UNICEF, Infant-Formula Makers Mired in Ethical, Political ControversyUNICEF and infant-formula makers are embroiled in an "incendiary" debate over whether and how formula should be donated to HIV-positive pregnant women in developing countries to prevent transmission of the virus to babies through breastfeeding, the Wall Street Journal reports in a front-page story. Between 1.1 million and 1.7 million babies have been infected via breastfeeding, mostly in Africa, but most hospitals in the developing world do not supply the formula, which can be used in place of breast milk. In addition, most women in developing countries cannot afford the formula that is sold in local shops. Two major formula manufacturers -- Nestle SA and Wyeth-Ayerst Laboratories Inc. -- are willing to donate free formula to HIV-infected women, but UNICEF has turned down their offers "because it doesn't want to endorse an industry it has long accused of abusive practices in the developing world." UNICEF and the industry have butted heads since the 1970s, when Nestle and other formula makers "blitzed" developing countries with ads displaying "fat formula-fed babies" and distributed free samples in maternity wards to draw women to the formula. Women eventually became dependent on the free samples, and by the time samples ran out, women's breast milk had dried up. A majority of women could not afford to buy additional formula, and resorted to diluting formula to make it last longer -- starving their babies in the process. The ordeal spawned a worldwide boycott of Nestle products and formula industry donations were turned away by UNICEF. In addition, UNICEF and WHO in the 1980s devised a "voluntary marketing code" restricting advertising and specific labeling, and prohibiting free distribution of baby formula anywhere in the world. The heart of the current debate stems from this code.
Cracking the Code
UNICEF and formula makers have continued to battle over the code, with UNICEF accusing the industry of non-compliance in several instances. Nestle reported that despite African hospitals' "desperate" requests for free formula, it is hesitant to donate the product in fear of violating the code, which in turn might spark another round of bad publicity and boycotts. But the Wall Street Journal points out that the code was drafted "long before anyone ever contemplated the ravages of AIDS in Africa," and some U.N. officials have acknowledged that the organization's "decades-old distrust of the formula industry should yield to a moral imperative to get formula to destitute, HIV-infected mothers." Peter Piot, UNAIDS executive director, said that UNICEF is "having difficulty accepting that the world has changed." But UNICEF Executive Director Carol Bellamy said that the formula still poses risks that may outweigh its benefits. If prepared with inadequate sanitation, formula "can expose infants to diarrhea and other traditional killers of the developing world, while breast milk contains antibodies to help ward off such illness." Therefore, Bellamy notes that even if the formula could prevent transmission of HIV through breastfeeding, "it could prove deadly later on." UNICEF officials have also voiced concern over a potential "spillover" phenomenon -- providing free formula to HIV-positive women might "undercut support for breastfeeding among healthy women." And Bellamy is concerned that UNICEF should focus on the "vast majority" of infants "for whom breast milk is unquestionably the safest food." Bellamy said, "We continue to advocate that breast is best."
Wyeth, Nestle Enter the Fray
Although UNICEF continues to lead the "crusade for breastfeeding" in the developing world, it has somewhat softened its stance on baby formula since the outbreak of AIDS, endorsing an "informed choice" policy that encourages empowerment of women to choose the best method to feed their babies, including formula. But the organization has not embraced offers from Wyeth and Nestle to donate "tons" of formula to afflicted nations, and health workers in Africa are calling the "informed choice" policy a "cop-out" because most women can't afford the formula alternative. Wyeth had proposed in November 1998 donating formula to HIV-positive women in Africa, citing an exception in the marketing code that permits formula donations to women who have to feed their babies on breast milk substitutes. Following lengthy negotiations, the company in April 1999 was poised to provide six months' worth of free formula to 100,000 babies in a UNICEF pilot program. Wyeth had agreed that the formula would not carry a brand name to ensure that the formula was not exploited for marketing purposes. But when Wyeth requested a press release, thank-you letter and photo opportunity with UNICEF, the deal fell through. UNICEF spokesperson Liza Barrie explained, "It seemed that everything [Wyeth executives] were proposing could lead to a misunderstanding of our relationship with the company and our view of its practices." Meanwhile, Nestle had been negotiating for a similar donation deal with UNAIDS, but Nestle halted communication with the organization after the Wyeth deal fizzled out.
UNICEF Pilot Program Fraught With Issues
UNICEF decided to pursue a baby formula pilot program in Africa by taking on the costs of the "relatively small amount of formula" needed for the program. UNICEF chose to buy the formula from Jammet Dietetique Nouvelle SA, a French dairy cooperative, which agreed to package the product in generic containers. The program launched in Uganda in February, but was soon fraught with numerous problems. Warning labels on formula containers were only written in English and French, although most of the Ugandan women in the program speak local dialects. Women in Uganda, where like much of Africa an "enormous" stigma surrounding AIDS exists, were fearful that the donated generic tins would reveal their HIV-positive status. Kampala midwife Joyce Matovu explained, "Because this UNICEF package isn't anywhere in the shops, the moment people see it, they start suspecting." But UNICEF officials said they decided on the generic packaging and a "deliberately unattractive box" to discourage healthy women from using it. The pilot program now benefits 25,000 mothers in 11 countries, "a drop in the bucket of the HIV-infected female population," Wall Street Journal reports. But the paper warns that "if the UNICEF official in charge of the pilot program prevails, not many more African women will have the same opportunity." Program director Urban Jonsson, UNICEF's regional director for eastern and southern Africa, said that despite the program's accomplishments, it will not continue to use baby formula as an alternative to breastfeeding. "Infant formula is not the best alternative, even if it's free of charge." Instead, Jonsson advocates "home food alternatives," such as pasteurized breast milk or nursing by another noninfected women. Furthermore, Jonsson and some UNICEF colleagues are "pinning hope" on a recent study that suggests exclusively providing breast milk to babies for six months may protect infants against the AIDS virus. Anna Coutsoudis, the study's lead author at the University of Natal in Durban, South Africa, explains that feeding infants substances other than breast milk during this crucial period "alters the digestive tract of babies, potentially making them more susceptible to disease." Although the study has gained an "enthusiastic following" among UNICEF officials because it would provide support to their crusade for breastfeeding, educating women to provide their babies with breast milk exclusively would be a difficult endeavor. In addition, it would take at least two years before the study is confirmed (Freedman/Stecklow, Wall Street Journal, 12/5).