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

Like babies, some policy dilemmas never go away, they just grow up. That’s what’s happened to the decades-long debate about the promotion of baby milk and its effect on breastfeeding and child health.

In May, the World Health Assembly, which governs the World Health Organisation (WHO), will consider how to adapt its path-breaking 1981 code of marketing practice to the digital age, to regulate what has become a $55bn global industry. 

It is 45 years since a Swiss judge told the world’s biggest food company that if it did not want to be accused of immoral and unethical conduct by causing the illness and death of babies in poor countries, it would have to “fundamentally rethink its advertising practices”. Now it is the health sector that is having to rethink the way it responds to the marketing of baby foods in a digital world. 

In 1974, the British charity War on Want published a report “The Baby Killer” accusing Nestlé and other companies of causing death and illness in poor communities around the world by marketing their baby foods to mothers who were not able to afford them or use them safely.

Swiss development activists who translated the report wanted to highlight the role of their country’s flagship company. So they changed the title to “Nestlé Kills Babies” and were duly charged and found guilty of libel.

Life-threatening

The judge could not make a formal finding on the alleged libel in the report itself because those charges were withdrawn by the company. But he made his view clear: Nestlé’s advertising was transforming a life-saving product into one that was dangerous and life-threatening.

The report, the Swiss court action and subsequent Senate hearings in the US sparked a global campaign, which continues to this day. The International Baby Feeding Action Network (Ibfan) was established in 1979 and claims to be one of the world’s longest-surviving single-issue civil society organisations.

It scored an early success in 1981 when the World Health Assembly adopted the “International code of marketing of breast milk substitutes”, which outlawed many controversial marketing practices. The decision was (almost) unanimous, with 118 countries supporting it, three abstaining and only the US voting against — the Americans have never accepted the idea that global organisations should be able to regulate or judge their activities.

The code prohibited the direct marketing of baby milk to new mothers — the original report had referred to “sales girls dressed up in nurses uniforms” — inhibiting breast feeding by distributing free samples of milk and feeding bottles. But the code also introduced extensive restrictions on advertising and other forms of promotion, which provided a useful template for tobacco control 20 years later.

The code is still in force and most of its provisions have been followed, if grudgingly, by major companies, not least because advertising and promotional visits to clinics and hospital have been relatively easy to track. Many national health departments routinely monitor breastfeeding trends and support “baby friendly” hospitals and health facilities to encourage it, which includes keeping salespeople at bay. Even in countries where formal regulations are not enforced, the code is “soft law” and companies face substantial reputational risk in other markets if they don’t comply.

Baby milk battles have now moved into the virtual world, where it is more difficult to regulate, and digital marketing is being used to target pregnant women and new mothers.

But in baby food, as in so much else, the world has changed. Baby milk battles have now moved into the virtual world, where it is more difficult to regulate, and digital marketing is being used to target pregnant women and new mothers.

A recent study by Sara Jewett and Sukoluhle Pilime at the Wits School of Public Health found that through social media “marketing has shifted from traditional methods to the use of influencers, who command a huge following on their social media accounts and influence the daily decisions of their followers”.

Other research in SA has tracked how the industry’s marketing tactics have evolved to circumvent marketing regulations. As well as social media influencers, other digital marketing techniques are now being used rather than direct marketing to parents. Companies seek to build trust relationships with parents and professionals rather than simply promoting their products.

This is a worldwide phenomenon. In 2022, a WHO-sponsored study reported that “digital marketing techniques enable [advertisers of] breast milk substitutes ... to identify pregnant women and mothers in online spaces, identify their deepest concerns by observing or engaging them in conversation, exploit their most vulnerable moments, disguise their marketing content as information or advice, and enlist people women respect most to influence their infant feeding choices.

“Digital platforms feed breast milk substitute promotions directly to the screens of pregnant women and mothers, respond instantaneously to the concerns they express, use respected influencers to shape feeding decisions, generate word-of-mouth endorsements for breast milk substitutes products, and establish online support groups to build positive associations with breast milk substitutes brands. These low-cost and effective methods are known to increase purchasing behaviour as measured by sales.”

In countries ranging from Brazil to China, the combination of digital channels with chatbots and artificial intelligence to promote baby milk products to new mothers has raised concerns. In response, draft regulations already identify problems such as “commenting on content posted on webinars, chatbots or other tools powered by artificial intelligence” as a concern and recommend that companies should be prohibited from offering financial incentives for such promotion.

The health sector is also mobilising the new technologies. It has recognised that there are opportunities to enforce compliance “using digital technologies, such as social media intelligence platforms, screen-capture software, traffic analysis or artificial intelligence tools to identify potentially noncompliant digital marketing for investigation and enforcement”.

Marketing code update

These developments have put baby milk back on the global health agenda. When the World Health Assembly meets in Switzerland in May, it will discuss proposals to update and strengthen the organisation’s international marketing code. Brazil, one of many countries where a reduction in breast feeding rates has been associated with increased infant mortality, is among the countries that have said that they would propose formal measures to address the new challenges.

To reinforce the message, a local public health institute recently republished a 50-year anniversary third edition of “O Matador de Bebes”, the Portuguese translation of the original “The Baby Killer” with a preface highlighting the need to adapt to the new environment. The issues still matter, they say. Irresponsible promotion of artificial feeding is “putting the health and lives of countless children at risk”.

While breastfeeding is recommended for many reasons, the most critical is child health. There is a plethora of data to show that in poor communities, where unsafe water and sanitation combine with poverty, it remains a matter of life and death. And even in richer countries and communities, infant mortality among breastfed babies is lower than those who are bottle fed.

The question is now whether the “soft law” of an international code provides a hard enough incentive to change corporate behaviour in this critical area of public health.

• Muller is a visiting adjunct professor at the Wits School of Governance and author of the 1974 report ‘The Baby Killer’. Jewett is senior lecturer and co-ordinator of the social and behaviour change communication division at the Wits School of Public Health. 

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