Boston — * Angelita Flores is a housemaid in Bogota, Colombia. Advised against breast-feeding by the local health clinic, she feeds her little Jorgito on a bottled baby formula donated by a doctor. He calls this the modern thing to do.
* Irene Dunbar lives 3,000 miles away in southern Massachusetts. After bottle-feeding her first child, she switched to mother's milk for her second baby and will settle for nothing less for her third child. She considers breast-feeding the "modern," nutritional thing to do.
The contrast between Angelita and Irene illustrates one of the odd -- and many feel tragic -- ironies of this century: Just when women in rich, industrialized countries are returning to breast-feeding as a safer and more nutritional method, mothers in many poor nations are dropping traditional breast-feeding in favor of bottle-feeding.
The World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) see the third-world trend toward bottle-feeding as contributing to infant mortality and malnutrition. And when the WHO meets May 19 in Geneva, they will try to pass an international code of ethics to reverse the trend.
The new code, if passed, would urge governments to do far more to protect and promote breast-feeding and to take responsibility for distributing reliable information about breast-milk substitutes.
For years debate has been raging over the bottled milk vs. mothers' milk issue. Baby-food officials argue they have a useful product. Their critics say that baby-food marketing in poor countries is discouraging mothers from breast-feeding, thus compounding some already severe health problems of babies. They say that bottle-feeding often leads to pollution or over-dilution of the milk formulas.
UNICEF's executive director, James Grant, says that a million infant deaths could be prevented each year if the international community would promote natural breast-feeding.
Seldom has an initiative of the United Nations, which has no real power to enforce its recommendations on its members, generated so much political heat.
The reason: The WHO code could strengthen the hands of politicians who want to diminish the influence of infant formulas. The result could be a far tougher climate for the marketing of mothers-milk substitutes in developing countries -- and even perhaps in the US.
Infant-formula companies scream "Foul!" -- and say the milk question raises the possibility of other government restrictions on free enterprise.
In recent weeks the companies put aside their competitive instincts and combined forces, aggressively lobbying Congress and the Reagan administration to oppose the new code. Some have sent out mass mailings to leading American businessmen. Several weeks ago former Sen. Sam Ervin Jr. testified in Congress to the effect that the code was a totalitarian document that could undermine American constitutional values of free speech, free press, and free competition.
Industry spokesmen have been arguing the dangers no less adamantly.
"We at Mead-Johnson [a subsidiary of Bristol Myers] and other formula companies agree that infant formula should not be promoted at the expense of breast-feeding," says spokesman Gary Mize.
"But as we interpret the code, its prohibitions on communication with the public are far too sweeping, far beyond just cutting back advertising that would discourage breast-feeding, a goal to which we subscribe."
The industry lobby appears to have prevailed. The White House has decided to oppose the code, according to a State Department spokesman. He acknowledged that the US could be the only United Nations member to take that stand.
The reasons for the decision closely parallel reasons why many companies oppose the code. Industry representatives told the Monitor that the code cannot be adopted in the United States without violating rights of free speech and enterprise. They said it could be stretched to apply to other foods besides breast-milk substitutes. The code is not, they say, the best way to encourage breast-feeding, and there is no definitely proven connection between the marketing of breast-milk substitutes and declines in breast-feeding (all points denied by the code's advocates).
Still, the advocates believe that in poor countries a vast number of young mothers urgently need help from the international community. Too often, they argue, many of these women find themselves caught in a cross fire of slick arguments that they do not understand. Says Edward Baer of the Interfaith Center on Corporate Responsibility in New York:
"There is simply too much danger of women in developing countries being enticed by infant-formula advertizing to abandon breast-feeding, of the high cost of formula resulting in poor women diluting it to nutritionally dangerous levels, or of powdered formula being mixed with polluted water."
The number of malnourished babies in the world has reached the 300 million mark, estimates Dr. Michael Latham, director of the Program on International Nutrition at Cornell University. Bottle-feeding is directly related to the main illnesses associated with that malnutrition, he believes.
To help turn the tide, the WHO code would urge governments to prohibit both the promotion of breast-milk substitutes to the general public and the distribution of free formula samples to pregnant women.
The code doesm recognize the need for infant formula to be available in case a mother is unable to breast-feed. But it urges that formula-company employees should not try to educate mothers, should not be given bonuses or quotas for sale of breast-milk substitutes, and that health care facilities not be used to promote or advertize of infant formula.
The code also urges that infant formula labels provide information about the correct use of products in a way that will not discourage breast-feeding.
Ironically both the infant formula companies and the US government were actively involved in the writing of the code they now oppose. Various company spokesman interviewed by the Monitor said they actually agree with the board principles and purpose of the code.
Nevertheless Mead-Johnson's Gary Mize explains that the corporations' recommendations for the code were largely ignored by the WHO.
The point puzzles one US government official, who says that years of negotiation and mutual compromise among the UN agencies, US government, formula companies, and health officials had gone into the writing of that code.
"We worked long and hard to get a compromise code that would realistically be workable for all parties involved. But now all of that work has been scuttled as our government has changed its view as a result of the infant formula companies' lobbying."
The US decision to oppose the code has also deeply disturbed a range of top-ranking development experts in the US government agencies. The experts, who declined to be identified at this writing, plan to make public May 18 their concern that the US posture signals to the world that America cares more about corporate activities than about the health of children, that it could endanger cooperation with developing countries and many joint ventures already under way in the area of infant health.
In the final analysis, there is something about the code that rings "too legalistic" for the formula industry and the Reagan administration -- despite the fact that the code provisions are called "recommendations."
If there is to be regulation, the companies want it to be voluntary and adapted to the needs and conditions of each country. Bristol-Myers and Abbott-Ross Laboratories are two American formula producers that have acknowledged a need to curb advertising that could discourage breast-feeding. (American Home Products and Switzerland's Nestle Company have not.)
Bristol-Myers also claims to have clamped down on employees who have not done this.
But code advocates are not willing to leave the regulation of formula promotion up to the producers themselves. They worry about the producers' long-term motives. With trends pointing toward increased breast-feeding in the industrialized West the companies may be forced to look for new markets. And markets in the developing countries -- already worth an estimated $1 billion -- could be exceedingly lucrative, since the vast majority of new babies will be born there.
All of this, worry the code advocates, could put enormous pressures on the companies to promote their formula aggressively.
The companies are already organizing campaigns to influence those governments working on codes for baby-food sales ethics, says Edward Baer of the Interfaith Center for Corporate Responsibility. The guidelines being suggested by industry , he says, recognize the need for voluntary restraint by companies but still allow free promotion of their products.
Codes In Malaysia and Singapore have indeed adopted guidelines offered by the International Council of Infant Food Industries (ICIFI), according to the organization's secretary-general, Dr. Stanislas Flache. (ICIFI member companies with major formula sales in developing countries include Cow and Gate from Britain, Nestle of Switzerland, five Dutch companies, four Japanese companies, Wyeth International of the US, and a Danish and a French firm.)
In addition, various companies were influential in formulation of the codes in Peru, Kenya, South Africa and Nigeria, says Dr. Flache.
The Interfaith Center feels that some industry jockeying has been less than ethically upstanding.
Last year, says Mr. Baer, the Nestle Company offered a large money grant to the Indian Academy of Pediatricians, whose president happened also to be on India's committee for drafting a code for baby food marketing. The president proposed guidelines offered by formula industries. But health experts and others got wind of it and prevented passage.
In addition, some industry-promoted codes already in existence seem chock-full of loopholes. Loopholes in Kenya's new code, for example, was criticized recently, according to Monitor special correspondent John Worrall in Nairobi.
On the other hand, the Kenyan code urges that the companies marketing formula should avoid competing with breast milk or creating an artificial need for the product, that mothers should be encouraged to seek competent advice on safe use of the formula and that labels and advertisement to the general public give clear information along these lines. With these guidelines the Kenyan government hopes to restrain food companies from taking advantage of easily persuaded, illiterate women.
However, the Kenyans were not willing to lay down penalties for manufacturers who abuse the code. And some health officials and news commentators in Kenya criticized the code for allowing free infant formula samples in maternity houses and clinics, samples that critics say convince mothers of the merits of specific formula brands at the outset. And too little attention was given, the critics charged, to the poverty and other social factors that can be linked to poor lactation in mothers.
Nevertheless, as final vote now draws near in the World Health Assembly on whether to set up an international standard to guide the marketing of infant formula, uncertainties abound.
Will US opposition pressure other countries to oppose the code? Will the American position force developing countries to harden their own stands even more to demand a code with even stronger regulatory language? And what will be the legacy for the future of cooperation between developing countries and the industrialized West?
Much will depend on whether the delegates can find compromises that put industry and governments at ease about the future of free enterprise, while at the same time keeping in mind the need to ease the suffering of children in countries where poverty already makes basic survival hard enough.