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Imagine that
the world had invented a new "dream product"
to feed and immunise everyone born on Earth. Imagine
also that it was available everywhere, required no storage
or delivery - and helped mothers to plan their families
and reduce the risk of cancer.
Then imagine
that the world refused to use it.
At the end
of a century of unprecedented discovery and invention,
even as scientists discover the origins of life itself,
this scenario is not, alas, a fiction. The "dream
product" is breastmilk, available to us all at
birth, and yet we are not using it (ref
1).
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In 1981 the World
Health Assembly adopted the International Code of Marketing
of Breastmilk Substitutes (ref 2) to address
the serious concerns that had arisen over the effects of marketing
of artificial feeding on the health of infants and young children.
Since then the Assembly has adopted eight subsequent Resolutions
clarifying the Code and attempting to close loopholes in the
original text. Since the Code itself was adopted as a resolution,
these subsequent resolutions have the same legal status as the
Code itself and should be read along with it.
In the preamble to
the Code, the Member States of the World Health Organisation
recognised that:
"inappropriate
feeding practices lead to infant malnutrition, morbidity and
mortality in all countries, and that improper practices in
the marketing of breast-milk substitutes and related products
can contribute to these major public health problems;"
This statement contains
two of the major elements underlying the Code:
FIRST: The
Code applies in ALL COUNTRIES. As its name suggests,
the Code is INTERNATIONAL and applies globally (ref
3). The drafters never contemplated that it should apply
only to developing countries. Parents of infants in Europe and
North America have the same right to protection from inappropriate
marketing as parents in Asia, Africa and South America.
SECOND: The
Code applies to ALL BREASTMILK SUBSTITUTES and related
products, which include feeding bottles and teats. The Code
is not limited to basic infant formula intended for healthy
babies born after nine months of gestation and with adequate
weight and length for age as many companies would argue. The
Code covers special formulae such as those for premature infants,
hypoallergenic formulae, lactose free formulae and follow-on
formulae (ref 4). It also covers waters,
juices, teas, and foods if marketed or in any other way represented
as a partial or total replacement for breastmilk.
These two principles,
universality and the scope including all breastmilk substitutes,
cannot be overemphasised given the tendency of the infant feeding
industry to attempt to limit the application of the Code.
The Code does not,
of course, try to lessen the availability of breastmilk substitutes.
It seeks to regulate the way in which they are promoted. According
to the World Health Assembly:
"...in
view of the vulnerability of infants in the early months of
life and the risks involved in inappropriate feeding practices,
including the unnecessary and improper use of breast-milk
substitutes, the marketing of breast-milk substitutes requires
special treatment, which makes usual marketing practices unsuitable
for thes products." (ref 5).
A THIRD
key principle is contained in Article 11.3 of the Code (ref
6). This Article states that manufacturers and distributors
of products covered by the Code must make sure that they comply
with the Code irrespective of measures that have, or have not
been taken by others to implement it. (ref 7).
Thus even if no action has been taken in a country to give effect
to the Code and subsequent relevant Resolutions, all companies
must still comply.
Many people have
questioned the continued relevance of the Code in the context
of mother-to-child transmission of HIV through breastfeeding.
Let me assure you that there is an even greater need
to ensure Code compliance in areas of high HIV prevalence. The
Code protects artificially fed children as well as those mothers
who decide to breastfeed.
One of its aims,
as specified in Article 1, is to ensure the proper use of breastmilk
substitutes when these are necessary. If incorrectly prepared,
infant formula can be lethal. Over-dilution, the result of unsuitable
availability of formula, leads to malnutrition. Under-dilution
can cause serious health problems such as kidney failure. This
is without discussing whether sanitation and access to clean
water, fuel, and adequate skills permit safe preparation.
The Code ensures
that labels contain suitable warnings, and clear and understandable
preparation instructions. The decision to feed an infant artificially
and the choice of brand should be made on the basis of full
information provided through counselling by an independent health
worker, and not influenced by commercial interests. The Code,
when implemented and monitored, also helps prevent spillover
of artificial feeding to the majority of infants in the world
who would benefit from breastfeeding, and whose lives, in many
cases, depend on it.
Given the fundamental
importance of Code implementation to infant health, survival
and development, it is hardly surprising that UNICEF expects
every company to fulfill its obligations under this instrument
in every country in the world. Every child has the right to
the highest attainable standard of health. The Convention on
the Rights of the Child, an international treaty ratified by
all but two nations, recognises this right. Moreover, the CRC
recognises the fundamental role that breastfeeding plays in
fulfilling the child's right to health, and the importance of
ensuring that parents receive full and unbiased information
on the benefits of breastfeeding. The promotion of artificial
feeding undermines a mother's right to make an informed decision
about how to feed her infant. Implementation of the Code protects
against misinformation that will interfere with the rights of
infants and their caregivers.
In conclusion, the
5 key points that UNICEF would like to leave in your minds are:
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The Code and
subsequent relevant resolutions are global, not limited
to developing nations.
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The Code and
resolutions aim to regulate the marketing of all breastmilk
substitutes, feeding bottles and teats. The scope is not
limited to infant formula.
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Manufacturers
and distributors of breastmilk substitutes, feeding bottles
and teats must comply with the Code and resolutions irrespective
of action taken by national authorities to translate them
into domestic law.
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The Code and
resolutions protect both breastfed and artificially fed
children. Its implementation becomes even more important
in the context of the HIV pandemic.
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Implementation
of the Code and resolutions is an important component in
protecting the right of every child to the highest attainable
standard of health under the Convention on the Rights of
the Child.
References
1.
Slightly reworded from Take the Baby-Friendly Initiative! A
global effort with hospitals, health services and parents to
breastfeed babies for the best start in life. UNICEF, New York
2. International Code of Marketing of Breast-milk
Substitutes, WHO, Geneva 1981
3. World Health Assembly Resolution 34.22
which adopted the Code in 1981 "URGES all Member States:
(2) to translate the International Code into national legislation,
regulations or other suitable measures;".
4. In discussing the definition of infant
formula, Sami Schubber, the former Senior Legal Officer of WHO
states that "The wording of the definition contains nothing
to suggest a distinction between a certain type of infant formula
and another, or between a certain infant and another."
Shubber, S., The International Code of Marketing of Breast-milk
Substitutes: an international measure to protect and promote
breastfeeding. The Hague: Kluwer Law International, 1998.
5. Preamble, International Code of Marketing
of Breast-milk Substitutes, WHO, Geneva 1981
6. Article 11.3 states "Independently
of any other measures taken for implementation of this Code,
manufacturers and distributors of products within the scope
of this Code should regard themselves as responsible for monitoring
their marketing practices according to the principles and aim
of this Code, and for taking steps to ensure that their conduct
at every level conforms to them".
7. There is support for the proposition that
the obligation placed on companies under Article 11.3 is a legal
one and not just a moral one. See Shubber, op.cit., p.262
Note from Baby
Milk Action
Asked if Nestlé
correctly interpreted the International Code and Resolutions,
UNICEF commented that the titles of the Code and Nestlé's
"Charter" gave an indication of how accurately Nestlé
interpreted the Code. The International Code of Marketing
of Breastmilk Substitutes is international (applying to
all countries) and covers all breastmilk substitutes. On the
other hand Nestlé infant formula policy in developing
countries (its "Charter") applies only to a very
narrow classification of breastmilk substitutes and does not
apply to all countries.
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