On Wednesday 23rd February 2022, Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) and partners launched a new report, ‘How the marketing of formula milk influences our decisions on infant feeding’. This report – the largest of its kind to date – draws on the experiences of over 8,500 women and 300 health professionals across eight countries, including South Africa. It exposes the aggressive and manipulative marketing practices used by the formula milk industry and highlights the negative impacts on families’ decisions about how to feed their babies and young children.
The largest formula milk producing company has had a century and a half of experience perfecting the marketing of an inferior child feeding product. How? By positioning its formula milk as the closest formulation to human breastmilk, and by using trusted and credible health professionals to endorse and recommend formula milk as a suitable replacement to breastmilk. The infant formula industry has mastered the art of manipulation by using product marketing strategies to convince mothers that infant formula ‘is just like breastmilk’. But the established scientific body of evidence has illustrated that breastmilk is far superior to formula milk and that child health costs due to inappropriate formula feeding are multiple, robbing children of optimal health and cognitive development while fuelling the obesity epidemic in childhood and adulthood, and increasing the risk of children dying of pneumonia and diarrhoea. And while industry profits, these costs are carried predominantly by the public health system.
As a society, we must recognize how efforts to increase infant formula sales undermine breastfeeding. As Phil Baker pointed out in the United Nations University IIGH webinar: Infant and Young Child Feeding: Policy, Power and Politics – as the formula industry has globalized so has its “power of marketing”. Exposure to such marketing reduces breastfeeding initiation, duration, and exclusivity irrespective of context. Without significant and purposeful interventions to protect, promote and support breastfeeding, many countries, particularly here in Africa, will see a steady decline in breastfeeding rates and a concurrent rise in malnutrition, with more pronounced childhood obesity and its associated health conditions of non-communicable diseases like hypertension, diabetes, and cardiovascular diseases. While we may think of these as adult diseases, their origins lie in early inappropriate infant feeding.
This is why South Africa committed to protecting, promoting, and supporting breastfeeding at Tshwane in 2011 and introduced Regulations relating to Infant and Young Child Feeding, R991 to protect mothers and caregivers from the inappropriate and misleading marketing of formula milk. Yet despite these efforts, the 2016 Demographic Health Survey found that one in four infants under the age of six months has never received breastmilk (25%), while only one in three is exclusively receiving breastmilk (32%), the larger portion of 43% is mixed fed, receiving breastmilk and other feeds, predominantly infant formula. This means that 68% of infants under six months of age are receiving sub-optimal feeding and are not being exclusively breastfed as recommended by the national Department of Health and WHO.
At the same time, the infant formula industry has earmarked low and middle-income countries for market expansion, and Euromonitor reported that the sale of formula milk in South Africa more than doubled from 2000 to 2015. The R991 prohibits the advertising and promotion of infant formula, in any form, on all media platforms. But since then infant formula companies have continued to breach the existing regulations and developed new strategies to promote and market their product. These include below-the-line advertising on social media, the sponsorship of continuous professional development courses for health professionals, sponsorship of conferences and symposiums linked to infant and young child nutrition, funding for students and researchers through industry-affiliated entities like the Nestlé Nutrition Institute, Africa (NNIA) and sponsorship of lecturer positions that specifically teach infant and child nutrition. Without diligent monitoring and reporting, infant formula companies continue to cross the line and test the strength of R991.
In recent years, these formula milk marketing strategies have exploited social media to reach consumers with enticing and misleading health claims and false promises of better growth and development of their children often coaxing mothers with words that conjure up superiority like ‘Opti-pro’, ‘Gold’ and ‘Supreme’. This is in modern terms ‘false advertising’. The survey of pregnant women and mothers that was part of this study found that strikingly almost half of women (49%) believed that formula is very much like breastmilk. These perceptions are clearly aligned with formula companies’ marketing messages said Prof Tanya Doherty from the South African Medical Research Council, one of the researchers assisting with analysis of the South African data.
What is particularly concerning in the context of South Africa’s high levels of poverty, unemployment and food insecurity, is the inability of households to adequately and safely provide infants with sufficient formula milk to ensure good growth and development. One in three children in South Africa live in households below the food poverty line which leaves insufficient money to buy sufficient formula milk to meet the needs of growing children. Ms Pumla Dlamini from Vitamin Angels and Nutrition Lead for the health rights coalition, South African Civil Society for Women’s, Adolescents’ and Children’s Health (SACSoWACH) points out, “What is most frustrating is that Nestlé uses home-grown social protection measures like stokvels to idealize and liken infant formula to breastmilk. This erodes indigenous healthy feeding practices such as breastmilk, rendering them less desirable.”
In 2021, civil society efforts led by HEALA galvanized action through the #NotTodayNestle campaign to stop a Nestle-funded series of mom & child events. The formula milk industry has a track record of violations and underhand tactics, and in this case, Nestlé, a Swiss-based company, chose to exploit the long-held tradition of stokvels – using these community-based savings schemes to market their products to women who can ill-afford formula milk, highlighting the lengths that the profit-focused formula industry employs to ensnare unsuspecting and trusting consumers.
As researchers and food justice activists, we, therefore, call on the government of South Africa, to place children’s health before profits and support WHO’s efforts to protect women from exploitative marketing practices. This can be done by strengthening the enforcement of R991 and to accelerate efforts to gazette the regulations governing the advertising of unhealthy food to children. We call on the whole of society to protect, promote and support breastfeeding. This includes progressive maternity protection and paid maternity leave for six months for all mothers, regardless of employment status; state-funded childcare services; and community-based support for breastfeeding mothers. If South Africa is to turn the tide on childhood obesity, it will have to counteract the aggressive and insidious marketing of infant formula. The health of the nation depends on strategic and decisive leadership to curtail the inappropriate marketing of the $55 billion formula milk industry.
HEALA is a civil society coalition working to advance food justice in South Africa to ensure that communities are able to exercise their right to affordable, nutritious food.
SACSoWACH is a civil society coalition that advocates for the health of newborns, children, adolescents, women and mothers.
Dr Chantell Witten
Lecturer, Faculty of Health Sciences, Division Health Education, University of Free State
SACSoWACH Nutrition Working Group Member
+27(0)71 485 5893
Nutrition Programme Manager for HEALA
+27(0)72 078 3160
Professor Tanya Doherty
Health Systems Research Unit, SAMRC