Weak legislation on marketing of breastmilk substitutes in Lao PDR worries the CRC Committee

The review of Lao PDR took place today by the Committee on the Rights of the Child. The Committee was very much concerned about the issue of child nutrition in general, due to the situation of high malnutrition prevalence in Laos. There was also a particular concern raised in relation to breastfeeding and the International Code of Marketing of Breastmilk Substitutes.

The International Baby Food Action Network had presented an alternative report on the situation of infant and young child feeding, information which was used by the Committee to interrogate the government delegation. The Committee members expressed concern on the low rates of breastfeeding and initiation to breastfeeding, and also on the disparities, both regional and cultural in breastfeeding indicators. 

It also expressed concern that Laos has weak legislative measures that are adopted to regulate marketing of breastmilk substitutes (BMS), which lead to aggressive forms of marketing, in violation with the International Code. In these way, women are pushed away from breastfeeding with consequences for the health of children, in a country where baby food companies have a strong influence.  
The government has not been involved in monitoring violations of the Code and there are no sanctions in place for violators.

The Government delegation responded to questions by  Committee members by saying that exclusive breastfeeding up to 6 months is a priority and that the government has undertaken some initiatives at the village level to increase awareness and knowledge of mothers: e.g. through theater shows by village organizations. TV and radio campaigns were said to have been organized with the same purpose. In order to prevent use of artificial milk, government tries to raise awareness of mothers of the negative impacts of these products. Some 4000 professionals have been trained for this purpose.

The direct questions on the International Code and the Lao legislation were not answered by the government delegation.

On malnutrition, the government said that the objective for 2015 is to reduce the percentage of malnutrition down to 4%. One of the main institutions working on the issue is the Lao Women Union. The government also said that it is their policy to provide basic health care access to mothers and children. Unfortunately they failed to respond to the question posed by the committee on concrete measures taken at the grassroots level to eradicate maternal and child mortality.

In response to the BMJ article, WHO confirms the recommendation for exclusive breastfeeding up to 6 months for babies everywhere.

On January 13th, the BMJ journal published an article which briefly reviewed evidence on the optimal duration of exclusive breastfeeding. The study suggested that mothers in developed countries should not follow the official advice for exclusively breastfeeding up to six months. The study claimed that mothers could increase the chances for their babies to eat a healthier food later in life by introducing solid foods at three to four months of age. It also claimed that babies weaned before six months have lower chances to develop allergies and anemia (1).

WHO Head of Nutrition, Francesco Branca stated: “The paper in this week’s BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 (“Optimal duration of exclusive breastfeeding (Review)”, Kramer MS, Kakuma R. The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations.” (2)

Several academics have criticized the article for representing a critique of a partial selection of previous studies, and not being systematic. No criteria have been given for the selection of the studies taken into consideration and no details are given for the methodology selected.

The article seems to represent the interest of baby food industry, which has tried to push for an early introduction of weaning at 4 months rather than at 6 months as recommended by the WHO. To support this argument, Baby Milk Action reveals that three out of the four authors of the article (Mary Fewtrell, Alan Lucas and David Wilson) receive funding from baby food industry (3).  

Two days after the publication of this article, WHO responded by reaffirming that “exclusive breastfeeding for six months is best for babies everywhere”. The latest systematic review of evidence on exclusive breastfeeding is the review by Kramer & Kakuma (2009), which included two control studies and 18 other studies in both developing and developed countries worldwide. This study supports the WHO recommendation for exclusive breastfeeding up to 6 months of life and continuous breastfeeding up to two years. WHO affirms that it periodically reviews and follows research findings and re-examines its recommendations (4). 

The advantages of exclusive breastfeeding up to 6 months as compared to 3-4 months include: “a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.” – says Branca (2).

(1) BMJ article: http://www.bmj.com/content/342/bmj.c5955.full

(2) Francesco Branca's response: http://www.babyfriendlynl.ca/2011/01/25/world-health-organization-continues-to-recommend-exclusive-breastfeeding-for-six-months/

(3) Baby Milk Action article: http://info.babymilkaction.org/news/policyblog140111

(4) WHO article on January 15th 2011: http://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/index.html

Breastfeeding advocates should give their input to the General Comment on the right to sexual and reproductive right

The Committee on Economic Social and Cultural Rights (CESCR) is preparing a General Comment (GC) on the right to sexual and reproductive health, which is expected to be finished in May 2011.The general right to the highest attainable standard of health (Article 12) has already been tackled by the CESCR in the General Comment 14

The right to sexual and reproductive health (RSRH) is understood as a component of the right to health under article 12 and the right of family to protection and assistance under article 10 (2) of the Covenant on Economic, Social and Cultural Rights:

Article 12

1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for:

(a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;

(b) The improvement of all aspects of environmental and industrial hygiene;

(c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;

(d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.

Article 10

The States Parties to the present Covenant recognize that:

2. Special protection should be accorded to mothers during a reasonable period before and after childbirth. During such period working mothers should be accorded paid leave or leave with adequate social security benefits.

As part of the preparatory work leading to the formulation of a general comment by CESCR on the right to sexual and reproductive health and, the Committee called for a Discussion Day in November 2010. It provided an opportunity to exchange views and insights from practitioners and experts on the RSRH with a view to foster a deeper understanding of the content and implications of articles 12 and 10 (2) of the Covenant. In this occasion, the CESCR has called for written subscription on the theme of the general comment. 

This GC will assist stakeholders (governments, courts, academia, etc.) to better understand the right to sexual and reproductive health. National courts may refer to the general comment in order to clarify legislative provisions. In some cases, national courts have based judgments on treaty jurisprudence, including GCs. In addition, they may encourage States parties, UN agencies and NGOs to work on this specific issue addressed in this GC.

  

Why should breastfeeding advocates make a contribution?

The General Comment on the right to Sexual and Reproductive Right is a valuable opportunity for breastfeeding advocates to strengthen their work on breastfeeding from a human rights approach; it is a valuable opportunity to highlight the link between mother and child health, which should be reflected also at a human rights level.

If the General Comment will include breastfeeding, this will be beneficial to the work of breastfeeding advocate groups’ work at the country level. The work with breastfeeding can be framed under a perspective of this right, and can help identify breastfeeding advocates as human rights defenders (not only for the rights of the child but also the rights of the women). It may help in strengthening national advocacy and can be used as a framework for accountability. They can also be used by stakeholders to push for changes in legislation.

Breastfeeding is an important linking element between the two articles mentioned above (Art. 12 and 10) because it links not only mother and child health, but it is also a fundamental element for introducing the discussion on maternity protection (covered in Art 10). 

Low rates of exclusive breastfeeding in the artificial milk exporter country of New Zealand worry the Committee on the Rights of the Child

New Zealand was reviewed by the CRC Committee on the 19^th of January 2011. One of the major concerns of the Committee concerned the hardening of the juvenile justice system who has taken up a more punitive approach, contrary to the recommendations of the Committee and the spirit of the Convention. The Committee on the Rights of the Child is concerned about the low exclusive breastfeeding rates for infants under 6 months. It questioned the government on the measures that have been taken to promote breastfeeding. 

The government response on the health issues came from Mr. Patrick Tuohy from the Ministry of Health. He said that government considers breastfeeding to be very important. Breastfeeding rates are moderate, he said, and they are lower among the Maori population, and for this reason the government has done social marketing especially among indigenous groups. 

The government also mentioned measures taken for implementing the International Code of Marketing of Breastmilk Substitutes. It has been adopted as a voluntary agreement between the government and baby food industry. However, alternative reports from breastfeeding advocates in New Zealand show that the implementation of the Code is weak and there is no state monitoring of Code compliance. The baby food industries in New Zealand are very strong and this impedes the government from enforcing the voluntary agreement into a national law. 

The government representative mentioned the importance of breastfeeding in fighting obesity. In this respect, the government, according to Mr. Tuohy, has released new guidelines for nutrition and overweight, and has adopted the 2006 WHO Growth Charts. These charts show that what used to seem as retarded growth in old New Zealand charts is actually a normal growth rate for breastfed infants. 

"WHO should avoid conflict of interest in key public health policies" - Consumers International and IBFAN at the Executive Board of the WHO

Patti Rundall, from Baby Milk action (UK) spoke at the Executive Board Meeting at the World Health Organisation in Geneva. The point made was clear: public health policies should be led by public interest bodies, otherwise there is a great risk of conflicts of interest.

(integral body of the speech:)

Thank you Mr Chairman for allowing me the opportunity to speak on behalf of Consumers International, the global federation of consumer organisations worldwide and an IBFAN founding member. 

We congratulate WHO on seeking to raise the profile of NCD prevention and control and support the call to integrate the prevention and control of non-communicable diseases into policies across all government departments. If interventions with the best health outcomes are to be prioritized, health ministry’s should take the lead in the development of heath policy and implementation. Providing guidance on the role of different stakeholders is critical, especially if the private commercial sector is considered as an actor, as the risk of conflicts of interest is high. We therefore urge the WHO to give Member States practical guidance on how to minimize or avoid conflicts of interest in relation to the development of key public health policies.

This becomes even more critical considering the proposal for a multi-stakeholder forum for global health. This seems to amount to a restructuring of global health governance.  The notion of actors with commercial interest sharing policy making and governance platforms is worrying. In our experience of multi-stakeholder platforms, it is hard to ensure that strong policies to protect health do not take a back seat to market-led initiatives that mainly benefit industry.  Did the DG herself not warn that policies are “influenced by the action of powerful industries and multinational corporations”?

Member states count on the WHO's impartial and authoritative advice to protect the health of their citizens.  Therefore the WHO's independence in the preparation, implementation and follow-up to the high-level meeting on prevention and control of NCDs must not be compromised by inappropriate partnerships and funding.

The food industry is keen to be involved and fund education, specifically seeking out children, teenage girls and young mothers.  While some governments may welcome such assistance, they should be reminded that there is no such thing as a free lunch. ‘Education’ is all too often used by industry as a subtle and pervasive form of marketing to build trust and to promote ”better for you”  junk foods to children. Since few  governments have legislation to control health and nutrition claims,  the door is left wide open for these market-led strategies leading to dependence on unnecessary products and undermining of sustainable local healthy feeding practices and skills. CSR initiatives should be carefully evaluated and should not be seen as an alternative to regulation.

The Global Strategy on IYCF clearly defines the role of industry: comply with the International Code and manufacture products in line with Codex standards. Given the double burden of malnutrition facing many countries today, WHO must ensure that work on NCDs does not undermine this Global Strategy. The role of industry in the NCD prevention and control needs to be more strictly scrutinized and regulated.

Support to breastfeeding is now recognised as a key strategy to prevent obesity in children, as illustrated in this weeks  Call to Action on Breastfeeding by the US Surgeon General.. We would urge WHO and members states to include protection promotion and support of breastfeeding, including implementation of and compliance with the International Code, as a key strategy to protect the health of citizens globally- both for under- and over-nutrition.

The CRC Committee: Breastfeeding is important in the difficult context of Afghanistan.

The Committee on the Rights of the Child (CRC Committee) emphasized the role of breastfeeding in the difficult context of Afghanistan, during the review of the initial report of Afghanistan. This review took place on the 18^th of January 2011, at Palais Wilson in Geneva. 

The CRC Committee reviewed the progress made by the state party on the implementation of the Convention of the Rights of the Child. The progress made on basic health services and access to health care was discussed. Many Committee members posed questions regarding the access to health service of children, of girls in particular and the training of health professionals and midwives. 

The chair of the CRC Committee - Ms. Yanghee Lee - emphasized the importance of breastfeeding in Afghanistan. Because of the high malnutrition and the poor sanitation conditions the low breastfeeding rates are alarming, said the chairperson. She went on to emphasize the importance that the Committee places on the International Code of Marketing of Breastmilk Substitutes. Afghanistan has adopted this code; however its implementation is not adequate as violations persist. Example of television interviews of baby foods were brought to the attention of the Afghan delegation. The Committee also interrogated on the availability and adequacy of training provided on this code to health professionals.

Ms. Nadera Hayat Burhani – Deputy Minister of Public Health – responded to these issues. She said that the International Code has been endorsed and enforced by the government. The Ministry of Public Health has responded to the cases of violations on television by sending a letter to all the media in the country, instructing them to ask for authorization from this ministry before airing or publishing advertisement on “powder milks”.

The review of the situation of child rights in Afghanistan touched upon the many difficulties that children face in a country that is still facing internal conflict and is striving to find economic and social stability. Especially critical is the situation of girl children which are often the victims of forced and early marriage, suffer abuse and have less access to education and health care. Also the Committee raised questions in relation to the co-existance of three different legal systems in place: the laws ratified by the parliament, the Islamic law and the customary law. Other subjects include: the lack of monitoring and coordination between different institutions dealing with child rights; the recruitment of children in the armed conflict; children working on the street; the rights of children living with their parents in prisons.

Nonetheless the Committee recognized some of the positive steps that the new Afghan government has undertaken despite the turbulent time and the lack of a stable peace in the country. Efforts have been made to set up and strengthen institutions that will protect child rights, adopt laws and incorporate the Convention on the Rights of the Child and enhance the education of boys and girls in this country.