Report on WHO’s Global Congress on the Implementation of the International Code of Marketing of Breast-milk Substitutes (the Code)

by Lisa Mandell, MBA, IBCLC, Global Advocacy Adviser, ILCA

As the Global Advocacy Adviser for International Lactation Consultant Association® (ILCA®), I had the honor and privilege of attending the Global Congress on the Implementation of the International Code of Marketing of Breast-milk Substitutes in Geneva, Switzerland, 20-22 June 2023, on behalf of our association. This informative and inspiring meeting was attended by more than 400 delegates from over 100 countries, all of whom gathered to learn more about,  develop plans for, and make commitments to the implementation of the Code.

The Purpose of the Congress

The Code has been shown to improve breastfeeding rates, yet many countries have not enacted legislation (or have weak legislation). The Congress served as an opportunity to increase the knowledge and understanding of the Code, help develop national roadmaps for implementation or improvements of the Code, and develop regional networks to continue support for work on the Code.

Summary of the Congress

The Congress opened with a presentation by Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. Dr. Tedros explained that the Code helps protect health, nutrition, and development in the first years of life, and cited that rates of exclusive breastfeeding are 20% higher in countries with legislation substantially aligned with the Code than in those without. He identified that the original concerns that prompted development of the Code were contamination of water used for formula in poor areas, but now, increased research and understanding of health impacts shows the importance of the Code in both low- and high-income countries, but that legislation has mostly been very limited in high income countries. He identified that the Code is a core obligation of countries and exclaimed that now is the time to end exploitative marketing, which is what the Code aims to do.

A series of other high-level speakers brought up many important points:

• Half of the world’s children are not exclusively breastfed
• Sophisticated marketing of commercial milk formula is impacting breastfeeding rates
• We must recognize and uphold the right of every child to good nutrition and of every family to accurate information and support
• Structural discrimination and racism impact the right to health, creating health inequities
• Commercial determinants of health are important factors to understand
• There is an important need for paid maternity leave, access to safe, clean, private places to express milk, and listening to women
• Breastfeeding thrives with skilled support

Of particular interest, Clare Patton from the School of Law at the University of Leeds spoke about breastfeeding in a human rights framework. She explained that the Convention on the Rights of the Child (CRC, article 24) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, article 34) identify breastfeeding rights. She said breastfeeding should be recognized as a standalone human right, and further explained that human rights laws apply to states (countries), that the state has the duty to educate, protect citizens, and enact legislation such as the Code. The commercial milk formula industry has no responsibility to protect, promote, or support breastfeeding; rather, their responsibility is to NOT market commercial milk formula.

Katie Pereira Kotze from First Steps Nutrition Trust clarified the scope of the conflict between public health and industry by contrasting a WHO video on social media that had 10,000 views and a video from a commercial milk formula company that had over 500,000 views. She also contrasted WHO’s entire annual budget of $3.3 billion vs. the $55 billion market for commercial milk formula.

Jeanette McCulloch from the Global Breastfeeding Collective offered guidance on advocacy around the Code and reviewed the importance of establishing a strategic group including influencers, enforcers, and experts, determining concrete actions you want the target of your efforts to take, and building a network of allies. She emphasized that efforts supporting Code legislation are not about restraining individual feeding choices (and the importance of making that clear). She quoted Loretta Ross with this advice: “Don’t confuse problematic allies with your enemy.”

Marion Nestle, professor emerita, New York University, spoke compellingly about the conflicts of interest in many industries, and how industries work hard to lobby government officials, sponsor research, and hide their influence. Phillip Baker of Deakin University cited the incredible $55 million spent just on lobbying for the commercial milk formula industry in the United States over a 12-year period and identified the fundamental conflict of interest between the baby food industry and public health. He reviewed strategies for countering industry influence.

Kathy Shats from UNICEF, David Clark, legal consultant formerly with UNICEF, and Fatmata Fatima Sesay from UNICEF provided lots of information on understanding the Code. Kathy later identified steps to take in pursuing Code legislation, starting with establishing baseline measurements on breastfeeding rates, companies operating in the country, current marketing practices, and more. Next, reviewing existing laws, including in other industries, and evaluating their effectiveness and how they are being monitored and enforced. Additionally, considering financing mechanisms, and what to include in legislation vs. regulations. David later presented information on ensuring effective legal enforcement. Kate Robertson from WHO provided detailed information on how to draft legislation that does not trigger concerns about restraint of trade, and how to address those concerns if they do arise. Marcus Stalhofer from WHO provided further information on monitoring and enforcement provisions, and how to strengthen them.

Elizabeth Zehner from Helen Keller International reviewed the many resources on the Code, most of which are available on the Global Breastfeeding Collective Toolkit. She and others highlighted several new resources:

• What I Should Know About ‘the Code’: A guide to implementation, compliance and identifying violations
• Clarification on Sponsorship of Health Professional and Scientific Meetings by Companies that Market Foods for Infants and Young Children
• Protecting Infant and Young Child Nutrition from Industry Interference and Conflicts of Interest

Speakers also reviewed the findings of these recent important publications:

• How the marketing of formula milk influences our decisions on infant feeding
• Scope and impact of digital marketing strategies for promoting breastmilk substitutes
• The Lancet series on breastfeeding 2023

In addition, there were several presentations from countries and from non-governmental organizations (NGOs) sharing inspiring examples of how they overcame resistance to implement or strengthen legislation on the Code. Of particular interest to me was a speaker from Timor Leste who spoke about the importance of positioning nutrition as “politics neutral.”

On the first day of the Congress, a panel of mothers was included to help illustrate the importance of Code legislation. The mothers spoke about their experiences of having their infant feeding choices impacted my manipulative marketing. One mother said “I wish breastfeeding support would be marketed as much as formula.”

Perhaps the most important work of the Congress occurred in breakout work sessions, where country delegations from a region gathered to work on understanding their Code legislation (or lack thereof), and what they can do to move forward, culminating with commitments for actions to take. I was a facilitator for the North America and Caribbean Region and was delighted to work with fellow facilitators from UNICEF and the dedicated groups of people from Canada, United States, Antigua and Barbuda, Barbados, Guyana, Haiti, Jamaica, St. Kitts and Nevis, and Trinidad and Tobago. In total, over one hundred countries’ commitments were shared visually and select countries highlighted their commitments verbally. Additionally, the countries provided information on how they might continue to work together in regional networks to continue to advance work on the Code.

Next Steps and What You Can Do

The real determination of success of this Congress will be in seeing countries fulfilling these commitments and moving forward with enacting new legislation or strengthening existing legislation. This work will depend on much support from beyond governments, including from those working with breastfeeding families. I was thrilled to see at least 20 IBCLCs in attendance at the Congress and was able to gather 15 of them together for a photo! It is important to have IBCLCs at the table when policies related to infant and young child feeding are being determined, and it is exciting to see IBCLCs in health ministries and other positions. Look for more information and opportunities to become involved and advocate for the Code in your country.