Nutrition advocates have accused the U.S. of siding with private sector interests, sparking a controversy over what they assumed would be a routine effort to provide advice on breastfeeding and the use of breast milk substitutes.
What should have been a non-controversial discussion on breastfeeding turned rancorous at the recent World Health Assembly (WHA) in Geneva.
Advocates at the event have accused the U.S. delegation of trying to stop a resolution on infant and young child feeding from being introduced. The U.S. representatives later pushed for diluted text that removes references to regulating aggressive marketing of breast milk substitutes. The move underscores the influence the private sector still wields in this discussion, experts said, despite the consistent evidence that exclusive breastfeeding is far better for infants than commercially available breast milk substitutes.
The final resolution highlights the importance of breastfeeding and serves as a guide for countries on how to encourage the practice, but stops short of enforcing any action on private-sector interference, especially the monitoring and enforcement of a World Health Organization (WHO)-approved code against aggressive marketing of breast milk substitutes.
“We are upset that the democratic processes that should kick in at the WHA, and have kept the WHA true to its constitutional mandate, were absent,” said Patti Rundall, the policy director of the International Baby Food Action Network, a global advocacy group. “All the member states needed to have a say. The U.S. didn’t need to have to a bigger say.”
While the resolution is not binding for any countries, declarations such as these by the WHA are especially significant for low-income countries that do not have the resources to develop their own research. Thus, experts are worried about the impact the toned-down language might have on such efforts.
A Battle Over Breastfeeding
Nutrition is on the agenda every two years at the World Health Assembly, an annual gathering to discuss critical health issues. This time advocates were hopeful that the resolution on infant and young child feeding, which updated the evidence to support breastfeeding, would pass without much debate.
The first draft was originally supported by Sri Lanka, Sierra Leone, Cambodia and Nepal, and contained several references to the International Code of Marketing of Breast-milk Substitutes, which outlines what levels of marketing are acceptable while seeking to protect the health of infants and young children.
As it became clear at the Geneva conference that the resolution was in danger, nutrition experts, such as advocacy organization 1000 Days’ executive director Lucy Martinez Sullivan, started mobilizing forces on Twitter. “A battle over #breastfeeding has been brewing this week at WHO headquarters at the #WHA71,” she tweeted, adding, “It is now essential that countries #HoldtheLine to protect the #breastfeeding resolution at the World Health Assembly.”
Meanwhile, advocates were building consensus inside the Assembly, too. Speaking at a side event called Millions4Billions the day before the resolution was passed, WHO director general Tedros Adhanom said, “Breastfeeding is essential to prevent undernutrition, yet too few countries have measures protecting, promoting and supporting it, this is unacceptable.” A recent status report released jointly by UNICEF and WHO also called for countries to adopt robust measures to implement the code.
The opposition from the United States caught advocates completely unaware.
“We didn’t expect that there was going to be any pushback,” Martinez Sullivan told News Deeply. She said the first rumblings of U.S. resistance to the resolution came when U.S. officials held its listening session for stakeholders earlier this year, and companies voiced their objection to the resolution. Martinez Sullivan said the Grocery Manufacturers of America also came out against the resolution.
This opposition made its way to the WHA, where the U.S. delegation allegedly threatened countries with trade retaliation if they introduced the resolution, according to civil society advocates. Ecuador, which had led the drafting of the resolution, actually pulled out from introducing it.
“We have heard widespread reports that the countries were pressured [by the United States],” Rundall said. Eventually, after Russia introduced the resolution, advocates scrambled to shore up support and ensure that a version with strong anti-breast milk substitute language passed. The United States also attempted to stall this passage, advocates say, by suggesting an alternative text that omitted any reference to the WHO code or any of the text relating to specific guidance around inappropriate marketing of infants foods.
The U.S. delegation, led by Health and Human Services Secretary Alex Azar, declined requests to provide on-the-record comments.
But in an emailed statement issued after the initial publication of the story, an official with the department said the United States shares “a common objective with other countries to promote breastfeeding as well as adequate and timely complementary feeding, and also by ensuring breast-milk substitutes are properly used, when necessary, on the basis of adequate information and through appropriate marketing and distribution.”
The official wrote that the United States remains committed to working with all stakeholders, including the private sector, “to improve infant, child and maternal health and nutrition through cost-effective and evidence-based measures tailored to national context.”
The goal of the resolution was to make member states aware of new operational guidelines on infant feeding in emergencies. It also sought to make member states aware of the revised Baby-friendly Hospital Initiative, which provides guidance on breastfeeding as a practical option. In addition, the resolution underscored the importance of tackling inappropriate promotion of foods for infants and young children that was issued by WHO in 2016, and was seen as a support document to strengthen advocacy efforts globally.
What ultimately passed was a watered-down version of the draft text, with only one mention of the International Code of Marketing of Breast-milk Substitutes. The final version also removed the provisions in the draft that countries could ask the WHO director general for technical support in “implementation, mobilization of financial resources, monitoring and assessment” of the code, and in “enforcing relevant national legal, regulatory, and/or other measures.”
Civil society organizations like Save the Children called the final resolution “significantly weak,” adding, “[We] are appalled that the drafting committee was unable to reaffirm commitment to implementing existing WHO guidance and policies which are vital to save lives of our children and mothers.”
Advocates see the episode as a wake-up call and said that it pointed to the need to improve the resources for the nutrition community in order to push back against industry influence.
“As an NGO community, we need to establish a regular dialogue with the folks who are leading these negotiations,” Asma Lateef, director of Bread for the World Institute – a nutrition advocacy organization – told News Deeply. “But that takes capacity building and intentionality that we don’t currently have due to lack of resources.” She said the private sector can afford to hire lobbyists, which civil society cannot.
Sullivan Martinez said she is doubtful whether this resolution will prove useful. “The real takeaway for advocates is that there’s a lot of opposition to things that shouldn’t be controversial, and its coming from the Trump administration,” she said.
“We think it’s spearheaded by industry, and the close ties that they have with the administration. Advocates and consumers need to be watching for what happened behind closed doors. That is the lesson.”
This story has been updated to include a response from the U.S. government.