Pediatricians want to improve child health and
survival. Poverty, pathogens and ignorance are their enemies but
commercial capital and marketing manipulation are also powerful
adversaries. For over a century, motivated by high profits, the
manufacturers of artificial infant feeding products have promoted their
products through a series of overt and subtle strategies. The global
value of baby food sales is now over US$16,453 million (78,978 crore
rupees)(1). The resulting loss of confidence in breastfeeding has had
devastating results. Health services worldwide, including in rich
countries, are overloaded with preventable morbidity, and the poor
endure many unnecessary infant deaths(2).
Breastfeeding research (to which Indian scientists
have made an impressive contribu-tion), using more rigorous study
designs, continues to reveal powerful evidence of the value of
breastfeeding and breastmilk(3-5).
There is a dose-related response to different feeding
patterns. Exclusive breastfeeding for the first six months significantly
reduces morbidity and mortality(6). This practice, followed by continued
breastfeeding, together with nutrient-dense complementary feeding, into
the second year and beyond, is the cornerstone of WHO/UNICEF’s Global
Strategy for Infant and Young Child Feeding(7). Almost all mothers can
achieve this if given skilled practical, emotional and social support,
feasible even in poor slum communities in India(5). The realisation that
hypertension(8), obesity(9) and diabetes(10) are influenced by infant
feeding patterns has restimulated interest in industrialised societies,
as does the evidence of the health benefits for women. For example, each
year of breastfeeding independently reduces the risk of breast cancer by
4.3%(11). Women in Europe and North America, aware of the benefits to
their children and themselves, are finding ways to breastfeed for
longer.
The International Code of Marketing of Breastmilk
Substitutes (the Code) was adopted by the World Health Assembly (WHA) in
1981 to stop the damage to breastfeeding through promotion of the
substitute products. Apathy on the part of governments, lack of
breastfeeding knowledge in the medical establishment and the guile of
the companies contributed to inertia in implementation of the Code(12)
However, thanks to the persistence of individuals and organisations,
often linked with the International Baby Food Action Network (IBFAN),
and the intrinsic ethical and moral content of the Code, its aims are
gaining ground. The biennial WHA Resolutions have clarified ambiguities
and addressed new health and development issues. The Code is designed to
protect the breastfeeding mother from misinformation and undermining
practices, and the infant who must be artificially fed, through
impartial feeding decisions untainted by commercial influences. It also
shields health professionals who individually may find it difficult to
withstand the blandishments of the companies.
Research has shown that the companies will flout the
Code where they can, but will curb their excesses when governments
act(13). To date 25 countries have enacted the full Code as law(14).
India achieved this in 1992 through the Infant Milk Substitute Act (IMS).
Moreover, India included tools for implementation through the wise step
of utilising the expertise of citizens’ organisations, particularly the
Association of Consumer Action on Safety and Health (ACASH) and the
Breastfeeding Promotion Network of India (BPNI). Prosecutions, or the
threat of legal action, have made companies back off and eschew
practices which are rampant in other countries. Nestle were forced to
change misleading labels, and Johnson and Johnson were stopped from
pushing feeding bottles. But loopholes in the law allowed continuing
exploitation.
Perhaps the most successful promotional strategies of
the companies is their financial sponsorship and gift inducements for
the medical profession, both through professional bodies and to
individuals. For this reason the WHA adopted Resolution WHA 49(14) in
1996. Concern was expressed that "health institutions and ministries may
be subject to subtle pressure to accept, inappropriately, financial and
other support for professional training in infant and child health";
Member States were urged "to ensure that the financial support for
professionals working in infant and young child health does not create
conflict of interest, especially with regard to the WHO/UNICEF Baby
Friendly Hospital Initiative."
The Lok Sabha and the Rajya Sabha have approved the
Infant Milk Substitutes, Feeding Bottles, and Infant Foods Regulation of
Pro-duction, Supply and Distribution Amendment Bill 2003 (IMSAB) which
has closed the loopholes in the IMS Act of 1992. This is exactly the aim
of the global consensus of the WHA Resolutions. The WHO/UNICEF Global
Strategy for Infant Feeding emphasises rapid implementation of the Code
and all subsequent resolutions. India is at the helm of this flagship of
infant and young child health protection.
The IMSAB comprehensively bans all forms of promotion
of infant feeding products, including offering any kind of benefits to
any person. Funding of seminars, meetings, research or any sponsorship
is prohibited. The beauty of this legislation is that it lifts the
individual’s ethical responsibility into a communal one and lightens the
burden. Many readers of this journal may have been recipients of gifts
and sponsorship from these manufacturers. This entrenched practice was
established way back in the 1920s in the United Kingdom and North
America. No one need wallow in guilt and everyone may rejoice in a move
towards ethical practice knowing the law is on their side.
In the USA, a recent analysis of the nature and
effect of sponsorship on doctors showed that 61% of physicians believe
that promotions do not influence their own practice but only 16%
believed this about other physicians. Small gifts have as potent effect
as large. "The sheer ubiquity of trinkets.......is evidence of
effectiveness; why else would profit -minded companies continue to
provide them? Thus policies against gifts should not be limited to large
gifts." All gifts subliminally influence, thus undermining the quality
of clinical decision-making. The authors argue cogently how unconscious
and unintentional is the recipient’s bias towards the gift-giver and
state that a policy of prohibition is the only answer(15). India has
done just that.
This Indian law will support the excellence in
practice for which every paediatrician strives and they have a key role
in its implementation. Monitoring is crucial and notification must be
swift to help compliance become established. Many doctors may need to
update themselves in breastfeeding management skills and pre-service
curricula reform must gather momentum. Fortunately, materials are at
hand available for national and local use (Breastfeeding counselling: A
training course. WHO/UNICEF publication).
The implementation of this law gives all
paediatricians the chance to invest in the true wealth of India, the
health and wellbeing of her children. India, through democracy and the
skill of dedicated citizens, has had the political will to bring the
Code and subsequent WHA Resolutions into effect. The health and
development of Indian children is being taken seriously.
Gabrielle Palmer,
Research Fellow,
Nutrition Unit,
London School of Hygiene and
Tropical Medicine, U.K.
E-mail: [email protected]
Anthony Costello,
Professor of International Child Health,
International Perinatal Care Unit,
Institute of Child Health,
University College, London, U.K.
E-mail:
[email protected]
