Infant Milk Corporations Are Exploiting the Pandemic to Prey on Mothers

Ho Chi Minh City, Vietnam — On a Sunday morning in April, at a small, quiet market tucked away on a side street far from the mayhem of Ho Chi Minh City, a group of breastfeeding mothers — and one lone father — met for their weekly get-together. Their children ranged from six months to four years old. Some of the women were tandem feeding their second and third child.

They are members of Betibuti, a 264,000-strong breastfeeding support group, founded by breastfeeding advocate Le Nhat Phuong-Hong, in 2013, in response to what she saw as widespread ignorance on the topic.

Prior to Betibuti, Le Nhat said there was a dearth of available information on breastfeeding in Vietnam. “I Googled ‘cho con bú’ (‘breastfeeding’) as a keyword in Vietnamese, and there was literally nothing except Nestlé’s ‘About’ page,” the former bank worker told Women Under Siege from her home in Melbourne, Australia.

The breastfeeding information vacuum in Vietnam offered infant milk corporations the opportunity to fill the void with supposedly helpful advice and educational information on feeding targeted at pregnant women and mothers of infants and young children — while simultaneously facilitating the advertisement of their products to their key demographic.

Over the past year, baby formula companies across the globe (including in Vietnam) have been using the pandemic to boost sales of their products — from advertisements that appear to be approved by the World Health Organization (WHO) to targeted ads on social media — and, in many instances, violating the WHO’s code on marketing ethics for breastmilk substitutes.

The International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly (WHA) — the forum through which the WHO is governed — in 1981 in response to the way unregulated marketing during the previous decade had led to an “alarming decline in breastfeeding and widespread infant malnutrition and mortality.” WHA deliberates on issues related to maternal, infant and young child nutrition (including the Code) every two years, with relevant resolutions implemented where applicable.

The Code sets out to ensure “the protection and promotion of breastfeeding,” as well as “the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.”

In reality, however, not only is implementation of the Code patchy, but there is also little consequence for repeat violations.

As 2021 marks 40 years since the Code was implemented, a new peer-reviewed report by Alive & Thrive, an initiative aimed at improving mother and child health through optimal nutrition and breastfeeding, highlights how companies have capitalized on COVID-related fear to spread misinformation about breastfeeding — despite evidence that points to an increase in antibodies among breastfed babies whose mothers had recovered from the virus.

In the past 15 years, global sales of formula have more than doubled, from 3.5 kg (7.7 lbs) to 7.4 kg (16.3 lbs) per child, thanks in large part to a growing consumer base in East and Southeast Asia. In 2005, China accounted for only 14 percent of global sales; now, it accounts for 33 percent.

Today, the industry is worth $56.6 billion a year, of which $5 billion goes toward marketing.

But with sales of breastmilk substitutes in industrialized nations plateauing in recent years due to stabilizing birth rates and a more regulated market, companies have set their sights on lower and middle-income economies where larger numbers of women are joining the workforce every day.

Researchers looked at the marketing campaigns of nine companies across 14 countries: Burkina Faso, Canada, China, India, Indonesia, Kenya, Laos, Malaysia, Myanmar, Pakistan, Singapore, The Philippines, United States, and Vietnam. They found examples of exploitative marketing among all countries listed, including wealthier ones.

In Singapore, Nestlé-owned Illuma 3 took out a double-page advertisement in Mummys Market Pregnancy and Baby Guide, dedicating an entire page to the benefits of breastfeeding — including purportedly expert advice on “How can I protect my newborn from COVID-19?” and “How long should I breastfeed my child for it to be beneficial?”

The advice contained multiple references to the benefits and key properties of the fatty acid “sn-2” and milk protein“A2 beta-casein,” derived from cow’s milk — which, formula companies say has a structure more comparable to the protein naturally occurring in human milk. Both properties are essential for the healthy development and energy needs of a newborn.

In the second ad, the two properties were singled out and featured prominently in a milkdrop graphic.

“When reading the two pages together, it became clear that Nestlé was allying its product with the superiority of breastfeeding, and then stressing the product’s similarity to breastmilk,” wrote the report authors. “Thus, the more it promoted breastfeeding, the more their product was promoted.”

In Pakistan, the brand Nestlé Nangrow published a series of video clips on its Facebook page in which it made reference to the high number of COVID-19 infections, asking parents if they were concerned about their children and what they were doing to prepare them for the wider world — while asserting that Nangrow’s human milk oligosaccharides (HMO) could help boost their child’s immunity.

Some of the most egregious examples, however, were found in Vietnam.

A Facebook ad for ColosBaby, in the early days of the pandemic, featured a headshot of WHO Director-General Dr. Tedros Adhanom Ghebreyesus with the following caption along the top: WHO RAISES COVID-19 THREAT WARNING TO ITS HIGHEST LEVEL. “The world is entering a decisive moment when coronavirus disease is spreading more rapidly,” the ad reads in quotation marks next to Ghebreyesus’ photo.

Colosbaby, produced by Vietnam’s VitaDairy, contains bovine colostrum imported from the United States. It is intended for newborns through to infants under two years old.

Next to images of their products, which appear on a banner along the bottom, they added: “ColosBaby BOOSTS THE IMMUNE SYSTEM” and “PREVENTS RESPIRATORY AND DIGESTIVE INFECTIONS CAUSED BY VIRUSES AND BACTERIA.”

Social worker Constance Ching, who worked on the Alive & Thrive report and has advocated for better implementation of the WHO Code, described the ColosBaby’s marketing as one of the most “bold and aggressive” examples she has come across. It’s clear, Ching said, that the use of Ghebreyesus’ photo was done without approval and permission, yet it conveys the message that “this product is endorsed by the highest authority on public health in the land, which is completely false.”

Nutritionist Roger Mathisen, Southeast Asia regional director for Alive & Thrive, explained how VitaDairy, the company behind ColosBaby, has taken advantage of a legal quirk in Vietnam that allows them to register their product as an infant milk supplement rather than as a substitute, raising serious questions regarding the principles of fair competition.

“On the one hand they say, ‘It's not a breastmilk substitute but a supplement, so we’re not covered by the law,’” said Mathisen. And yet, “they use the prefix ‘Colos’ to refer to colostrum milk,” the fluid produced before the body actually begins to produce breast milk.

“If the product is registered as a breastmilk substitute, then it would be subject to the laws that are giving effect to the Code,” Ching explained over the phone from Malaysia.

In its Facebook post dated March 3, 2020 — a few weeks before Vietnam closed its borders in response to the virus — ColosBaby told parents that its products help infants “gain weight healthily, avoid constipation, sleep well and grow rapidly, and increase height,” which critics say is a direct appeal to the Vietnamese belief that larger children are more “healthy” — a notion particularly persistent among older generations, who have survived periods of famine and war.

According to Le Nhat, it’s not just aging grandparents — and their offspring — who hold these views. “Many doctors also believe this,” she said. “The only way they know to judge a baby’s health is by weighing them — the heavier, the better.”

Le Nhat said such enduring attitudes make Vietnamese mothers an “easy target” for companies selling infant formula, which she believes has contributed to a rise in childhood obesity. “Obesity did not exist in children of my generation,” she said. “Unlike in Western diets, we did not grow up on processed foods.”

In mid-April, Vietnam published the results of its largest-ever National Nutrition Survey, involving 22,400 households across 25 provinces and cities. It found that children’s obesity rates had more than doubled in the past decade to 19 percent.

“Many Vietnamese see Western people, who are often much bigger than us, and aspire to be like them,” said Kinh Thu Phuong, 30, a Betibuti member who was nursing her nine-month-old daughter. “In Vietnam, bigger and stronger isn’t just about being healthier; it’s also seen as richer.”

“The more they market their products [in these new markets], the less mothers are likely to breastfeed. And that's where the dilemma is,” said Mathisen. “You’ve heard of Big Pharma. This is Big Formula.”

Over the years, the industry has been repeatedly called out for failing to comply with the Code, but leveraging the current global public health crisis to boost their profit margins risks undoing years of breastfeeding progress, particularly in countries with under-developed healthcare and limited access to sanitation and clean water.

Ching acknowledges that conversations around breastfeeding and the use of infant formula have become “emotionally charged and polarized,” with mothers often defensively sparring with one another.

The scope of the study, she said, is not to make mothers feel bad about their decisions but to ensure an environment in which they can make an impartial choice based on facts. “Parents have a right to accurate information on which to base their decisions,” Ching said.

There has perhaps never been a more pressing time for Vietnamese parents to be better informed about the marketing strategies of breastmilk substitutes, as greater numbers of domestic and foreign manufacturers train their sights on this burgeoning market.

Japanese food manufacturer Meiji announced in March that it plans to import and sell infant milk in Vietnam in order to tap into the country’s baby boom: 1.5 million babies are born there annually — a rate 70 percent higher than in Japan, the company said.

In the same press release, the company said it was “committed to working continuously towards the resolution of undernutrition among women in Vietnam, with a goal of providing education on nutrition to 650,000 people by 2030,” but there is no mention of how it expects to address a clear conflict of interest given their overlapping commercial interests.

Meanwhile, Vietnam’s government is actively promoting breastfeeding, with some of the most progressive laws in Southeast Asia when it comes to encouraging working mothers to continue expressing or breastfeeding: The 2012 amended labor code, for example, extended paid maternity leave from four to six months and offered workplace lactation support as well as flexible working hours, including breaks for breastfeeding/pumping mothers.

Last month’s National Nutrition Survey revealed that at 45.4 percent, Vietnam is on course to reach the global exclusive breastfeeding target of 50 percent by 2025. With much credit due to the collaborative approach between the Vietnamese Ministry of Health and organizations like Alive and Thrive and UNICEF, steps to encourage breastfeeding appear to be paying off.

Back at the market in Ho Chi Minh City, the mothers discussed the taboo of breastfeeding their older children, who are busy tucking into a breakfast of java apples, steamed rice cakes, spring rolls, and creamy tofu laden with ginger syrup. For 30-year-old Le Thi Hien Thuong, Betibuti has supported her continuing breastfeeding her toddler son. “Some of us may not have continued past the first year” without it, she said.

Bo Sua Bach Vinh, the lone father sitting among the women, took out a bottle and started feeding his three-year-old son.

“This is my wife’s milk,” he said, explaining for my benefit. “She’s a nurse and busy working today.”

In Vietnam, where childcare is often seen as a mother’s duty, the father is something of an anomaly. “I’m in good company,” he said, as his son fed on his mother’s milk, blissfully unaware of the hard work and perseverance that goes into producing each bottle of liquid gold.