Expert Views: What’s Next on the Agenda for Nutrition Advocates?

Malnutrition Deeply asked nutrition experts and practitioners about the history of U.S. opposition to breastfeeding and how the lessons from the WHA will help guide their future approach to this issue.

Written by Amruta Byatnal Published on Read time Approx. 5 minutes
An Indian laborer breastfeeds her child in Mumba.NDRANIL MUKHERJEE/AFP/Getty Images)

The Trump administration came under fire for efforts to undercut guidelines that encourage exclusive breastfeeding at this year’s World Health Assembly (WHA) in May – something Malnutrition Deeply reported shortly after it happened

Trump pushed back on Twitter, insisting that “the U.S. supports breastfeeding but we don’t believe women should be denied access to formula.” Many activists and experts disagree.

They say he has joined an American tradition of opposing policies that encourage breastfeeding in favor of supporting the milk-substitute industry. Malnutrition Deeply asked nutrition experts and practitioners about this history and how the lessons from the WHA will help guide their future approach to this issue.

We are also eager to hear from you about how you think exclusive breastfeeding supporters should respond to this situation. Tell us here.

Aunchalee Palmquist, Assistant Professor, Gillings School of Global Public Health at the University of North Carolina

Advocates need to be aware that there is a lot of potential for conflicts of interest with commercial industry in the field of nutrition.

When the resolution to adopt the International Code of Marketing of Breast Milk Substitutes was introduced in 1981, the U.S. was the only country that opposed it and voted against it. And in the convening years, there hasn’t been active opposition against similar resolutions. This year was unique in the sort of direct lobbying and pressure on member states who were planning on supporting it, to not endorse it.

The U.S., according to a 2016 report, has never had and does not have any legislation related to the Code or provisions that offer any kind of enforcement of the Code. And the WHO Code was designed to help strengthen member states’ ability to prevent the predatory marketing of breast milk substitutes and other related infant feeding products. So the WHA resolution provides guidance for member states, but then member states can put in different official legislation and policy around it, but the United States doesn’t have anything in place.

Some have argued that these kinds of actions are linked directly to protecting the interests of the multibillion-dollar dairy industry.

I think the ongoing work for practitioners is reiterating in any way that they can that breastfeeding is a public health priority. It’s a public health nutrition priority, and there need to be supports in place to protect breastfeeding. And in advocating for breastfeeding, it doesn’t mean that people are anti-formula feeding, and I think clarifying misconceptions around what the WHO Code is, and what the Baby Friendly Hospital Initiative is and what it does, is really important. Nutrition advocates, including those who focus on breastfeeding, can continue to work to ensure that accurate messages are getting out into their communities of practice, to the public and to their government representatives. Governments and health care institutions also have the responsibility of ensuring that families are able to make infant feeding decisions based on the highest quality of scientific evidence and are not unduly biased by the commercial and political interests of industry, including unethical marketing. Breastfeeding protects mothers and infants from malnutrition and poverty.

The WHO Code and BFHI provide guidance and implementation recommendations for protecting the right to breastfeed by putting into place safeguards against aggressive marketing of formula companies. These guidance documents are not anti-formula feeding and in no way prevent a parent’s access to formula feeding when it is medically indicated or is a parent’s choice. We need more organizations and advocates to get involved in the WHA resolution process in Geneva since it is dominated by industry and there is high potential for burnout by the few individuals and orgs who represent the public health perspective on Infant and Young Child Feeding (IYCF).

(Palmquist spoke to Malnutrition Deeply in her personal capacity.)

Mary Champeny, Program Officer, ARCH Research and Communications

There is a very clear next step: and it’s especially a rallying cry for and middle income countries.

The November Codex Alimentarius Commission on Nutrition and Food For Special Dietary Uses meeting is, where member states and organizations will be reviewing and hopefully finalizing the standard for follow up formula. For the past several years we’ve been involved in a long-standing policy process, revising this food standard. Our advocacy has focused on briefing country advocates on the issue. These are countries in official observer standing with the WHO and the FAO, which make up the Codex Alimentarius.

Fundamentally, we believe that the products that function as breast milk substitutes need to be all defined as breast milk substitutes and then regulated as such, which is really a big policy win that we achieved with the World Health Assembly Resolution 69.9 in 2016, and which was part of why the infant and young child feeding resolution at this past World Health Assembly was so controversial because it made direct reference to that previous policy.

We want to see this Codex Alimentarius standard for follow up formula; we want to see it aligned with that World Health Assembly resolution, with all of the WHO language that says that a breast milk substitute is any milk-based product that replaces or functions as a breast milk substitute in the diet of children from zero to 36 months of age. That’s a sticking point for many industrialized countries where the formula manufacturers are based. We anticipate lots of lobbying at this November meeting, and expect to see the same flavor of opposition that we saw at WHA. That’s also because industry is more represented at Codex. Part of the Codex Alimentarius mission to protect public health and consumer interest, and then the other part of it is to act in the interest of trade. They’re setting these standards that are supposed to be applied globally. The World Health Assembly is focused on health issues whereas Codex’s scope is broader, and offers more of a role and opportunity in the conversation for the private sector.

There’s a large, well-resourced coalition of EU countries and other western industrialized nations that have either large dairy industries or powerful formula manufacturers. They have big delegations, and you can expect that they will have a polished and well-articulated argument that these milks for older children are not breast milk substitutes, and that they don’t need to be regulated under the code. We need to see other countries show up to the meeting, as every country gets a vote. We need to get as many countries as possible to be informed on this issue, to send representatives from their government to this meeting in Germany in November, and be willing to stand together in a united front against what we expect to be strong opposition, based on what we’ve seen in the past. It’s especially a rallying cry for middle income countries – and it’s time to get there and to speak up.

Resources for nutrition advocates and practitioners include:

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