September 2006
Health and the Filipino

Tempest in a (feeding) bottle

Despite several groundbreaking initiatives as the Milk Code of 1986 and the Rooming-in Act of 1992, formula-milk manufacturers seem to be winning the battle vs breastfeeding advocates.

BREAST IS BEST. Mothers and their babies set a new world record for simultaneous breastfeeding at the San Andres Complex in Manila last May 4, 2006. [photo courtesy of P. Repelente, DOH]

BREAST OR bottle?

That may seem a no-brainer to many, but it’s a question that’s still throwing mothers, activists, government officials, medical experts, milk manufacturers, and apparently even U.S. diplomats in the throes of deep distress. To think that two decades ago, health officials had considered the matter already settled with the passage of the groundbreaking Milk Code, which aimed to protect breastfeeding and regulate the promotion of breast-milk substitutes. Yet officials say that instead of seeing more mothers breastfeed, the opposite has been happening. And those who still breastfeed are doing so for shorter periods of time.

“The norm now is infant formula, not breastfeeding,” laments health undersecretary Alexander Padilla. “The situation is tragic as it is desperate.”

Health experts say that as a result, many children are being denied the best nourishment freely available to them. They add that these children are made more vulnerable to falling ill, and mothers themselves are unable to take advantage of the health benefits of breastfeeding.

Blame the aggressive marketing of manufactured milk products, say government officials and breastfeeding advocates. But both also admit that the lack of education about breastfeeding and a frail legal environment are contributing factors, too, to the feeding bottle’s ever-growing popularity.

Yet the trend isn’t exactly new. Medical anthropologist and health activist Michael Tan points out that in 1963, the average period of breastfeeding in the country was 14.5 months; by 1982, it had dropped to 12.1 months. Tan guesses, though, that these survey data likely referred to breastfeeding in general, meaning it includes the weaning period where other foods are introduced to the baby, and not exclusive breastfeeding.

Exclusive breastfeeding means breast milk is the only food and drink given to the infant; not even water is given. The international standard for how long this should last is six months. But based on the two latest rounds of the National Demographic and Health Survey, Filipino mothers hardly come close to reaching that. In 2003, the median period for exclusive breastfeeding in this country was a mere 1.4 months. By 2003, the figure has declined to 0.8 months.

In 1998, a quarter of Filipino mothers exclusively breastfed their children for the first six months. Today that proportion is down to 16 percent.

Health officials have been working double time to increase that number. They also want more mothers breastfeeding until their children turn two years old. Last July, in fact, more stringent implementing rules for the Milk Code — known formally as Executive Order 51 — would have taken effect. But then several milk manufacturers went to court, arguing that the health department had overstepped its bounds. It should have left rulemaking to Congress, said the milk companies. They also said they were being deprived of their right to unrestrained trade.

Initially, the Supreme Court ruled in favor of the health department. But just a few weeks later — much to the consternation of health officials — it reversed itself and granted a temporary restraining order on the implementation of the new Milk Code rules. Legal experts, though, predict that it may take some time before a clear winner emerges from the court battle.

TO MANY people, it had seemed like breastfeeding advocates had already won the war. When this writer undertook an informal poll among her friends in their 30s, for instance, all of the 15 mothers who responded had tried breastfeeding. Most of them also said they knew breastfeeding brought immense health benefits to their children. (See highlights of survey.)

One even felt guilty for being unable to feed only breast milk to her baby. “I didn’t have enough milk to breastfeed him exclusively,” said lawyer Andrea Pasion. “I’ve had guilt feelings about this. I even bought expensive feeding bottles, those with teats that are supposedly similar to real nipples. I really had very little milk — and I had two breast pumps ha.” She said she hoped it would be “better with my next pregnancy.”

Since 1986, all infant formula ads, whether print or broadcast, have had to carry the message, “Breast milk is best for babies.” It was no empty claim; the Department of Health (DOH) says breastfeeding could prevent up to 16,000 infant deaths each year in the Philippines. The UK medical journal Lancet has also said that breastfeeding can prevent over 10 percent of child deaths worldwide.

Under the Milk Code, all milk ads have had to be approved by an inter-agency committee, which monitors violations as well. In addition, baby-food companies cannot give away samples and supplies of their products and “gifts of any sort” to the general public, to health institutions (including hospitals), and to “personnel within the health care system.”

Milk manufacturers are refrained from having containers and labels of their breast-milk “idealize” the use of infant formula. Containers and labels have to have a statement on the superiority of breastfeeding.

Since 1992, the Rooming-in and Breastfeeding Act has been in force, providing more push to the government’s breastfeeding campaign. The law requires hospitals to room-in newborn infants with their mothers — those delivered normally, within 30 minutes after birth, and those by C-section, within three to four hours — so that breastfeeding could be initiated.

But the likes of Tan, along with health officials, say all these have been undermined by milk manufacturers, which have remained as aggressive as ever. Indeed, the Bureau of Food and Drugs (BFAD) says that between July 2001 and December 2004 alone, there were 63 violations of the Milk Code. Alessandro Iellamo, the World Health Organization’s (WHO) nutrition consultant for the Philippines, says the BFAD tally “is even small, taken in the context of all the other violations that have gone on since 1986.”

Most of the violations BFAD recorded involved the distribution of print advertisements without proper approval by the inter-agency committee. There were also companies that used clinics and hospitals to promote their products, gave out samples to mothers, or printed unacceptable covers in reading material.

Tan is aware mothers choose not to breastfeed for a variety of reasons. “More often though,” he says, “Filipino couples think that infant formula is superior to breastfeeding, and spend hard-earned money — up to P1,000 a week — on the milk powder. The reason is simple: They’re victims of the relentless marketing campaigns of the milk companies.”

Still, health undersecretary Padilla himself concedes, “We have failed to implement the true intent and spirit of the law.” But it is precisely because of this, he says, that a revision of the Milk Code’s governing rules became crucial.

He also notes that when the health department, in consultation with WHO, the United Nations Children’s Fund (Unicef), and local breastfeeding advocates, began a process of updating these rules more than two years ago, the milk companies were represented in the public consultations.

“There were always these diametrically opposed views,” says Padilla, who chaired the committee that drafted the revisions. “We had to take a stand, and sometimes we had to compromise.” (Read a transcript of PCIJ’s interview with Padilla.)

The revisions were completed after 19 drafts. In May, the entire health council, headed by Health Secretary Francisco Duque III, signed the revised implementing rules through Administrative Order No. 2006-0012.

“IT MUST be stated for the record that the Milk Industry is in full support of the Milk Code and the government’s breastfeeding campaign, ” said the Pharmaceutical and Health Care Association of the Philippines (PHAP) in the petition it filed with the Supreme Court on June 28, seeking to prevent the implementation of the Code’s revised rules. (View petition, in pdf files, 1, 2, 3, and 4.)

“In fact,” said the group, “it has poured its own resources to supplement the meager P1 million fund allotted by the government for the said campaign. However, even as the Industry concedes the need to put more teeth in the Milk Code to further its effectiveness, the same must be done legally by means of legislative action, and not by mere issuance of administrative rules and regulation.”

PHAP head Leo Wassmer Jr. declined PCIJ’s request for an interview. In its petition, though, the PHAP, whose members include U.S.-based transnationals Abbott Laboratories, Wyeth Philippines, and Mead Johnson, said the revised rules’ premise that breastfeeding substitutes are hazardous to health and that there is no substitute or replacement for breast milk is “fundamentally flawed.”

“The impetus of the Milk Code was precisely to regulate the proper use of breastmilk substitutes, in recognition of the fact that in certain instances breastfeeding is not appropriate or possible,” it said.

The PHAP repeated these arguments in its motion for reconsideration. It also quoted a position paper from the Department of Trade and Industry (DTI) that said the revised rules, if enacted, would be “an infringement of the fundamental right of consumers to information and freedom of choice,” and result in the “damage of the infant formula sub-sector which employs a substantial number of Filipino employees.”

The PHAP estimates that displaced employees would reach 1,500. It says the proposed changes may cost its members to lose some P9.96 billion in all, including a P3.5-billion tab that would come from the “destruction of existing non-compliant inventory, withdrawal and destruction of trade stock due to non-compliant labels, and write-off of existing and pre-ordered packaging materials including, among others, tin, cartons cans, tin plates, plastic caps, labels.”

“But we are not asking the milk companies to destroy their products,” says Padilla. “The (revised rules cover) advertising, and promotional materials. If at all, what they will be changing are the labels. Not the products themselves.”

The revised rules in part ban the advertising, promotion, sponsorships, or marketing materials and activities for breast milk substitutes intended for infants and young children up to 24 months. Among the strictest prohibition perhaps is an “absolute” ban on “all health and nutritional claims for products within scope of the Code,” including “any phrase or words that connote to increase emotional, intellectual abilities of the infant and young child.”

The rules even disallow the use of pictures of babies and children with their mothers, fathers, siblings, grandparents, other relatives or caregivers in any advertisements for infant formula and breast milk supplements — as these would tend to “idealize” their use.

“OF COURSE they didn’t want to diminish their market, ” harrumphs Health Secretary Duque, who says he is not surprised that milk manufacturers are putting up a fierce fight. “They don’t want their bottom lines affected.” (Read a transcript of PCIJ’s interview with Duque.)

He confirms reports that officials of the U.S. Embassy and U.S. State Department talked to him, as well as to Trade Secretary Peter Favila about the changes in the rules. “They wanted the old provisions of the law, that they be reflected as is in the implementing rules and regulations,” Duque recalls. “We could not agree. Those were the very loopholes that existed and allowed them to go around the (rules).”

Responding by e-mail to the PCIJ’s query about the matter, U.S. Embassy Information Officer Matt Lussenhop wrote: “The U.S. believes that infant health is very important and that breast-feeding should be the first choice for infant nutrition. We support the broadest possible availability of information and educational materials regarding infant health.”

“At the same time, ” he continued, “this is an important issue that concerns a number of interested parties including private industry. We encourage the government of the Philippines to make regulatory decisions and rulings in a transparent manner that incorporate the concerns and views of all interested parties, including private industry, as an important principle in developing sound public policies.” (View a transcript of PCIJ’s communication with Lussenhop.)

But breastfeeding advocates say the milk companies and their supporters are simply too preoccupied with protecting, well, a cash cow. The DOH estimates the Philippine market of breast-milk substitutes is worth P21 billion ($400 million) annually. Padilla cites BFAD figures that show that in the last five years alone, there have been some 139 infant-formula products introduced in the Philippine market.

“The Philippines market is something (the milk companies) care for,” says WHO’s Iellamo. “Their interest is here.” He says Cambodia recently went through a similar process of legislating the regulation of breast-milk substitutes — “with very little resistance” from the milk industry. Iellamo notes that in contrast to the Philippines’ high birth rates, Cambodia sees only 300,000 newborns every year. Official statistics show that each year, some 2.5 million babies are born in the Philippines.

AC Nielsen Media Research says that the total advertising expenditures for powdered milk products in the Philippines was around P2.3 billion in the first half of this year alone. Milk-product advertising ranked sixth in AC Nielsen’s top ten ad big spenders. Nielsen executive director Jay Bautista told BusinessWorld recently, “These products cater to the biggest segment of our population. About 23 percent of our total population (82 million) are nine years old and below.”

Yet it’s not as if the efforts of breastfeeding advocates have been for naught. Reenalee Imperial, for one, is such a believer in breastfeeding that she did not let her infant son Joaqui’s inability to suckle stop her from giving him her milk. She would express and store it until it was time to feed Joaqui, who had a congenital heart ailment. The boy got his mother’s milk through a tube.

But the increasing pressures of a fast-paced lifestyle in a deteriorating economy seem to be pushing more mothers, especially those who work outside the home, toward milk formulas instead. Some do start their babies on breast milk, but then switch to formulas once they return to work. In all probability, a mother who commutes to work would find it difficult to lug around a breast pump, sterilized bottles, and a mini cooler (to keep the expressed milk fresh).

Some mothers also get frustrated when they cannot express as much milk as their babies seem to need. Breastfeeding can be painful for some women as well. Discouraged, they give up on the practice early.

YET HEALTH officials are hopeful an “enabling environment” could have even such mothers suckling their infants for longer periods. Says Secretary Duque: “(You)…have to work on the infrastructure, the social marketing and advocacy — convincing the public at large about the superior qualities of breastfeeding.”

It could help if more medical professionals pointed out those “superior qualities” to patients. Among this writer’s poll of 15 mothers, all of whom belong to the middle class, only eight said their obstetrician-gynecologists provided them with adequate information about breastfeeding. A mother who said her doctor gave her not only lectures, but also literature and strong encouragement for her to breastfeed, is based in the States.

As for what Duque refers to as “infrastructure,” some pending proposals in Congress do address this. Set to be filed at the House of Representatives is the Working Mothers Breastfeeding Act, which aims to provide tax incentives to companies that set up lactation rooms for their employees. Another bill, the Family Support for Breastfeeding Act, would require couples to undergo breastfeeding-counseling seminars before getting married.

In the city of Manila, meanwhile, social-work officials plan to have a milk bank that would store breast milk for babies whose mothers work outside the home. Earlier this year, too, Manila made a highly publicized pitch for breastfeeding, with 3,738 mothers taking part in a record-breaking simultaneous breastfeeding. (View a DOH photo gallery of that event.) Then on the last day of August, Quezon City saw an army of about 200 mothers and their babies swarm the grounds of City Hall, promising to advance breastfeeding. (The nongovernment group Arugaan organized the event, with the help of the local government and Unicef. View a slide show.)

Malls have joined in as well, thanks to incessant lobbying by breastfeeding advocates. Last March, SM Megamall in Pasig City opened a breastfeeding station. Five months later, the new Mall of Asia in Pasay followed suit. There is a similar set-up in Davao’s NCCC Mall — the first to have one in Mindanao. (View photographs of the breastfeeding stations of Mall of Asia and NCCC.)

When the PCIJ recently visited the Mall of Asia’s breastfeeding station, it had at least five mothers busy with their babies every half-hour. But one pregnant woman apparently just popped in to check out the room. She said she had breastfed her first child (now 11 years old), and was planning to do the same with the second.

“I would breastfeed anywhere,” she also said, recalling her experience with her firstborn. “I didn’t need a breastfeeding station.”