A customer buys Nestle baby formula at a supermarket in Rizhao, a city in China's southeastern Shandong province, in April 2014. Credit: AP Images

Changes made to an international breastfeeding resolution under pressure from the Trump administration are more extensive than previously reported and were aimed at diluting efforts to limit the marketing of baby formula.

Most provisions related to stopping “inappropriate promotion” by baby formula companies were eliminated from the United Nations’ World Health Assembly resolution, according to documents and interviews with attendees by Reveal from The Center for Investigative Reporting. Also removed was a provision to educate HIV-positive mothers about safe breastfeeding.

The resolution’s original goal was to promote breastfeeding as the healthiest option for mothers around the world and discourage marketing of infant formula, which has been shown to be less healthy for most babies. Every country at the assembly except the United States already had signed off.

According to some who attended the May assembly, U.S. officials threatened to end foreign aid and impose trade restrictions on Ecuador, which was introducing the initial draft. Ecuador backed off, and other countries followed suit. Russia then proposed the resolution, but U.S. delegates continued to fight it until major changes were made.

“Shamefully, despite the opposition of most of the delegates, (the U.S.) managed to force some key concessions to the original draft,” said Elisabeth Sterken, national director of the Infant Feeding Action Coalition who was present at the meeting.

Sterken said that U.S. Secretary for Health and Human Services Alex Azar and agency spokesman Ryan Murphy were “active in the opposition to the resolutions and the aggressive attempts to dilute and eliminate” it.

Globally, baby formula is a $70 billion-a-year industry. Of the four largest manufacturers of baby formula, multiple representatives from threePfizer, whose formula division was acquired by Nestlé; Abbott Laboratories; and Reckitt Benckiser, which owns the formula company Mead Johnsonattended the World Health Assembly, according to the WHO’s official list of attendees.

A Nestlé spokesman told Reveal that “Nestlé strongly supports breastfeeding and has not wavered on this position. We have not, nor would we ever, lobby any governments – including the U.S. government – to oppose breastfeeding policies anywhere in the world.”

However, the company’s talking points at the assembly closely mirror the U.S. government position in its distaste for what it considers overly restrictive language aimed at formula companies and its defense of nations’ right to determine their own marketing restrictions.

Documentation of the two drafts and votes show that the provisions related to baby formula grew weaker after Americans intervened.

The U.S. was the only country of 122 that voted against the initial resolution May 22, according to documents. Japan, Argentina and South Korea abstained.

The initial draft, proposed by Russia, which stepped in for Ecuador after the U.S. threatened that nation, called for nations to develop tools to help end what the World Health Assembly considered inappropriate marketing of infant formulas, support for policymakers to avoid formula company influence and guidance on how to breastfeed with HIV.

The final draft, submitted four days later and after intense pressure from the U.S. delegation, contained almost none of this language.

That draft, which passed May 26 by a unanimous vote, doesn’t push states to take “any action on private-sector interference,” according to Patti Rundall, chairwoman of Baby Milk Action, a U.K.-based pro-breastfeeding group.

Gone are 3 out of 4 references to “inappropriate promotion” of baby formulas, a provision about fighting conflicts of interest and a request for the assembly’s director-general to review marketing procedures for baby formulas.

Instead, the new resolution contains one general provision recommending countries take “all necessary measures” to end inappropriate promotion of infant products. It also states in a footnote that “member States could take additional action.”

Resolutions of World Health Organization assemblies generally do not involve enforceable laws or requirements. Instead, they offer guidelines and promote universal best practices for nations to follow.

American government officials unsuccessfully tried to remove language recommending governments “protect, promote and support breast-feeding,” according to a New York Times report.

But they did succeed in removing a paragraph recognizing the World Health Organization’s guidelines for breastfeeding mothers with HIV. The WHO recommends that these mothers breastfeed, but do so while taking antiretroviral drugs. The WHO has advised HIV-positive mothers on antiretrovirals to breastfeed their babies since 2010, after multiple studies showed that these infants were less likely to contract HIV than if they were fed other milks and foods.

U.S. health department officials did not comment on why they wanted the HIV provision removed. Amal Omer-Salim, a member of the World Alliance for Breastfeeding Action, suggested that the U.S. might have wanted it dropped because the U.S. advises mothers against breastfeeding when they are infected with the virus. The U.S. Centers for Disease Control and Prevention and American Academy of Pediatrics recommend that American HIV-infected mothers “completely avoid breastfeeding their infants.”

The CDC recommends this to American mothers in large part because they have access to clean water and nutritious food. In lower- and middle-income countries, however, the WHO found that babies born to HIV-positive mothers who were fed formula were more likely to contract HIV than breastfed babies.

Predatory marketing or freedom of choice?

Since 1981, the World Health Organization has banned baby formula companies’ direct advertising of breast milk substitutes, donations to doctors and other health workers and contact with pregnant women or mothers. Yet manufacturers conduct what some critics call predatory marketing tactics in lower- and middle-income countries.  

A Guardian investigation published in March reported that formula companies in the Philippines, including Nestlé, Abbott and Mead Johnson, were engaging in aggressive and illegal advertising to promote their products. These companies handed out baby formula promotional materials in the guise of scientific pamphlets, put false claims in TV ads, and bribed doctors and midwives with free trips and gambling tokens, the Guardian reported.

A related report by the aid group Save the Children found that in Mexico, where 31 percent of infants are exclusively breastfed – compared with 52 percent in the U.S. – formula companies marketed their products to doctors, who then recommended them to mothers. More than half of Mexican mothers surveyed said they had been recommended formulas, mostly by health professionals.

President Donald Trump took to Twitter on Monday to make his position clear.

The U.S. strongly supports breast feeding but we don’t believe women should be denied access to formula,” he tweeted. “Many women need this option because of malnutrition and poverty,” Trump tweeted.

Caitlin Oakley, a spokeswoman for the Department of Health and Human Services, added: “The United States was fighting to protect women’s abilities to make the best choices for the nutrition of their babies.

But health experts generally agree that babies fed formula are less healthy, and it is not an affordable option for women in poor countries.

One study, released in March, found that availability of formula in low- and middle-income countries likely resulted in about 66,000 infant deaths in 1981. The study compared data from Nestlé’s annual corporate reports with available birth and infant mortality data. Availability of formula was linked to increased deaths of 9.4 babies per million overall. Universal breastfeeding would likely save 820,000 infant deaths per year, the authors said.

The high cost of formula can lead mothers to dilute it, which reduces important nutrients. Also, many areas of the world lack clean water to mix with powdered formula.

Babies who are breastfed have less diarrhea, fewer respiratory diseases and better heart health and cognitive functioning than formula-fed babies, medical experts say.

The American Academy of Pediatrics calls human milk “uniquely superior for infant feeding,” and says that “extensive research … documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding.”

“Obviously, breastfeeding is superior,” said Hussein Tarimo, a member of World Alliance for Breastfeeding Action, who attended the assembly.

Infant formula cost the world $302 billion in 2012, the authors reported. In another study, women given formula samples at hospitals had a twofold increase in irregular breastfeeding in the first month compared with women who exclusively breastfed.

Although the Nestlé spokesman denied that the company lobbied the U.S. government, he was the one who provided Reveal with Nestlé’s talking points for this year’s World Health Assembly.

According to the memo, Nestlé’s position on conflicts of interests mirrors the U.S. positionthat rather than develop international guidelines on inappropriate marketing, “member States are in the best position to make individual assessments … as to what engagements are both appropriate and in the best interests of their respective countries.”

“We believe that to significantly increase breastfeeding rates and promote healthy diets, the Guidance … should consider other important measures other than simply recommending additional restrictions on the promotion of commercial baby food,” the memo continued.

Molly Sustar, an Abbott spokeswoman, said the company supported the WHO’s goal of increasing breastfeeding rates, “including promoting exclusive breastfeeding during the first six months of life, where possible. … It is also important for all mothers and their health care teams to choose the best feeding options for their babies and themselves – if breast milk is not available or not chosen, infant formula is the only safe and recommended alternative.”

Officials with the U.S. Department of Health and Human Services said the original drafted resolution would have made it difficult for nations to determine what constitutes fair advertising.

Ties between Trump and formula makers

The Trump administration’s position “was a sharp turn from previous U.S. participation during the Obama era, which (was more accepting of) resolutions on infant and young child feeding,” Sterken said.

Abbott’s CEO, Miles White, is a Trump supporter. He said during the 2016 presidential election that he was “optimistic” about his company’s future under Trump, and the company donated to Trump’s inauguration.

Three Trump-appointed employees at the Department of Health and Human Services previously worked for Pfizer, and Mari Stull, a senior adviser at the agency’s Bureau of International Organization Affairs, who was part of the U.S. delegation at the assembly, used to lobby for the Grocery Manufacturers’ Association, whose members include Nestlé and Abbott. In this capacity, Stull worked closely with an executive at Danone on private solutions to global hunger issues.

This isn’t the first time the Trump administration has tried to weaken international children’s health standards.

In December, Trump administration officials took an aggressive stance against a similar anti-formula marketing resolution at the annual WHO/FAO Codex Alimentarius Commission, a nutrition committee that sets standards for global food and goods trading. This resolution included regulations on “growing-up” milks, or formulas targeted to children up to 3 years old.

According to Rundall, who was present at that meeting, industry representation increased sharply from 2016, when the U.S. had one industry representative on its 13-person delegation. At last year’s meeting, five industry representatives sat on a 15-person delegation, including ones from Nestlé, Mead & Johnson and Abbott.

In that meeting, Rundall wrote on her website, the U.S. and France “cast doubt on the global consensus achieved for (the children’s health) resolution and went on to call for the removal of references to recommendations of the World Health Organization generally.”

The recent assembly also isn’t the first time the U.S. has taken a pro-formula stance. NYU professor and food politics researcher Marion Nestle noted that back in 1981, the U.S. was the only country that opposed the International Code for marketing of breast milk substitutes. The Trump administration, she said, appears to be reverting to this position, which came under President Ronald Reagan.

“Really? Again?” Nestle wrote in an email. “The U.S. government is again fighting the world about breastfeeding?”

Back then, the U.S. government made a First Amendment argument, saying restricting advertising would “run counter to our constitutional guarantees of free speech,” Elliott Abrams, then-assistant secretary of state for International Organization Affairs, told the WHO. The leading manufacturers of formula during that time included Abbott and Nestlé. Pediatricians had been linking formula to child malnutrition for years.

To Rundall, the head of Britain’s Baby Milk Action, the American position on breastfeeding, then and now, has been about prioritizing private interest over children’s health.

“America wants to export tons and tons and tons of this baby milk at a high rate,” Rundall said. “The mothers are paying a small fortune for it, and babies are getting sick and fat.

“It’s Trump saying, ‘America first,’ and you can hear it loud and clear.”

This story was edited by Marla Cone and Amy Pyle.

Susie Neilson can be reached at sneilson@revealnews.org. Follow her on Twitter: @susieneilson.

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