World Health Organization Adopts a Code on Breast-Milk Substitutes Summary

  • Last updated on November 10, 2022

After studies showed that irresponsible promotion of infant formula was putting infants in developing countries at risk, the World Health Organization approved a code calling for a universal ban on the advertising of infant formulas.

Summary of Event

Most experts agree that mother’s milk is best for babies. Breast milk is healthier, cheaper, and more natural than infant formulas. It contains maternal antibodies that help prevent infections, and it is less likely to cause allergic reactions or bowel problems than are formulas. Despite these advantages, breast-feeding rates in the industrialized world declined prior to the 1970’s as a result of a variety of factors: the availability of breast-milk substitutes, urbanization and changes in women’s work patterns, and the decline of the extended family (leading to a lack of family support and role models). Breast-feeding declined in developing countries as well. The upper classes, many of whom were educated in Western countries, copied the practices of the West. They associated bottle-feeding with modern lifestyles, and breast-feeding was considered primitive and impractical. When, in the early 1970’s, increasing numbers of mothers in the developed countries returned to breast-feeding, formula companies increased their efforts to tap the expanding market in developing countries. Infant formulas World Health Organization;infant formulas International Code for the Marketing of Breastmilk Substitutes [kw]World Health Organization Adopts a Code on Breast-Milk Substitutes (May 21, 1981) [kw]Organization Adopts a Code on Breast-Milk Substitutes, World Health (May 21, 1981) [kw]Code on Breast-Milk Substitutes, World Health Organization Adopts a (May 21, 1981) [kw]Breast-Milk Substitutes, World Health Organization Adopts a Code on (May 21, 1981) Breast-milk substitutes[Breast milk substitutes] Infant formulas World Health Organization;infant formulas International Code for the Marketing of Breastmilk Substitutes [g]Europe;May 21, 1981: World Health Organization Adopts a Code on Breast-Milk Substitutes[04500] [g]Switzerland;May 21, 1981: World Health Organization Adopts a Code on Breast-Milk Substitutes[04500] [c]Health and medicine;May 21, 1981: World Health Organization Adopts a Code on Breast-Milk Substitutes[04500] Jelliffe, Derrick B. Joseph, Stephen C. Lefever, Ernest W. Resnick, Idrian N. Babb, Eugene

In 1975, Dr. Derrick B. Jelliffe, a noted pediatrician, warned that the aggressive promotion of bottle-feeding by formula manufacturers was persuading women in developing countries to substitute formula for breast milk unnecessarily, with harmful, and sometimes fatal, results. Infant formula can be an acceptable substitute for breast milk. The parent, however, must have an adequate income, be literate enough to follow printed instructions, and have clean water, good sanitation, and refrigeration conditions frequently lacking in developing countries. As a result of ignorance or poverty, formula powder was often overdiluted, mixed with polluted water, or left standing without refrigeration, and babies died from diarrhea, gastroenteritis, malnutrition, and other diseases as a direct result. Studies by the World Health Organization (WHO) showed that infants who were breast-fed for less than six months or not at all were five to ten times more likely than breast-fed babies to die in the second six months of life. The United Nations Children’s Fund (UNICEF) estimated that one million infant deaths each year could be prevented if breast-feeding were promoted internationally. The irresponsible promotion of infant formula was denying infants in the Third World the right to life.

A coalition of consumers, health care professionals, anti-industry groups, religious groups, and other social activists called for the major infant formula companies to act more responsibly. Protest in the United States was led by the Minneapolis-based Infant Formula Action Coalition Infant Formula Action Coalition (INFACT). The controversy focused on the sales tactics of the two-billion-dollar-per-year infant formula industry: the distribution of free samples, offers of scholarships and travel allowances to rural health officials to promote formulas, and advertising that idealized bottle-feeding.

The International Council of Infant Food Industries, International Council of Infant Food Industries whose members accounted for more than 80 percent of formula sales in the developing countries, argued that babies died from poor hygiene, malnutrition, and poverty when breast milk was unavailable or insufficient, no matter what substitute foods were used. Formula companies stressed the legitimate need for breast-milk substitutes: Formula was an important supplement for breast-feeding mothers who were ill or working, and good-quality formula was better for babies than the herbal teas and home remedies traditionally used as breast-milk substitutes by mothers in the developing countries. Formula companies viewed attempts to restrict advertising as an interference with their rights to freedom of trade and freedom of speech.

In November, 1975, the council adopted a voluntary code of ethics that prohibited advertising and promotional practices that discouraged breast-feeding. The coalition of breast-feeding advocates who monitored the council members’ adherence to the code in the years to come reported that formula companies continued to persuade mothers in developing countries to bottle-feed their babies unnecessarily. Promotional excesses by the Swiss-based Nestlé Company, Nestlé Company boycott the leader in the sector with a 50 percent share of the Third World market, led to a worldwide boycott of the company in 1977 that did not end until 1984. Consumers exercised their right to express concern about and demand change in the marketing practices of infant formula companies. The coalition was joined by WHO and UNICEF, and in November, 1978, the National Council of Churches overwhelmingly endorsed the boycott. Three American companies Ross, an Abbott subsidiary; Mead Johnson, a Bristol-Myers company; and Wyeth Laboratories (SMA), an American Home Products subsidiary were urged to stop trying to persuade unsophisticated mothers that artificial infant formula was superior to breast milk.

In 1979, WHO and UNICEF held a joint conference for 150 representatives from governments, health organizations, industry, and anti-industry groups. There was apparent consensus on recommendations to promote breast-feeding and the need for an international marketing code. Industry hailed the conference as an important landmark in the battle against malnutrition and agreed to voluntary guidelines banning marketing abuses.

In 1980, the thirty-third World Health Assembly endorsed the recommendations made by the 1979 WHO/UNICEF conference, including the need for an international marketing code. Breast-feeding activists pressed WHO to draw up the code, asserting that the rules were being violated by commercial infant formula companies. They wanted a code to promote breast-feeding that would apply to wealthy industrial nations as well as to poorer countries. Formula manufacturers wanted broad guidelines instead of the very restrictive code being drafted by WHO and UNICEF staffers. The debate was intense: Groups opposing formula promotion made inflammatory claims, and manufacturers attempted to influence the media and the U.S. government.

On May 21, 1981, after a decade of debate between baby formula manufacturers and breast-feeding advocates, WHO, meeting in Geneva, voted 118 to 1 to adopt the International Code for the Marketing of Breastmilk Substitutes. The Geneva code restricted advertising that idealized infant formula, banned the advertising and promoting of infant formula to the general public, restricted the distribution of free samples to pregnant women and health care workers (except for testing), prohibited company incentives for doctors to promote formula, barred salespeople from contacting mothers, outlawed commissions on sales, and required wording on labels that acknowledge the superiority of breast milk.

Although formula companies said that the code went too far, they agreed to abide by restrictions in countries that adopted the code. (The code was strictly voluntary and served as a guideline for national laws, but it was up to each country to pass its own laws.) Companies had already reduced promotional materials, and their research indicated that the ban would not dampen sales or slow the growth of the worldwide market for infant formula.

The only opposing vote was cast by the United States. Responding to months of lobbying by the makers of powdered milk in the United States and the Grocery Manufacturers of America, who feared that the ban on advertising would be extended to all baby food, Ronald Reagan’s Reagan, Ronald presidential administration directly ordered the negative vote. The Departments of State and Health and Human Services had recommended that the United States abstain, but Reagan officials saw the code as a dangerous precedent for controlling the pharmaceutical industry and other multinational corporations. They contended that WHO should not be involved in the regulation of business and claimed that the code, by restricting advertising, threatened both freedom of speech and freedom of trade, resulting in an unfavorable climate for the marketing of breast-milk substitutes in the United States as well in developing countries. They also pointed to the lack of large-scale studies supporting a clear connection between the promotion of powdered milk and a decline in breast-feeding.


Passage of the code drew complaints from American formula manufacturers, but Nestlé which stood to gain the most, given that marketing restrictions would favor the company already dominating the market in developing countries announced that it welcomed the code. The U.S. vote against the WHO code on baby formula powders created an immediate storm of protest. The State Department reported that the negative vote drew an extraordinary amount of mail critical of the administration’s position. Eugene Babb, a nutritionist and deputy assistant administrator for food and nutrition for the U.S. Agency for International Development (USAID), and Dr. Stephen C. Joseph, USAID’s top health officer, called the administration’s vote unconscionable and resigned in protest. Senator Ted Kennedy Kennedy, Ted of Massachusetts held an unofficial public forum on the issue and found an increased use of baby formula accounting for infant illnesses among poor families in the United States. The House of Representatives voted 301 to 100 to rebuke the administration for casting the only vote against adopting the code. Breast-milk substitutes[Breast milk substitutes]

Ernest W. Lefever, President Reagan’s nominee for assistant secretary of state for human rights and humanitarian affairs, had supported Nestlé’s position on the international marketing of infant formula, but he withdrew his name from consideration for the post on June 5, 1981, after it was revealed that his Ethics and Public Policy Center (a tax-free research organization of which he was president) had received grants from Nestlé. He denied any conflict of interest, but the Senate Foreign Relations Committee voted thirteen to four to recommend that the Senate reject his nomination.

At the thirty-seventh World Health Assembly meeting in 1984, some 130 countries and territories reported on legislation and other measures they had adopted to encourage breast-feeding and the appropriate marketing of breast-milk substitutes. The U.S. representative expressed the American administration’s opposition to the United Nations’ support for uniform commercial standards, asserting that those standards went beyond the legitimate concerns of the organization.

In 1989, the International Baby Food Action Network International Baby Food Action Network (IBFAN), which had grown from a coalition of thirty-five citizen groups in 1981 to more than 140 groups in seventy countries, announced the renewal of the Nestlé boycott and initiated a boycott of American Home Products. (The first Nestlé boycott was suspended in 1984 when Nestlé promised to abide by the code.)

Ten years after the adoption of the WHO code, formula manufacturers reaffirmed that they would stop distributing promotional supplies of breast-milk substitutes to hospitals and maternity centers only when governments required it. Consumer groups continued to report thousands of serious violations of the code each year by the industry. Dr. Idrian N. Resnick, the executive director of Action for Corporate Accountability, Action for Corporate Accountability the U.S.-based group of IBFAN, warned that the international code was needed as much as ever. Nestlé continued to distribute free samples of infant formula in hospitals, which often meant that by the time mothers left the hospital their own milk had dried up, forcing them to rely on artificial milk. Nestlé was still insisting that it abided by the code and intended that the formula go to malnourished and orphaned infants.

It was questionable whether any citizens’ organization or even any national government could overcome the corporate power of industrial giants such as Nestlé, but grassroots alliances continued the struggle into the 1990’s as activist organizations and UNICEF continued criticizing the industry, accusing it of ongoing violations. The Interagency Group on Breastfeeding Monitoring (IGBM), formed in 1996, produced a highly critical study in 1997 titled “Cracking the Code.” In 1998, WHO sought a more conciliatory tone, promoting high-level roundtable discussions. In 2005, a major comparative study by GES Investment Services examined the infant food industry’s compliance with the code. It rated Nestlé the most advanced company in adopting code-compliance mechanisms, indicating that years of activism, pressure, and reform had produced some results, but there was still a need for ongoing vigilance. Breast-milk substitutes[Breast milk substitutes] Infant formulas World Health Organization;infant formulas International Code for the Marketing of Breastmilk Substitutes

Further Reading
  • citation-type="booksimple"

    xlink:type="simple">Cunningham, Allan S., Derrick B. Jelliffe, and E. F. Patrice Jelliffe. “Breast-Feeding and Health in the 1980’s: A Global Epidemiologic Review.” Journal of Pediatrics 118 (May, 1991): 659-666. Literature review of important research on previously unrecognized benefits of breast-feeding, including protection from gastrointestinal and respiratory illness, infection, and immunologic disorders. Ninety-nine references.
  • citation-type="booksimple"

    xlink:type="simple">Frisby-LaRue, Jeannine. “Infant Formula: A Little Knowledge Can Be Dangerous.” NJEA Review 55 (April, 1982): 16-18. Discusses WHO’s International Code for the Marketing of Breastmilk Substitutes, Nestlé’s response, and the boycott of Nestlé products by the Infant Formula Action Committee.
  • citation-type="booksimple"

    xlink:type="simple">Jelliffe, Derrick B., and E. F. Patrice Jelliffe, eds. Programmes to Promote Breast-feeding. New York: Oxford University Press, 1988. Compiles ten years of research about diverse breast-feeding programs throughout the world, including issues related to marketing practices by manufacturers of breast-milk substitutes. Includes an excellent summary, “The State of the Code by Company and Country: A 1986 Analysis.”
  • citation-type="booksimple"

    xlink:type="simple">Murphy, Elaine M., and Patricia H. Cancellier. “The Infant Formula Controversy: Is the Boycott Justified?” Social Education 46 (November/December, 1982): 527-530. Presents a discussion of the International Code for the Marketing of Breastmilk Substitutes along with both the negative and positive aspects of using infant formula in the Third World.
  • citation-type="booksimple"

    xlink:type="simple">Rowe, Jean. “The International Code on Breast Milk Substitutes.” Health Visitor 55 (February, 1982): 72-73. Traces the development of the trend toward bottle-feeding in the Third World and the implications of the International Code for the Marketing of Breastmilk Substitutes for health care workers. Firsthand report on the thirty-fourth World Health Assembly in Geneva by a British participant.
  • citation-type="booksimple"

    xlink:type="simple">Salmon, Carol-Linnea. “Milking Deadly Dollars from the Third World.” Business and Society Review 68 (Winter, 1989): 43-48. Report on the resumption of the boycott against Nestlé and initiation of a boycott of American Home Products, another infant formula company, for violating the WHO infant formula marketing code.
  • citation-type="booksimple"

    xlink:type="simple">Sauve, Reginald S. “The WHO Code and Its Effect on Breast-Feeding Promotion in Hospitals.” Journal of the Canadian Dietetic Association 48 (Summer, 1987): 156-162. Well-written feature article that outlines the events leading to development of the International Code for the Marketing of Breastmilk Substitutes. The Canadian National Breast-feeding Advocacy Program, aimed at promoting breast-feeding in hospitals, is described. Good discussion of hospital routines that discourage breast-feeding.

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