Milking Profits

How Nestlé puts sales ahead of infant health

How one more bottle baby death sparked a global exposé

Every 30 seconds a baby dies because it was not breastfed. One such bottle baby death occurred in Sialkot, Pakistan in March 1997. When the doctor returned from attending the child and informing the parents, he found Syed Aamar Raza, a Nestlé Medical Delegate still waiting in his office. "Why did this child die?" Aamar asked the doctor. "Because of people like you," replied the doctor. So began a crisis of conscience which led to a young man taking on the World's Largest Food Company. It is a story of institutionalised malpractice and Aamar's struggle to be heard.

A respected company

Syed Aamar Raza joined Nestlé Milkpak as a Medical Delegate in December 1994 at the age of 24. It was a dream come true to work for a multinational company and he was quickly indoctrinated with Nestlé's "Be the Best" slogan.

Aamar was responsible for promoting breastmilk substitutes and infant cereals. One of his first tasks was to run a baby show, already organised by the Area Detailing Executive. Baby shows were popular with health workers and mothers and provided an opportunity for marketing staff to make direct contact with both and to display the company's range of breastmilk substitutes and discuss them. Such activities are banned by Article 5.5 of the International Code of Marketing of Breastmilk Substitutes and Nestlé's own "Charter".

Nestlé's "Charter"

Aamar says he received no training from Nestlé on the International Code. But in December 1996 he received a copy of Nestlé's weak version of it - known as the "Charter".

Aamar says:

"I was confused when I read the 'Charter'. It said Nestlé does not give gifts to doctors, but we did this. My bosses signed the cheques. It said we did not make direct contact with mothers, but we held baby shows and in clinics we used Cerelac samples as a way of striking up conversations to push the milks. The "Charter" says Nestlé does not pay staff by incentives, but my salary revisions signed by Mr. Roland, Marketing Manager, includes incentives. Infant formula received the most points in the scheme. "By bosses told me to do all these things which the 'Charter' says we do not do."

Some of the Nestlé Medical Delegates at an annual sales meeting. Minutes reveal that breastmilk substitutes receive most points in the company "sales incentive scheme"

Crisis of conscience

Several months after first seeing the "Charter" Aamar was visiting one of the 200 doctors on his circuit. This doctor was one of the very few who refused the gifts offered by Nestlé. The doctor was called from his office to attend a sick child, a child he could not save. "This is the result of marketing by people like you," he told Aamar when he returned to his office. He explained that the child had been breastfed for just one month and then a doctor had prescribed infant formula. Two months later the child was sick with diarrhoea. A month after that he was dead.

Aamar says that during training he had been told to quickly say "breast is best" before launching into his sales pitch, but the risks associated with bottle feeding had not been explained. Leaving the doctors clinic, Aamar understood that unsafe bottle feeding could kill - had killed the child of the distraught parents he saw grieving outside the office.

Aamar returned home to his 2 year old son and pregnant wife and began to think about what he must do.

"I resign with immediate effect"

Aamar's first action was to resign his well paid and prestigious job with Nestlé. He returned his motorbike, but he kept copies of the documents relating to his job. These had been gathered following instructions from his superiors. He had been instructed to maintain records of incentives to doctors so that he could later use them to pressure the doctor into prescribing more Nestlé products. He also had to keep copies of the instructions he had been issued. Aamar realised that he held irrefutable proof that Nestlé was systematically breaking the International Code and its own "Charter." It was not enough to resign his job, he had to do more to stop the unnecessary death and suffering to which Nestlé contributed by such activities.

Legal Notice

Six months after his resignation, Aamar issued his former employers a Legal Notice (dated 12/11/1997), attaching nearly 80 pages of evidence of the company's unethical marketing practices.

Advised by his father in view of his legal experience, Aamar demanded in his Legal Notice that the company "stop its business of infant food manufacturing in Pakistan and withdraw all its infant food products from the Pakistani market within 15 days of receiving this legal notice". He also directed the company to "terminate the services of staff involved in non-professional and unethical practices of promoting and selling infant formulas within the same period of 15 days."

Documentary evidence

The evidence contained in the Legal Notice and Aamar's other files, is damning and substantiates the findings of monitoring conducted in 33 cities by a group in the International Baby Food Action Network (IBFAN) - The Network, Association for Rational Use of Medication in Pakistan - published as the Feeding Fiasco in March 1998. The Network has reproduced some of Aamar's evidence in the new report Milking Profits. Here we summarise the evidence presented in the report.

Impress money - bribes to doctors

"All the supports are with you as usual," reads a handwritten note signed by Aamar's immediate supervisor, the Area Detailing Executive. "Supports" including cash for gifts. Every month Aamar received "promotional expenses" or "impress money."

"This budget is used to fulfill the demands of doctors," Aamar explains, which could include lunches and air tickets. Nurses were usually given lipstick and perfume. Aamar was required to keep receipts of this expenditure and submit them to the accounts department. If sales were good in his area, he would be given larger sums of money, in amounts which were two or three times his own salary.

Doctors' details were recorded on Contact Data Cards, which include entries for date of birth and wedding anniversary, reminding Medical Delegates when to give special gifts to the doctor.

At the end of the fasting month is the festival of Eid. Aamar's supervisor provided him with gift packs for doctors, made up of Nestlé food products. Class A doctors received a more generous pack than those of lesser rank.

Authorisation required

Larger expenditure had to be specifically approved by Aamar's superiors beforehand. When a doctor asked for an air conditioner, Aamar wrote to his supervisor, seeking guidance, who consulted the Group Brand Manager at the national headquarters. The Group Brand Manager authorised part payment and wrote "Aamar, OK. But Nan and al110 sales should go up."

Pressure to perform

Monthly, brand-by-brand target sheets are prepared by the Area Detailing Executive for the Medical Delegates (for breastmilk substitutes Lactogen 1&2, Al110, Nan, Pre-Nan as well as complementary foods Cerelac, Neslac and Nestum).

The sales team is continuously reminded of these targets and the importance of meeting them. They are under pressure to perform.

A notice from Aamar's supervisor informs him, "Please receive your last quarter achievements report against target. Your small towns need a lot of improvement in all products and special emphasis is needed in Sialkot..."

Another time, Aamar was informed, "Your most concern area is Cerelac [a complementary food] as well as Nan [an infant formula] also specially in Sialkot. Also start taking Rx of Al110 also"

Al110 is a formula for use for the rare condition of lactose intolerance, but even with this product Nestlé set sales targets. The minutes of an Annual Delegates Meeting, signed by the Group Brand Manager, state that "Targets of Al-110 must be rationalised according to the real potentiality of the towns."

Fruits of their labour

A letter from the Marketing Manager of Nestlé Milkpak, provides the break up of Aamar's salary. The letter informs Aamar he "will also continue to be entitled to participate in the Performance Incentive Scheme... Please remember your actual performance is regarded to be of key importance and has therefore been duly considered when revising your salary."

Aamar's pay-slips show the "Incentive to Salesman" payments, which vary from slip to slip but are sometimes nearly as much as the fixed pay. On later slips, where fixed pay is broken down into basic pay and various allowances, the incentive to salesmen is sometimes more than double the basic pay.

The minutes of an Annual Delegates Meeting reveal that infant formulas receive the most points in the "sales incentive scheme" and Delegates receive an extra bonus for hitting all their targets. Like the promotional activities already discussed, incentives and sales quotas are banned by the International Code. Interestingly, Aamar's pay slips are marked "strictly CONFIDENTIAL."

"Well done tigers"

The entire sales team was invited to the annual sales conferences at the luxurious hotel, Pearl Continental Bhurban. The invitation letter informs that the winners of the Tiger Cup will receive their award during this event. Awards are given to the "Medical Delegate of the Year". Winners receive plaques and cash awards of as much as Rs25,000. Winners are determined by their sales performance.

Aamar did not win an award, but he received a special commendation for his work in "crushing" the competition, Japanese company, Morinaga, in CMH Military Hosptial Sialkot. A military doctor, who will be referred to as "The Colonel", wrote to the Group Brand Manager, an old friend, asking for two air conditioners "for my two clinics (one at CMH and the other at my residence). I am sure that these air conditioners will keep on reminding me of the efforts your company makes for the improvement of patient and health care services in Pakistan."

Aamar was told that The Colonel had to first show what he could do for the company. The Colonel issued a circular to staff stating that only Nestlé products could be used in the hospital. He then received two air conditioners.

Free supplies

Aamar's evidence contains forms for providing free supplies. The measures adopted by the World Health Assembly state that there should be no free supplies in "any part of the health care system."

When Aamar forwarded one doctor's request for 10 packs of Lactogen 1 for free, he was advised by the Group Brand Manager to buy the stock from his impress money for the doctor.

How Nestlé responded to Aamar's Legal Notice

After Aamar issued the Legal Notice to Nestlé, the Area Detailing Executive and the Group Brand Manager came looking for him. When they failed to persuade Aamar to come to the office of a doctor who who is a friend of Aamar's, they went to the office of The Colonel. The Colonel called Aamar on a pretext and asked him to come to his office.

Aamar arrived at The Colonel's office to find his former superiors there. He says: "The Group Brand Manager said Nestlé was such a giant company that I could not harm it. He asked me to withdraw the legal notice and said that if the company's interests were damaged with legal action, I would suffer serious consequences. Nestlé is a multinational company, he reminded me, and has money to do anything to me. My Area Detailing Executive offered me any amount of money I like. The Group Brand Manager said that If I continued to be stubborn, the company would file cases against me in many different cities. They said anyone from my family could be kidnapped, or I could even be killed. They said there are lots of gangsters in Karachi and Lahore ready to kill for money. I told them to go ahead and do what they wanted to do and I would do what I wanted to do."

To escape the office and the three men, Aamar said he would discuss the matter with his family. He did not return, but sent a letter to Nestlé saying the 15 day period in the Legal Notice had expired and he would take action.

It was a brave move, but one Aamar realised he could not pursue alone. Accordingly he wrote to the World Health Organisation office and contacted the IBFAN group, known as The Network.

WHO says no

WHO wrote back saying it had only an advisory role and could no take no action against Nestlé. It forwarded Aamar's letter to the District Health Officer, without Aamar's permission.

Soon after Aamar says he received a call to visit The Colonel, who said he was interested in some pharmaceutical products Aamar was then selling, but again there were threats and offers of money.

"After that meeting I told The Colonel I was dropping the issue. Then I made sure to keep everything very secret."

IBFAN agrees to help

By March 1998 Aamar had shown his evidence to The Network, who said they would publish a report if he decided he wanted to go public. He also wrote a review for the Feeding Fiasco report.

The Network contacted other groups in IBFAN, first to evaluate Aamar's documentary evidence and then to prepare a media strategy. Baby Milk Action and the German group, AGB, have played key roles in this, putting Aamar in contact with Stern Magazine and ZDF television in Germany, who spent nearly a year putting together stories.

Milking Profits was launched on 9th December 1999 in Berlin and on 15th February 2000 in London.

Milking Profits is available from Baby Milk Action for £5.50 including postage and packing in the UK.

Latest developments

Aamar presented his evidence to a meeting at the House of Commons on 29th February. Shortly before his family in Pakistan received an anonymous threatening letter telling him to end his campaign and on 27th February shots were fired at his house. NestlŽ was asked to condemn the attack, but instead distributed a report claiming the attack did not happen. Baby Milk Action has evidence of the attack and has forwarded this with NestlŽÕs report to PakistanÕs anti-corruption body which is investigating AamarÕs evidence.

On 13th April NestlŽ announced it had commissioned an external audit of its Pakistan operation.

* Milking Profits is available from Baby Milk Action for £5.50 including P&P in the UK.(visit the Virtual Shop)

What is to be done?

Nestlé's dismissal of Milking Profits already demonstrates that it is more concerned with attacking its critics than protecting infants.

Still, we have asked Nestlé to respond to specific violations documented in the report and to reveal results of internal audits if any really have been conducted. We have received no response to these requests. Other steps need to be taken.

The new administration in Pakistan needs to regulate the marketing of baby foods by implementing the draft law which was sitting with the previous Cabinet.

The Pakistan Paediatric Association needs to me more proactive in educating its members on the International Code and Resolutions and ending malpractice.

Finally, Aamar requires maximum publicity to make it impossible for violent action to be taken against him or his family.

You can help by sharing this information.

 

On 27th February 2000, two days before Aamar presented his evidence at the UK Parliament, shots were fired at his brother at his house in Pakistan by an early morning caller. On the left, one of the bullet marks. Below, 6 cartridges found outside the house after the attacker had fled. Baby Milk Action asked Nestlé to condemn the shooting and to call for restraint from all those implicated in Aamar's Legal Notice. Instead the company has circulated a report claiming that the attack never took place.