The formula section in a supermarket. Picture: WENDY KNOWLER
The formula section in a supermarket. Picture: WENDY KNOWLER

There is wide agreement that policy should be based on evidence. Indeed, a useful trick in any policy negotiation is to demand solid evidence in support of your opponents’ positions. This has created a growth industry for academics as well as generating a range of spurious methodologies.

Sometimes though, the tactic can backfire. So spare a thought for the US health policy negotiators at the recent UN World Health Assembly (WHA). They always have a tough time with a health community that naively puts the public good ahead of details like industrial profitability and national trade balances. And, this year, they had to deal with emotive proposals to place new global curbs on the marketing of baby foods.

This issue has a history. When it comes to feeding young babies, there is consensus that "breast is best". Despite this, it has long been alleged that the world’s food companies have tried to encourage new mothers to do otherwise. As a result, a global campaign was launched in the 1970s to protect child health by stopping the aggressive marketing of manufactured baby milks.

Back then, Arbeitsgruppe Dritte Welt, the Swiss partners in this campaign, focused on Nestlé, the world’s largest food company, whose headquarters are in their country. They alleged that the company’s promotion — through advertising, the deployment of sales girls in nurses’ uniforms to mother and child clinics, supported by incentives for medical personnel — was encouraging bottle feeding and resulting in the death and illness of thousands of babies.

To ensure that people took notice, they provocatively changed the ambiguous title of the original British report, The Baby Killer. That could be interpreted as blaming the bottles, not the companies. The Swiss translation was titled simply, Nestlé Kills Babies. In the trial that inevitably followed, the Swiss judge found the group guilty of libel for the title. They could not prove their allegations, he said, and fined them a nominal amount. But he warned Nestlé that, if it did not want this kind of allegation to be made, it should change the way they sold their products.

One obvious problem in the poorer developing countries that remain the growth market for the baby foods industry is that, if milk is prepared with unsafe water, it will be unsafe for babies. And if the product is watered down by poor mothers trying to stretch supplies that they cannot really afford, their babies will be undernourished. What was lacking was formal evidence (as opposed to general observations) that this was actually happening and causing illness and death.

Finally, more than 40 years later, evidence has been presented which shows a clear association between baby milk marketing and increased infant mortality.

A remarkable study published by the US’s well-respected National Bureau of Economic Research showed a statistically significant association between the Nestlé’s marketing of milk in poor countries and a rise in infant deaths. Indeed, it concluded that 66,000 babies died in 1981, at the height of the controversy, when these baby milks had been put on the market.

The study covered 46 low- or middle-income countries and used two sets of data. Annual reports from Nestlé gave the year in which the company started selling baby milk in countries concerned. To ensure that the results were significant, neighbouring countries were used as controls.

This information was paired with health data taken from the long-running international Demographic and Health Surveys. These surveys collect detailed records on household health and illness, as well as living conditions including households’ incomes and whether or not they had clean water supplies.

The study found that "the availability of formula increased infant mortality by 9.4 per 1,000 births, among mothers without access to clean water…. We estimate that the availability of formula in [low- and middle-income countries] resulted in approximately 66,000 infant deaths in 1981 at the peak of the infant formula controversy.

"Specifically, infant formula availability had a significantly negative effect on mortality of infants born in households that used surface water. The availability of formula increased infant mortality by 12.9 per 1,000 for households that used surface water relative to higher-quality water using households. The net effect of formula availability is an increase of 9.4 infant deaths per 1,000 among mothers with poor-quality water."

Back in 1981, the WHA, the governing assembly of the UN World Health Organisation, had approved a code that restricted the marketing of breast food substitutes by an overwhelming majority. Only the US voted against it, with Japan, South Korea and Argentina abstaining; Switzerland was not yet a member of the UN.

Since then there have been regular allegations that companies — including Nestlé — have failed to abide by the terms of the marketing code. This prohibits direct advertising to mothers, the use of free samples to hook them on bottle feeding, as well as offering incentives to medical personnel.

At the WHA annual meeting in Geneva last month, it became obvious that it is not just milk that can be watered down. There were angry arguments when the US sought to water down resolutions that would have strengthened global control on how baby milks are sold — and succeeded.

One of their demands was that any new policy proposals should be evidence based on a country-by-country basis. At the preparatory meetings where these issues were discussed, national delegations from milk-exporting countries such as the US and France included employees from the milk industry.

These events offer important insights into the way global policy is made and implemented. They show that the need for policy is often recognised long before there is formal evidence to support it.

In the baby-milk case, a combination of civil society pressure and government action helped to mobilise a global campaign, long before the internet facilitated such efforts.

But, when commercial interests and potential profits are involved, there will always be attempts to roll back regulatory oversight.

So the final insight is that policy initiatives on public interest issues — like good infant health — need more than evidence. They need continued political pressure and a willingness to confront powerful commercial interests.

Muller is a visiting adjunct professor at the Wits School of Governance. He researched and wrote The Baby Killer for British charity War on Want in 1974, and then spent the next three decades improving water supplies in Southern Africa, latterly as director-general of Water Affairs and Forestry.

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