Breastfeeding: A Philippine Battleground

MANILA: Nurjana Dones is bucking a trend in the Philippines. Now eight months into her first pregnancy, she decided early on that she would breast-feed her baby.

"I'm convinced this is the only way to feed my child," said Dones, 21. "I don't care about what all those television advertisements are saying: that formula milk will make my child smarter," she said, while waiting for a checkup at a government health center in Quezon City.

Besides health, another factor is money: Dones, who is jobless, cannot afford the $50 a month that formula costs.

Her husband works at a warehouse, earning the minimum wage of less than $200 a month.

Filipino and UN health authorities are heartened by the resolve of mothers like Dones, who make up a dwindling minority as breast-feeding rates decline in the Philippines and throughout Southeast Asia. As economies develop and more women take on full-time jobs outside the home, they have less time to breast-feed and more cash to spend on formula.

In the Philippines, the proportion of babies who are exclusively fed on breast milk in their first six months dropped from 20 percent in 1998 to 16 percent in 2003.

Throughout Southeast Asia, only 61 percent of women breast-feed their babies up to four months and 35 percent up to six months, according to the World Health Organization, or WHO.

But what has health authorities here most concerned is the role of aggressive advertising by formula producers. Now the long-running battle over what companies can say and do to promote commercial substitutes for breast milk has reached the Philippine Supreme Court.

"Infant formula has been glamorized to the point that many mothers are now convinced that it is superior to mother's milk," said Dr. Nicholas Alipui, the Unicef representative to the Philippines. He was referring to advertisements that claim formula milk and follow-on milk - for children one year old or older - make babies smarter.

For instance, Wyeth, a pharmaceutical and nutritional company based in the United States, has been running television advertisements for its Promil brand that feature child prodigies who can paint or play the piano. The ads have become so well known that a Filipino who shows above-average intelligence is often teased as a "Promil kid."

Nothing, Alipui said, could be further from the truth. He said that about 82,000 children under 5 die each year in the Philippines, mainly because of poor nutrition. He cited a WHO statistic that said 16,000 of these deaths are caused by "inappropriate feeding practices, including the use of infant formula."

He and other health officials are concerned that, while infant mortality rates remain high, the benefits of breast milk, such as enhanced immunity for the child, are being lost.

To encourage breast-feeding, the Philippines government enacted a Milk Code in 1986 that regulates the marketing of formula. The code bans advertisements and other promotional activities for formula intended for babies up to 1 year old. Last year, the Philippine Department of Health, concerned about the steady decline in breast-feeding and arguing that formula companies had been violating marketing regulations, revised the code, extending the promotion ban to milk substitutes for children up to 2 years old.

The companies, Wyeth among them, went to the Supreme Court to challenge the revisions, arguing that they were unconstitutional because they restricted free expression and that the health department had exceeded its mandate.

The court issued a temporary restraining order against the new regulations and is expected to rule on their legality within a few weeks.

The companies have said they do not dispute the value of breast milk but that the new regulations unfairly restrict information from reaching women who cannot breast-feed.

"This is not a battle between breastfeeding and formula," said Felicitas Aquino-Arroyo, a lawyer for the Pharmaceutical and Health Care Association of the Philippines, the industry group that filed the suit, in an interview in June. "This is about the arrogance of the Department of Health." She called the assertion that formula was a factor in the high rate of infant mortality in the Philippines a "malicious insinuation."

The Philippine Milk Code case is being closely watched because of its potential impact in Southeast Asia as a whole.

The stakes are certainly high for the milk companies, which sell nearly $500 million worth of milk substitutes annually in the Philippines, according to the Health Department. Breast-milk advocates also stress its importance to shaping how babies are fed.

"If the milk companies succeed in the Philippines case, it will have a huge negative impact because countries in the region will be deterred from promoting breastfeeding," said Yeong Joo Kean, a legal adviser in Kuala Lumpur for the International Baby Food Action Network, a breast-feeding advocacy group.

Only the Philippines has a Milk Code that regulates the advertising and promotion of formula, Yeong said. "Most countries in Southeast Asia have been doing something to promote breast-feeding over the years but aggressive marketing by the milk companies have eroded these gains," she said.

The WHO blames the decline of breast-feeding not just on advertising, but on other promotional tactics by formula manufacturers, such as giving free samples to health care professionals, sponsoring travel and seminars, even giving away such items as air conditioners.

In June, the WHO called such aggressive marketing tactics "an alarming threat to child survival" and said that in many countries in the region, "the combination of weak public health systems, slick and expensive marketing of milk formula and poor enforcement of marketing regulations have contributed to the decline of breast-feeding."

In the Philippines, more than $100 million are spent annually to advertise milk substitutes, according to a 2006 report from AC Nielsen.

The companies have largely complied with the Milk Code restrictions pertaining to formula for infants up to 12 months; what they distribute are samples of products intended for kids 12 months and older. But according to the health department and Unicef, the promotion of milk substitutes for older children is dissuading mothers from breast-feeding newborns.

"They're using follow-on milk as a backdoor," Alipui, of Unicef, said of the companies.

This is why the Health Department revised the Milk Code to include a ban on advertising and promotion of follow-on milk products, said Alex Padilla, the Philippines undersecretary of health.

To be sure, health experts say, commercial promotions are not the only factor for the decline in breast-feeding. Alipui said that formula is a convenient fallback for many Filipino mothers who work outside the home.

Moreover, although the Health Department has ordered all government and public offices to provide breastfeeding stations or at least open their clinics to breast-feeding mothers, it has been less successful in persuading private establishments such as shopping malls to do the same.

For Dones, the mother from Quezon City, it is all about changing the mind-set created by advertising - a mind-set that, according to the Unicef and the health department, forces even poor mothers to spend what money they have on formula.

"Here we are, a poor country where many families cannot afford a decent meal on a daily basis and yet spend 2,000 pesos a month on formula milk - milk whose benefits don't even come close to the benefits of mother's milk, which is free," she said. Two thousand pesos amounts to about $44. "It's amazing what those television commercials can do."