Although more countries have been passing laws to promote and to protect breast-feeding, the breast-milk substitutes industry continues to present a formidable challenge to achieving universal breast-feeding goals, a new report by United Nations agencies and a large advocacy group reveals.
The laggards? Some of the richest regions in the world. Europe, for example, remains at the bottom of legislating laws to promote and protect breast-feeding.
Paradoxically, research published this year in the medical journal The Lancet shows that breast-feeding is one of the few positive "health behaviors" that is more prevalent in poor countries than in wealthy ones.
Of the 194 countries analyzed in the May 2016 report from the UN and the International Baby Food Action Network (IBFAN), a sprawling advocacy group that strives to reduce infant and child deaths worldwide, 135 countries have set up some form of legal measures related to the International Code of Marketing of Breast-Milk Substitutes.
The code was adopted in 1981 by the World Health Assembly, the governing body of the World Health Organization, and augmented with later resolutions tied to the code's mandate. It aims to support breast-feeding while also ensuring the "proper use" of breast-milk substitutes and the "appropriate marketing and distribution" of them worldwide.
The infant formula industry has fought the code with remarkable power, advocates say, as a new generation of sweetened milks for children begins to saturate the market with dubious health claims, through blessings from such countries as the United States and New Zealand, advocates also warn.
The rate of compliance by nations to abide by the international code has increased 88 percent since 2011, when the World Health Organization last analyzed this topic. The 2016 report notes, however, that the increase partly reflects that more information has become available on adherence to the code since before 2011.
Only 39 countries have laws enacting all provisions of the code, a mere five percent increase from 2011. A broad range of 49 countries has no legal measures in place, including the United States, Australia, Belarus, Haiti and elsewhere in the Caribbean, Bhutan, Japan, New Zealand, Chad and other nations in Africa.
Full provision of the code is enacted in an equally disparate group of nations, such as Afghanistan, Bahrain, Brazil, Cameroon, Costa Rica, India, Kenya, Lebanon, Nepal and, recently, in Vietnam.
Patti Rundall, the policy director of Baby Milk Action (part of IBFAN), singled out India, the second-most populous country in the world, for its strong legislation to conform to the code and for pushing back against the infant formula industry.
Although no single reason explains why certain countries have passed laws or measures to conform to the code and others have not, some countries provide a "friendly atmosphere" to the lobbying industry of infant formula makers, said Laurence Grummer-Strawn, who was involved in the report as a technical officer in the Nutrition for Health and Development sector of the World Health Organization in Geneva.
Certain countries, Grummer-Strawn added, may be more open to the arguments of the breast-milk substitutes industry, which is dominated by such multinational corporations as Nestlé and Danone, so these countries have weaker laws or none at all regarding the marketing of infant formula.
Moreover, a sense that breast-feeding in rich countries is not important may be related to people thinking that if they have access to clean water (in which to mix the formula), using it is a fine alternative, Grummer-Strawn noted.
The report, titled "Implementing the International Code of Breast-Milk Substitutes in Countries: Time to Accelerate Action," featured the rare participation of the World Health Organization and Unicef with an advocacy group, IBFAN, Rundall said in a conversation from her base in Cambridge, England. (IBFAN, founded in 1979, was a main campaigner behind the code's realization.)
"It's the first time such a report was done with all three," she said. "Why didn't we do this before? We come at it from slightly different places, so the report is a compromise, a struggle to get it, but it's fine, it's O.K."
The region with the highest rates of enacting full legislation is Southeast Asia, at 36 percent; followed by Africa at 30 percent; and eastern Mediterranean, 29 percent.
The Americas (including the US) had 23 percent, or 8 out of 35 countries; Western Pacific region, 15 percent; and Europe, six percent.
Most national data that were used for the report were submitted through questionnaires, with information gaps filled by experts. No data was available from 10 nations, including in Africa, Europe and the Western Pacific region.
Both the World Health Organization (WHO), a staunch supporter of breast-feeding, and Unicef recommend that babies be fed breast milk exclusively for the first six months of their lives, after which they should continue breast-feeding -- as well as eating other "safe and nutritionally adequate foods," the report said -- until two years old or beyond.
WHO member states have made commitments to increase the rate of exclusive breast-feeding in the first six months of life to at least 50 percent by 2025, among other global nutritional goals.
Breast milk is considered safe and clean and contains antibodies that help protect infants against many common childhood illnesses, research shows. Breast-fed children perform better on intelligence tests, by about three IQ points, Grummer-Strawn said, and they are less likely to be overweight or obese and less prone to diabetes later in life.
The act of breast-feeding itself stimulates proper growth of the mouth and jaw and secretion of hormones for digestion and satisfied bellies. Women who breast-feed have a lower risk of breast and ovarian cancers.
Only one Sustainable Development Goal focuses strictly on nutrition. Goal 2 aims to end all forms of malnutrition, including addressing the nutritional needs of lactating women and others.
Near-universal levels of breast-feeding, The Lancet reported earlier this year, could save 823,000 annual deaths for children under five years old. Globally, nearly two out of three infants under six months old are not exclusively breast-fed -- a rate that has not improved in two decades.
Fewer than one in five infants is breast-fed for 12 months in high-income countries, and only two out of three children between 6 months and 2 years old receive any breast milk in low- and middle-income countries.
The goal to reach universal breast-feeding contends with a well-financed foe: the breast-milk substitutes industry, which has annual sales totaling nearly $45 billion worldwide, the WHO says. The industry is projected to grow to $70 billion by 2019, with new products like sweetened milk for children flooding the market.
These projections are based on many factors, Grummer-Strawn said, including how fast countries are growing economically as well as national politics. Heavily populated China, for example, is considered a huge emerging market for consumer products, while reports of unscrupulous marketing tactics by outside salespeople of infant formula in China have been exposed.
Aggressive marketing of breast-milk substitutes -- infant formula, feeding bottles, pacifiers and other items -- continues to undermine work to improve breast-feeding rates, say specialists at the UN and at IBFAN.
Globally, the prevalence of breast-feeding at 12 months is highest in sub-Saharan Africa, South Asia and parts of Latin America, according to The Lancet. In most rich countries, the prevalence is lower than 20 percent, with stark differences found even among those nations -- like between Britain (less than 1 percent) and the US (27 percent); and Norway (35 percent) and Sweden (16 percent).
Promotion of breast-milk substitutes is shifting from advertising in stores and mass media to the Internet and social media, raising legal and practical challenges, The Lancet said, requiring countries to better manage the newest sales methods of reaching consumers.
The UN report stressed the importance of monitoring the International Code of Marketing of Breast-Milk Substitutes through a mechanism to detect violations and report them to authorities. But political engagement is almost nil: only 32 countries have such a mechanism, with few fully functional.
The use of infant formula in poorer countries can be problematic because of lack of clean water and sanitizing equipment to prepare the formula for feeding. In addition, social and commercial pressures worldwide to stop breast-feeding, Unicef says, contributes to its stall in becoming universal.
These pressures combine with faulty or inadequate information in health care centers, such as hospitals, where support for new mothers to breast-feed can be minimal or conflicting. (In New York, for example, this writer, preparing to leave the hospital soon after giving birth in 1988, was handed several cans of free infant formula by a nurse, despite actively breast-feeding.)
Complicating matters, Unicef says that many women must return to work soon after they give birth, leaving them with tough choices as to whether to keep breast-feeding exclusively. Grummer-Strawn said working women throughout the world face barriers to breast-feeding, not just in well-off countries. The goal, he said, is to better enable breast-feeding in all work settings.
Infant formula was highlighted by many international media when a long-awaited UN-led convoy of aid destined for Syrians in Daraya, a besieged area outside Damascus, was blocked on May 12 by soldiers in the 4th division of the Syrian Army, which is controlled by Maher al-Assad, the brother of Bashar al-Assad, the country's president.
Which leads to the question why infant formula was being donated to residents of an area that reportedly has no running water or other appropriate sanitary conditions in which to prepare the baby food. Standards by WHO and Unicef on managing the use of infant formula in humanitarian emergencies have been outlined in policies, including banning free donations of such supplies.
Linda Tom, a spokeswoman for the UN Office for the Coordination of Humanitarian Affairs in Syria referred questions to the Syrian Arab Red Crescent, or SARC, as to why infant formula was part of the UN convoy to Daraya.
"You are correct in that the UN does not usually delivery infant formula," Tom wrote in an email. "On the rationale, you will need to address your question to SARC." That group did not answer emails from this reporter.
Breast-milk substitutes should be used only as a last resort, two UN experts recently wrote in an essay but common misconceptions persist, they said, including that mothers who may be malnourished or who live in stressful situations cannot breast-feed.
Grummer-Strawn of WHO said that aid provisions of infant formula to emergency situations are done on a case-by-case basis, and though potable water may not be available to mix infant formula powder, water can be boiled for ingestion. Up to five percent of women in emergency settings cannot breast-feed for various reasons, such as illness or being separated from their infants, he added.
Rundall noted that WHO and UNICEF policy states that donations of breast-milk substitutes, bottles, teats and other milk products in emergencies should be avoided, but she added that a fairly high percentage of bottle feeding exists in Syria, "so all this must be handled sensitively."
"If formulas are needed -- and of course they sometimes are -- they should be purchased, distributed and used according to strict criteria by those who really need them. Well-meaning people are often unaware that these products can do more harm than good. What's needed are health workers who are well trained in providing breast-feeding support."
The global controversy over infant formula use originated with a boycott carried out in the US in 1977 against the Swiss-based Nestlé company, prompted by concern over its aggressive marketing tactics of breast-milk substitutes, particularly in poor countries, and the possibility of fostering malnutrition.
The boycott spread to Europe in the early 1980s, with actions still underway in Britain through Baby Milk Action, Rundall's organization. The 1977 boycott led to the creation of the International Code of Marketing of Breast-Milk Substitutes.
The controversy continues, as a statement from Baby Milk Action, IBFAN and others remarked on a recent World Health Assembly meeting regarding "two closely linked hot topics: how WHO should interact with businesses and venture philanthropies and whether trade should come before health when tackling the marketing of baby foods and formulas."
The statement said: "During a full week of behind-closed-doors negotiations on both topics, the United States and rich producer countries in the EU and New Zealand, pushed the interests of their corporations: opposing the adoption of effective safeguards to protect WHO's independence, integrity and credibility and attempting to sabotage the adoption of a new WHO Guidance on baby foods. The bullying power of these nations and their disregard of public health was evident in the two Resolutions that were finally adopted today."
The resolution on infant and young-child feeding focused, for example, on a "new generation of processed, expensive, sweetened and flavored milks that are fuelling the obesity epidemic and causing great concern," the statement said.
These products are not infant formula, so they can be exempt from laws regulating the marketing of such goods, although they resemble infant formula packaging and are targeted for infants and children, Grummer-Strawn said.
Rundall said that the US, backed by the European Union and New Zealand, was leading the fight against new WHO guidance for ending the inappropriate marketing of baby foods and formulas, "after the White House had been heavily lobbied by the formula industry, arguing that trade should come before health."
"These rich producer countries clearly wanted the freedom to dump these formulas onto developing world markets, especially in Asia, and have no concern about the impact this has on global health and the environment," Rundall added in an email.
The new generation of sweetened flavored milks accounts for 50 percent of absolute growth in a market that is projected to rise to $70 billion in the next few years, according to Rundall, by "using misleading idealised health claims" that the products "are essential for child health and development."
"But they are totally unnecessary and are fuelling the obesity crisis," she added. "Thankfully the worst amendments being pushed by the USA did not succeed. What's needed now is for governments to implement the Guidance and stop this tidal wave in its tracks."