The MacNeil/Lehrer Report; Infant Formula Abuse

ROBERT MacNEIL: Good evening. This is a story in the Things Don`t Get Any Simpler Department, one of those situations where increasingly, it seems, one quite straightforward value runs into another. You might think that nothing was more innocent or wholesome than for American companies to be selling infant formula to promote adequate nourishment for babies in third world countries. Not quite so. For at least eight years interested groups have charged that companies marketing such products were in fact contributing to disease, even malnutrition, and the death of babies. All of this surfaced more publicly in this country recently when the Senate subcommittee on health and scientific research held hearings under the chairmanship of Senator Edward Kennedy. Tonight, are we actually starving children by trying to feed them, and if so, who`s responsible for the problem? Jim?

JIM LEHRER: Robin, the mother`s milk substitute for babies is called formula by most everyone who sells it, uses it or gets up in the middle of the night to heat it. It mostly consists of diluted skim milk, plus specially added protein, fat, carbohydrate and minerals. It`s used by mothers who are physically unable to breast-feed or just don`t want to. Here in the United States the formula often comes in premixed liquid form, but because of storage and shipping problems it is usually sent overseas as a powder, and that`s where the problem starts.

Directions on the packages say to mix with boiled water and put in sterilized bottles, but many mothers, particularly in the third world, can`t read; and the only water available may be contaminated. They have neither the know-how nor the facilities to make it safe. Some may also try to stretch the formula by adding sugar or cornstarch. The end result, say the critics, is disease or malnutrition or both. Robin?

MacNEIL: Powdered infant formula is marketed in more than a hundred third world countries. A number of them have begun restricting its distribution. Jamaica, for example, has banned so-called mothercraft, or milk, nurses from public hospitals. These were women paid by the companies to distribute the formula to new mothers. Here`s an excerpt from a report on the Jamaican situation made by the Canadian Broadcasting Corporation.

ALLAN JACKSON, M.D., Kingston, Jamaica: This is a baby who`s come from one of the country areas who was breast-fed until he was two months of age. At that age his mother changed him to the bottle, and he`s been going downhill ever since, over the past five months. He`s seven months old now, and he`s only eight pounds. He`s gone from eleven pounds down to eight pounds in the intervening five months and he`s now a very sick child. The mother doesn`t have a lot of money, and certainly the amount of feeding that she had, whether she cannot afford it or doesn`t understand, is not that clear to ascertain. The feeding that she has costs two dollars a tin, and she had six tins that were lasting her somewhere between six and eight weeks.

So whereas one tin should last something around two and a half to three days, she was making the feeding last much longer. If you consider an average family whose child would end up coming into this ward, then you may have a mother and father, three or four children living in a single room with an income of maybe ten to fifteen dollars a week. They don`t have any refrigeration facilities, they share a standpipe with maybe ten or twenty other families, they share toilet facilities; their cooking facilities are not very sophisticated. And so it`s almost impossible for them to reasonably prepare bottle food in a reasonably clean, let alone hygienic, fashion.

ROY BONASTEEL, CBC: In many developing countries formula companies advertise by hiring registered nurses and sending them into maternity wards to promote their product. These milk nurses discourage new mothers from breast feeding by offering free samples along with glossy brochures. Nurse Sha Lyons works in public health. She visits children who`ve been treated for malnutrition. The milk nurses make her furious.

NURSE LYONS: They go to the hospitals, they check the postnatal, antenatal clinics and the mothers who are pregnant. They get a list of their names and when they`re due to have their babies. Then they visit them at home; usually they are the first ones to visit at home, even before the mother is due back to hospital after six weeks when she goes for her postnatal check. And formula is forced on you -- that is, given freely. Then you are going to try the formula to see how the baby takes it, and you eventually end up buying this formula and stop breast-feeding before you really need to do so.

JACKSON: Obviously, people who are in the market selling things must bear some responsibility for what happens to their products. Approximately half the population is estimated to earn less than the recommended minimum wage, which is twenty dollars a week. Now, if you consider that to properly feed a four-month-old child on the kinds of preparations that we are talking about costs something in the region of seven or eight dollars a week, then it is obvious that for more than half our population those things are too expensive. And so. the people who are marketing those things must have some responsibility either to see that they market them at a price that people can reach or that they do not market them in a way that people who cannot afford them are tempted to buy them and utilize them wrongly, or even dangerously. And I think that there has to be some sharing of the responsibility in this regard.

LEHRER: The reporter on that story was Roy Bonasteel of the CBC. At those Senate health subcommittee hearings last month here in Washington on the problem, the companies denied charges involving improper marketing practices. Here are some excerpts from three company spokesmen.

FRANK A. SPROLE, Bristol-Myers: We believe it is simplistic and dangerous to contend that more breast feeding and less formula feeding will solve the nutritional and health problems of infants in the developing world. We believe that the effects of poverty, lack of food and safe drinking water, the absence of sanitation and the shortage of health care are the primary causes of disease and death among infants in the developing world.

QUESTIONER: Would you agree with me that your product should not be used where there is impure water? Yes or no?

OSWALD BALLARIN, President, Nestle Brazil: We give all the instructions...

QUESTIONER: Just answer it. What is your position?

BALLARIN: Of course not! But we cannot cope with that.

QUESTIONER: "Of course not." Do you think that your product ought to be used in areas where there`s illiteracy, vast illiteracy?

BALLARIN: Beg pardon?

QUESTIONER: Where there is illiteracy?

BALLARIN: Well, that...

QUESTIONER: People can`t read.

BALLARIN: That is very difficult to control, Senator, because you go in a region and they are not all illiterate. There are some places where how can you control that the product goes to one rather than to the other?

JOHN R. STAFFORD, American Home Products:... we do not want our product used by women improperly; we do not want it made available to women...

QUESTIONER: Do you do anything to prevent it, or what do you do?

STAFFORD: Well, we don`t -- one, as a matter of business practice our customers tend to be, as I`m advised by our foreign managers, the middle class of those countries, and the abject poor in the rural environment is not the customers that we target at. Often they cannot afford the product, and we don`t target...

QUESTIONER: You don`t target, but do you know what gets in to the poor people?

STAFFORD: If the product gets there, we hope that they will have a company...

QUESTIONER: Well, do you know whether it does get there?

STAFFORD: Yes, the product is available in stores...

QUESTIONER: Well, do you know what percentage does get there and is not being used correctly? Do you have any idea?

STAFFORD: Yes, the...

QUESTIONER: The World Health Organization feels that it`s an important health hazard....

MacNEIL: One woman who testified at those hearings is Leah Margulies. Since 1974 she`s headed the Infant Formula Action Group of the Interfaith Center for Corporate Responsibility. Ms. Margulies, do you object to these products being marketed in the third world, period, or just the manner in which they`re marketed?

LEAH MARGULIES: Well, primarily we object to the manner in which they`re marketed. I think first of all they`re heavily promoted, both through advertising and also and in particular to the hospitals and to health professionals through free samples, milk nurses, et cetera. But I think another key part is their widespread distribution and marketing to poor people in poor areas. I myself found them in rural areas and in barrios in Latin America this summer.

MacNEIL: Has it actually been proved that cases of infant malnutrition or disease or even death were caused by use or misuse of this formula and not by other local causes?

MARGULIES: Well, I would say that it was very much a contributing factor. I think that has been proved. In terms of our data that we collected for the Bristol-Myers lawsuit, which was a legal action one of our members took against Bristol-Myers, Dr. Jackson whom you saw earlier submitted an affidavit actually testifying to the number of malnourished and sick babies on his ward and what products in fact, by company and brand name, the babies used; and they felt it was a very serious contributing factor.

MacNEIL: Has it been proved that it is only the use of those products, or were other possible causes connected with these conditions?

MARGULIES: Well, usually what happens is the baby is weakened -their resistance is weakened. If a baby isn`t breast-fed early and is living in those kind of conditions, the baby loses out on the natural immunities that breast milk affords the child; and then, once you start introducing a contaminated bottle feed, you`re introducing it into a weakened system and then all kinds of complications occur: pneumonia, measles, you name it. But it`s because the body is already weakened through, basically, diarrhea and vomiting.

MacNEIL: Who does your organization think has the responsibility for doing something about this, the companies who market it, the governments locally in the countries that receive it, or the United States government?

MARGULIES: I think all of them do, really. Our agency as a group of church stockholders have been primarily directing their criticism against the companies, but we think all should get involved. I think what we think about the companies, though, is that it`s very hard for a third world government or a hospital to change things if the promotion doesn`t lay off. It`s really hard to fight, it`s like an uphill battle, against things like free samples and inducements of equipment to doctors, et cetera.

MacNEIL: And that promotion has not laid off, in your view?

MARGULIES: I don`t really think so, no. Some of the companies have stopped mass media advertising, or parts of it, but we`re really concerned with the kind of promotion directly to the doctor and to medical personnel in the hospitals. Only in one case do we have a substantial change, I think, in promotion.

MacNEIL: Thank you. Jim?

LEHRER: One of the formula companies which has developed a code of marketing ethics on its own is the Ross Division of Abbott Laboratories. Ross has also financed a pro-breast-feeding campaign in some third world countries. David Cox is president of Ross. Mr. Cox, there are several points here to be covered. Let`s take them one at a time -- number one, that formula companies are responsible for the decline of breast-feeding in third world countries and actually encourage mothers not to breast feed. Is that true?

DAVID COX: We don`t think it`s true. The reasons for the decline of breast- feeding in the third world are multiple in number. Perhaps the two biggest ones are the multiparity of the mother, meaning that it`s a fifth, sixth, seventh or eighth child, and we do know that the volume of breast-feeding becomes lower with each successive pregnancy. And the other reason for it is simply the inadequacy of the volume of breast milk to meet the minimal energy needs of the baby. In our first international conference on this subject in Bogotg in 1970, in which I participated, our host, Dr. Pius Franco, who`s head of the Department of

Nutrition in Colombia, had taken his own survey, and he said that the causes for weaning were lack of maternal milk by forty-eight percent of the mothers; milk simply gave out. A new pregnancy was contracted in twenty- five percent of the cases; the refusal by the child, thirteen percent; and the illness of the mother, including mastitis, seven percent. We believe that malnourished mothers traditionally give birth to low-weight babies, and the low-weight baby needs more, and more careful nutrition, than the normal baby; while at the same time that malnourished mother who gave birth to the low-weight baby also herself is malnourished and becomes more malnourished with each pregnancy.

LEHRER: All right. To the basic question, that companies that sell formulas in the third world countries are responsible for widespread malnutrition and even deaths among babies.

COX: Well, to me that`s preposterous that when you have all these causes involved we would be singled out as an industry when there is no definable evidence against us. There`s a lot of emotional, anecdotal, testimonial type of things that have been brought up against us. We formed a research team as soon as we knew about this; that research team has tried everywhere to document this case, but again, you run into the term bottle feeding -- for instance, Leah has used "bottle feeding," Dr. Allan Jackson has used "bottle feeding." If you go into the museums, one of the oldest relics in the human race attempts to feed a baby when its mother`s milk was unavailable. So in the bottle when the breast milk is inadequate and the mother knows the baby`s hungry, she`s going to feed that baby something, and she`s got to feed the baby through a bottle and a nipple. So earlier, the babies probably got, in the non-monied sectors of the economy; and we should be careful that this program does not lead people to believe that these poor people are our target. Our target are the upper classes and the middle classes, the working group of people, whereas this program will probably center on the non-monied economy.

Now, in the non-monied economy, when they can`t buy anything, they take a sweet potato and they mash it up and they make a paps, they call it, or a gruel, and they put it in some kind of a bottle and nipple and they force it in the baby. Or it`s a paps of corn, millet, or of rice. Many less educated mothers, more illiterate mothers, may even just give the baby sugar and water, or they may give the baby flour and water. So to bring balance to this problem the first thing we need to do is to quit using "bottle feeding" as a generic term. Now, in more recent decades the American government has given literally hundreds of millions of tons of milk -- Chile has a milk program; there are eleven countries that buy milk from us on bid, and they have their own milk programs to give milk to put in these bottles when the breast milk is deficient. Mexico, Chile and India even have their own manufacturing plants.

LEHRER: Okay. I`ll get back to you in a moment on this question of corporate responsibility in marketing practices and all that, but in terms of the two basic issues, of whether or not this contributes to the decrease in breast-feeding or to malnutrition, whether it`s been proved, your position is, in a word, no, it has not, in both cases.

COX: It`s not definable. We have been unable to define a contribution that we`ve made to that.

LEHRER: All right, thank you. Robin?

MacNEIL: The marketing of formula in third world countries and the efforts of their governments to control it have recently been studied for the Rockefeller Foundation. The author was James Post, Professor of Marketing at Boston University. Professor Post, first of all, in looking over the evidence, how serious a health problem attributable to the use or misuse of formula is this, in your view?

JAMES POST: Well, there`s a serious health problem; whether it`s attributable entirely to formula is open to question, as Mr. Cox has said. In Colombia, which was the country in which we did our field study, the government`s own statistics indicate that infants account for approximately four percent of the population, and yet they account for nearly thirty percent of all deaths occurring in the country. That`s about 50,000 children a year. So it`s a serious problem. We know that the conditions of poverty, illiteracy, lack of sanitation all contribute, and the evidence is that formula as well as other products are found in those environments.

MacNEIL: How effective are the efforts that third world governments -- those that are trying -- are making to control the distribution? We mentioned Jamaica; there are others. How effective are those efforts?

POST: Well, those efforts are largely beginning, and they have not been thoroughly studied. Some of the evidence, though, does suggest that there are collaborate steps that the industry and the third world governments can take. In Colombia, for example, the government has supported a breast- feeding education program. There is some limited evidence that that`s beginning to turn the tide in the demand for bottle feeding, or formula products. The World Bank has made a large nutrition loan to the government of Colombia and part of the terms of that loan include a major commitment by the Colombian government to a breast-feeding education program. So the evidence is mixed, but there is some hope.

MacNEIL: Do the corporations marketing this product, as has been suggested, actually have more control than the local government might over the distribution of the product? It`s been suggested the advertising is so powerful, or the distribution is so powerful.

POST: Well, the corporations operate with a different set of incentives. They`re well-administered organizations, by and large, and they have the ability to make people in the field take notice probably faster than the governments do. What we found in Colombia was a lot of interest at the highest levels of the government -- in the National Planning Office, for example, in the Health Ministry -- but it was a long way down that pyramid to the field level; and there were strong reasons to believe it was going to take a long time for that trickle-down to work. In the corporations the trickle-down is much faster, the incentives are much more powerful.

MacNEIL: Finally, whose responsibility do you believe it is to do something about this problem?

POST: Well, with Ms. Margulies and Mr. Cox I share the view that it`s the responsibility of a significant number of institutions. Certainly the corporations have it in their power to identify who are the vulnerable publics and to ensure that the product is not sold to those publics. Local governments unquestionably have a role in affecting both the supply in those countries and the demand for it. The government of the United States, through the Agency for International Development, for example, has now begun to take an interest in this as well. And we have to include the international organizations such as the World Health Organization, which has been urging the developing countries to take an interest in this matter, encourage breast-feeding and enact some kinds of regulations that will help stem this problem.

MacNEIL: Thank you. Jim?

LEHRER: Mr. Cox, your company has adopted a code of ethics. Under your code of ethics, what is ethical conduct in terms of selling formula to a third world country and what is not?

COX: Well, we certainly agree with the superiority of breast milk; we think it`s a tremendous natural resource which should be protected in every possible way. We believe that the parents are not aware of the narrow homeostatic mechanisms of an infant -- too much protein, too much water -- and therefore throughout our entire company history we`ve directed our merchandising, our promotion, at the health professions, because...

LEHRER: So no TV commercials aimed at the general public, or anything like that.

COX: No mass media advertising. We have always felt that mass media advertising or any kind of advertising to the parent is inappropriate. So we direct our promotion at the health person, the health professional, who we feel should intercede between our commercialism and the baby`s need for the product.

LEHRER: What about the mother nurse? Are there mother nurse programs run by your company?

COX: No, we have never had mother craft nurses in the true sense. I wouldn`t attempt to defend it, except just to give one example, since we didn`t do it but the industry does do it. Dr. Thomas Stapleton, who was president of the International Pediatric Association for five years, met with us in Vienna in 1971. He lives in Sydney, Australia, and he said it would be catastrophic to withdraw the nurses from Indonesia because they were the only contact that mothers had with any kind of information. The medical professions in Indonesia, he said, were reaching ten percent of the population.

LEHRER: But you do agree with the basic point, though, that the mother nurse or the milk nurse could dissuade a patient or a mother at an early time to go to the formula rather than to try to breast-feed, and that`s a bad thing, is that right?

COX: The way the industry has used it, I think it`s been largely more good than bad, although there has been perhaps some misuse and some abuses of it. But when the situation became competitive in the foreign field, I think that is when its usefulness ceased, and that is why we don`t do it today.

LEHRER: Ms. Margulies, let me ask you: what do you think of the code of ethics and how this particular company, Mr. Cox`s firm, operates? Is that adequate to meet your objections?

MARGULIES: No; I don`t think so. First of all, I think the codes basically legitimize the kind of promotion we think ought not to happen. Like it tells you how to give out free samples instead of stopping them, or how to dress the milk nurses. Also, frankly, from our previous conversations with Ross-Abbott, we were under the impression that they did have milk nurses and that in fact they told us where they had them, and that they recently had taken them out of uniform. I think our experience with the codes is that they`re very hard to enforce. This last summer I found a Mead Johnson milk nurse on the ward of a Jamaican hospital, even though it was against government policy and their code of ethics. And since that time Mead Johnson/Bristol-Myers has discontinued all their milk nurses, which I`m happy about. And I just have one little point, which is it`s very hard to administer codes and any kind of restrictive marketing procedures right now if there isn`t uniform industry restrictions, et cetera. I`d like to show you, this is a little key ring that I just got sent to me from Mexico and it advertises Similac. And while Ross-Abbott has told us that they don`t market in Mexico, nonetheless unless there`s very stringent management directives for how things do get across borders, et cetera, we`re faced with situations like this.

LEHRER: Robin?

MacNEIL: We`ve heard what the companies have attempted to do. You would like them to go much further. Let`s go back to what the United States government must do. You both said the United States government has some responsibility. What could it do?

MARGULIES: Well, I think it could do two things. First of all, I think we should begin to have some model legislation to control the practices of multinationals overseas. At this point in history, people say business is not controllable overseas.

MacNEIL: That`s a much wider issue. Specifically, on this.

MARGULIES: Right. But that`s what was said at the turn of the century before we had any FDA or FDC or any protective consumer legislation. I also think that we could control promotion right here, that many third world doctors have said to me, "How can you expect us to do something that you`re not willing to do?" And we have in this country mothers going home every day with free samples of formula and the promotion goes right on in our hospitals right here, and I think we should be setting an example.

MacNEIL: What could the U.S. government do, in your view, or should.

POST: Well, my suggestions are much less extreme than Leah`s, I suspect. I would like to see the U.S. government work through the institutional mechanisms of AID, for example. We contribute a great deal to the developing world...

MacNEIL: The Agency for International Development.

POST: That`s correct. We contribute a great deal in terms of direct food support, in terms of health assistance to the developing world, and one role that the U.S. can play in this is to heighten the awareness of the developing countries about this problem: make available those resources that are usable for the developing countries to take some tentative steps in this direction.

MacNEIL: Mr. Cox, finally, do you think that the United States government has any role in this?

COX: I would rather see the industry take a role, along with the governments of the individual countries and the health professions in those areas. But I would like to comment on Leah`s remark about our mother craft nurses.

MacNEIL: If you could do it in about fifteen seconds, sir; we`re just at the end.

COX: All right. In the sense of this context, Leah, we have never had mother craft nurses calling direct on the public; we have had qualified nurses and midwives who give talks in clinics under the supervision of clinic personnel. Also, I think if you check that key case, that big bob you`ve got there, I believe it`s an Isomil, isn`t it, instead of a Similac?

MacNEIL: It says Similac.

MARGULIES: No, it says Similac on one side and Isomil on the other.

COX: Well, I`m wrong on that. I thought they were only Isomil. We do not promote in Mexico; we`re not in the Similac in Mexico.

MacNEIL: We have to leave it there, Mr. Cox, I`m afraid. Thank you for joining us this evening, and thank you both. Good night, Jim. That`s all for tonight. We`ll be back tomorrow night. I`m Robert MacNeil. Good night.