Conflicts of interest everywhere one turns

The authors of Call to end sponsorship from commercial milk formula companies published in The Lancet last month urge all health-care professional associations (HCPAs) to commit to ending sponsorships from companies that market commercial milk formulas (CMFs) by the end of 2024.

Greed depicted in an image that is part of a series of prints of the Seven Deadly Sins, engraved by Pieter van der Heyden after drawings by Pieter Bruegel the Elder. More at https://www.metmuseum.org/art/collection/search/338698

The CMF industry targets healthcare providers, because they understand providers’ influence on parents’ decisions.

The group of leading HCPAs  is working to compile case studies, references, guidance on how to manage without sponsorship, and more to help any associations in ending such relationships. 

The effort is not a restriction on parental choice, and the authors recognize that all healthcare professionals (HCPs) must support parents on a case-by-case basis. 

Instead, this work focuses on combating the inappropriate marketing of CMFs which interferes with parents getting accurate information to make decisions. The 2023 Lancet Series offers much more information on the industry’s tactics. Find it here.

The CMF industry has its tentacles tangled in affairs beyond the health care provider-patient relationship, raising concerns about conflicts of interest everywhere one turns. 

Healthy Children Project’s Karin Cadwell, PhD, RN, FAAN, ANLC, CLC, IBCLC points out that other fields have separated themselves from industry.  For instance, the Accreditation Council for Continuing Medical Education (ACCME) will not accredit an organization that it defines as a commercial interest. The American Medical Student Association (AMSA) adopted policies opposing gifts to physicians and medical students from the pharmaceutical industry in the early 2000s. This piece describes some of the more recent policies governing physician interactions with industry. 

Yet, formula companies and breast pump companies are right in the middle of the baby feeding arena at conferences, like at  WIC (Women, Infants, and Children) and the American Academy of Pediatrics (AAP). 

Industry at conferences 

Rob Revelette MD, PhD FAAP questions the AAP’s relationship with formula companies in this essay where he notes that the AAP, both at the national and state level, accepts money from formula companies for advertising and sponsorship of meetings.https://www.metmuseum.org/art/collection/search/335169

Greed Breaks the Bag (“La codicia rompe el saco”)
Leonardo Alenza y Nieto Spanish
1807–45
https://www.metmuseum.org/art/collection/search/335169

Saroj Jayasinghe offers in Pharmaceutical industry sponsorship of academic conferences: ethics of conflict of interest, “The most definite way to prevent COI is to completely avoid industry funding of conferences…” 

Because this isn’t always feasible, Jayasinghe writes, it is crucial to establish these proposed guidelines:  “(1) avoid the sponsors having any influence on the decision-making of conference; (2) avoid promotion of specific products; (3) transparency of sponsorship; (4) develop guidelines for future interactions; (5) consider contextual factors such as the trust in the profession and social roles of physicians; (6) ensure that the long-term objective of the organisations is independent of influences of the industry.” 

Dr. Revelette points out that The Royal College of Pediatrics and Child Health and the British Journal of Pediatrics have both cut ties with formula companies. He writes that “The time for the American Academy of Pediatrics to do the same and comply with the Code is long overdue.” 

CMF companies in science 

CMF marketing commonly and effectively uses science to build brand credibility and influence the scientific community as Rollins, et al detail in Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

‘Landscapes and seaports’ (Paysages et ports de mer, dans des ronds)
Stefano della Bella Italian
1639
https://www.metmuseum.org/art/collection/search/412519

The authors detail how they misrepresent research and their sponsorship of journals and conclude “the capture of science as a strategic objective of CMF marketing fundamentally shapes medical practice in addition to boosting CMF sales. Science is used in a pincer movement: parents looking to resolve problems accentuated by marketing, with health professionals offering marketing-constructed solutions.” 

One government employee, a practicing physician, who asked to remain anonymous suggests that “most academicians can’t survive (as academicians) without getting sponsor grants for research”. That’s because public funding has decreased in the last couple of decades.  

Patricia Baird notes in Getting it right: industry sponsorship and medical research “…the pharmaceutical industry has become the single largest direct funder of medical research in Canada, the United Kingdom and the United States.”

The anonymous physician says that the number and type of potential competing interests do not tend to concern him especially when there is supplementary data available for review. 

He shares that “Most multi-center studies are done by funding from sponsors since no one Institution has deep enough pockets to do these critically important studies.  I get red flags going off and my ‘BS detector’ starts sounding when I see a small, short author list with a single sponsor funding the study that lacks supplementary data and is making extraordinary claims.” 

One of the touted benefits of working with industry in research is the development of new therapies for patients, as Baird writes and is also noted in ‘Deal with the Devil’: Harvard Medical School Faculty Grapple with Increased Industry Research Funding

However, Baird shares: “…a lack of balance in research activities, with a focus mainly on potential medications, is likely to divert talented researchers from the pursuit of profound scientific questions, or divert them from the pursuit of questions without market relevance but with an aspect of public good. A company has little incentive to support trials evaluating whether inexpensive, off-patent drugs, or whether nonpharmaceutical interventions, could replace their profitable patented drug.”

Because profits are foremost for industry, Baird continues that “it is unrealistic to expect drug companies to stop making drugs to treat diseases that result from [unhealthy behavior].”

This reality, Baird goes on, “highlights the need for funding of research into new and effective ways to get people to change behaviour, and of research into policies that provide incentives and support for healthier behaviours at a population level.” 

*Ahem… Family-friendly policies that support breastfeeding and adoption and adherence of the Code!*  One has to wonder, would maternal infant health look differently if we put as much effort into breastfeeding and supportive policies as we did responding to the formula crisis

One group, the Access to Nutrition Initiative (ATNI) conducts the BMS and CF Marketing indexes which assess the marketing policies of the 20 largest baby food companies globally. This spring, the organization released the Breast Milk Substitutes and Complementary Foods Marketing in the United States: Launch of the 2024 Country Report as a complement to the indexes. The recording of this event can be accessed here

ATNI has created a model policy for companies’ full compliance with the Code. 

Interestingly, ATNI itself has been criticized for its interactions with CMF companies. 

During the release event, ATNI presenters addressed their involvement with CMF companies. It was reported that ATNI consults independent expert groups and releases their methodology on their website. It was also stated that ATNI engages companies at certain points in their process, but that companies cannot decide whether or not they will be evaluated and do not have influence over the research results.

CMF business affairs within nations 

The United States has an enmeshed relationship with formula companies.

L’Avarice (Greed), from “Les Péchées Capitaux” (The Deadly Sins)
Jacques Callot French
ca. 1620
https://www.metmuseum.org/art/collection/search/417673

For instance, in Scorched Earth Legal Tactics author Valerie McClain illuminates that “Both the CDC and the FDA have foundations that partner with corporations that donate to their organizations. While these US governmental bodies are not allowed to take money directly from corporations, their foundations through partnerships donate for programs run by the CDC or FDA. The CDC Foundation has a long list of partners who donate various amounts.” 

McClain goes on: “From a political science perspective, corporations entangled with governmental agencies is part of the definition of fascism-a merger of state and corporate power. Every US governmental agency that I have seen has a foundation. So one gets the impression that is one way to pretend that corporations have no influence on governmental policy.” 

She details some of these relationships with specific dollar amounts in the remainder of her piece. 

In another revealing article– The U.S. Government Defended the Overseas Business Interests of Baby Formula Makers. Kids Paid the Price.— author Heather Vogell demonstrates how “the U.S. government repeatedly used its muscle to advance the interests of large baby formula companies while thwarting the efforts of Thailand and other developing countries to safeguard children’s health.” 

And there was the disgraceful act when the U.S. opposed a WHA resolution in 2018 and “blackmailed” Ecuador. 

An administrator from Breastfeeding Advocacy Australia (BAA) explains their country’s involvement with industry: “…Our Government gave the Formula Industry co-operative body, the Infant Nutrition Council (INC) a government grant to expand their international markets. This government one was for India, a country working hard to improve breastfeeding. Last government gave a grant for expansion in Cambodia, a country with historically high breastfeeding now rapidly plummeting. It is immoral and unjust. We must fight for women and babies. It gets worse here in Australia as a developed nation who is enabling this industry. One of our main research organisations SAHMRI has joint trials with Nestle and validates their participation. Unsurprisingly, the result of one trial we’ve seen requires the administration of a Nestle product as an outcome. Then our Doctor group the RACGP, the doctors that virtually all Mums and Bubs see, has their annual conference sponsored by Nestle and that’s just what we’ve seen publicly stated. There is probably much more. We have much work to do.” 

Until our governments do a better job of protecting health over profits and untangle their industry ties, how can we, as maternal child health advocates,  turn down the commercial noise when its notes seem to play everywhere? 

Steven R. Brown’s, MD, FAAFP American Family Physician editorial Physicians Should Refuse Pharmaceutical Industry Gifts offers guidance that is easily adopted for those working as lactation professionals. 

Certified Lactation Counselors should remember the specific line in the Academy of Lactation Policy and Practice (ALPP) Code of Ethics for Certified Lactation Counselors (CLC) which reads that we must “Abide by the International Code of Marketing of Breast-Milk Substitutes and subsequent resolutions which pertain to health workers.”  

The aforementioned Call to end sponsorship from commercial milk formula companies is a promising launching pad in the dismantling of inappropriate care provider- industry relationships. It signifies progress and as BAA offered, we have so much more work to do.  

 

Further reading/ related resources 

 

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