Old Tricks, New Opportunities: How Companies Violate the International Code of Marketing of Breast-Milk Substitutes and Undermine Maternal and Child Health during the COVID-19 Pandemic

"...misleads the public to accept bottle-feeding as the social norm, changing infant feeding from a dynamic maternal and child relationship to a commodity..."

According to Alive & Thrive (A&T), breastfeeding and its nutritional and protective health benefits are particularly important in the context of COVID-19, as the pandemic is straining healthcare systems and increasing food insecurity, especially in low- and middle-income countries (LMICs). Inappropriate marketing of breastmilk substitutes (BMS), feeding bottles, and teats threatens the enabling environment of breastfeeding and violates the International Code of Marketing of Breast-Milk Substitutes. This A&T study explores marketing tactics of BMS companies since the start of the COVID-19 pandemic by reviewing promotional materials and activities from 9 companies in 14 countries, as well as the official Code reporting data from the Philippines.

As explained here, inappropriate BMS marketing tactics come in different forms, including direct promotion to consumers (TV advertisements, home visits, or sending samples through the mail), to (and through) health professionals and systems (stipends to attend sponsored meetings, free gifts with company logos, and free formula in hospital maternity discharge packs), and to policymakers (lobbying with government trade and commerce departments by industry). Conducted from August to October 2020, this study looked at promotional activities and materials by BMS companies dating from January 30 2020, when the World Health Organization (WHO) declared COVID-19 a "public health emergency of international concern". Analysis focused on data gathered from the internet and print magazines in Burkina Faso, Canada, China, India, Indonesia, Kenya, Laos, Malaysia, Myanmar, Pakistan, Singapore, The Philippines, United States (US), and Vietnam.

Eight qualitative themes emerged that indicate companies are capitalising on fear related to COVID-19:

1. Unfounded health claims on immunity that prompt fear (e.g., Nestlé, Pakistan, on Facebook
2. Association with public health authorities to gain legitimacy (e.g., Vitadairy, Vietnam, Facebook
3. Appeal to public sentiment on solidarity and hope (e.g., Abbott, China, online news portal)
4. Influx of donations of BMS products and supplies related to COVID-19 (e.g., Danone, Malaysia, company website)
5. Prominent use of digital platforms to reach out to parents (e.g., Danone, Indonesia, Instagram
6. Promotion of uncertainty by endorsing breastfeeding in complicated and confusing ways (Nestlé, Singapore, print magazine
7. Discounts on BMS products that are linked to COVID-19 (e.g., Abbott, US, company website)
8. Educational events for healthcare providers on topics relating to COVID-19 and infant and young child feeding, which may be "fraught with conflicts of interest" (e.g., Nestlé, Kenya, blog)

Corroborating these thematic findings are quantitative findings indicating a sharp increase in inappropriate marketing activities in the Philippines in parallel with the onset of the COVID-19 outbreak: 291 during the first months of the outbreak compared with 70 in all of 2019; especially apparent is the high number of donations among the reported cases since the start of the outbreak. A&T suggests that lack of public awareness about the harm of donations and inadequate Code implementation and enforcement have exacerbated these problems.

In short: The overarching concept of consumer vulnerability is encompassed by the themes emerged from the findings. Tactics including unfounded health claims and misguided information on breastfeeding are designed to cultivate parents' fear and uncertainty in the context of COVID-19. Paradoxically, companies capitalise on people’s sense of hope and solidarity - the donations campaigns and offering of support and services have a solidarity effect to help gain goodwill. They take advantage of the vulnerability inherent in these sentiments through emotional appeals. Companies also target vulnerable populations, including low-income families, with free samples and sales discounts linked to COVID-19. Furthermore, as people spend more time on digital platforms, their personal data become more accessible to advertisers for marketing purposes.

In discussing the findings further, the authors note that BMS companies' use of health claims as a prime promotional tool to increase market value is not new, but the COVID-19 pandemic has provided them with a new platform for promotion. Furthermore, amid the COVID-19 pandemic, dependence on digital platforms for daily living needs has grown exponentially; in this context, "promotion of BMS has found even newer heights through the virality and omnipresence of digital marketing". A&T asks, "Where is the accountabilty from social media?"

A&T recommends immediate action on the part of governments and non-governmental organisations (NGOs), including:

• Monitoring findings to be used to inform actions at the World Health Assembly (WHA) - e.g., advocate for stronger and continued Code implementation and support at the national level.
• Conducting targeted enforcement with existing inspections - e.g., issue warning letters and providing a period for corrective action, while publicising results and using them to advocate for the adoption of legal measures.
• Promoting breastfeeding in the context of COVID-19 - e.g., scale up public awareness campaigns to reassure the public that breastfeeding with appropriate precautions is not only safe but necessary during the pandemic.
• Making efforts to prevent spillover effect of BMS donations - e.g., reach out to food pantries and social services programmes to sensitise them to the harmful effects of donations and inappropriate distribution of BMS products on child health.
• Establishing Code-compliant best practices in health systems and programmes as policy - e.g., include as basic Code knowledge and the importance of Code compliance in health-related education curriculum and health workers' training.

Long-term action on code implementation might involve:

• Raising Code awareness through public education and social messages - e.g., use popular media platforms to communicate that the Code concerns everyone (the public's right to accurate and adequate health information) and that it is governments' duty to protect the avenues of disseminating such information.
• Conducting systematic, sustainable, and independent monitoring - e.g., communicate results to policymakers and used them to advocate for stronger Code implementation and enforcement.
• Holding social media platforms to account for violating the Code - e.g., request social media outlets to incorporate the Code into their internal vetting policy, provide user features for reporting Code violations, and take down posts that violate the Code.
• Reviewing or adopting laws to keep up with marketing tactics - e.g., go further than the Code by adopting more stringent measures to cover a wider range of marketing tactics.
• Tackling conflicts of interest within the government and health systems - e.g., provide training and capacity-building to sensitise officials to the risks that undue influence have on their duty to protect health.
• Exploring alternative funding options in health systems - e.g., impose tax on profits from BMS sales and using that to support scientific meetings, seminars, and research.
• Cultivating high-level political support - e.g., mobilise support from NGOs, health professionals, government officials, policymakers, and intergovernmental agencies by facilitating effective communications, collaboration, and coordination.

In conclusion: "The fact that inappropriate marketing can even thrive in global emergencies, indicates that companies are nefariously taking advantage of the lagging Code implementation and enforcement. The imminent risks of increased child mortality, morbidity, and malnutrition during the COVID-19 pandemic should convey to governments the urgency to drastically scale-up efforts to restrict harmful marketing practices of BMS companies to protect breastfeeding."