Breaking the Rules 2001 describes the evidence of violations collected during a 14-country survey of company compliance with the International Code of Marketing of Breastmilk Substitutes and relevant World Health Assembly Resolutions. The monitoring results cover 16 transnational baby food companies and 13 manufacturers of bottles and teats.

It is important to recognise that for each violation spotted and supported by documentation, there are surely thousands more of the same, many remain unreported and still others ­ in the form of private deals, transactions and agreements ­ escape from the public eye. The violations documented in this report therefore represent only the proverbial tip of the iceberg.

Companies are learning that as markets have gone global, so, too, must the concept and practice of corporate social responsibility. And they are discovering that doing the right thing at the end of the day, is actually good for business.

UN Secretary General, Kofi Annan at the World Economic Forum, Davos, Switzerland, 28 Jan 2001

Health care facilities continue to be the most widely used and most efficient avenue for companies to reach mothers. Companies are confident of recovering their promotional expense through sales to mothers after they leave the hospital. For example, at least four companies have contracts to pay hospitals in Taiwan US$ 25-30 per infant-fed for the privilege to be their exclusive supplier of infant formula! Mothers in health facilities receive promotional materials such as booklets and leaflets on infant feeding, free samples and gifts such as car stickers, baby records, coupons, bottle bags and towels. Company names or brand names appear on posters, clocks, and calendars. Often the company and brand names are the same.

Almost all companies included in this survey provide free infant formula to health care facilities. In fact, the survey registered an alarming resurgence in donations of free “supplies” of infant formula, follow-up formula, and other baby foods such as cereals. Free or low-cost samples and supplies are sometimes requested by the facility but, more often than not, they are unsolicited donations. The technique of not collecting payment against invoices for supplies continues to be used by several companies.

Almost all companies provide free samples to health workers. The samples are passed on to mothers, conferring medical endorsement. Since samples nowadays are in regular sized tins, the overloading of samples sometimes leads to a racket involving shops. Health workers sell the formula to shops who re-sell to consumers undercutting the market price but still making an (un)healthy profit.

Promotion directed at health workers often reaches mothers as well. Many mothers rely on health workers for objective advice but receive promotional materials, ostensibly printed for health workers. Some companies provide health workers with materials written specifically for mothers. Gifts to health workers are intended to remind the health worker of the company, its brand names and its largesse. These gifts include pens, notepads, chocolates, wall and desk calendars, posters and much more. One company gave an American doctor fresh halibut! Even small gifts are known to evoke a sense of loyalty and goodwill towards the company, let alone the very prevalent practice of sponsorship for travel and research.

Promotional materials such as magazines, leaflets and booklets are made available to mothers in shops, health care facilities, or through the mail. Often appearing to support breastfeeding, these materials frequently contain incorrect information about breastfeeding and inaccurate images carefully designed to create doubts in the mother’s mind about her capacity to breastfeed.

At least seven baby food companies use baby clubs as a strategy for contacting mothers and promoting their products. Baby clubs are promoted in magazines, on leaflets, via shelf talkers and label inserts. Mothers who become members receive gifts, samples of formula, complementary food and discount coupons. Membership lists provide companies continued easy access into mothers’ homes for at least a year after the birth of their baby.

The Internet opens the door to the worldwide market for several companies. In addition to advertising on their own website, several companies sponsor public, health-related sites or physicians’ homepages, where links direct visitors to the company site. Links from the homepages of doctors and their associations to company websites offer not only increased traffic but also implied medical endorsement of the company’s products.

None of the companies included in this survey comply fully with the labelling requirements of the International Code. At least three companies use labels that bear pictures or images that idealise the use of infant formula. Many labels make comparisons to breastmilk or make unsubstantiated health claims. Labels are for many women the only source of information about infant formula. Yet, in several countries, labels are in a foreign language. Follow-on formula labels of several companies closely resemble the company’s infant formula labels, allowing promotion by association and presenting a dangerous risk of confusion by mothers.

Confusion for both health workers and mothers has also been increased by alarming product diversification: monitors found an endless variety of “special” formulas promoted for so-called allergy-prone and regurgitation-prone babies. The latter are usually thickened infant formulae which are found to have a negative effect on infant growth. Another new development is the appearance of much cheaper “store brands” which may unleash a wave of direct promotion.

Advertising and labels of many complementary foods promote their use from as early as the first week for teas and as of one month for cereals. In some cases they suggest the product’s use in a bottle. Some still have labels which idealise bottle feeding by showing a photo or drawing of either a baby or a feeding bottle. Many brands are being promoted as suitable for babies below six months.

The evidence collected demonstrates systematic disregard for the Code. Companies must be aware of this and there can be no excuse. Promotion was found to be most intense in affluent countries where there are no marketing restrictions and where there is fierce competition.

IBFAN is determined to see the Code implemented globally as a minimum health standard. It hopes this publication will help to raise awareness about the many threats to breastfeeding and stimulate an increasing number of concerned citizens to become Code monitors.