices that are timely, nutritionally appropriate and bio-logically safe and in devising suitable measures to give effect tothe International Code;

(4) to draw the attention of Member States and other intergov-ernmental organizations to new developments that have an impor-tant bearing on infant and young child feeding and nutrition;

(5) to consider, in collaboration with the International LaborOrganization, the options available to the health sector and otherinterested sectors for reinforcing the protection of women in theworkplace in view of their maternal responsibilities, and to reportto a future Health Assembly in this regard;

(6) to mobilize additional technical and financial resources forintensified support to member States.

14 May 1992 A45/VR/13(emphasis added)

WHA 47.5 (1994)The Forty-seventh World Health Assembly, 1994

Agenda item 19Infant and young child nutrition

Having considered the report by the Director-General on infant andyoung child nutrition;Recalling resolutions WHA33.32, WHA34.22, WHA35.26,WHA37.30, WHA39.28, WHA41.11, WHA45.34 and WHA46.7, con-cerning infant and young child nutrition, appropriate feeding practices

and related questions;Reaffirming its support for all these resolutions and reiterating the rec-ommendations to member states contained therein;Bearing in mind the superiority of breast-milk as the biological normfor nourishing infants, and that a deviation from this norm is associat-ed with increased risks to the health of infants and mothers;1. THANKS to the Director-General for his report;2. URGES Member States to take the following measures:(1) to promote sound infant and young child nutrition, in keeping with

their commitment to the World Declaration and Plan of Action forNutrition,1 through coherent effective intersectoral action, including;

(a) increasing awareness among health personnel, non-govern-mental organizations, communities and the general public of theimportance of breast-feeding and its superiority to any other infantfeeding method;

(b) supporting mothers in their choice to breast-feed by removingobstacles and preventing interference that they may face in healthservices, the workplace, or the community;

(c) ensuring that all health personnel concerned are trained inappropriate infant and young child feeding practices, including theapplication of the principles laid down in the joint WHO/UNICEFstatement on breast-feeding and the role of maternity services;2

(d) fostering appropriate complementary feeding practices fromthe age of about six months, emphasizing continued breast-feedingand frequent feeding with safe and adequate amounts of localfoods.(2) to ensure that there are no donations of free or subsidized sup-

plies of breast-milk substitutes and other products covered by theInternational Code of Marketing of Breast-milk Substitutes in any partof the health care system;

(3) to exercise extreme caution when planning, implementing orsupporting emergency relief operations, by protecting, promoting andsupporting breast-feeding for infants, and ensuring that donated sup-plies of breast-milk substitutes or other products covered by the scopeof the International Code by given only if all the following conditionsapply;

(a) infants have to be fed on breast-milk substitutes, as outlinedin the guidelines concerning the main health and socioeconomic cir-cumstances in which infants have to be fed on breast-milk substi-tutes,3

(b) the supply is continued for as long as the infants concernedneed it;

(c) the supply is not used as a sales inducement;(4) to inform the labor sector, and employers� and workers� organi-

zations, about the multiple benefits of breast-feeding for infants andmothers, and the implications for infants and mothers, and the impli-cations for maternity protection in the workplace;3. REQUESTS the Director-General:(1) to use his good offices for cooperation with all parties concerned

in giving effect to this and related resolutions of the Health Assemblyin their entirety;

(2) to complete development of a comprehensive global approachand program of action to strengthen national capacities for improving

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infant and young child feeding practices; including the development ofmethods and criteria for national assessment of breast-feeding trendsand practices:

(3) to support Member States, at their request, in monitoring infantand young child feeding practices and trends in health facilities andhouseholds, in keeping with new standard breast-feeding indicators

(4) to urge Member States to initiate the Baby-friendly HospitalInitiative and to support them, at their request, in implementing thisInitiative, particularly in their efforts to improve educational curriculaand in-service training for all health and administrative personnel con-cerned;

(5) to increase and strengthen support to Member States, at theirrequest, in giving effect to the principles and aim of the InternationalCode and all relevant resolutions, and to advise Member States on aframework which they may use in monitoring their application, asappropriate to national circumstances;(6) to develop, in consultation with other concerned parties and aspart of WHO�s normative function, guiding principles for the use inemergency situations of breast-milk substitutes or other products cov-ered by the International Code which the competent authorities inMember States may use, in the light of national circumstances toensure the optimal infant-feeding conditions;(7) to complete, in cooperation with selected research institutions,collection of revised reference data and the preparation of guidelinesfor their use and interpretation, for assessing the growth of breast-fedinfants;(8) to seek additional technical and financial resources for intensify-ing WHO�s support to Member States in infant feeding and in theimplementation of the International Code and subsequent relevantresolutions.

Eleventh plenary meeting, 9 May 1994A47/VR/11(underscoring added)

1: World Declaration and Plan of Action for Nutrition, FAO/WHO,International Conference on Nutrition, Rome, December 1992.2: Protecting, promoting and supporting breast-feeding: the specialrole of maternity services. A joint WHO/UNICEF statement. Geneva,World Health Organization, 1989.3: Document WHO A39/8 Add.1, 10 April 1986. These guidelinesprovide suggestions for health care management which permitscontinued breastfeeding or breastmilk feeding in many situations.

WHA 49.15 (1996)The Forty-ninth World Health Assembly, 1996

Agenda item 17Infant and young child nutritionHaving considered the summary report by the Director-General oninfant feeding and young child nutrition;Recalling resolutions WHA33.32, WHA34.22, WHA39.28, and

WHA45.34 among others concerning infant and young child nutri-tion, appropriate feeding practices and other related questions;Recalling and reaffirming the provisions of resolution WHA47.5concerning infant and young child nutrition, including the empha-sis on fostering appropriate complementary feeding practices;Concerned that health institutions and ministries may be subject tosubtle pressure to accept, inappropriately, financial or other sup-port for professional training in infant and child health;Nothing the increasing interest in monitoring the application of theInternational Code of Marketing of Breast-Milk Substitutes andsubsequent relevant Health Assembly resolutions,1. THANKS the Director-General for his report1;2. STRESSES the continued need to implement the InternationalCode of Marketing of Breast-Milk Substitutes, subsequent relevantresolutions of the Health Assembly, The Innocenti Declaration,and the World Declaration and Plan of Action for Nutrition;3. URGES Member States to take the following measures:

(1) to ensure that complementary foods are not marketed foror used in ways that undermine exclusive and sustained breast-feeding.

(2) to ensure that the financial support for professionals work-ing in infant and young child health does not create conflicts ofinterest, especially with regard to the WHO/UNICEF BabyFriendly Hospital Initiative;

(3) to ensure that monitoring the application of theInternational Code and subsequent relevant resolutions is carriedout in a transparent independent manner, free from commercialinfluence.

(4) to ensure that the appropriate measures are taken includ-ing health information and education in the context of primaryhealth care, to encourage breast-feeding;

(5) to ensure that the practices and procedures of their healthcare systems are consistent with the principles and aims of theInternational Code of Marketing of Breast-Milk Substitutes;

(6) to provide the Director-General with complete and detailedinformation on the implementation of the Code;4. REQUESTS the Director-General to disseminate, as soon aspossible, to Member States document WHO/NUT/96.4 (currentlyin preparation) on the guiding principles for feeding infants andyoung children during emergencies.

Sixth plenary meeting, 25 May 1996A49/VR/6(underscoring added)

1: Document A49/4.

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We are a national NGO incorporated with the Corporate Law Authority as a company limit-ed by guarantee not having a share capital.

The Association for Rational Use of Medication in Pakistan (The Network) is a voluntarygroup of health professionals and citizens working to promote the rational use of medication andthe Essential Drug concept in Pakistan in order to optimize the usefulness of drugs and helpbring equity in their access. This voluntary group acts as an apex council of the organization.Currently the Council is Chaired by Prof. Akhlaque un Nabi Khan and Dr. Tasleem Akhter is theVice-Chairperson.

We have a vision of national consumer protection organization and we believe in consumerempowerment to combat the weaknesses of the free-market culture.

This vision and belief is driving us towards general consumer protection work. More specifi-cally, we are sharpening our focus on such products and services that have negative implica-tions for the consumers. This is in addition to our ongoing work on pharmaceuticals. The protec-tion of breastfeeding and young child nutrition from irresponsible and ruthless promotion of artifi-cial milk and baby food products is one such new area which we have added to our project list.

Our work strategies include:Advocacy and campaigningInformation/Education/CommunicationOperational researchResource center developmentGradual expansionThe Network publishes a bimonthly English newsletter for health professionals and con-

sumers and a bimonthly Urdu newsletter Sarfeen aur Sehat for consumers. We also producecampaign briefing papers, brochures, reports, etc. Relevant and important books at low-cost arealso published under our �Network Publication Service�.

We also maintain a Resource Center on pharmaceutical issues, consumer protection andrelated issues.

For further details about our activities please contact:The Network,P.O. Box 2563, Islamabad.PakistanPh: 92-51-281755; Fax: 92-51-291552E-mail: zafar@arump.sdnpk.undp.org

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