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Shared Principles of Ethics for Infant and Young Child Nutrition in the Developing World
© Singh et al; licensee BioMed Central Ltd. 2010
- Received: 30 December 2009
- Accepted: 8 June 2010
- Published: 8 June 2010
The defining event in the area of infant feeding is the aggressive marketing of infant formula in the developing world by transnational companies in the 1970s. This practice shattered the trust of the global health community in the private sector, culminated in a global boycott of Nestle products and has extended to distrust of all commercial efforts to improve infant and young child nutrition. The lack of trust is a key barrier along the critical path to optimal infant and young child nutrition in the developing world.
To begin to bridge this gap in trust, we developed a set of shared principles based on the following ideals: Integrity; Solidarity; Justice; Equality; Partnership, cooperation, coordination, and communication; Responsible Activity; Sustainability; Transparency; Private enterprise and scale-up; and Fair trading and consumer choice. We hope these principles can serve as a platform on which various parties in the in the infant and young child nutrition arena, can begin a process of authentic trust-building that will ultimately result in coordinated efforts amongst parties.
A set of shared principles of ethics for infant and young child nutrition in the developing world could catalyze the scale-up of low cost, high quality, complementary foods for infants and young children, and eventually contribute to the eradication of infant and child malnutrition in the developing world.
- Fair Trading
- Common Goal
- Exclusive Breastfeed
- Complementary Feeding
- Complementary Food
Despite potentially very large demand for high-quality, low-cost commercially produced fortified complementary foods (i.e., food given in addition to breast milk) for infants aged 6-24 months, the commercial sector has been slow to develop such products for the developing world . If industry rises to this challenge by producing affordable, nutritious products and creating demand through appropriate marketing campaigns, such an approach could result in improved feeding and nutritional status and a corresponding decrease in death and disability in the developing world. The lack of private sector participation in this area is closely linked to the issue of trust, the lack of which is a key barrier along the critical path to optimal infant and young child nutrition in the developing world.
In June 2008, the Pacific Health Summit was held in Seattle, Washington. The topic focussed on global nutrition challenges. Delegates comprised approximately 150 individuals from a range of nutrition-related constituencies. We noted that there was consensus amongst delegates that the erosion of trust among various stakeholders - for example, breastmilk advocates, international bodies such as UNICEF, infant nutritionists, pediatricians, governments, and industry - in the infant feeding arena was undermining the scale-up of complementary feeding products for infants between the ages of 6-24 months in the developing world during the critical transition period from exclusive breastfeeding to total reliance on family foods. Inspired by shared principles of ethics that have been drafted to bring diverse groups together on common concerns and issues [2–4], we proposed to draft a set of shared ethics principles on complementary feeding as a confidence-building attempt to seed trust amongst stakeholders involved in the infant feeding arena.
The Shared Principles of Ethics for Infant and Young Child Nutrition in the Developing World described herein is intended to unite stakeholders in a shared vision and common goal: reduce and eventually eliminate childhood malnutrition in the developing world through the scale-up of low cost, high quality complementary foods, using home available or locally procured ingredients wherever feasible. The principles were drafted after a review of sources that have relevance to virtually all stakeholders and constituencies in the infant feeding arena. These include civil society codes of conduct, corporate social responsibility frameworks, governance frameworks, global health ethics frameworks, international health guidelines, consumer rights frameworks, and human rights instruments. The proposed principles are intended to complement and supplement existing laws, trade regimes, international Codes, and international goals (see Additional file 1). In this paper, we outline our proposed shared principles for stakeholders in the complementary feeding arena.
Benefits of complementary feeding for infants aged 6-24 months
The World Health Organization recommends exclusive breastfeeding for the first 6 months of life, and continued breastfeeding until two years of age. However, after 6 months, breast milk alone is inadequate to meet dietary needs, both in terms of calories and vitamins and mineral of growing children. Therefore, WHO also recommends after 6 months the introduction of nutrient rich complementary foods .
Optimal breastfeeding could save about 1.5 million lives per year, almost all of which would be in the developing world. Evidence also indicates that micronutrient-enriched complementary feeding amongst infants aged 6-24 months play an important role in countering micronutrient deficiencies and could play an important role in lowering childhood mortality [6–9]. The Copenhagen Consensus is a process whereby economists conduct cost-effectiveness analyses of various interventions to tackle global problems (and not just in health). For the 2008 Copenhagen consensus - which focused on infant and child nutrition - over 50 economists worked for two years, and presented their arguments to a panel of eight top economists, including 5 Nobel Laureates, who assessed the research and made the final selections. After considering more than 40 proposed interventions to counter infant and child malnutrition, the panel proposed its top solutions with estimates of costs and benefits. The top two were: (1) Micronutrient Supplementation, involving the provision of Vitamin A capsules and therapeutic zinc supplements for under two-year-olds. This would cost a total of $60.4 million annually, with benefits worth more than $1 bn yearly (benefit cost ration [BCR] of more than 17:1); and (2) Micronutrient Fortification, which would entail the provision of iodized salt and iron; This would cost $286 million annually, while the corresponding benefits are $2.7 bn (BCR of 9.5:1). Although the provision of micronutrient supplements was ranked highest amongst proposed interventions, the panel recognised that its provision, alone, wouldn't suffice to counter infant and child nutrition. Rather, it would ideally be part of a package of neonatal care, which would include de-worming, nutrition screening, and measles vaccination. The provision of affordable, commercially produced complementary foods could also provide needed micronutrients but would necessitate buy-in from all stakeholders involved in the infant and child feeding arena. This may be challenging given the erosion of trust in this sector.
The erosion of trust in the infant feeding arena
Trust entails "a firm belief or confidence in the honesty, integrity, reliability, justice" as a condition of some relationship . The defining event in the area of infant feeding is the aggressive marketing of infant formula in the developing world by transnational companies in the 1970s. This practice shattered the trust of the global health community in the private sector and culminated in a global boycott of Nestle products. This boycott persists today in at least 18 countries .
In response to such marketing practices, the World Health Organization drafted the International Code on the Marketing of Breastmilk Substitutes  in 1981, The Code recommends, amongst other measures, restrictions on the marketing of breastmilk substitutes, such as infant formula, to ensure that mothers are not discouraged from breastfeeding and that substitutes are used safely, if needed., However, evidence that some transnational companies have continued to promote substitute feeding products over breast-milk [15–21], in violation of the International Code, has further stigmatized the private sector in this arena. The resulting anti-industry sentiment in some quarters has unfortunately distracted attention from the potential value [6–9] of complementary feeding products for infants aged 6-24 months. Moreover, past transgressions of the Code on the part of industry related to both formula promotion has have fuelled suspicions that industry will exploit the opportunity to promote complementary products to push supplementary products for infants aged under 6 months of age. This is true for companies who have been in violation, and even those who have not. There has been a "chilling effect" on companies getting into the complementary food for 6-24 month space. Industry, in turn, has become suspicious of breast-milk advocates and activists, seeing such parties as hostile to their business interests and unnecessarily wary of their humanitarian goals.
Consequently, industry has been reluctant to play a meaningful role in scaling-up complementary products in markets where there is relatively small profits, for fear of harming their global brand. This, in turn, may be reducing human capital potential given the important role of adequate nutrition in the 6-24 month period for growth and development.
To begin to bridge this gap in trust, we developed a set of shared principles as a starting point (see Additional File 2 for the proposed principles, without the accompanying commentary).
We recognise that no set of principles is a panacea that will automatically restore trust in a situation where it has been lost, such as in the infant and young child nutrition arena. However, the shared principles of ethics set forth herein can create an enabling environment for those who must work closely together to save lives, to begin to do so. There is a huge opportunity cost (i.e., the best alternative that is forgone because a particular course of action is pursued), measured in millions of lives, of not collaborating and engaging the private sector in scaling up of infant and young child nutrition. The shared principles of ethics outlined here are a modest attempt, but a start that might bring to the table people who normally rarely find themselves in the same room. We are also aware that our approach may very well not work if any of the parties does not genuinely want dialogue, believing that their current approach is serving them well. It is our hope that in making such principles explicit, the shared principles of ethics can serve as a platform on which various parties in the complementary feeding arena, and the broader arena of infant and young child nutrition, can begin a process of authentic trust-building that will ultimately result in coordinated efforts amongst parties. We also hope the proposed set of principles and their subsequent evolution will catalyze the scale-up of low cost, high quality, complementary foods for infants and young children, and eventually result in the eradication of infant and child malnutrition in the developing world.
We are grateful to Jocalyn Clark for comments throughout the writing of this paper. We are also grateful to Katharine Kreis, Ellen Piwoz, and Shelly Sundberg for their helpful feedback.
This paper was funded by a grant from the Bill & Melinda Gates Foundation through the Grand Challenges in Global Health Initiative. JAS is also supported by the Centre for the AIDS Programme of Research in South Africa (CAPRISA), which forms part of the Comprehensive International Program on AIDS funded by the US National Institute of Allergy and Infectious Diseases.
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