263 these two groups only accounted for 3.3% and 6.3% of the fatal cancers (expected proportions 2.0% and8.6%). Regional Cancer Registry, Queen Elizabeth Hospital, Birmingham 15
GEORGE KNEALE ALICE M. STEWART
THE INFANT-FOOD INDUSTRY
SIR,-The statement (June 10, p. 1250) by the International Council of Infant Food Industries and your leading article (p. 1240) deserve comment. I.C.I.F.I. does not represent the formula industry as a whole, since several major companies have not joined, and, indeed, policies vary considerably. Some have banned "milk nurses", others have not. Rival codes of ethics have been pre-
pared. The I.C.I.F.I. code of ethics is ambiguous and removed from For example, "to inform mothers on the importance of and methods of obtaining safe water for the preparation of breast-milk substitutes" makes little sense in most developing countries, where uncontaminated water-supplies do not exist. Also, it is a delusion to expect self-regulating voluntary control to work in the real world of competitive business, whether the product be cigarettes, sugar-coated cereals, or infant formulas. The failure of the Advertising Standard Authority to monitor advertising in Britain does not give grounds for optimism.’1 The supervision of promotional practices at the periphery can be even more difficult, as was commented on at a recent hearing before the U.S. Senate subcommittee on health (May 23), which was examining the promotional practices of American formula companies in developing countries.2 It was noted that distribution within a country could take place through an illcontrolled subsidiary and that, in any-case, the sales representative on the spot would be mainly concerned only with selling as much of the product as possible, not the promoting of a rival product, human milk. As the chairman of the subcommittee, Senator Edward Kennedy, emphasised several times, the key question is that of justification for the promotion of expensive formulas in countries where the vast majority of the population are very poor indeed, and have a totally inadequate and contaminated water-supply and a high rate of illiteracy. There was no adequate response from the representatives of the formula industry present.2 A seemingly logical approach would be a closer and franker dialogue between the infant-formula industry and the health profession. Yet tactics and power of major industries are little appreciated by technically trained health professionals, and the risk of "manipulation by assistance" and "endorsement by association" are very real indeed. To put it bluntly, recurrent annual financial support for a worthy and quite unconnected research project has a marvellous muting effect. For those who see this as a paranoid view, the article by Dr Yudkin (April 15, p. 810) on provision of medicines in a developing country provides insight through a similar situation. A few phrases from his paper are: "a major factor in determining the country’s expenditure on drugs is the promotional activities of pharmaceutical companies"; "many companies take advantage of their control over the supply of information"; "some countries have considered banning the promotion of drugs by company representatives and others are curtailing the distribution of free samples and gifts to doctors"; "the drug industry has a role in the improvement of health in the underdeveloped world, but this role is smaller than it would have us believe". The World Health Organisation is exploring methods to deal with the situation in developing countries, as evidenced by
reality.
1. Medawar, C., Hodges, L. Campaign, June 22, 1973, p. 22. 2. U.S. Congressional Record. Report of Hearings before the Subcommittee
Health, 1978.
on
a recent expert-committee meeting, blandly entitled "the selection of essential drugs". Similar issues need to be considered in relation to processed infant foods, both formulas and weaning foods. What are really needed? How should these be selected, marketed, and distributed in countries with some form of free-enterprise system? How should scientific information on infant feeding be disseminated to the health profession? The censure of the infant-formula industry may have resulted, temporarily or permanently, in less direct advertising to the public in some developing countries. At the same time, pressure on the health profession seems to have been intensified by grants, other aid, and much literature, by attempts made to discredit critics on the grounds of "political motivation" or scientific ineptitude, and, in some countries, by company pressure on government administration. Without doubt, there is a role for processed infant foods in developing countries. However, as noted in your leading article, the priorities should be towards low-cost and little-advertised formulas for those really in need, towards inexpensive weaning mixtures for children in some parts of the world (particularly during famines or in urban impoverished communities, where the diet depends largely on purchased foods), and possibly towards less costly food supplements for pregnant and
lactating women. The health profession
must review its role and realise that it has to be well informed about nutrition, particularly of young children, including breast-feeding. Major reorganisation of curricula and changes in practices in antenatal clinics, maternity units, and psediatric wards must follow. Health professionals who accept aid from the infant-food industry for research, for meetings, and in other ways must clearly weigh the implications. Firstly, such funds cost companies little or nothing; they are often tax-exempt and/or taken up by the cost of the project itself. Secondly, is it possible to accept such assistance without involvement or commitment-or endorsement ? Extremely difficult questions of mixed loyalties and conflicts of interest can arise, especially if continued funding is hoped for. Some mechanism is needed to ensure wide circulation of the vast amount of new information on infant nutrition to the health profession in developing countries. The flood of new data is overwhelming and, since it is printed in a wide range of journals, it is unlikely to be available to those working in developing countries, who (as in the case of the pharmaceutical industry) depend too largely on the promotional material produced by the formula companies. Lastly, the clamour of critics of the infant-formula companies has achieved changes, at least temporarily, in the more overt "direct" promotional practices directed to the general public. The question now is how to devise a method both practical and effective for the continuing independent monitoring of practices for the promotion of infant foods in developing
countries. An expert committee on the selection of processed infant foods for developing countries might be feasible, in the context of policies designed to support breast-feeding and locally prepared weaning "multimixes".’’ The best model for such a meeting is that employed in the preparation of a report5 in the Un ited Kingdom, when industry had the fullest opportunity for technical input, but the recommendations were those of experienced and commercially uncommitted health professionals. Division of Population, Family, and International Health, School of Public Health,
University of California, Los Angeles, California 90024,
DERRICK B. JELLIFFE U.S.A.
E. F.
PATRICE JELLIFFE
3. Wld. Hlth Org. tech. Rep. Ser. 1977, no. 615. Jelliffe, E. F. P.J. trop. pediat. envtr. Chld Hlth, 1971, 17, 135. Department of Health and Social Security. Present-day Practices Feeding. H.M. Stationery Office, London, 1974.
4. 5.
in
Infant
.
GEORGE KNEALE ALICE M. STEWART
THE INFANT-FOOD INDUSTRY
SIR,-The statement (June 10, p. 1250) by the International Council of Infant Food Industries and your leading article (p. 1240) deserve comment. I.C.I.F.I. does not represent the formula industry as a whole, since several major companies have not joined, and, indeed, policies vary considerably. Some have banned "milk nurses", others have not. Rival codes of ethics have been pre-
pared. The I.C.I.F.I. code of ethics is ambiguous and removed from For example, "to inform mothers on the importance of and methods of obtaining safe water for the preparation of breast-milk substitutes" makes little sense in most developing countries, where uncontaminated water-supplies do not exist. Also, it is a delusion to expect self-regulating voluntary control to work in the real world of competitive business, whether the product be cigarettes, sugar-coated cereals, or infant formulas. The failure of the Advertising Standard Authority to monitor advertising in Britain does not give grounds for optimism.’1 The supervision of promotional practices at the periphery can be even more difficult, as was commented on at a recent hearing before the U.S. Senate subcommittee on health (May 23), which was examining the promotional practices of American formula companies in developing countries.2 It was noted that distribution within a country could take place through an illcontrolled subsidiary and that, in any-case, the sales representative on the spot would be mainly concerned only with selling as much of the product as possible, not the promoting of a rival product, human milk. As the chairman of the subcommittee, Senator Edward Kennedy, emphasised several times, the key question is that of justification for the promotion of expensive formulas in countries where the vast majority of the population are very poor indeed, and have a totally inadequate and contaminated water-supply and a high rate of illiteracy. There was no adequate response from the representatives of the formula industry present.2 A seemingly logical approach would be a closer and franker dialogue between the infant-formula industry and the health profession. Yet tactics and power of major industries are little appreciated by technically trained health professionals, and the risk of "manipulation by assistance" and "endorsement by association" are very real indeed. To put it bluntly, recurrent annual financial support for a worthy and quite unconnected research project has a marvellous muting effect. For those who see this as a paranoid view, the article by Dr Yudkin (April 15, p. 810) on provision of medicines in a developing country provides insight through a similar situation. A few phrases from his paper are: "a major factor in determining the country’s expenditure on drugs is the promotional activities of pharmaceutical companies"; "many companies take advantage of their control over the supply of information"; "some countries have considered banning the promotion of drugs by company representatives and others are curtailing the distribution of free samples and gifts to doctors"; "the drug industry has a role in the improvement of health in the underdeveloped world, but this role is smaller than it would have us believe". The World Health Organisation is exploring methods to deal with the situation in developing countries, as evidenced by
reality.
1. Medawar, C., Hodges, L. Campaign, June 22, 1973, p. 22. 2. U.S. Congressional Record. Report of Hearings before the Subcommittee
Health, 1978.
on
a recent expert-committee meeting, blandly entitled "the selection of essential drugs". Similar issues need to be considered in relation to processed infant foods, both formulas and weaning foods. What are really needed? How should these be selected, marketed, and distributed in countries with some form of free-enterprise system? How should scientific information on infant feeding be disseminated to the health profession? The censure of the infant-formula industry may have resulted, temporarily or permanently, in less direct advertising to the public in some developing countries. At the same time, pressure on the health profession seems to have been intensified by grants, other aid, and much literature, by attempts made to discredit critics on the grounds of "political motivation" or scientific ineptitude, and, in some countries, by company pressure on government administration. Without doubt, there is a role for processed infant foods in developing countries. However, as noted in your leading article, the priorities should be towards low-cost and little-advertised formulas for those really in need, towards inexpensive weaning mixtures for children in some parts of the world (particularly during famines or in urban impoverished communities, where the diet depends largely on purchased foods), and possibly towards less costly food supplements for pregnant and
lactating women. The health profession
must review its role and realise that it has to be well informed about nutrition, particularly of young children, including breast-feeding. Major reorganisation of curricula and changes in practices in antenatal clinics, maternity units, and psediatric wards must follow. Health professionals who accept aid from the infant-food industry for research, for meetings, and in other ways must clearly weigh the implications. Firstly, such funds cost companies little or nothing; they are often tax-exempt and/or taken up by the cost of the project itself. Secondly, is it possible to accept such assistance without involvement or commitment-or endorsement ? Extremely difficult questions of mixed loyalties and conflicts of interest can arise, especially if continued funding is hoped for. Some mechanism is needed to ensure wide circulation of the vast amount of new information on infant nutrition to the health profession in developing countries. The flood of new data is overwhelming and, since it is printed in a wide range of journals, it is unlikely to be available to those working in developing countries, who (as in the case of the pharmaceutical industry) depend too largely on the promotional material produced by the formula companies. Lastly, the clamour of critics of the infant-formula companies has achieved changes, at least temporarily, in the more overt "direct" promotional practices directed to the general public. The question now is how to devise a method both practical and effective for the continuing independent monitoring of practices for the promotion of infant foods in developing
countries. An expert committee on the selection of processed infant foods for developing countries might be feasible, in the context of policies designed to support breast-feeding and locally prepared weaning "multimixes".’’ The best model for such a meeting is that employed in the preparation of a report5 in the Un ited Kingdom, when industry had the fullest opportunity for technical input, but the recommendations were those of experienced and commercially uncommitted health professionals. Division of Population, Family, and International Health, School of Public Health,
University of California, Los Angeles, California 90024,
DERRICK B. JELLIFFE U.S.A.
E. F.
PATRICE JELLIFFE
3. Wld. Hlth Org. tech. Rep. Ser. 1977, no. 615. Jelliffe, E. F. P.J. trop. pediat. envtr. Chld Hlth, 1971, 17, 135. Department of Health and Social Security. Present-day Practices Feeding. H.M. Stationery Office, London, 1974.
4. 5.
in
Infant
.
