Q. (9 August 2006) What is the story behind the British Journal of Midwifery article being distributed by Nestlé?

A. Although it claims to be 'evidence based' the article is notably lacking in evidence and misrepresents or excludes the key facts....

• Overview
• The need to protect breastfeeding
• The Baby Killer trial
• Senate hearings into Nestlé
• WHO/UNICEF collaborative Study into breastfeeding
• Development of the International Code
• The boycott
• Campaigns against malpractice by other companies
• Nestlé's misrepresentation of the Code
• Evidence of on-going malpractice
• The ethical investment sector
• Relevant issues missing from the BJM article
• Authors desire for further funding from Nestlé
• Nestlé management techniques
• The Lisa Newton paper
• How did the BJM article come about?
• Conclusion - look to the evidence

Overview

Nestlé (UK) has posted an article from the British Journal of Midwifery in the 'Developing World Issues' section of its website and has been sending this out as part of its strategy to undermine action to hold it to account over its baby food marketing activities. (Apparently Nestle posted the article on its website without permission and was asked by BJM to remove it. Baby Milk Action has asked for permission to post it or link to it, but this has been denied. To obtain a copy of the article you have to register at the BJM site for which there is a fee - click here).

The article is entitled: "The Nestlé issue from an evidence based midwifery perspective". However, the most striking feature of the article is its lack of evidence.

It is based upon an expenses-paid visit made by the authors to Nestlé global HQ in Vevey, Switzerland. The 'evidence' presented to support Nestlé's claims that it is abiding by the marketing requirements for baby foods consists of assertions such as:

"All the professionals that we met appeared to be very open, honest and eager to answer our difficult and challenging questions. Their responses were liberally accompanied by hard evidence. In terms of breastfeeding, all the speakers and staff had a detailed working knowledge of the WHO International Code of Marketing of Breast Milk Substitutes (1981) that any midwife or health professional would be proud to possess."

The fact that Nestlé misrepresents the Code and subsequent, relevant Resolutions of the World Health Assembly - and has been criticised for doing so by authorities such as UNICEF - is not considered.

The documentary evidence provided by global monitoring projects is not countered by anything that might have been made available to the midwives during their visit to the Nestle HQ. Rather than seeking to verify if the reports on systematic violations of the Code and Resolutions are true and get detailed evidence to the contrary, the authors simply state:

"To be evidence based we cannot rely on one source; as any student would testify, reliance on one source results in failure. Therefore, reliance on Baby Milk Action alone is not professionally sound."

This is a very poor basis for dismissing the documentary evidence. It also denies the fact that monitoring conducted independently of Baby Milk Action and peer-reviewed studies in the British Medical Journal support our findings. In response to one such study UNICEF stated that the monitoring done by Baby Milk Action with its partners in the International Baby Food Action Network was 'vindicated'.

While claiming 'we cannot rely on one source', the authors draw selectively on the work of Lisa Newton Truth is the the Daughter of Time: The Real Story of the Nestle Case (1999) (click here - there is a fee to access this paper).

In several key areas important information from the Lisa Newton paper has been excluded or claims have been attributed to the wrong body. In addition the authors have not acknowledged information from other sources that conflicts with that given in the paper. In this response Baby Milk Action quotes the relevant text from the Lisa Newton paper and refers to the source documents to show how the history of the baby milk issue has been misrepresented.

Baby Milk Action asked the BJM to clarify the review process the article underwent as even the primary reference is so poorly used. We were told reviewers are not expected to check every reference and the editor could not say whether they would have, or even should have, read the Lisa Newton paper. This is very surprising given the article begins by stating: "Anyone who has a genuine desire to know the background to the boycott, rather than relying on the views of Baby Milk Action alone, should read the work of Lisa Newton Truth is the Daughter of Time: The Real Story of the Nestlé Case (1999)" and over 1,000 words of the article relate to the history covered by the paper. If the reviewers did indeed read the Lisa Newton paper then why were the errors and omissions documented in detail below allowed to remain in the article?

The authors appear to have an agenda in attempting to persuade midwives that Nestlé is complying with the marketing requirements. They state:

"Nestlé have financial and education resources available which would improve services to women and, as a result of fact finding, we see no reason not to tap into those resources at a time when most Trusts and educational establishments have very limited funds available."

This not only shows a lack of solidarity for mothers and health workers around the world who experience the impact of Nestlé's aggressive marketing practices, it shows a lack of understanding of the World Health Assembly Resolutions on conflicts of interest and the provisions of the UK Infant Formula and Follow-on Formula Regulations 1995.

The authors also advocate Nestlé management techniques be imported to the National Health Service:

"Another transferable point is the culture of an organization... we could not help but notice the energy that a clear and positive culture created. This was often rooted in the simple premise that if staff are empowered and treated with respect, this will be repaid with staff loyalty and hard work. We cannot help but consider that, if midwives were treated in the same way, then the profession would emulate a transparent and united service from which the women and their families would ultimately benefit."

Before pressing their managers to follow Nestlé methods, midwives may find it wise to first consider the cases where Nestlé has locked out staff, sacked a workforce, denounced trade unionists as 'enemies of the company' (who have then been targetted by paramilitaries), ignored high court orders on negotiating with trade unions and closed down a factory as the bulk of the workforce was nearing retirement and trade unionists believe the company thought it cheaper to pay redundancy than pensions (you can listen to interviews with some of those affected by following the links in the full presentation of these cases below).

Nestlé is now using the article in its lobbying against action to hold it to account. The article was posted on the Nestlé website (without permission, it has emerged) and copies are being sent to Baby Milk Action's partners and others who question the company's practices.

The article states the group was: "invited to join a Nestlé nutritionist, Zelda Wilson, in a visit to Nestlé headquarters in Vevey, Switzerland, on a fact-finding mission."

However, Nestle's Senior Policy Advisor, Beverley Mirando, suggests their staff member led the team that produced the article. Beverley wrote in a cover letter sent with the article:

"Last October, a group of senior Health Care Professionals led by one of our colleagues visited Nestlé in Switzerland and the Nestlé Research Centre. This article, which appeared in the 'British Journal of Midwifery' dated July 2006, is written by them..." [emphasis added]

The article contains many factual errors and omissions. These will be discussed in detail below with links to supporting information and original documents.

Nestlé is an advertisers in the British Journal of Midwifery. In July 2004 Baby Milk Action reported an advertisement for Nestlé Nan HA infant formula that appeared in the magazine to the Advertising Standards Authority as we believed its claims to be misleading and we asked if they were supported by the references. Unfortunately the ASA told us that it does not investigate claims in marketing addressed to health professionals. We understand this is because the editors of the journal are assumed to be better qualified to check references. Two years later it was revealed on Canadian television that the study used to justify some of the claims had never even been conducted (see Nestlé Scientist's False Claims Exposed by Canadian Broadcasting Corporation (CBC)).

If you come across Nestlé using the BJM article in its PR campaign, please let us know.

The need to protect breastfeeding

The authors begin by giving an overview of the issue, drawing on materials favourable to Nestlé or produced by the company itself such as one of Nestlé's own booklets Infant Feeding in the Developing World (click here to download from the Nestlé website - please let us know if the link dies). The authors quote this as evidence for the claim that mothers in Sri Lanka use 'cow's milk and full cream milk powder' as substitutes, not infant formula.

The authors highlight that there are cases when breastmilk substitutes are necessary. This is not disputed (see our article Baby Milk Action is not anti-baby milk. Our work helps to protect all mothers and infants from irresponsible marketing - this predates the BJM article and it is unfortunate the authors did not reflect our position).

In the authors' history they refer to Dr Derrick B Jelliffe who did research in Jamaica in the 1960s and coined the term 'commerciogenic malnutrition' for malnutrition resulting from the aggressive marketing of breastmilk substitutes which encourages mothers and health workers to artificially feed rather than breastfeed.

Dr Jelliffe's findings continue to be supported. The following is taken from the UNICEF website (click here - accessed 26 July 2006 - let us know if the link dies):

"It has been estimated that improved breastfeeding practices could save some 1.5 million children a year. Yet few of the 129 million babies born each year receive optimal breastfeeding and some are not breastfed at all. Early cessation of breastfeeding in favour of commercial breastmilk substitutes, needless supplementation, and poorly timed complementary practices are still too common. Professional and commercial influences combine to discourage breastfeeding, as do continued gaps in maternity legislation."

Commercial influences - the promotion of baby foods in breach of the World Health Assembly International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions - are accepted as part of the problem.

In countries where these measures have been implemented in legislation and independently monitored and enforced violations are stopped, which helps breastfeeding rates to recover. See, for example, UNICEF Progress of Nations 1999 (click here - let us know if this link dies), which states:

"Breastfeeding gains stem from initiatives to publicize the benefits to both mother and child and to prohibit the advertising and promotion of breastmilk substitutes, feeding bottles and teats."

Where legislation does not exist or is not enforced, monitoring shows that aggressive marketing continues (as discussed below).

The Baby Killer trial

The authors refer to the Baby Killer booklet. They state:

"A representative of War on Want visited [Nestlé] and then wrote The Baby Killer (Muller, 1974)..."

The original version of the Baby Killer booklet can be downloaded by clicking here. This too acknowledges that formula is a legitimate product and that social changes are complex, but it also highlighted the evidence that marketing undermines breastfeeding:

"A survey of infant feeding around Kingston revealed that nearly 90% of mothers started bottle feeding before 6 months, (the time at which most authorities agree it is necessary for the baby to have some additional foods).

"Why did they begin bottle feeding? Fourteen per cent said that they had been told to start by a milk company nurse or been given a free sample and bottle when they were still satisfactorily breast feeding. Only 13% gave up breast feeding because they were working. The largest proportion, 43% said that they had insufficient milk .

“There is some doubt as to the validity of the reasons given by some mothers for beginning the bottle,” writes Dr. McGregor who conducted the research. 'Many mothers who said they had insufficient milk obviously had enough when questioned further. It is interesting to note that milk company advertising stresses “when breast milk is not enough.”'"

The same type of promotional techniques are used today (see below). In the UK most mothers who stop breastfeeding early say they did not want to stop, but experienced problems. These problems can in the vast majority of cases be overcome if there is adequate support. Baby food companies exploit a mother's concerns, encourage supplementation of breastfeeding (which interferes with lactation) and promote formula as the solution when a mother experiences difficulties.

The authors of the BJM article present Nestlé's challenge to the Swiss version of the Baby Killer booklet as if Nestlé had disproved the claims against it:

"A representative of War on Want visited and then wrote The Baby Killer (Muller, 1974), which was then picked up by a small European political student organisation. It translated the pamphlet but removed all the points of qualification about there being cases where formula was needed and called it ‘Nestlé Kills Babies’ [translation]. Nestlé sued and won but it damaged their public profile."

This presentation is, at best, disingenuous. The truth is a little more complex. Nestlé sued on several charges, but experts attended the trial and substantiated the allegations of aggressive marketing.

Just as the two-year case was coming to an end in 1976 Nestlé withdrew three counts of its charge that the allegations were libellous.

"that the activity of Nestlé and other companies was unethical and immoral;"

"that by its selling practices Nestlé was responsible for the death of or the permanent mental and physical injury to thousands of infants;"

"that the baby food sales personnel in developing countries were camouflaged as nurses."

This meant the claims could be repeated by campaigners. Nestlé clearly knew it would lose if it had pursued the case and according to The Guardian (28 June 1976 - click here to download) "Nestlé's chief executive, Arthur Fuerer, told jounalists last November that he and other directors concerned with the company's baby foods would resign in all probability if the claim that Nestlé's baby food advertising was 'unethical and immoral' was proved correct."

The final Judgement stated (translated by Berne Third World Action Group):

"The fact-finding procedure has shown that the incorrect use of powdered milk can lead to the death or to the serious illness of infants.

"It is considered proved by evidence that the Nestlé company uses health nurses who have an advertising task and who, by their activity, have an advertising effect.

"Hence, the need ensues for the Nestlé company fundamentally to rethink its advertising practices in developing countries as concerns bottle feeding, for its advertising practice up to now can transform a life-saving product into one that is dangerous and life-destroying. If the complainant in future want to be spared accusation of immoral and unethical conduct, he will have to change his advertising practice."

Nestlé won on the single remaining claim which was against the title, as translated, Nestlé Kills Babies.

In the opinion of the Judge:

“What is decisive in this connection is the meaning that an unbiased hearer or reader in the circumstances was to give to the incriminatory utterance. He will give a narrow interpretation to the charge of the killing in the sense of a premeditated act. The charge is formulated categorically, must correspondingly be understood in a narrow sense and does not admit of any attenuation. The incriminatory utterance goes far beyond the moral charge of moral responsibility and unmistakably accuses the Nestlé company of punishable doings.”

In other words, Nestlé won on the grounds it was not guilty of premeditated killing.

Significantly the editors of Konzept who had published accusation in an article given the title The Gentle Killers were acquitted because they said that the title was directed not against Nestlé, but against the baby's feeding bottle (see letter from Nestlé referred to below).

The fact that this was a technical victory was evidenced by the fact that the defendants were fined a token amount of 300 Swiss Francs each.

Click here to download a scan of the Berne Third World Action Group translation of the key sections of the ruling (we have not been able to find the original court documents archived on-line).

Nestlé's Managing Director, A Furer, sent a letter to staff (click here for Berne Third World Action translation - letter dated 2 July 1976) in which he said:

"As we said in our press communique upon receiving the judgement, our company notes with satisfaction that justice has been done: in spite of the leniency of his judgement and the comments he deemed fit to make on Nestlé's advertising, the judge made good the wrong which the defamatory statements inflicted on all company members and, in particular, in those who cooperate in the manufacture and promotion of our dietetic products all over the world."

Had Nestlé continued to challenge the substance of the allegations it is clear it would have lost.

The Lisa Newton paper which the authors used selectively does explain: "In June 1974, Nestle sued the [Swiss group] for libel on several counts, eventually narrowing them down to the title alone."

The authors of the BJM article do not give this important information, but simply state: "Nestlé sued and won but it damaged their public profile." The reader is, therefore, unaware of why the trial and the Judge's comments were so devastating to Nestlé.

Senate hearings into Nestlé

The year following the trial the Nestlé boycott was launched and the year after, in 1978, prompted by the boycott, Senator Edward Kennedy organised public hearings in the US Senate.

The authors state:

"The result of this investigation was that Nestlé suffered a further public battering in its attempt to defend itself, mainly because the Senator believed Jelliffe’s premise that ten million infant lives per year would be saved with the return of breastfeeding."

The insinuation is that Senator Kennedy was misled. However, Dr. Jelliffe was open in saying his 10 million figure was 'based on figures, but partly a guesstimate'. The Lisa Newton paper does give this information.

Dr. Jelliffe did not place all the blame on baby food companies, but said: "I regret to say that the promotion - and it is not just advertising - through the health services has been a very large part in this story."

Would the need for action have been any less compelling if Dr. Jelliffe had used the figure of 1.5 million deaths cited above, or the 1.3 million that lives that could be saved through breastfeeding in the 42 countries where most infant mortality occurs (as given in the Lancet study How many child deaths can we prevent this year? Lancet, Vol 362, July 5, 2003 (click here - you need to register to access the document)?

The most devastating impact on Nestlé's image came not from Nestlé's critics, however. It came from Oswaldo Ballarin, Chairman and President of Nestlé, Brazil, in the following exchange (one of several reported in a briefing by the Corporate Information Centre - click here to download a scan of the briefing):

Senator Kennedy: Let us take rural Colombia, with 72 percent poor water. What are you distributing down there? Do you think you should be distributing down there?

Dr. Ballarin: It is almost philosophical, with your permission, because if we do not distribute the product where we suppose the water is no good, also the persons who have the possibility of having good water will not have access to this product.

Senator Kennedy: Well, you can obviously make a judgement about the numbers of people that are going to be able to have decent water, even within those general kinds of areas, now, versus the great numbers of people who are not going to have it. Well, I am just wondering what you think your corporation ought to be doing in terms of reviewing, to the extent that it is being used in those areas.

Dr. Ballarin: Well, of course, we can study and we can review.

Senator Kennedy: Well, are you doing that?

Dr. Ballarin: Not yet, we cannot review that; from that standpoint, to be very frank, we cannot do it for the time being.

Dr. Ballarin attacked the health experts who had spoken of the impact of aggressive marketing on infant feeding practices. According to The Washington Post (24 May 1978 - click here to download a scan):

"Oswaldo Ballarin, President of the Nestlé Co. Brazil, which produces infant formula, angrily denied the charges, saying: 'The US Nestlé Co. has advised me that their research indicates this is actually an indirect attack on the world's free economic system.' A red-faced Kennedy shot back: 'Now you can't seriously expect us to accept that... that these people are involved in some worldwide conspiracy to attack the free world's economic system.' Ballarin apologised."

Senator Kennedy had opened the hearing asking:

"Whose responsibility is it to control the advertising, marketing and promotional activities which, in and of themselves, may create a market in spite of public health considerations? When economic incentives are in conflict with public health requirements, how shall that conflict be resolved?"

WHO/UNICEF collaborative Study into breastfeeding

Following the hearing Senator Kennedy asked WHO and UNICEF to look into the matter at international level. A meeting was held in 1979 under the auspices of WHO and UNICEF to discuss a solution, involving health experts, campaigning groups and the industry.

WHO and UNICEF prepared the first phase of a study on breastfeeding for the meeting. The authors of the BJM article state:

"The WHO/UNICEF’s collaborative study into breast feeding showed that it was not being abandoned, but various forms of mixed feeding were taking place, not including formula as the women could not afford it."

This claim is not made in the collaborative study. The Lisa Newton paper (page 374) gives the statement in a quote attributed to Dana Raphael of the Human Lactation Center based on her own research. If the BJM reviewers looked only to the primary reference, the Lisa Newton paper, they should have seen the authors were incorrectly attributing the claim to the collaborative study. However, when asked the editor of BJM could not say whether the reviewers had read the paper.

The WHO/UNICEF collaborative study (click here for PubMed entry) itself speaks of significant bottle-feeding, even amongst poor groups, which were classified as:

Group A: Economically advantaged, educated families in an urban area.

Group C: Poor, disadvantaged and usually poorly educated families in an urban area.

Group R: Families in rural areas, usually following a traditional way of life and often dependent on subsistence agriculture and local marketing.

"[page 20] Breast or bottle. Mothers were asked whether they preferred breastfeeding or bottle feeding for a child aged 3-6 months, or whether these were equally good. Breastfeeding was favoured by 70% or more of mothers in all groups except in Hungary, where a large majority (74%) of mothers favoured bottle feeding; the next largest percentage favouring bottle feeding (16%) was in the Ethiopian rural group. In Nigeria (all groups) and Guatemala group A there was also a tendency to feel that bottle feeding was best. Nearly 100% of mothers in Zaire group R, and India groups C and R, favoured breastfeeding. In Nigeria and Ethiopia group R, more than half the mothers thought that breast and bottle were equally satisfactory."

The influence of relatives on decisions to give supplementary feeds was considerable, along with medical advice. 'Advice from husbands, friends or from the media was not commonly quoted in any country or group'. [page 41] (subsequent studies have found a link between promotional materials and infant feeding decisions - click here for details).

An impact from free supplies was found:

"[page 31] Provision of free samples of milk and feeding bottles while in hospital was not uncommon among some groups in Nigeria, Guatemala and the Philippines. In Guatemala, breastfeeding was less common among those who received such gifts, and in the Philippines the practice may be associated with the high proportion of economically advantaged mothers who did not breastfeed. Among the rural group in the Philippines where free samples were also provided, there was no obvious association between this and breastfeeding.... [page 28] The custom of breastfeeding may still be sufficiently strong among these rural mothers that their behaviour was not greatly influenced by commercial pressures."

Free gifts of milk or feeding bottles in health facilities were investigated:

"[page 28] more than 10% of mothers in Nigeria groups A and B [urban middle-income], Guatemala group C, and the Philippines groups A and R received free milk samples; in the Philippines no less than 41% of mothers in the rural group. Giving free bottles was less common; the highest percentage was observed in Nigeria group A, where nearly 10% of mothers reported having been given a bottle, and in Guatemala group C where 12.5% were provided with them."

It notes:

"[page 58] The distribution networks used were wide and included pharmacies, food stores and other commercial outlets. Almost all the companies studied also worked in one way or other, through the health sector; in some cases this meant regular visits on the part of salesmen to health care institutions and to health personnel. Some companies, however, employed 'nurses' or 'mothercraft' staff working within or having access to health institutions and the mothers in them. The distribution of free samples was relatively common, although its scale varied considerably according to the company and to the national setting."

National or international aid organisations were also distributing foods in some countries in the study.

Companies donated large amounts through the health care system:

"[page 65] Considerable amounts of free infant formula were also being provided to health institutions and it was estimated that an average clinic in Nigeria received up to 8,000 cans of baby food during the course of a year; private clinics tended to receive more than public health institutions. In Nigeria and the Philippines it was estimated that up to 1.5 million cans of infant food were provided free per year, which represented 1% and 7% of the total sales volume in those countries respectively."

Today it is found that products such as Nestlé Nido whole milk is displayed in infant feeding sections alongside infant formula, which can cost three times the price. Poor mothers are more likely to purchase the whole milk, which is unsuitable for infant feeding (click here for details). The same approach was found in the collaborative study:

"[page 66] The way in which products were presented often made it difficult to distinguish between infant formula and other milk foods. This was particularly so when products such as milk powder and condensed milk were presented in containers that have feeding tables printed on them.

"Multinational infant food companies were active in the four countries in which the field study was undertaken. Infant foods including formula and other products that can be used as breastmilk substitutes were sold through a wide variety of commercial outlets. Free samples were relatively common but the intensity of this promotion technique differed according to country."

The study noted that the most common reasons cited for supplementation were problems such as 'lack of milk' and 'child will grow better' [page 40]. 'Milk or milk-based products' were the most common supplements given' (no breakdown of milk-based products into infant formula, other breastmilk substitutes and whole milk is given).

So while there are factors other than marketing by baby food companies at play, aggressive marketing was found to be widespread as was significant use of feeding bottles with milk or milk-based products.

The authors of the BJM article have not given a true impression of the collaborative study by misapplying the Dana Raphael quote to it.

The authors continue regarding the collaborative study:

"Instead of confirmation of the report into the increase in infant mortality, it was shown that a significant decrease had occurred."

This is quoting from the Lisa Newton paper, but the authors omit the sentence that follows: "Babies still got sick from environmental contamination, but mothers were able to take sick babies to clinics for rehydration, vitamins, and antibiotics, and these simple remedies were saving children who otherwise would have died."

The WHO/UNICEF meeting that considered the collaborative study issued a statement (click here to download) which said:

"The question of adequate nutrition for mankind has been exercising international and national bodies for the last three decades, but the problem of malnutrition is not becoming less. It is taking a heavy toll in deaths and in long-term mental and physical disability."

The statement opened:

"Poor infant-feeding practices and their consequences are one of the world's major problems and a serious obstacle to social and economic development. Being to a great extent a man-made problem it must be considered a reproach to our science and technology and our social and economic structures, and a blot on our so-called development achievements. It is not only a problem of the developing world: it occurs in many parts of the developed world."

Development of the International Code

The authors of the BJM article state:

"By the time the conference took place, in 1979, 'Nestlé had already developed international guidelines limiting advertising and sales promotions, curbing free samples and supplies, spelling out the content of informational materials and ending all financial incentives to health professionals to sell formula'" and "Following the conference consensus, it was agreed that a voluntary code would be developed by the industry, in collaboration with certain Governments."

This is inaccurate and misleading. The Lisa Newton paper (page 376) explains accurately:

"The conference developed a (somewhat strained) 'consensus' on the subject of formula promotions, urging the limitation of many types of promotions and calling upon WHO to develop a full Code for the governance of the marketing practices of the infant formula industry. Immediately after the 'consensus' was announced, ICIFI [the industry body] announced that an industry-generated voluntary code would be drafted as a working model, and proceeded to put one in place, working with the governments of Malaysia and Singapore..."

It was the industry that was proceeding with its own Code instead of accepting the consensus of a Code developed under the auspices of WHO. Again, the authors have misrepresented the history as set out in their primary reference, the Lisa Newton paper, and this does not appear to have been spotted by the reviewers.

The actual statement adopted by consensus at the 1979 meeting states (click here to download):

"There should be an international code of marketing of infant formula and other products used as breastmilk substitutes. This should be supported by both exporting and importing countries and observed by all manufacturers. WHO/UNICEF are requested to organize the process for its preparation, with the involvement of all concerned parties, in order to reach a conclusion as soon as possible."

From the start, NGOs were invited participants in the process. As WHO's invitation letter (15 March 1979) to War on Want (one of the founders of the Baby Milk Action Coalition) states (click here to download):

"We have pleasure in informing you that the World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF) are jointly organizing a Meeting on Infant and Young Child Feeding... We have pleasure in inviting you to appoint a representative to attend on behalf of your organization..."

So Non-Governmental Organisations (NGOs), including a founders of Baby Milk Action, were a legitimate part of the consultation.

The authors of the BJM article imply, however, the NGOs somehow acted in bad faith stating:

"However, activists of two organisations joined together to form the International Baby Foods Action Network (IBFAN) and it did not feel that the consensus went far enough, so they set up the International Nestlé Boycott Committee (INBC)."

This is inaccurate on several counts. The consensus was for a Code developed under the auspices of WHO (not a voluntary code developed by industry) and NGOs were invited to participate in its development. IBFAN was formed by 6 groups at the initial 1979 meeting to do so. The boycott had already been launched in 1977 in the US and rapidly spread to other countries. National coordinating organisations only formed INBC when discussions started with Nestlé about ending the first boycott in 1984.

The industry opposed the measures in the draft Code, just as health advocates were calling for loopholes to be removed.

In a 1981 submission the International Council of Infant Food Industries (of which Nestlé Vice-President, Ernest Saunders, was President) set out its Summary position statement re proposed WHO International Code for the Marketing of Breast Milk Substitutes (click here to download). This included:

"Throughout the WHO/UNICEF consultation process, ICIFI has criticised the form and content of the successive code drafts which were found to contain unacceptable provisions being too detailed, counter productive, and in parts, incompatible with the constitutional requirements of a number of countries."

ICIFI also submitted detailed commentaries and responses to the arguments of health advocates - or the industry's misrepresentation of these. One such document submitted by ICIFI in March 1981 provides an insight into company thinking on its target market for breastmilk substitutes. Click here to download pages from Feeding Babies in the Third World - Industry Responds to Misinformation. This includes:

"The following facts show that the majority of women need to use a breast milk substitute at some time during the first months of life whether as a supplement or as a replacement for breastmilk.

"Well-nourished mothers can usually breast feed their babies adequately (without supplements) for up to 4 or 6 months.

"Poorly-nourished mothers (i.e. the majority in poor communities) need to give supplements earlier if growth failure is to be avoided.

"The earlier supplements are needed, the more necessary it is to give a properly-formulated infant food whose composition approaches that of breast milk."

So the industry, led by Nestle, was arguing that the majority of mothers in poor communities would need to use breastmilk substitutes.

As the Lancet study referred to above makes clear, promotion of exclusive breastfeeding for the first six months followed by continued breastfeeding with local complementary foods into the second year of life and beyond could prevent 13% of under-five deaths in the 42 countries where the majority of these deaths occur. Appropriate complementary feeding, including an end to introduction before 6 months, could save an additional 6%.

Even today Nestlé targets pregnant and lactating women suggesting they will be unable to breastfeed unless they take expensive food supplements themselves or supplement breastfeeding with formula (see examples in the codewatch section).

It would perhaps have been useful if the authors of the BJM article had informed their readers of Nestlé's view of the Code. Nestlé Vice President, Ernest Saunders, as the head of ICIFI and wrote to the President of the World Health Assembly with the industry view, which included (click here to download the full letter):

"The World Industry has found this present draft code unacceptable and speaking individually, and also through ICIFI, has already expressed its concern to the WHO Secretariat that a single detailed and highly restrictive code, as presently drafted for your review at this meeting, would be often irrelevant and unworkable, bearing in mind the enormous differences in socio-economic, cultural and political conditions between the Member States."

So much for the consensus the authors of the BJM article claim existed between industry and governments and was not being respected by IBFAN.

In the discussion in the Assembly over the Code many governments stressed the importance of strong marketing requirements. Click here to download a contemporary compilation of government quotes. These include:

"It also happens that publicity makes us victims of habits and practices which are economically wasteful and wholly contrary to good health. You are all familiar with the controversy over the export of baby foods to developing countries."

Mrs. Indira Ghandi
Prime Minister of India

"There is of course, also the killer in the bottle, the breastmilk substitutes, for which we must prepare the hangman's noose, in the form of the code of marketing."

Dr. Ushewokunze
Zimbabwe Government

"We also appeal to the industrialized countries of the world to recognize the great harm they do to the lives of children in developing countries by dumping in these countries baby foods as substitutes of breastmilk, which they back up with intensive advertising... It is easy to advise the developing countries to guard against the abuses of the milk substitutes or to ban them when necessary, but we of the developing countries would be deceiving ourselves if we ignored the power of the multinational business concerns which have no place for moral considerations when it comes to maximising profits."

Mr Ugwu
Government of Uganda

"In recent times we have been observing a marked increase in the number of cases of diarrhoea among infants due to increased artificial feeding of babies as a result of brain-washing the population through constant advertisement by the producers. It is a known fact that in most developing countries, besides the adverse effect of artificial feeding, the average family cannot afford the high cost."

Dr. Karpeh
Government of Liberia

Fortunately the industry attack on the Code failed and it was adopted by 118 votes to one against (the United States) with three abstentions.

Click here for the Resolution 34.22 adopting the Code as a minimum requirement for all countries, to be implemented in its entirety.

The boycott

The boycott was launched in 1977 in the United States and rapidly spread to other countries.

The first boycott was called off in 1984 after Nestlé gave undertakings to the International Nestlé Boycott Committee (INBC) and Nestlé claims that today only extremists are keeping it going. Yet Nestlé not only broke the 1984 agreement, prompting the re-launch of the boycott in 1988, but continues to break it. For example:

• Nestlé said it would abide by the International Code globally in 1984, including supporting implementation of the Code in Europe. Today Nestlé claims the Code applies only to a list of developing countries of its own invention.

• Nestlé said it would bring its policies into line with the Code. The joint statement ending the boycott of 4 October 1984 stated: “Nestlé and INBC welcome WHO and UNICEF's advice in providing clarifications and definitions which would aid in expediting effective implementation of the WHO International Code" (click here to download). Nestlé did not make the required changes and today refuses outright to make changes called for by UNICEF (click here for UNICEF's 1997 letter to Nestlé setting out some of the company's incorrect interpretation).

• The 1984 agreement was to be the start of a process. In the 1984 statement ending the boycott in Europe, Lisa Woodburn, Coordinator of INBC Europe, said: “We have a clear program of further negotiation, coupled with compliance and accountability, worked out for Nestlé.” As the boycott ended, so did Nestlé’s willingness to respond to campaigners’ concerns.

• In 1984 monitoring by the International Baby Food Action Network (IBFAN) showed Nestlé had to take action to end violations of the marketing requirements. IBFAN’s 2004 monitoring report shows Nestlé is responsible for more violations than any other company.

The authors of the BJM article suggests support for the boycott had ended. They state:

"Baby Milk Action and the Church of England backed the boycott in the UK, until 1994 when the C of E withdrew its support."

The situation with the Church of England is again more complex than the authors present. In 1994, after Nestlé aggressively opposed a move at the Synod for disinvestment, confused as to who to believe, the Church suspended its support for the boycott while conducting its own monitoring independently of Baby Milk Action (see the details of the Cracking the Code report below). This monitoring found 'systematic' violations by Nestlé and other companies. UNICEF said our monitoring was 'vindicated'.

However, when the issue came back to Synod in 1997 it decided against resuming support for the boycott in favour of trying to use its investment in Nestlé to exert pressure. The implication by the authors that the Church withdrew support because it thought Nestlé malpractice had stopped is disingenuous.

Many other groups in the UK were and are supporting the boycott. A list of endorsers can be found by clicking here. In June 2006, the Methodist Conference adopted text stating that in addition to trying to 'engage' with Nestlé to prompt change (click here for full details):

"The Conference shares with the [Oxford] Circuit the substantial concerns regarding the promotion of breast milk substitutes... JACEI [Joint Advisory Committee on the Ethics in Investment] acknowledges the continuing concern with regard to some aspects of Nestlé's interpretation of the International Code, the implementation of company guidelines and the transparency of the procedures for monitoring compliance. These concerns may cause some through conscience to maintain a consumer boycott of Nestlé products."

The authors of the BJM article imply the boycott is only active in the UK. In the abstract it states:

"However, despite its formal end in the USA in 1984, and further rejection in 1989, it continues to this day in the UK."

The boycott was not rejected in 1989. In June 1988 our US partner gave Nestlé until the end of October to address the specific practice of distributing free and low-cost supplies. Nestlé failed to do so and the boycott was relaunched by groups in the US, Germany and Canada at the end of October. Groups in Ireland, Finland, Mauritius, Mexico, Norway, Sweden, and the UK launched the boycott in 1989. One might have thought the authors would have asked INBC about the history of the boycott or looked at the chronology of the campaign on the IBFAN website.

The second boycott has now been launched by groups in 20 countries, including in Cameroon, Africa, after campaigners found Nestlé promoting formula in health centres. It is possible to hear interviews with boycotters in Europe in the broadcasts section.

Thanks to the support of boycotters around the world, Nestlé is today one of the four most boycotted companies on the planet. The Guardian newspaper reported on 1 September 2005:

"What do Nike, Coca Cola, McDonald's and Nestlé have in common? Apart from being among the world's most well-known brands, they happen to be the most boycotted brands on the planet. That finding came from this week's global GMIPoll, an online opinion poll that surveyed 15,500 consumers in 17 countries. Nestlé emerges as the most the most boycotted brand in the UK because of what respondents consider its "unethical use and promotion of formula feed for babies in third world countries."

Nestlé won a global internet poll for the world's 'least responsible company' coinciding with the World Economic Forum in Davos in January 2005. Nestlé received 29% of the votes. This was more than twice that of joint second Monsanto and Dow Chemicals (of Bhopal infamy), each on 14% (click here for details).

The boycott keeps this issue in the public eye and the pressure on Nestlé. During national demonstrations in 2003 Nestlé agreed to stop promoting complementary foods from too early an age. Baby Milk Action had been asking for this since 1994 when the World Health Assembly called for complementary feeding to be fostered from about 6 months, not earlier. Click here for details.

In 2000 after exposure on national television Nestlé agreed to label products in the appropriate language for where they are sold - 19 years after the Code made this a requirement. Click here for details.

Baby Milk Action has put a four-point-plan to Nestlé aimed at saving infant lives and ultimately ending the boycott. Nestlé refuses to accept the first point - that it should be abiding by the Code and Resolutions - or the second point - that it needs to make changes to its policy and practices to bring them into line. If it did so we would then discuss the timetable for it making necessary changes and, if there were no violations for 18 months, would call off the boycott with our partners in the International Nestlé Boycott Committee. It is imperative to keep up the pressure.

Campaigns against malpractice by other companies

The authors of the BJM article state:

"In 2004 IBFAN published a document entitled ‘Breaking the Rules, Stretching the Rules’, indicating alleged violations of the WHO Code. This document lists 16 manufacturers of infant formula who are allegedly ‘guilty’. Nestlé was included in this list, but so were other manufacturers well known in the UK, such as Heinz, Gerber and Wyeth. Wyeth, in fact, was fined £60,000 for illegal advertising in the UK (IBFAN 2004). Why then does Baby Milk Action seem to only target Nestlé? Why are we not asked to boycott all products by Heinz, or refuse all medications produced by Wyeth? If any manufacturers violate relevant codes they should be brought to account for it, but it seems unethical to promote what seems to be a witch hunt against just one.

It is a little difficult to understand this reasoning.

The authors are aware of malpractice by other companies because Baby Milk Action and IBFAN conduct global monitoring projects and launch reports exposing violations, bringing malpractice to media and public attention. Companies are shamed and excluded from ethical investment lists.

The report referred to was launched at the House of Commons - click here for IBFAN's press release. A DVD of the launch is available in the on-line Virtual Shop and is used to expose the practices of the biggest baby food companies.

The reason for singling Nestlé out for boycott action is a matter of public record - for example, see the boycott section of this website. An evidence-based article would surely have answered this question instead of leaving it hanging. The authors might have thought to ask Baby Milk Action if they did not know the answer. Nestlé is targetted with the boycott because monitoring conducted by IBFAN finds it to be responsible for more violations of the World Health Assembly marketing requirements for baby foods than any other company.

As well as the reports and media campaigns which alerted the BJM article authors to malpractice by other companies, Baby Milk Action uses letter writing campaigns. See the Campaign for Ethical Marketing action sheets.

The authors refer to the case of the prosecution Wyeth for illegal advertising in the UK. Again the authors are aware of this case because of the work of Baby Milk Action. Our materials were used in court by the prosecution and we attended the 8-day hearing to report on it ourselves and to raise awareness in the media. Click here for our press release on the case. This links to some of the media coverage we generated.

Baby Milk Action actively monitors baby food companies in the UK, coordinating a monitoring project on behalf of the Baby Feeding Law Group (click here for details). We report cases to the Advertising Standards Authority, Ofcom and Trading Standards as appropriate.

In addition Baby Milk Action and IBFAN work for implementation of the marketing requirements in legislation, in the face of lobbying (principally by Nestlé) opposing independently monitored and enforced measures in favour of voluntary codes of conduct.

The boycott of Nestlé is one strategy amongst many used to hold the baby food industry as a whole to account.

Nestlé's misrepresentation of the Code

The authors of the BJM article went on an expenses-paid trip to Nestlé's global HQ in Vevey, Switzerland and met with staff.

Although the article claims "all the professionals that we met appeared to be very open, honest and eager to answer our difficult and challenging questions" there appears to have been no critical analysis of the assurances given by Nestlé.

For example, reference is made to the Nestlé Instructions for the Implementation of the WHO International Code of Marketing of Breastmilk Substitutes and these are portrayed as being in line with the Code.

The International Baby Food Action Network (IBFAN) has conducted an in-depth legal analysis of the Nestlé Instructions against the Code and subsequent, relevant Resolutions and discovered numerous shortcomings - click here for the full analysis.

Similar findings were made in a legal review commissioned by IBFAN conducted by an outside legal expert - click here for the full review.

Independently UNICEF has written to Nestlé (click here) and presented evidence at a European Parliament public hearing on some of the ways in which the Instructions misrepresent and fall short of the provisions of the Code and Resolutions (click here).

Evidence of on-going malpractice

The authors of the BJM article suggest that Nestlé malpractice is in the past. They ask:

"One wonders if it is possible for an organisation to change. In a way, it appears that in the Nestlé case an organisation can never recover from its mistakes; it is worth considering what this would mean if applied to our midwifery profession or health service."

As mentioned above a four-point-plan has been put to Nestlé aimed at saving infant lives and ultimately ending the boycott. This has been rejected by Nestlé as it refuses to accept the validity of the Code and Resolutions and that it needs to change its policies and practices to bring them into line.

The fact Nestlé policies are not in line has been addressed above.

The fact Nestlé systematically violates the Code and Resolutions in its practices is demonstrated by monitoring evidence.

Mention is made by the authors of the monitoring conducted by Baby Milk Action and IBFAN.

IBFAN consists of over 200 groups in more than 100 countries. Groups monitor what is happening in their communities, report violations to governments and companies (as they are mandated to do under Article 11.4 of the International Code) and periodically global reports are produced with examples of violations.

The report Breaking the Rules, Stretching the Rules 2004 included examples from 69 countries. Of the 16 companies profiled Nestlé was found to be responsible for more violations than any other company and to have violated more provisions of the Code and Resolutions than any other company. This is why Nestlé is singled out for boycott action. Other companies are targeted by exposés, such as the monitoring report, and letter-writing campaigns, such as Baby Milk Action's Campaign for Ethical Marketing action sheet.

The case against Nestlé is evidenced based. The BJM article concludes 'reliance on Baby Milk Action alone is not professionally sound'. Yet it is possible for midwives and members of the public to view the evidence for themselves. Much of it consists of the promotional materials produced by baby food companies. In the monitoring reports and elsewhere we analyse and explain how the materials violate the Code and Resolutions, so undermining breastfeeding and hiding the risks of artificial feeding. The authors of the article make no comment on whether they have viewed this documentary evidence or disagreed with the analysis.

Nestlé does, of course, disagree with IBFAN's evidence. This prompted the Church of England to join together with other faith, development and academic organisations to conduct independent research. The 27-member Interagency Group on Breastfeeding Monitoring (IGBM) published the report Cracking the Code in 1997, noting 'systematic' violations by Nestlé and other companies (click here). UNICEF commented that IBFAN's monitoring was 'vindicated'.

The British Medical Journal has published peer-reviewed studies based on this (click here) and other monitoring (click here).

The authors of the BJM article did not have to look very far for the desired other sources of information as the Lisa Newton paper refers to both IGBM's monitoring results and UNICEF's letter to Nestle setting out "the oustanding and significant differences in our views on the content and application of the International code" (page 384). The authors not only excluded this information from their article, but suggested the only source of criticism is Baby Milk Action.

The evidence is there for those prepared to look at it.

The ethical investment sector

Thanks to the documentary evidence of malpractice every credible ethical investment organisation in the world excludes Nestlé from its lists. If the authors had examined the criteria for the FTSE4Good listing, for example, they would have seen that the Nestlé Instructions do not comply with the policy section.

The only organisation that does include Nestlé is the one mentioned by the authors: GES Investment Services. GES is unusual in that it refuses to consider independent monitoring evidence, it only accepts reports from companies (click here for further details).

Of course, Nestlé's reports and the audits it commissions to its own Instructions (rather than the Code and Resolutions) clear Nestlé of most wrong-doing. Again IBFAN has prepared an in-depth analysis of the one report made public by Nestlé (that of Emerging Market Economics) into Nestlé activities in Pakistan and exposed its shortcomings.

Relevant issues missing from the BJM article

Important points included in the Lisa Newton paper but excluded or misrepresented in the article. Aside from these there are many other issues an evidence-based article could have included.

For example, in 1999 Nestlé published and distributed around the world a book of letters which it claimed were official verification by governments that Nestlé complies with the Code. This quickly became an embarrassment for Nestlé as it became clear the letters were no such thing. Far from commenting after a detailed analysis of Nestlé marketing policies and practices, as the company claimed, many of the letters were simply thanking Nestlé for attending a meeting or setting out the way the government had implemented the marketing code. Nestlé had to apologise for misrepresenting the letter from Denmark, which made no mention of Nestlé marketing. Click here for a detailed analysis.

Baby Milk Action has never faced a legal challenge from Nestlé. We write to it frequently to raise our concerns and take part in public debates, where Nestlé has been defeated time after time (click here or borrow a video or listen to radio interviews).

We have also invited Nestlé to participate in an independent, expert tribunal which could go over the evidence in depth, calling witnesses as necessary. Nestlé has refused to even discuss the terms of reference for such a tribunal. Why? Because it knows its claims do not stand up to scrutiny. Click here to send a message calling for Nestlé to attend.

In 1999 we won a case before the Advertising Standards Authority after Nestlé published an anti-boycott advertisement in which it claimed it markets infant formula 'ethically and responsibly'. All our complaints were upheld, but Nestlé continues to make similar claims in its public relations materials which cannot be challenged before the ASA. (click here for details of the complaints and here for the final ruling and here for the Chief Executive's response).

Authors desire for further funding from Nestlé

The authors of the BJM article appear to have an agenda of seeking funding from Nestlé, stating:

"Nestlé have financial and education resources available which would improve services to women and, as a result of fact finding, we see no reason not to tap into those resources at a time when most Trusts and educational establishments have very limited funds available."

Analysis of materials shows these often contain misleading messages and promote the company name. The World Health Assembly has adopted Resolutions 49.15 and Resolution 58.32 calling for care over conflicts of interest. Taking action to bring Nestlé materials onto the wards and into pre- and post-natal classes inevitably presents a conflict of interests.

It is also worth reminding midwives that under the UK Infant Formula and Follow-on Formula Regulations 1995 information materials can only be provided by companies if explicitly requested and they have the written approval of the Secretary of State for Health and approved. Article 21 states:

"(3)  No manufacturer or distributor of an infant formula shall make a donation of any informational or educational equipment or materials except in accordance with the following conditions—

(a) the donation shall be made following a request by the intended recipient;

(b) the donation shall be made with the written authority of the Secretary of State or in accordance with guidelines drawn up by the Secretary of State;"

As guidelines have not been issued companies producing information and educational materials should be able to produce a letter from the Secretary of State approving the donation. If they cannot, they are breaking the law (Baby Milk Action has urged the UK authorities to take action over such cases).

It is Baby Milk Action's view that it is far better for midwives to advocate the NHS produce any materials that are necessary than seeking to bring Nestlé materials into the health service.

It is worth recalling that for many years the Indian Paediatric Association refused to accept funding from baby food companies and this is now enshrined in law.

In Brazil, a country that is only now recovering breastfeeding rates thanks in part to strong law and monitoring systems for the Code and Resolutions, the provision of company-sponsored materials is illegal.

It is not surprising that Nestle was apparently urging the authors on this visit to accept Nestle materials - it is one of the company's favoured promotional techniques to link its name with the health care system.

The named lead author has worked with Nestle in the past on a breastfeeding video which was presented to midwives with the suggestion they question their support for the boycott (see Update 36).

Nestlé management techniques

The authors advocate Nestlé management techniques be imported to the National Health Service:

"Another transferable point is the culture of an organization... we could not help but notice the energy that a clear and positive culture created. This was often rooted in the simple premise that if staff are empowered and treated with respect, this will be repaid with staff loyalty and hard work. We cannot help but consider that, if midwives were treated in the same way, then the profession would emulate a transparent and united service from which the women and their families would ultimately benefit."

Before pressing their managers to follow Nestlé methods, midwives may find it wise to first consider the following cases:

• When former Nestlé Medical Delegate Syed Aamar Raza resigned and called on Nestlé to stop aggressive marketing in Pakistan he (and a witness) say he was threatened by management (see the report Milking Profits).

• In the Philippines Nestlé is refusing to negotiate with the trade union at the Nestlé factory in Cabuyao, Laguna, over their pension rights, despite rulings in the union's favour from the National Labor Relations Commission, the Court of Appeals and the Supreme Court of the Philippines, which forced the union to call a strike in 2002, which is still on-going. Nestlé has employed a replacement workforce. Click here to listen to interviews with campaigners.

• In Colombia a workforce was forced to resign so replacement workers could be employed on significantly less money and without the benefits won by the trade union before Nestlé took over the company they worked for. Trade unionists have been denounced as enemies of the company and then targeted by paramilitaries. Click here to listen to interviews with representatives of the Colombian trade union who presented evidence at a tribunal in Switzerland in October 2005 organised by trade union, church and development organisations.

• Nestlé is accused of enforcing an illegal wage cut by trade unionists in Japan. Click here for details.

• The International Union of Food Workers alleges that Nestlé closed down its factory in Fulton, New York state, because the workforce had an average age of 52: "Many of them were getting close to retirement and the pensions that the Retail, Wholesale and Department Store Union had won for them years before. The sooner the company could close the Fulton plant, the less it would be required to pay into the workers' pension plan. By avoiding these costs, Nestlé could save millions of dollars... Nestlé's problem wasn't that it was struggling to survive or that the Fulton plant was costing the company money. Instead it was that, to its management, being successful and making a good profit simply weren't enough: Management wanted more and wanted it fast. It's a familiar story. Instead of generating new sales by offering innovative products, Nestlé opted to take the low road. The company replaced skilled workers with machinery at some plants, closed others and abandoned some of its areas of core competency. In 2000 alone, Nestlé closed 38 factories worldwide." Click here for details.

• In 2003 Nestlé locked out staff in a dispute over pay in South Korea and threatened to close its factory and shift production to China. Click here for further information.

While Nestlé may argue some of these tactics are normal business practices, midwives may wish to consider carefully whether it is so wise to advocate Nestlé-style management techniques be applied in the NHS.

The Lisa Newton paper

The authors of the BJM article have taken aspects of the Lisa Newton paper out of context, confused issues and misapplied quotes. The flaws with the paper itself are less glaring (it can be purchased by clicking here).

Although it is also selective in its presentation of issues such as the Baby Killer trial and the WHO/UNICEF collaborative study, its central argument is that health advocates were mistaken to believe what Lisa Newton refers to as the 'Jelliffe scenario' - that irresponsible marketing of baby foods undermines breastfeeding and contributes to the unnecessary death and suffering of infants. Evidence gathered since then, and the success in reversing the decline in breastfeeding where aggressive promotion has been stopped, support Dr. Jelliffe's view, even if the figures of infants affected are different to his original 'guesstimate'. Lisa Newton, however, states: "as far as we can tell, the advertising and other promotional practices of the infant formula companies have little to do with any mother's choice to bottle or breast feed".

Lisa Newton's dismissal of the role of aggressive marketing on undermining breastfeeding is principally based on a study by Dana Raphael: "The fact that the despised infant formula maufacturing corporations, whose research departments missed nothing, pounced on the findings of their own innocence and trumpeted the results to the Kennedy Hearings and to anyone else who would listen, only made the findings more suspect." The fact that there was contradictory evidence was surely more significant. However, the issue of industry involvement in distributing the Raphael study was indeed questioned by activists such as Fred Clarkson in an article in the Fairfield County Advocate in 1983 (click here to download). After the initial grant used for the study ran out, Raphael's Human Lactation Center was largely financed by the industry purchasing its papers and later making direct grants, according to Clarkson, particularly during the critical time when the Code was being developed.

Lisa Newton takes the cynical view that NGOs maintain the controversy to maintain their power and quotes the bizarre suggestion: "NGOs are able to push around even the largest governments". Those who support Baby Milk Action's campaigns to bring in legislation will know how hard this is to achieve, particularly in the face of lobbying by transnational corporations with public relations budgets many many times larger than our entire operating budget (Nestle's turnover is about £39 billion and it spends about 15% on marketing and public relations - more in 15 minutes than Baby Milk Action's annual operating budget).

She describes the boycott as 'senseless'. Yet it has very clear objectives. As described above Baby Milk Action has put a four-point plan to Nestle to save infant lives and ultimately end the boycott. The plan asks nothing unreasonable from Nestle, other than the apparently impossible requirement that it stops putting its own profits before infant health. If it accepted the validity of the Code and Resolutions and brought its policy and practices into line there would be no more violations and the boycott would end.

Calling on Nestle to marketing breastmilk substitutes appropriately does not deny that they are legitimate products, nor are health advocates 'anti-industry' as Lisa Newton suggests.

To date Nestle gives every impression of having taken a strategic decision to continue aggressive marketing to grow its market at the expense of breastfeeding. The marketing requirements seem to be seen as an inconvenience to be watered down in internal policies and in lobbying against legislation. The efforts of health advocates are undermined through a strategy of denials and deception and investing in persuading third parties to come to the defence of the company in articles such as that published by the BJM.

How did the BJM article come about?

Nestlé is using the BJM article in its lobbying of Baby Milk Action partner organisations.

The article states the group producing the article was: "invited to join a Nestlé nutritionist, Zelda Wilson, in a visit to Nestlé headquarters in Vevey, Switzerland, on a fact-finding mission."

While admitting that travel, accommodation and food was funded by Nestlé, there is a closer relationship with Nestle.

Zelda Wilson earlier worked with one of the named authors, Chris Sidgwick, on a video project as part of a strategy aimed at improving Nestle's image. In a paper describing the launch in 2004 Chris Sidgwick commented:

"The project was initiated at the end of 2003 by Nestle dietician, Zelda Wilson, with the dual purpose of producing an educational resource which would encourage teenagers to breast feed their babies while giving the silent majority of midwives reason to enter the debate around Nestle in infant feeding."

Describing one launch event, Chris Sidgwick, wrote:

"many expressed a view that it was time to put the 30 year Nestle boycott to one side in the wider interest of mothers and the midwifery profession should move from idealism to realism."

Nestle's Senior Policy Advisor, Beverley Mirando, suggests that their staff member led the team that produced the article, writing in one letter (click here to download):

"Last October, a group of senior Health Care Professionals led by one of our colleagues visited Nestlé in Switzerland and the Nestlé Research Centre. This article, which appeared in the 'British Journal of Midwifery' dated July 2006, is written by them following the visit and covers their view of the long-standing issue on Nestlé and the marketing of breastmilk substitutes. [emphasis added]

"I trust you will find that, whilst it makes interesting reading, it also gives you an insight into this long-running issue."

The authors open the article stating:

"The NMC Code of professional conduct: standards for conduct, performance and ethics (2004, Code 6) expects that registered midwives will update and maintain their knowledge. It clearly states that they will base their care on evidence, best practice and appropriate research. Why is it then that the approach of many midwives to Nestlé and its products is based on dogma, rather than evidence?"

Hopefully midwives will be reassured by the evidence presented above and continue to support action to hold the baby food industry to account and the Nestlé boycott.

They may also wish to reflect on whether the authors of the article have complied with the points they highlight in the NMC Code of professional conduct in producing their article, or whether they should have questioned Nestlé's assurances and investigated whether they could be substantiated.

The way in which information from their primary reference, the Lisa Newton paper, has been misrepresented is also a cause for concern: the misapplication of comments made by Dana Rapahel to WHO/UNICEF, the confusion over the 'consensus' arising from the 1979 meeting, the incomplete information regarding the Baby Killer trial, the failure to relate the criticisms of organisations such as IGBM and UNICEF.

Baby Milk Action asked the BJM to clarify the review process the article underwent as even the primary reference is so poorly used. We were told reviewers are not expected to check every reference and the editor could not say whether they would have, or even should have, read the Lisa Newton paper. This is very surprising given the article begins by stating: "Anyone who has a genuine desire to know the background to the boycott, rather than relying on the views of Baby Milk Action alone, should read the work of Lisa Newton Truth is the Daughter of Time: The Real Story of the Nestlé Case (1999)" and over 1,000 words of the article relate to the history covered by the paper. If the reviewers did indeed read the Lisa Newton paper then why were the above errors and omissions allowed to remain in the article?