BABY FOOD | TRAGEDY

With help from baby-food advertisements and manufacturers’ promotion campaigns, more and more mothers in Africa, Asia and Latin America are bottle-feeding their babies. But there is growing evidence that the way in which these artificial baby milks are advertised and sold, misunderstood and misused, in poor and often illiterate communities can lead to earlier malnutrition. And there is no doubt that malnutrition in the first few vital months of a child’s life can inflict permanent mental and physical damage. HUGH GEACH talks to two leading child nutrition experts about this new and fundamental threat to future generations in the developing world and asks about the methods, including the employment of nurses as salesgirls,which some companies are now using to promote their goods.

These interviews are concerned with the increasing use of artificial baby-milk in normal circumstances where breast-feeding is a clear alternative. In abnormal circumstances, such as in famine or disaster situations or in the treatment of already malnourished infants or where for whatever reason the mother cannot breast-feed, such foods can and do supply a vital need.

Dr. R. C. Hendrikse is the Director of the Tropical Child Health Course at Liverpool University where he also holds a senior lectureship in child health and a National Health Service Consultancy to the Alderley Hey Children’s Hospital. He qualified from the University of Cape Town in 1948 and for the next six years worked at the McCord Zulu Mission Hospital in Durban, Natal, where his earliest medical research centred on child malnutrition. After six months in Southern Rhodesia, studying child health in a remote rural area, he went to Nigeria where for the next fourteen years he encountered "malnutrition in all its forms ". He has also visited East and West Africa, the Mickile East, Pakistan, the West Indies, and Puerto Rico observing child malnutrition at both community and hospital levels.

H.G.: We are concerned here about the increasing swing away from breastfeeding towards commercially produced baby-milks in developing countries and the possible harmful effects of the way in which they are used.

DR. HENDRICKSE: There can be no doubt at all that, not only in the Western world but also in the developing world, there has been a very worrying swing or drift away from breast-feeding, in recent years.

And I don’t think there can be any doubt at all, on the basis of my own personal experience, that the vigorous advertising of baby-foods, baby milks, and various other products, in communities where these foods cannot be afforded, where the proper use of these foods is not understood, and where the facilities for the correct use do not exist, has created serious health problems.

In consequence, mothers who have given up breast milk thinking that they can confidently feed their children on these new preparations, have got into trouble. First, they have not been able to give enough of the milks to provide adequate nutrition. Second, the circumstances in which they prepare and store the milk for the babies, and particularly the use of unclean or semi-sterile or sometimes plain filthy feeding bottles, has of course introduced the risk of infection. And in consequence one of the major and growing problems in most of the urban areas of the developing countries at the present time is a combination of malnutrition in infancy combined with diarrhoeal disease, so called gastro-enteritis, in babies who are not being breast-fed and are getting artificial milks.

H.G.: How exactly can the use or mis-use of powdered milk baby foods lead to malnutrition problems?

DR. HENDRICKSE: Well, let’s say a woman who is not breast-feeding a baby for one reason or another is using a milk food in which a tin of a particular size is meant to last a baby of that age and weight for a period of a week. Her income is such that she cannot aftbrd a tin a week. Maybe she can afford a tin every ten days or every two weeks. Her answer to this problem is often to use a smaller quantity of the milk powder and stretch it With a larger volume of water. So that the baby in effect is getting dilute milk-feed which does not supply it with the proper amount of calories, protein, etc., for its requirements. In consequence that baby’s weight-gain stops and then starts sliding down, and he becomes progressively like a little shrivelled up old man, a condition that we call merasmus. Now when the child’s state of nutrition slips into this state, he becomes increasingly susceptible to infection. And if we take it that this diluted milk is also contaminated milk, because of the conditions under which it is prepared and stored, then it must be obvious to you that you have got a vicious circle being set up in which the malnourished child is prone to get diarrhoeal disease from the infections he is exposed to, and because of the diarrhoeal disease he is able to assimilate even less of the milk that is given to him because his tummy and intestines are not working properly, as a result of which his nutritional state gets worse. And if you look at the mortality statistics for almost all the developing countries you will find two things dominate. A combination of malnutrition with respiratory infections and with gastro-enteritis. These are the top three, but in fact it is usually malnutrition plus one of the other two, chest infections or gastro-enteritis. They are always at the top of the list of causes of death in infants in the developing world.

H.G.: Now, given these facts, one would expect the companies selling milk-based baby foods in a developing country to show a great deal of responsibility and promote their products in a way which avoided, whenever possible, their misuse. Is this, in general, the case?

DR. HENDRICKSE: No. I think that many of the companies who are making baby foods pursue advertising and promotion policies which are clearly directed at maximum sales at almost any cost. I think that in some instances people use attractive advertisements to promote sales of their baby foods without necessarily being aware of the impact that these advertisements may have on the community they are dealing with. But I think there is enough evidence now to make anybody sitting on a company board sit up and take note of what their sales promotion campaigns may be doing.

H.G. What kind of evidence and examples can you give from your own experience?

DR. IIENDRICKSE: I recall that when I first went to Nigeria, I found a very high incidence of kwashiorkor — this is the extreme kind of protein malnutrition which children get. I was staggered to find that on questioning the mothers about the diet they had been giving their children, these mothers, with few exceptions, would probably say that the baby had been having Ovaltine and when one went into it one found that these mothers were mixing one or two teaspoons of Ovaltine with water to give to their babies. And the reason for this was that there were many large hoardings round the town carrying advertisements showing a nice plump baby next to a tin of Ovaltine and these mothers presumed that there was some magical quality in this and that a few teaspoons of this would make good all kinds of deficiencies in their babies. But it was a strange thing that in the kwashiorkor clinic, almost all the mothers were claiming to have given their babies Ovaltine. They clearly expected a lot more from Ovaltine than the manufacturers claimed for it, but on this pattern of advertisement in an illiterate community the inference was ‘Ovaltine means a fat healthy baby’.

H.G.: Do the companies use any other form of promotion?

DR. HENDRICKSE: Oh yes. Quite apart from advertisements in newspapers and journals, quite often in medical journals, there are now advertisements over commercial radio and a growing use of loud-speaker vans which go round advertising medicines, foods, etc. They also in some situations have local sales promotion people who go round and approach people in local clinics, or anywhere where babies are likely to gather, put up posters, talk to people, and hand out samples.

In the last ten years or so in Nigeria, one of the companies in particular, Nestles, was employing well-qualified people who had their midwifery and nursing certificates, and some of them with even post- graduate qualifications, as part of their establishment and their job would be to go into clinics, if they were permitted to do so, to show how the foods promoted by the company should best be used. Now, in fairness to this company under pressure from the Nigerian Society of Health and Nutrition, Nestles did in fact modify its advertising policies, and you’ll find that right up to the present time that an advert for, let’s say, Nestles milk over the Nigerian radio will start with the quote, "You should always breast-feed your baby, but if you cannot then use... such and such." I think this is a very reasonable approach. I personally would like to see all governments make a stipulation that advertisement of milk foods for babies should always indicate that breast-feeding is best for babies, and that this substitute feeding should be used only as an alternative to breast-feeding.

H.G.: Nestles is an international company. Did it then follow the same policy of using this responsible advertising in other countries in Africa?

DR. HENDRICKSE: To the best of my knowledge, no. I have made enquiries about this from colleagues in East Africa, Rhodesia, South Africa, and so forth, and to the best of my knowledge they have not instituted the same advertising policy elsewhere as they did in Nigeria.

H.G.: You say that advertisements should always start by saying "Mother’s milk is best." Why, briefly, is breast-milk so much better than cow’s milk?

DR. HENDRICKSE: In the first day or two after birth, there is not much breast milk, but there is some secretion from the breast. And there is now complete confirmation of the fact that these special secretions from the mother’s breast provide the baby with certain immunilogical protection; they get certain antibodies from the mother’s breast, even before the milk comes. The milk itself is, without doubt, the most easily assimilable, most balanced, most naturally clean and safe supply for infants. We also know from increasing studies, that there is a real protection afforded in breast milk against certain infections which cannot be afforded by cows’ milk, quite apart from the nutritional values. And so, for every conceivable reason breast milk is a superior food for babies than any artificial substitutes. I’ve no doubt in my mind about this at all.

H.G.: From your first-hand experience, have you formed the opinion that many mothers in developing countries cannot afford to buy the right amounts of artificial baby milk?

DR. HENDRICKSE: Well, this can quite easily be resolved without reference to opinion. If you look at the estimates of gross per capita incomes for most of the African countries, and then work out what it costs to artificially feed an infant, including in this cost not just the cost of milk but the cost of preparation of the milk, bottles, or cup and spoon, whatever it may be, you will find that the slice of the budget needed to afford adequate artificial feeding is just totally disproportionate to the other demands of their budget. And I don’t think there can be any doubt that the vast majority, probably 80%, of the population of many countries in Africa, just cannot afford to adequately artificially feed infants. No doubt about it at all.

H.G.: Is artificial baby-food usually imported or is any of it produced in the developing countries?

DR. HENDRICKSE: No, to the best of my knowledge there are very few of the developing countries which are manufacturing their own milk products. Most of them are imported from Europe or possibly from America. There is unconfirmed but very worrying suspicion among some of my colleagues that some of the supplies of foods that come in to developing countries are, in fact, foods which possibly are so close to the expiry date, that maybe their value on home markets may not be as good as their value on overseas markets. Now, I can’t confirm this but it’s worth noting the suspicion that some of the stuff that is offloaded in developing countries may, in fact, not be of the same high standard as that which should be acceptable on home markets.

H.G.: A great many doctors in the developing world are either trained in the West or in the Western tradition. Because conditions in poor countries are so different, do doctors tend at all to recommend inappropriate measures in connection with infant feeding?

DR. HENDRICKSE: I take it even further than this. In many countries abroad, and even in many of the medical schools in Europe at the present time, doctors at the time of graduation know so little about infant feeding in practical terms that I personally wouldn’t trust the advice of 90% of them. The teaching of infant feeding in most medical schools, in the tropics and elsewhere, is done appallingly badly or has been done appallingly badly in the past, and the negligible emphasis given to general paediatric training in undergraduate medical curricula in the past has been such that most doctors have qualified knowing precious little about child health anyhow. This is one of the reasons why, in the revised medical curricula of many of the developing countries, a far greater emphasis has been given to paediatric training than in the past.

Photo: Marcel Ganzin / FAO

H.G.: What effect does malnutrition have on a baby’s mental development?

DR. HENDRICKSE: You are aware, as I am, that there has been increasing concern and awareness about the possibility that severe malnutrition in childhood can limit intellectual development. All the evidence that is accumulating points to the fact that the earlier in life there is nutritional insult, and the longer this persists, the more likely it is that intellectual development is going to be impaired. Children who, for instance, develop severe malnutrition of the kwashiorkor type at the age of 3 or 4 years can probably recover completely because by that time in their life brain development has already reached a very advanced state. Concern at the moment is being felt increasingly about the fact that nutritional problems are moving backwards earlier and earlier into infancy. In those areas where breast-feeding is most rapidly being given up and ineffective artificial feeding being implemented at an earlier and earlier age the children are becoming merasmic say at the age of 3 or 4 months and staying merasmic during their early infancy —this is the group that most concern is being felt about because it would appear that those children may never fully recover from that early malnutrition because it happened at the time when active brain growth and development should be occurring. And having lost out in that early development they may never catch up. This is why I think I and a number of my colleagues are feeling increasing concern about the evidence that indicates that there is an increase in merasmus in early infancy in the developing world, and that this is related to abandonment of breast-feeding and improper artificial feeding.

H.G.: To your knowledge, apart from the case of Nestles in Nigeria, has any of the baby foods companies acknowledged these facts?

DR. HENDRICKSE: Well, in all fairness one of my earliest contacts with a food-producing company was in South Africa years ago when the Heinz Group in South Africa tried to produce a relatively cheap and nutritious food for use particularly among African babies. And in fact they did bring something onto the market called ‘Incumbe’ — it’s an African word implying baby food — which for one reason or another did not gain great popularity. If one goes round the world one would find that there are instances of this kind of concern. I certainly know that a number of these milk firms have sponsored certain aspects of child health development or have given support to child health institutes or conferences on paediatric procedures and so forth. But I am not aware that they have made a policy in their advertising to emphasize the need for breast-feeding and made a point of saying that breast-feeding is best — if you can’t breast-feed then use this kind of product in this kind of way. I’m not aware that this is internationally accepted policy. I don’t believe it is.

H.G.: Should not the distribution, if not the production, of these foods be controlled by the governments of the developing countries in order to arrive at a policy concerned primarily with people’s health rather than profit?

DR. HENDRICKSE: I will counter that by telling you that there are in many countries of the world at the moment warehouses loaded with foods donated from abroad, dependent upon government distribution to needy areas, and many governments have been incapable of undertaking this kind of distribution at all. Or where they have undertaken it, it has been on an inequitable basis and often the benefit has gone to a few local entrepreneurs who have collared the food and diverted it to local markets where they have sold for a profit. Now we know that this happens and we know that many governments do not have the manpower, the storage capacity, or the wherewithal to undertake this kind of distribution on an equitable basis.

H.G.: Do you think that a special international organistion could perhaps play a role here?

DR. HENDRICKSE: I feel there is a need for an international organisation or international concensus to agree on an advertising policy which will give full emphasis to the vital importance of breast-feeding in developing countries. And I think there is a great need here for governments and commercial producers of these foods to get together and define policy. I think there may be a need for the commercial firms who are prepared to co-operate in this, and who may do it on a basis of sustaining a loss, to be subsidised if not by the government, then by some international agency which is sufficiently concerned about this. I would like to see this kind of approach. I believe there is a sufficient need for certain kinds of baby foods in the world for judicious policies to pay off in the long run.

Btit it would be a mistake if we believed that the drift away from breast-feeding is entirely due to the seduction of advertisement. It is not. There are a number of other factors which go along with this. The changing role of women in developing countries, for example, or the changing concept of motherhood as against shared parenthood. When a young girl gets married but has a university career ahead of her, she will artificially feed because it is inconvenient for her to breast-feed. Her husband can share the artificial feed but he can’t share the breast-feeding. If a woman goes into service to work to supplement the family income, this mother is often not allowed to take her baby to work with her and then she has got to artificially feed.

More and more women are going into factory employment and you know there are many big companies based in Europe or America who have established factories in developing countries because labour is cheaper and things of this kind. We see it in South Africa where they move factories from white areas near the Bantu reserves and employ female labour, and so forth. Now all these factors will tend to push against breast-feeding. I would like to see in the commercial world an acceptance of breast-feeding as being a vital and natural role of a woman which is not incompatible with her doing a good job. And when they build factories that are going to accommodate women, let provision be made in the factories for a crêche for the babies and let women take their babies to work, breast feed them and do their job. I think this is the kind of thinking we need. We can’t put the clock back and say women must return to the home. We can’t do that. But in developing our modern commercialism and so forth, we must bear in mind the human needs of the people concerned.

Dr. David Morley is Reader in Tropical Child Health at the University of London. Between 1956 and 1961 he undertook a unique long-term study of children growing up in a Nigerian village. This study included research into infant feeding practices. He has since re-visited Nigeria every year for the last twelve years and travelled and studied extensively in East Africa, Asia, and Latin America.

H.G: Dr. Morley, is it the case that there is a swing away from breast-feeding in developing countries?

DR. MORLEY: Very strongly so.

H.G: What role do you think the makers of tinned baby milk are playing in this trend?

DR. MORLEY: It would take a lot of research to disentangle the part that the milk producers have in this. But it is a fact that they are spending a lot of money on advertising and that some of them employ local nurses to go into government clinics to sell baby-milk. These girls are dressed in nurses’ uniforms. The mothers are not to know that they are not paid by the government. They go into the clinics and try and sell their products.

H.G: Can you give any specific examples from your own experience?

DR. MORLEY: Yes, I can give you a very good example. In Bangkok, I saw a mother who was just about to leave hospital with a baby that had just been born and she had on the locker beside the bed, a tin of Nestles milk and a small bottle with Nestle written on it which, I was told, is given to all mothers before they leave hospital.

H.G: The different properties of breast-milk and cows’ milk have been the subject of much research in the last ten years or so. What is the significance of this research from the point of view of infant-feeding in developing countries?

DR. MORLEY: We know, for instance, that there are antibodies in breast milk which protect babies against poliomyelitis and other diseases. Now, if these are important, and we have every reason to believe that they are, then they are even more important in the developing countries than in the industrialised. I mean by this that protection against infectious disease is vastly more important in developing countries.

H.G: Is it your experience that, as a result of the swing away from breast-feeding in developing countries, malnutrition is occurring at an earlier age and especially in the first few vital months of a child’s life?

DR. MORLEY: This is certainly true and it seems particularly true in the cities. For example, in Chile in South America I have reports that malnutrition now is very common in the first six months of life. The problem is that, as we now realise, this is the period when the brain is undergoing growth and we have reasonably adequate evidence that if there is malnutrition in this period it will have an effect on the intellectual potential later on.

H.G: In your opinion, do the baby-food companies sell their products in a responsible way? Do they in their advertisements, for example, put sufficient emphasis on how to use their product? And do they make it clear that breast-feeding is best?

DR. MORLEY: I think that the sellers ol these milks would like to paint the idea tc us that it is a responsible campaign. But I do not think that they have evaluated the total effect of their efforts on the health of the children. I think that to be really responsible they should do this. They will nearly always give some lip service to breast-feeding but if you read their advertisements the weight is still on bottle-feeding.

If you look at the circumstances under which a mother is to artificially feed (usually by bottle) it is quite clear that she cannot fulfil many of the conditions necessary. And under these circumstances, to prepare to bottle feed is extremely dangerous.

HG: I have here a Nigerian advertisement for Cow & Gate baby food, where it says, for example, that Cow & Gate has the "highest protein content . .

DR. MORLEY: This is a very evil and diabolical statement. Because the fact is that cows’ milk contains more protein than human milk because the calf grows quicker. Here you have a small calf and in six weeks it is a great big animal. A baby grows slower, and animals that grow slower have no need for the high protein levels that a cow, for example, needs. And therefore, to stress the high protein I think is wrong, because there is no evidence that a protein level higher than breast milk is in any way advantageous in the early months of life and may very well be harmful. The word ‘protein’ has caught on in developing countries and this is clearly why they use it here.

H.G: Can I come back to the role of doctors, nurses, and clinics and the part they can play in this trend? Can you tell me more specifically about this?

DR. MORLEY: I can tell you straight away because I feel very strongly about this. Almost any clinic you go into in a developing country, you will see the walls covered with charts given by baby-food companies like Nestle and Cow & Gate, showing pictures of beautiful babies which are given to that clinic with the very clear idea that this will be the first step. You may even go and see a pile of tins of various milks on sale. The mother very soon associates the child welfare or baby clinic with bottle-feeding or artificial feeding.

H.G: Is it the case that in many poor areas mothers simply cannot afford to artificially feed their babies?

DR. MORLEY: Very often you will find there is a three to four month-old baby and that a quarter or third of a husband’s salary goes on just feeding this one infant with artificial milk. This is clearly quite impossible to sustain. So in fact they still buy the milk but they don’t buy adequate quantities.

I feel that if these firms were really conscientious they would discover how much milk the mums were using, and they would probably find that less than 10% of the mothers buy sufficient milk to really adequately feed their babies.

HG: Do you think that the instructions for use on these tins of baby-food are adequate for the areas of the poor world where they are being used?

DR. MORLEY: Many of these mothers to whom these bottles are given are illiterate and even if they could read they would often not understand the complex instructions with mathematical measurements. Someone who has studied this in South Africa recently found that if the mothers were to understand the instructions, they would have to be very much simpler. But as far as I know, no milk company has troubled to look at this — which again is very reprehensible of them. Often the instructions for developing countries are identical with those of the developed.

It is very important not only just to get the right amount of food but also to sterilise the bottle. And I can’t believe that in a rural village or even in some of the urban areas that a mother is going to sterilise her baby’s bottle. Quite impossible. If I can just quote one fact: you need to have fresh water for making up the feed but you also need a running tap to cool the bottle if it’s been boiled. In a tropical country a bottle filled with boiling water or boiling fluid takes almost an hour to cool down to a temperature that a child could drink. Even if you stand it in cold water it will take over 15 minutes. It is only by running it under a cold tap that one can quickly cool a bottle and mothers don’t have these cold taps. And if you are boiling water in the kind of pot that is often used, it can take an hour or two to bring the water to the boil and very often the mothers do not have the fuel or the suitable utensils. So the answer is that they do not boil.

HG: Dr. Morley, do you think that there has been any increase in infant deaths caused by the swing away from breast-feeding towards artificial foods which in practice may not be used in the right way?

DR. MORLEY: Undoubtedly, the increase of malnutrition in the young baby and the many deaths which occur from this must have some relationship to the increased mis-use of artificial feeding.

H.G: Have you talked to Government officials about this and has there been any attempt, as far as you know, by a Government of a developing country, to control the situation?

DR. MORLEY: Yes, I think the attempt of the Zambian Government should be acknowledged. I wonder whether we should not have just as strong a statement as we now have on cigarette packets in this country on milk tins in developing countries, saying that artificial feeding can be dangerous for infants. I think a warning statement like this is very necessary. Also there should be very careful medical supervision for the small proportion of babies, who for one reason or another the mother cannot feed. And if the Governments themselves bought and marketed the milk as we did under our National Dried Milk Scheme, this is the sort of thing which is necessary.

H.G: Are there any other points you would like to add?

DR. MORLEY: I think there is one thing. Some companies employ a certain number of nurses, they call them ‘milk-nurses’, gong round selling their products. This I think is harmful. Here, people get a higher wage than they will get from the governnent and yet I would say what they are loing is harmful both to the economy and to the children of the country.