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Speakers' Corner

Dear SCN News Editor,

Nestlé and the Code

The marketing of breastmilk substitutes came under the scrutiny of Members of the European Parliament (MEPs) at a Public Hearing on 22nd November 2000 as they began to examine the effectiveness of international standards and codes of conduct. According to UNICEF, reversing the decline in breastfeeding could save the lives of 1.5 million infants around the world every year.

The International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly in 1981 under Resolution 34.22 as a "minimum" requirement to be implemented in its "entirety". Calls for the introduction of such a Code were given a boost by a hearing at the United States Senate in 1978. The European Parliament Public Hearing was called to examine why, nearly 20 years after the Code was introduced, baby food companies continue to be accused of marketing practices which put infant health at risk.

The Hearing, which was held before the Development and Cooperation Committee, focused on marketing in Pakistan. The non-governmental organisation The Network for Consumer Protection in Pakistan, was invited to present evidence, in part because it had registered complaints with the European Commission using export regulations which implement the Code. The Network, which is a member of IBFAN (the Internationnal Baby Food Action Network), has also conducted extensive monitoring in Pakistan. Its report, Feeding Fiasco, published in 1998, resulted from monitoring conducted in 33 cities, involving over 2,500 interviews with health professionals and mothers, examination of over 400 spec imens of promotional and informational materials and analysis of product packaging. The Network also published the report Milking Profits last year presenting documentary evidence of company marketing methods provided by Syed Aamar Raza, a former Nestlé employee. This substantiated the evidence found in the Feeding Fiasco report, including bribing of doctors with gifts and money, setting of sales targets and performance bonuses for marketing staff and direct marketing to mothers through baby shows and other activities.

Nestlé was invited to make a presentation to the Hearing. This was relevant because Nestlé figures prominently in the complaints of marketing malpractice from around the world. Nestlé's Swiss head office has taken action recently to counter the criticism, including launching a website and distributing occasional "Code Action" newsletters. At the Nestlé shareholder annual general meeting in 1999, Chairman Helmut Maucher, welcomed the opportunity for the company to present its case at the Hearing. It came as a surprise to the Parliamentarians, therefore, when Nestlé failed to send a representative to the Hearing, especially when different excuses were relayed by Members of the European Parliament. John Corrie MEP said he understood Nestlé was not coming because the event had been put on the agenda as a Special Meeting, a designation which did not seem sufficiently important. (Ironically Nestlé sent its Chief Executive to address students at the London Business School the following day.)

Richard Howitt MEP, who arranged the Hearing, said Nestlé had objected to the presence of IBFAN and UNICEF at the Hearing. Mr. Howitt told The Independent newspaper (23rd November) that Nestlé had demonstrated: "...utter contempt for a properly constituted public hearing. Not to attend reveals a combination of arrogance and distance which has set their cause back". UNICEF's Legal Officer, David Clark, made a presentation on the International Code and the subsequent Resolutions which clarify it and attempt to close loopholes in the original text. He commented: "...two principles, universality and the scope including all breastmilk substitutes, cannot be overemphasised given the tendency of the infant feeding industry to attempt to limit the application of the Code".

During questions, it was noted that Nestlé's "Charter" setting out its policy was limited to developing countries and to infant formula. Nestlé's incorrect interpretation of the Code and Resolutions was one of the criticisms of the third presentation by Sunil Sinha of Emerging Market Economics (EME) who had worked as a consultant for Nestlé, examining its activities in Pakistan. The audit involved interviewing Nestlé staff and doctors from a list provided by Nestlé. EME was told not to contact independent experts and an offer to provide information (made by Baby Milk Action, the UK IBFAN group) was not passed on to EME. All the same, the audit found violations, although these were either ignored because of the terms of reference or their seriousness minimised. A representative of the European Commission commented on its failure to act on the labelling violations reported to it by The Network. This highlighted the confusion over which organisations are the "competent authorities" to register complaints. Richard Howitt MEP called for the procedures to be reviewed as NGOs from several countries had registered complaints, but none had been acted upon.

The Hearings were called under a paper adopted by the European Parliament on 15th January 1999: EU standards for European Enterprises operating in developing countries. Amongst its provisions the paper calls on the Commission to implement international standards in a legally binding framework which is independently monitored so that trans-nationals can be called to account for their actions wherever they operate. This will require the support of the parliaments of the Member States of the European Union. The Commission is called on to work for trans-national accountability in other international fora, such as the World Trade Organisation (WTO). The Hearing is the first of what is to be an annual event. Its value in naming and shaming has already been demonstrated. In an interview on the BBC World Service a week afterwards, Nestlé Vice-President, Niels Christiansen, announced that Nestlé Swiss headquarters had instructed its Pakistan management to stop distributing gifts to doctors. However, it is business as usual in the rest of the world.

Mike Brady
Campaigns and Networking Coordinator, Baby Milk Action

Dear SCN News Editor,

Fortified Infant Foods

During a consultancy in Indonesia in February/March 2000 I was very disturbed about the direction of a project with UN involvement. There is a high prevalence of underweight in infant and children under five years of age and particularly under two years of age (less than -2SD weight-for-age using the WHO reference). This has been increasing over the period 1991 to 1998, according to surveys carried out by Bappanas. Yet much of the donor nutrition budget during my consultancy was being directed to supporting the UNICEF Complementary Feeding Initiative which involves the distribution of a highly fortified manufactured infant food at a cost of 500 Rp per packet through the posyandus (the local village health post) with minimal if any nutrition education, or home reach.

I understand that the composition of this infant food is based on the recent WHO publication Complementary Feeding of Young Children in Developing Countries. My reading of this document is that its recommendations are based on theoretical calculations from Recommended Dietary Intakes and an analysis of complementary foods from Mexico and one other developing country, without reference to hard data such as the results of well-controlled feeding trials.

My summary of the nutrition situation in Indonesia was that international agencies with expatriate nutritionists were dismissing the ability of local foods to meet nutrient needs of all infants and small children in favour of the distribution of these highly fortified foods to mothers attending the posyandus. Of course the real situation is that those infants and small children who were most malnourished were from poor, disadvantaged families and are not reached through the posyandus. Even if their mothers attended the health post they did not have the money to buy the packaged food for their infants. Unfortunately much needed resources for nutrition programmes were being directed to subsidising the sale of the commercial packaged food, which is not reaching those most at risk.

My concern is that industry with its highly fortified foods now seems to have penetrated nutrition activities with questionable results in a very poor country with high rates of underweight and malnutrition in young children in needy and disadvantaged communities. Has there been any discussion in the ACC/SCN about this situation? Or am I out of step with the new thinking on nutrition improvement programs? It was heartening that my views were supported by the national nutritionists in Indonesia, but not by the expatriate specialists.

Ruth English
Nutrition Consultant
Dear SCN News Editor,

Growth Monitoring to be buried or resurrected?

The charting of weights of children, which became known as growth monitoring, was introduced in the 60s and spread worldwide in the 70s. In the 80s, when cost benefit analysis was made, growth monitoring was found not to reduce mortality or affect levels of nutrition when studied nationally. However, in some communities particularly where NGOs are effective in health, it is still widely and successfully used. The reason for the failure was recognised in the 90s when discussion with those concerned with primary education brought to our notice the complexity of a line graph. Piaget, the Guru of education, considered line graphs one of the most difficult subjects to teach. In most developing countries the use of line graphs is not taught in primary schools. Fortunately a method of overcoming this problem has now been developed through the use of the Direct Recording Scale. With this scale the mother, when she places her child in the trousers below the scale, sees a large spring stretching up as she releases the child’s weight. She then herself makes the next entry on the growth curve on the chart which is located behind the spring and at its top has a pointer with a hole in it. She can then compare this entry with the previous months. Unschooled mothers from the Masai in East Africa come to understand the significance of the growth curve as do grandmothers and daughters. Weighing takes place in or very close to the home and relatives are involved. There is also evidence that when faltering occurs the mother and family take action in giving the child additional goat or cow milk.

A number of trials of the scale are underway. In one location in the Philippines it became demand led. That is the people themselves were demanding to have the scales. The scale is very robust and to date of many thousands sent out, none are known to have broken. There are of course many problems still to be solved but weighing in the community empowers the mother and perhaps can be a step towards greater understanding of numeracy in a community.

Kul Gautam and Eduardo Doryan (see p 35 and 37) both emphasize the importance of early child growth and the need for growth monitoring. If, as I hope, there is to be a renewed emphasis on growth monitoring, its success will depend on working with those involved in primary education. Community health workers and mothers need to understand the value of growth monitoring to take action.

David Morley CBE MD FRCP
Professor Emeritus, Institute of Child Health, University of London
Dear SCN News Editor,

I really want to thank ACC/SCN for publishing its papers on the web. I think that this is the best way to quickly disseminate information, news, and findings in our field. I wish other organizations would follow your lead!

Scott Poe
Centers for Disease Control and Prevention
Dear SCN News Editor,

Thank you for a copy of the RNIS supplement on Assessment of Nutritional Status in Emergency-Affected Populations, July, 2000.

I was pleased with the final product and think that it makes a useful contribution to practice guidelines for famine relief. I was also very pleased when I came across a copy being used by nuns to assess starving adults at a mission right in the middle of the Ethiopia bush! It's great to see that it is in use where it's needed.

Steve Collins
Independent Consultant (co-author of RNIS supplement on Assessment of Nutritional Status in Emergency-Affected Populations)

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