Celebrating the 40th Anniversary of the Code

The International Code of Marketing of Breast-milk Substitutes, now 40 years old, is as relevant as ever. 

Otherwise known as the Code, it was adopted by the 34th World Health Assembly (WHA) on May 21, 1981 in an effort to contribute to safe and adequate nutrition for infants by protecting breastfeeding and ensuring the proper use of breast-milk substitutes by restricting promotions that target the public, parents and health workers.

Formula milk companies– an industry worth 60 billion dollars and growing by about 10 percent annually– have done an incredibly successful job of positioning themselves as a trusted source for families, shaping infant feeding culture globally. They’ve achieved relationship-based marketing through digital avenues, shifted their target toward older children over the years, and used the COVID-19 pandemic to promote their brand undermining maternal child health. 

The baby food industry continues to use many of the promotional tactics they did in the 1970s but have become more sophisticated in pushing baby milk formulas through online social clubs, targeted ads, and hosting contests to be formula “influencers”.

This month, the United States Breastfeeding Committee (USBC) hosted its first webinar in its Unpacking Commercial Milk Formula Marketing: Communities, Contexts, and Impacts webinar series presented by World Health Organization (WHO) technical officer Laurence Grummer-Strawn, PhD and Senior Advisor Access to Nutrition Initiative (ATNI) Rachel Crossley, MSc.  

At the beginning of the webinar, USBC Deputy Director Amelia Psymthe Seger reviews what has led USBC to create the shared learning journey around the Code. In 2019, USBC conducted a survey of the knowledge of the Code among member organizations, which demonstrated “a fractured understanding of the Code”.  In 2020, member organizations expressed interest in active engagement around the Code, leading to an incubation conversation, testing the will and capacity of the interested organizations to take action on the Code. That conversation led to the creation of this 3-part webinar series as a platform for mutual learning to determine future actions.

Responding to ‘old tricks, new opportunities’ 

The marketing of formula milks impact mothers’ infant feeding decisions on a personal level, but Grummer-Strawn reviews how marketing tactics have impacted society in general, embedding corporate influence on many levels.

(Image credit: Alive & Thrive)

Formula milk companies have infiltrated the networks mothers find themselves in controlling the advice that they receive from friends and relatives. Companies have influenced health care providers’ messaging by sponsoring scientific meetings. What’s more, they’ve molded a culture that claims infant feeding to be a personal choice making it easy for employers and legislators to ignore investing in policies that affect healthy maternal child health outcomes. 

Since the adoption of the Code, Grummer-Strawn lists subsequent clarifications that have addressed loopholes, unclear resolutions and the ever-changing contexts families find themselves in like modifications to how to monitor the Code in emergency situations, conflicts of interest, recommendations for the duration of exclusive breastfeeding, labels, follow-up formulas, health care provisions and cross promotion. 

Grummer-Strawn goes on to highlight some of the most recent work around the Code:

  • research that looks at mothers’ experiences with formula milk marketing in eight countries
  • Review of how the industry uses digital marketing  
  • Understanding breastfeeding within the context of human rights as well as the right of the industry through free speech 
  • Consideration of standardized formula milk packaging 
  • Analysis of how countries are implementing the Code 

Over the next 18 months, we can anticipate another Lancet series on maternal child nutrition and a global summit on the commercial determinants of child health. 

Highlighting positive outcomes  

Since its inception and moving forward, the Code calls on many actors to implement the code; from manufacturers and distributors to national governments, to UN agencies, NGOs and professional groups to health care workers, media and creative industries.

(Image credit: UNICEF)

Crossley’s work at ATNI around private sector accountability on nutrition has documented equally crushing and hopeful reports. For instance, ATNI’s 2018 US Access to Nutrition Index found that “overall America’s ten largest food and beverage manufacturers lack comprehensive strategies, policies and action to effectively address the nation’s high levels of obesity and diet-related diseases.”  

However, she reports that one major formula milk company has made a “substantial, unilateral, voluntary commitment through the call to action process” to extend its policy by the end of 2022 in alignment with the Code. 

“It’s really quite a big step forward,” Crossley says in the webinar. 

Some of ATNI’s newest work includes its Responsible Lobbying Framework which assesses how companies’ lobbying aligns with the Code.

One country’s journey with the Code

In Sweden, Kristin Svensson of Karolinska Institutet and Elisabeth Kylberg of the University of Skövde have witnessed the effects of the Code over several decades.

(Image credit: UNICEF)

In the 1970s while breastfeeding rates in Sweden were on the rise, the National Board of Health and Welfare initiated breastfeeding promotion throughout the country by establishing an expert group and publishing a book to help train professionals working with families from pregnancy and beyond. In 1973, The Breastfeeding Mothers Association (Amningshjälpen) was formed. 

“It was a positive climate to promote breastfeeding,” Svensson and Kylberg share in an email interview with Our Milky Way

In this climate, applying the Code in 1983 was “one step further in an ongoing process to protect breastfeeding.”  

At this time, Kylberg and Svensson remember formula milk advertisements disappearing from pediatric health centers. 

“It was an incredibly positive change,” they write.  

It wasn’t until 2013 that Sweden adopted the Code into law (SFS 2013:1054) following the EU-directive. 

(Image credit: UNICEF)

Kylberg and Svensson point out that there are limitations in the law. The baby food industry is permitted to advertise formulas in papers for professionals and bottles and teats have been omitted from the law. But they report that the Code is still used as an important tool to report violations. 

Because there is no national monitoring in place though, whistleblowing falls on non-governmental and professional organizations as well as individuals working in the health sector, they explain. 

Promisingly, an initiative in the region of Skåne upholds the Code and urges all staff working in primary health care to follow it.

At the national level, a collaborative of different national agencies is working to find a solution on how to organize a holistic approach on breastfeeding and to revitalize the BFHI which now includes the Code, the duo shares. 

They add that the Code is now even more important in light of the COVID-19 pandemic.  

“We think that to monitor the Code is [continuous work] and to push the national agencies to do what they should do,” Svensson and Kylberg share. “That is the best honor of the Code.”

[This figure depicts the prevalence of exclusive breastfeeding in Sweden from 1964 until 2016. Note: no breastfeeding data collection occurred between 1975 and 1985. The upper line depicts breastfeeding at 2 months of age, middle at 4 months and the lower at 6 months.]

Onward 

Advancing the mission of the Code is an uphill battle, as Grummer-Strawn puts it.  

He details the many ways we can contribute to the cause.

(Image credit: UNICEF)

First, he encourages education. There are plenty of online opportunities offered including a health professinals’ guide from UNICEF, IBFAN’s resource page, as well as USBC’s upcoming webinars as part of their series Unpacking Commercial Milk Formula Marketing: Communities, Contexts, and Impacts. Up next is “Commercial Milk Formula Marketing: Communities and Emergencies” on Wednesday, June 2 from 2 to 3:30 p.m. ET. 

Documenting and publicizing the problem is paramount. 

“If we aren’t making noise so people understand what the problem is, it’s going to be very hard to get any action on it,” Grummer-Strawn explains during the webinar. 

For this piece, there are tools like the NetCode Toolkit and IBFAN’s Code Monitoring Toolkit.  

Crossley suggests writing directly to the entities at fault. You can report compliance concerns to one major company here. While some companies have a direct page to report complaints, you may be surprised to find the trail others lead you down. For example, in the U.S. one company takes you from here to here to here, making the whistleblowing process much more convoluted and distracting. 

(Image credit: UNICEF)

USBC webinar presenters emphasized the importance of lifting up the good actors, celebrating and amplifying the companies that are doing good things rather than solely focusing on companies’ wrongdoings. 

Honoring the Code, especially in the U.S., has to be a long term strategy, Grummer-Strawn says. Executing an incremental approach ultimately adds up to the goal of full Code implementation. 

In this light, Grummer-Strawn touches on U.S.-specific circumstances to consider: 

  • We have a shared understanding of the harms of tobacco and can restrict tobacco companies’ speech, but we don’t have that same understanding with formula milk.
  • Modifying procurement standards within organizations like WIC may improve the way infant formula is distributed in the U.S. For example, would it be feasible to use Code compliance as a factor used to determine how states, territories, and tribal organizations choose formula vendors for WIC contracts?
  • Addressing conflicts of interest between healthcare providers and pharmaceutical companies is a huge movement in healthcare; conflicts of interest with formula companies are in this same vein and voluntary action against this conflict should be taken. 
  • Educating and engaging retailers may be instrumental in changing the industry. 
  • Pressure from consumers and investors drives competition among companies to work ethically. 

Our nation’s health and global health are so deeply intertwined with the saturation of baby food industry’s influence. Without vilifying the use of baby milk formulas, companies must be held accountable for their exploitation of maternal child health outcomes.  The Global Breastfeeding Collective and its partners call on all governments and their actors to protect mothers and babies from commercial exploitation by enacting and enforcing strong national legislation. Put #BabiesBeforeProfits.

(Image credit: Alive & Thrive)

The 40th Anniversary of the #BMSCode is a powerful reminder of what happens when the world comes together to protect the youngest lives. This #NutritionYearOfAction, Governments can once again pledge to safeguard children’s lives by #ProtectingBreastfeeding + putting #BabiesBeforeBusiness. 

A recording of the Global Breastfeeding Collective’s celebration of the Code is available here in several languages. 

Additional resources and links from Global Breastfeeding Collective 

Event Landing page

The BMS Code resources from the Global Breastfeeding Collective

Capitalizing on fears, companies promote breastmilk substitutes during the pandemic | Alive & ThriveCode FAQs 

Marketing of breast milk substitutes: national implementation of the international code, status report 2020

https://www.llli.org/quick-guide-international-code-2/

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