The Epic Battle Between Breast Milk and Infant-Formula Companies

When Trump administration officials opposed a WHO breast-feeding resolution, they followed a long history of policymakers listening to baby-formula manufacturers.

A baby is breastfed by a woman
Thanasis Zovoilis / Getty

It was an issue over which a strong show of American exceptionalism wasn’t exactly expected: breast milk.

According to a recent report from The New York Times’ Andrew Jacobs, American officials at the World Health Assembly in Geneva this spring wanted to modify a breastfeeding resolution, and they went to the mat to do it, threatening other countries unless they promised to drop it.

The American delegates wanted to ditch language in the nonbinding resolution that called on governments to “protect, promote, and support breastfeeding” and another passage that called on policymakers to restrict the promotion of unhealthy food products. When that didn’t work, they threatened Ecuador, the country that intended to introduce the breastfeeding measure, with punitive trade and aid measures. Ultimately, it was Russia that agreed to introduce the breastfeeding resolution, and the U.S.’s efforts were “largely unsuccessful,” the Times reported.

A spokesperson for the U.S. Department of Health and Human Services, which led the negotiation on the resolution, denied that trade sanctions were part of the discussion about the resolution. “Recent reporting attempts to portray the U.S. position at the recent World Health Assembly as ‘anti-breastfeeding’ are patently false,” HHS national spokesperson Caitlin Oakley told me. “The United States was fighting to protect women’s abilities to make the best choices for the nutrition of their babies.”

Nevertheless, the episode shocked health-policy advocates because breastfeeding seems so, well, wholesome. To some critics of the U.S. delegation’s actions, it seemed like an example of the Trump administration bowing to the food industry and infant-formula manufacturers. “What this battle in Geneva showed us is that we have a U.S. government that is strongly aligned with the interests of the infant-formula industry and dairy industry, and are willing to play hardball,” said Lucy Sullivan, the director of 1,000 Days, an advocacy group that works on nutrition for mothers and children.

Sullivan and other health advocates point to a “stakeholder listening session” that the U.S. Department of Health and Human Services held with industry groups and nonprofits two weeks before the World Health Organization meeting in Geneva. As usual, dairy, grocery, and baby-formula groups gave their opinion to the U.S. delegates about the WHO resolutions. What seemed different this year, health advocates told me, is how forcefully the U.S. delegates acted on the trade groups’ opposition.

A representative from Nestle, which makes baby formula and baby food, spoke out at the session, according to Mary Champeny, a program officer with the nutrition group Helen Keller International who was at the listening session. The company said it opposed the resolution because of its reference to an earlier, 2016 World Health Assembly resolution, which they said “restricts complementary feeding,” the gradual introduction of solid foods along with breast milk starting at around six months of age. Champeny remembers another group, a supermarket lobby, also speaking out against part of the resolution at the same session. In talking points from the listening session provided to The Atlantic, a Nestle representative wrote, among other things, “We believe that to significantly increase breastfeeding rates and promote healthy diets, the Guidance when implemented by Member States should consider other important measures other than simply recommending additional restrictions on the promotion of commercial baby food.”

In prepared remarks written for the listening session, a coalition of dairy interest groups seemed to take issue with the fact that WHA guidance “redefines all milk products for children up to age three as ‘breastmilk substitutes,’” and said they “urge the U.S. government to ensure the WHA does not endorse the Guidance or call on member states to implement the Guidance.” Regarding another provision, the dairy groups said, “We encourage the United States to ensure that any future recommendations from WHO explicitly recognize the benefit of engaging with the food and beverage industry.”

This latest tussle in Geneva follows a decades-long battle by infant-formula makers to promote themselves as essentially on par with breast milk. And while health experts instead say “breast is best,” as this incident shows, policymakers aren’t always willing to put legislation behind that message.

Formula makers have responded to the cultural battle over breastfeeding in true corporate form: by lobbying for their interests and marketing their products. For example, Abbott Laboratories, which makes Similac and other formulas, spent $790,000 on lobbying this year, according to the Center for Responsive Politics. Though the company has spent more in past years, this year their disclosure lists having lobbied the U.S. Trade Representative, among others, on “proposals regarding infant nutrition marketing.”

“We support the WHO’s goal of increasing breastfeeding rates, including promoting exclusive breastfeeding during the first six months of life, where possible, and continued breastfeeding up to and beyond two years of age,” an Abbott spokesperson told me via email. “It is also important for all mothers and their health-care teams to choose the best feeding options for their babies and themselves.”

Some women rely on formula because they can’t or prefer not to breastfeed. Many women, especially working mothers in economically prosperous countries, breastfeed and supplement with formula. But health experts have concerns that poor women in developing countries buy formula because they think it’s better than breastmilk, then dilute it, sometimes with unsafe water, when they run low. In developing countries, formula has been found to increase the risk of infant death, when compared with breastfeeding. While the consequences of formula are not as severe in rich nations, the World Health Organization and the American Academy of Pediatrics both recommend exclusive breastfeeding for the first six months of a baby’s life because of breast milk’s health benefits. A British charity went so far as to call formula “The Baby Killer” in the 1970s. (Though formula maker Nestle sued for libel and won, a worldwide boycott of the company ensued.)

For decades, formula manufacturers went to creative lengths to get their product in the hands of new moms. In New York City in the 1970s, for example, the maker of Similac had a guarantee that every new mom leaving a city hospital would get a free supply of the formula, as Stephen Solomon wrote in The New York Times in 1981, and some companies employed nurse-like saleswomen who would give advice to new moms in maternity wards while subtly promoting infant formula. At the time, a doctor who worked for USAID blamed the reliance on infant formula for about a million infant deaths each year in developing countries.

That same year, the World Health Organization voted 118 to 1 to adopt a nonbinding code that advocated the end of promoting infant formula to the public. That one holdout vote? The United States. “Despite our governmental interest in encouragement of breastfeeding,” explained Elliott Abrams, then the Assistant Secretary of State for International Organization Affairs, according to The Times, the restrictions on formula advertisements “run counter to our constitutional guarantees of free speech and freedom of information.”

Today, countries that ban the advertising or promotion of infant formula, such as Brazil, tend to have higher rates of breastfeeding than those that don’t, like the United States. Still, even countries that adopted the WHO code into law don’t always crack down on formula manufacturers that break it.

Though 130 countries restricted advertising in the wake of the WHO code’s passage, a study in 2010 documented 500 violations of the code in 46 countries. One billboard in Laos, for example, showed a child happily eating “Bear Brand Formula Milk.” “This type of widespread marketing results in mothers’ recognizing certain brands and believing their children will be healthier with formula,” wrote the pediatrician June Pauline Brady in the Archives of Disease in Childhood in 2012.

In 2004, the U.S. Department of Health and Human Services tried to do the opposite: to advertise breastfeeding. Health officials were going to release ads showing some of the health issues—in the form of insulin syringes and inhalers—that they claimed babies who aren’t breastfed are more likely to face, according to a Washington Post story from the time. But the infant-formula industry hired lobbyists to appeal to the department, and the ads were toned down to feature happier pictures of ice cream and flowers. The new campaign, in the end, did nothing to boost breastfeeding rates.

Two years later, Massachusetts went further, becoming the first state to ban gift bags filled with infant formula in maternity wards. But the decision, crafted by the state’s Department of Public Health, was reversed by then-Governor Mitt Romney. The following month, Bristol-Myers Squibb, which makes formula, announced it would build a plant in Massachusetts. (“The decision to build our facility in Devens did not involve any consideration of our Mead Johnson business,” said a Bristol Myers Squibb spokesperson, referencing a former subsidiary.)

As recently as February of this year, a report by the group Changing Markets Foundation found that Nestle pitched its baby formulas as “closest to,” “inspired by,” and “following the example of” human breast milk, The Guardian reported. In some cases, the company contradicted itself, promoting Brazilian formula as being free of sucrose “for baby’s good health” while tucking sucrose into its South African formula. (A Nestle spokesperson told me, “The Changing Markets Foundation report on infant formula raises some important points. We engaged with CMF in a dialogue to clarify these points. We hope to collectively address the critically important challenge of ensuring access to the right nutrition for infants.”)

A few weeks later, an investigation by The Guardian and Save the Children found that infant-formula makers were offering health workers in the Philippines “free trips to lavish conferences, meals, tickets to shows and the cinema and even gambling chips, earning their loyalty,” in violation of the country’s laws. The investigation found:

TV advertising campaigns for follow-on milk by brands such as Bonna—which portray the “Bonna kid” as one who is smarter and succeeds in life—convinced them, they said, that bottle feeding is not only as good for the baby’s health as breast milk but will bolster their IQ and future prospects. Store displays of formula were splashed with claims such as “clinically proven to give the IQ + EQ advantage.”

The reporters spoke with one woman who could only afford to give her baby half-bottles of the formula. The girl’s stomach, they wrote, was visibly swollen from malnutrition.

Since 1981, the infant-formula WHO code has been updated through resolutions at the World Health Assembly. The last update was in 2016, during the Obama administration, and it was a big policy push, according to Elizabeth Zehner, a project director with Helen Keller International. As they often do, industry groups spoke out against it, said Sullivan, the 1,000 Days director who attended the 2016 session. The World Health Assembly “welcomed” the 2016 resolution “with appreciation,” a notch below endorsing it.

However, this year’s resolution wasn’t about updating the code. It was more modest, simply intended to remind countries of the importance of promoting breastfeeding, Sullivan said, and notify them about best practices around breastfeeding and HIV, or during natural disasters.

So it surprised health advocates that the United States would use such heavy-handed efforts to try to kill it. “They used very aggressive tactics to get rid of a resolution that really wasn’t a policy grab,” Zehner said.

Of course, aggressive is often the way of the Trump administration. As President Trump wrote on Twitter yesterday, “The failing NY Times Fake News story today about breast feeding must be called out.”