Everyone, you're all very welcome. We're just about to start the live stream so I'm going to kindly ask you to pause your conversations or at least reduce them to whispers and to put your phone on silent and yeah to get ready and take some notes to ask later on we'll be having a Q&A after the live stream ends so write down any thoughts you have as the event is proceeding but we'll be kicking off in one minute once Angelos gives me the thumbs up so I'll just stand here awkwardly until then. It's okay with you. Hello, a very warm welcome to you all, to you here at the Royal Society of Medicine in London, and to everyone joining from online around the world for this very important event, the 2023 Lancet Series on Breastfeeding. My name is Catriona Devereaux and I am an Irish documentary maker and science communicator and I've been making factual programming about health, science and the environment for 20 years.
And I'm also a mother of two and a voluntary breastfeeding counsellor with the Parent Support Order. organisation in Ireland. So I am thoroughly honoured to be guiding proceedings today to help unpack and unpick the three papers which really underline how aspects of politics, economics and wider society contribute to why less than half of infants globally are breastfed as recommended.
There has been huge interest in this event with in-person tickets gone in less than a day and so many joining online from around the world. It's really not surprising because more breastfeeding is critical to addressing a lot of the problems facing the world at the moment, from health inequality to racial injustice to environmental protection. These papers are detailed and thought-provoking and enraging and saddening in parts, but we'll get to all of that later.
It's really important to say that these papers and this event are not about infant formula as a product or criticising families who can't or choose not to breastfeed. Infant feeding is a highly emotive subject because... many families have not breastfed in the past or have experienced trauma in trying to breastfeed or stopping sooner than they expected to. No one who desires to breastfeed takes the decision to switch to formula lightly and I think it's really important to recognize that. The Lancet series is about unraveling the reasons why the great majority of women choose to breastfeed but are being prevented from doing so.
The papers shine a light on the tactics of the commercial milk formula industry which is driven by the fact that the health care system is not the only one that is driven by the pursuit of profit to the detriment of public health. Just to say that this event will be recorded and it will be available on the WHO website in the coming days. And we really want you to start a worldwide conversation about this issue, so I encourage you to share your thoughts and reactions and spread the word on social media using the hashtag protect breastfeeding.
We have a full agenda to learn about these papers and to hear the reactions from the panel of experts, so let's get going. First up, to explain why the Lancet are supporting this work please give a very warm welcome to its editor-in-chief Richard Horton. Well thank you very much for that welcome and thanks to everybody for coming today.
It's a it's a real pleasure for me to see so many of you in the room some old friends Patty. In a previous life, 2012 through to 2015, I was involved with WHO in a project on accountability. And every time we took public evidence...
for Women's and Children's Health. Patty was always there encouraging, let me put it politely like that, encouraging us to take this issue more seriously. It's taken us a decade, Patty, so I apologize that it's taken us a decade, but finally we're there. I'd like to just say how pleased I am to have worked with colleagues at the World Health Organization and CAP 2030 on this important series.
A huge thank you to. to the authors, Nigel. I remember us sitting in a room at the Lancet pre-pandemic and you were plotting this series and you've navigated it brilliantly. So thank you to you and Dave and all of the colleagues who've made this possible. To the speakers today, to our wonderful panellists as well.
In fact, the launch of this series on breastfeeding is actually a series of launches, not just one. We're in London today but there's a a launch for Southeast Asia tomorrow, a launch in South Africa on Friday, and in the Pacific region next Tuesday. I'd also like to thank all of my colleagues at The Lancet for their careful attention to the series, from peer review, the infographic that you'll see on our website, and the production, dissemination, and promotion of this series, which is so important. It's not just about putting an issue on a shelf, it's about making it do some work. Now I'm actually mildly anxious about making some brief opening remarks this morning because I've already been attacked on Twitter because somebody very kindly said they can't wait to hear Richard Horton mansplaining about breastfeeding So I'm not going to mansplain about breastfeeding Instead I'm going to confine my remarks to three...
Fairly simple points to try and frame the series. The first point I'd like to make is a contextual issue. The near universal institutional commitment... to and consensus around universal health coverage has been extremely welcome.
For too long, we did not pay enough attention to how we strengthen health systems. to deliver the Alma-Arta goal of health for all, and universal health coverage is one means to do so. But the commitment to universal health coverage has, I'm afraid to say, come at a significant cost, because in the Millennium Development Goal era, there was a laser-like attention and concern that was directed to women's and children's health.
Remember, MDGs... four and five and that was exemplified by the then UN Secretary General Ban Ki-moon's signature health initiative every woman every child which opened checkbooks from countries around the world and delivered many tens of extra billions of dollars for investment in women's and children's health but since the end of the MDG era and the beginning of the SDG era and the focus on universal health coverage, I'm afraid to say that the spotlight on women's and children's health has dimmed and that dimming is, to put it politely and diplomatically, more than regrettable. It's actually been a major setback for women's and children's health. Breastfeeding occupies a critical place in the health of the child and his or her mother and so this series, to my mind, one additional purpose of this series has a larger goal of drawing neglected attention to women's and children's health. A second observation in the Lancet's 2020 Commission on a Future for the World's Children and it's wonderful to see the leaders of several of the leaders of that Commission here in the room today was actually chaired by Helen Clark and Awa Kolsek.
They identified identified predatory commercial practices as increasingly threatening the future health of children in every country of the world. And the Commission identified the exposure of children and the threat they face to advertising from businesses whose products do harm the health and well-being of those children. The series we're publishing today takes that finding a step further, a big step further, by examining what is nothing less than the scandalous practice of commercial milk formula companies. What this series shows, in essence, is how the present and future health of our children is manifestly harmed by an exploitative industry that really...
really represents the unacceptable face of capitalism today. The third point I will make, and this is where I stray into my anxiety-provoking territory, although I hope it doesn't cross the threshold of mansplaining, it does remain true today that still too many children are dying in the first month of life. UNICEF's motion... most recent data that came out at the end of last year, beginning of this year, 2.3 million in 2021. That's over 6,000 newborns dying every single day.
And early and exclusive breastfeeding up to six months has a very, very important part to play in reducing exposure. among those children to contaminated food pathogens in contaminated food or untreated drinking water so children in low and middle income country settings who are not breastfed have a much higher risk of morbidity and mortality from diarrhea and pneumonia so All of us need to think about what more we can do to support women, to support families, to support communities in delivering safe and effective breastfeeding for children and mothers. That's all I want to say at the beginning. Thank you very much for coming today here in person and online. And so now let's dive into the detail.
Thank you very much. Thank you. Thank you so much Richard for setting the scene so well for us. We are going to dive into the content of the three individual papers now and please do welcome in order to help us to do that. We're going to be joined by Nigel Rollins from the Department of Maternal, Newborn, Child and Adolescent Health from the WHO and from the United Nations Universities International Institute for Global Health.
Professor David McCoy, a warm welcome please. Thanks Katie and to everyone for coming today. I first want to acknowledge the authors of the series, 25 in total from 12 different countries and I would also mention that there will actually be a further launch in South Africa. as well.
I would also like to thank the Lancet in particular for the opportunity to submit the series and going through the review process in such a constructive way and the staff here at the Royal Society of Medicine for their support in today's event. Infant feeding matters and as part of that breastfeeding is crucially important. In 2016 the first Lancet series on breastfeeding described just why that is so.
For those of you who may not be so familiar breastfeeding has a very significant influence on human systems biology that has lifelong impact on health and development. It's true for infants in low, middle, high income settings alike. Breastfeeding also affects maternal health reducing the risks of breast and ovarian cancer and at a simple crude level survival the 2016 series estimated that if all children were actually breastfed according to WHO recommendations then around about 800,000 child deaths will be prevented every year this series has come to be because of the observations by many that over the past 20 years infant feeding practices have changed and the recognition that globally fewer than half of all infants are fed according to WHO recommendations. So it's a really important issue. Two points on terminology.
We use the term commercial milk formula CMF instead of the term that is often used breast milk substitute. First to highlight the artificial and ultra-processed nature of all formula products but also because the term substitute conveys the notion of equivalence and the 2016 and this Lancet series show how the evidence has strengthened and our understanding deepened about how breast milk is different from formula products and the impact on human health. Second to clarify what we mean by marketing we refer to any form of commercial communication or activity that's designed or has the effect of increasing recognition, appeal, consumption of particular products.
and this includes advertising distribution promotion lobbying and sponsorship but it does not include the transportation or sale of the product itself so this is not about removing formula milk from the shelves of supermarkets or restricting access this is all about the marketing practices and there are four main messages that we distill out of the series the first is that breastfeeding success is a collective responsibility It's not the sole responsibility of women themselves. There are many externalities that constrain practices, and if we want improved infant feeding, then we need both societal and policy responses to support individual women and families. The second thing this series does is to take a deep dive into infant behaviours.
Like learning to walk or speak, sleeping and crying have normal trajectories. But these behavioural cues are... easily misrepresented or reframed. The third thing is that formula milk marketing influences our beliefs, our values, our practices.
It has negatively changed the infant feeding ecosystem. However, the extent of influence and both the power of marketing and the power to market has not been fully appreciated by those in health, civil society and government circles. Last, There are many constraints on women who decide to breastfeeding and it's the responsibility of government to implement structural interventions, policies to both support breastfeeding and also mitigate negative undermining influences. come to the first paper in the series breastfeeding is crucially important but increasingly challenged in a market driven world the paper starts with a conceptual framework that depicts the interactions ranging from the political and economic but especially the mother and infant relationships and their impact on exclusive and continued breastfeeding it documents how these interactions drive practices and what would be the policies and interventions to support breastfeeding like many paper published in the Lancet it is supported by robust methods analyses of nationally representative surveys systematic reviews case studies and so some insights from the papers The first big message is about the late initiation of breastfeeding globally and the early introduction of pre-lacteal feeds.
That's giving liquids such as water or formula milk before starting breastfeeding. We see in the figure on the left, the blue horizontal bars represent the proportion of infants initiating breastfeeding within the first hour of life as recommended by WHO. Less than half of all newborns are put to the best within the first six months of pregnancy. 60 minutes.
Now these data come principally from low and middle income countries because we don't actually have good data from high income countries but the probability is that these numbers would be even worse. On the right we see in all settings a clear correlation between giving any pre-lacteal feed and breastfeeding. Where you have higher rates of any pre-lacteal feed, that's the top left hand corner, you have low rates of early initiation of breastfeeding on the egg.
x-axis and this is associated with shorter durations of breastfeeding and increased consumption of formula products. As I mentioned paper one examines infant behaviors in a way few other publications have done so. So the first thing to say is that human babies are born in an immature state that's not a surprise to us but they remain in that immature physiological and behavioral state for longer than just about any other primate. That means there's a significant process of post birth maturation so it takes time and actually support for young babies to learn to feed to settle and sleep sleep patterns of babies as we all know don't align with the patterns that we have as adults newborns express their discomfort through crying and that signals the need for help and care so crying is adaptive it communicates many needs not just hunger the problem is not parents who are tired and anxious themselves, it's a very difficult time to understand and read those cues well.
In a systematic review of reports from 22 countries, different income levels, among healthy young infants, normal behaviours like regurgitation or crying are common. At least 50% of infants posset or regurgitate. The average time that normal babies cry or that parents label them to be fussy is about 2 hours each day.
day. And those are understandably distressing for parents, but they are not abnormal. And consistently, this undermines parental self-efficacy. And so it's no surprise that women report how their infant's behaviour shapes their assessment of their own milk supply, and how crying, fussiness, poor sleep undermine confidence. But it's not only the mothers, it's also the partners, family members, health staff who misinterpret.
misinterpret those cues. In these analyses, self-reported insufficient milk is the single most common reason given by 45% of mothers globally for first introducing formula milks in the first six months and by a third of mothers for actually stopping breastfeeding. The irony is that the same evidence shows how effective counselling and support really does help parents understand those normal behaviours and improve breastfeeding. The flip side is seeing how What is considered normal is being used as a marketing opportunity. New parents are legitimately concerned about those maturing baby behaviours, but maybe aren't understanding the cues.
We documented how marketing... frames these behaviours, the baby's crying too much, not sleeping because they're still hungry, and it presents them as abnormal, pathological, or that mothers are somehow inadequate. If you're not sure whether you have enough milk, then maybe your baby needs formula. If your baby has a rash or cries or is unsettled, maybe they have an allergy. So these inferences, these innuendos, are setting the stage to offer products as solutions for peace of mind.
of mind or certainty. And without skilled support and reassurance, parents change from breastfeeding to formula milk or from one formula to another. What we see in a series of case studies, however, is that where countries make investments, they can improve exclusive breastfeeding rates. In Burkina Faso, Mexico, the Philippines, the USA, we see a range of interventions, creation of mother support groups, landscape analyses to inform...
policies, strong position statements from academics, extending paid maternity leave, using data effectively can all result in improved rates. And this then takes us into an examination of the marketing of formula products. The title is provocative, a system to capture parents, community, science and policy, but we think it's justified.
The objective of the paper is essentially just to describe the marketing playbook. and its influence on people, families, health professionals and also the scientific and policy world. And again multiple methods were included that you can read in the paper.
And there are three major learning points. The first is that marketing practices are multifaceted, they are sophisticated and they're very well resourced and because of that they represent a powerful system of influence. It's not just a matter of some advertising here or bit of lobbying there together they come together to influence civil society health professionals and policy and regulatory environments and this system is made even more influential through digital systems the marketing playbook for formula is not actually all that different from what we see for other products like training shoes various foods or drinks what's different is that infant feeding has consequences for lifelong health and development and marketing infringes the the rights of children and families.
They also represent a violation of the International Code of Marketing of breast milk substitutes. Formula milk is the only food product where the UN World Health Assembly, the world's member states, where they have come together, expressed their collective will and put it down on paper. And marketing works.
It has been successful over decades to reshape individual societal and medical norms and values. So as with paper one we started with a conceptual framework and there's really only one point that I want to highlight and it's right in the middle that everyone is a target of marketing. Individuals, health professionals, governments, politicians, we are all targets and the objective is to shape our values and beliefs and alter our decisions.
On the left there are two figures. The bottom figure shows how sales per capita of all formula products are increasing. These are not just the total sales over time the past 15 years, it's sales per capita, the kilograms sold per infant. Across all four categories of standard, follow on, growing up formulas, specialised formulas, they're all increasing.
And that's why we can say that more infants than ever are receiving these products. The top figure shows the relationship between breastfeeding rates and formula sales per capita and the relationship is simple. Where you have higher sales of formula on the top of the x-axis, on the right of the x-axis, we see lower rates of breastfeeding at 12 months. In 2019 these data translated into annual sales of formula products to the tune of 55 billion dollars. Now there are many reasons for these changes.
Preferences of families, work constraints, and mothers, perceived insufficient milk, and poor support from health systems, but there's no doubt that marketing is a major influence as well. And in our analyses of industry data, between 4 and 7% of annual sales are spent on marketing and sometimes much more. That means for 2019 around 3.5 billion dollars was spent by industry on marketing and we know that this is an underestimate because this does not include lobbying, social media and sponsorship of health professionals.
As I said the title is provocative that marketing aims to capture parents and communities however I'll show you quotes now. from some of the 8,500 women in 8 countries and how they reflect marketing messages or suggestions. A mother in Mexico. All those scientific acronyms like DHA. You don't know what it is, but it sounds cool.
It's supposed to be a nutrient that goes down the drain. directly to the baby's brain. The mother in Vietnam who believed that, if I want to promote brain development or height, then she would purchase a specific formula.
Their beliefs have been captured. In South Africa, the mother liked the premium brand, the gold expensive look, conveying the sense of quality or it was somehow unique. And for that product, she will pay a premium price.
The mother from London sharing how ads popped up out of nowhere, cookies being used to identify when women are pregnant and anchoring a strategy of targeted messages. The process of capture. And we see the same joined up strategy in packaging now these are just illustrative mock-ups of actual packaging industry invests in the science of communication and semiotics everything is deliberate the colors used the little scientific emblem the language of comfort specially formulated for babies who are fussy, have colic or crying, appealing to the aspirations and parents'values, great start, the gold colour for premium babies, the baby with glasses who's going to be smarter quicker.
And these messages and strategies are very deliberate. At a trade meeting in 2017, the CEO of one company said that infant nutrition wasn't necessarily a bad thing. about ingredients or innovation. What they were selling was sleep.
Another panelist in the meeting said they were selling peace of mind, presumably to parents who had anxieties or specific hopes. Health workers are an important target. In marketing terms, they would be referred to as category entry points. For those of you in the UK or maybe Europe, if I say George Clooney, you possibly think of Nespresso. If you're in the US, and I say Michael Jordan or Serena Williams maybe you think Nike they are category entry points because as we saw in the interviews of those eight and a half thousand women if a health worker recommends a formula products then families are highly likely to follow that recommendation health workers are important because in all regions they are cited by families as being key informants about infant feeding but sponsorship of health professionals sponsored their research their guidelines are means of influence which actually most health professionals and associations believe that they are somehow immune to but these constitute clear conflicts of interest the figure of the echo chamber on the right is part of a stakeholder mapping that was undertaken in South Africa by a marketing company on behalf of a major formula producer they positioned the scientific and academic community at the center of their echo chamber and in the original there were specific names of individuals because they know that if they can influence the scientific and academic leaders then it influences their professional organizations spreading to the broader health community and ultimately affecting consumer behavior lastly we say that marketing captures policy and international recommendations none of this is happening in a vacuum international policy frameworks are being manipulated to decrease their effectiveness And we see this in the systematic reviews, the case studies and analyses of public access information.
The International Code of Marketing of Breast Milk Substitutes, agreed by the World Health Assembly in 1981, is in different ways blocked. reinterpreted, circumvented, ignored. The Codex Alimentarius is another critical international regulatory framework established to protect consumer health and the evidence is clear there as well how it is manipulated by to establish weak standards. In its marketing industry capitalises on the lack of implementation of maternity leave that protects breastfeeding and we see the effect of lobby groups as they influence policy environments that shift things. in favour of shareholder interests.
To be clear, marketing is not inherently bad, nor are these conclusions anti-profit. But what we have pieced together is a more complete picture of marketing than just advertising or occasional sponsorship of health workers, and we see the effects on policy investment and regulatory bodies. In particular, I want to highlight that a criticism of industry and its market is not a criticism of women, their decisions or circumstances, nor is it about trying to remove formula products from supermarkets. What we see is that industry deploys a system that is strategic, deliberate, very well resourced to turn the birth of an infant and the care of parents into a business opportunity and this undermines breastfeeding and human rights. So, the UK government is now going to to describe another set of perspectives and the findings of paper three.
Dave. Thank you, Nigel. So paper three is a political economy analysis, and it's one that's organised around this framework.
So at the top here in the grey boxes, you can see the tension between breastfeeding and commercial... feeding and its direct impact on health and on the social economic and environmental outcomes that affect health indirectly at the bottom in the blue box we have the political economic social and tech technological structures of society, including its institutions, its dominant ideas and beliefs, and the distribution of power and resources across society. So these are upstream and basic determinants. They are then linked to infant feeding practices and outcomes by looking at their influence in three selected domains of society, labelled in the yellow box. The first is Comus, where having described the power of...
in Paper 2, we look at the industry's Power 2 market. The second domain, Care and Work, focuses on gendered power systems and how society values breastfeeding. And the third domain looks at why health systems still fail to effectively promote, support and protect breastfeeding. And finally, and crucially, the pink box on the right looks at the agency mandates, interests and capabilities of different actors in both shaping and and being shaped by the factors in the blue box, and their actions and impacts across the three domains. As with papers one and two, paper three draws on an extensive literature and on primary research that's been published elsewhere.
So let's begin with domain one. Sir Nigel's already described the staggering growth of formula sales, but what's also important to understand is that these markets are highly concentrated. Six companies control over 60% of the global market. Furthermore, Formula is highly profitable, with research pointing to profit margins in excess of 20%. Now, these features of the market are important because they underpin the enormous economic power of Formula companies.
Indeed, collectively, the four biggest companies generate revenues greater than the average. than the GDP of all but 61 countries globally. They own assets that are more than the private wealth held in every African country bar South Africa.
And their workforce, which excludes the employees of advertising companies, legal firms and professional lobby groups that are hired by these companies, is bigger than the combined health workforce of South Africa, Zimbabwe and Lesotho put together. Now, understanding the economic power. the industry is crucial not just because it underpins its marketing power but because it also underpins a powerful and sophisticated political strategy This includes seemingly benevolent and public-facing corporate social responsibility activities aimed at purchasing social legitimacy and capital, and more covert action aimed at co-opting opponents and undermining implementation of the code. Much of this is carried out by extensive international and national lobbying networks that include a variety of industry funded front groups, food, beverage and grocery associations and the dairy industry. And efforts to curtail the regulation of marketing are also supported in international trade forums and at the Codex Alimentarius by formula and dairy producing states, notably the US, the EU, Australia and New Zealand.
And we also describe in the paper formula industry's involvement in multi-industry alliances to further corporate interests in general. general, including lobbying the US government to defund the World Health Organisation while undermining WHO's public health mandate and scientific credentials, even in the midst of the Covid pandemic. If the power of formula companies relative to governments, public health agencies and children and mothers is a problem, we have to understand how that power is accrued and how it may be curtailed. Globalisation and the integration of markets and supply chains is part of the story. But so are neoliberal policy approaches that have privileged deregulation at the expense of public health, that have commodified and marketised more aspects of life, including the care of children, and that have expanded the power of finance capital and the drive to extract profits in ever more aggressive ways.
International tax competition avoidance and and abuse, coupled with ineffective anti-trust measures, have also shifted power away from people, parliaments, regulatory bodies and public services towards transnational corporate and financial actors. And finally, formula companies are aided by the fact that the costs of not breastfeeding are externalised and paid for by others. This includes the health-associated costs that we're familiar with, but also the costs of of considerable environmental damage from plastic bottles and formula packaging, and the additional greenhouse gas emissions involved in milk production and the manufacture and transportation of formula.
This graph essentially shows how the increasing profits of the industry are accompanied by a trend of declining tax contributions. And because much of these profits end up in high-income countries, while the harms disproportionately burden people in low-income countries. low and middle income countries, the industry can also be characterized as neocolonial and is undermining sustainable development and worsening global inequalities. Let's move to the second domain. Across the world households are increasingly forced to live in systems that devalue or undervalue the time required to provide proper care to infants and children.
Care work in general is central to human survival. and flourishing and mostly done by women, but it's completely ignored by mainstream economic accounting, despite the fact that the value of unpaid care work has been estimated to be the equivalent of between 20 and 40 percent of GDP. Similarly, breastfeeding is rarely included in official food production accounts, despite the monetary value of women's milk production globally estimated to be around 3.6 trillion dollars.
So this treatment of breastfeeding as a free or costless activity or as a lifestyle choice, while formula is counted as meaningful food production and included in GDP calculations, is completely perverse. It undermines breastfeeding and it fosters a dependency on formula and helps divest governments of their responsibilities for safeguarding the rights of children and women. Indeed, the coverage of maternity rights protection and the provision of maternity protection in the United States is a key factor in the development of the system. provision of breastfeeding support in the workplace remains dismal and inadequate, making it difficult or impossible for millions of women to breastfeed.
A problem only compounded by the rising levels of women working in precarious and underpaid work in both the formal and informal sectors. Finally we come to the health domain. Where we raise three interconnected issues. First, we highlight the problem of patriarchal and biomedical cultures that hinder culturally sensitive and woman-centered maternity care, that encourage intrusive and interventionist obstetric practices that undermine breastfeeding, and that contribute to the gross lack of attention to breastfeeding in the training of health professionals. Second, we note the rise and normalization of public-private partnerships and the increasing private...
privatisation in health systems as trends that foster an inappropriate and unquestioning acceptance of commercial influence over health education, research and clinical guidelines despite clear conflicts of interest. Finally, we identify inadequate public budgets that leave health systems under-resourced as a major structural barrier to breastfeeding. We argue that greater amounts of public finance and investment can be generated by the use responsibly and without causing economic instability echoing the same conclusions made by w-h-o's Council on the economics of health for all so that's paper three in a nutshell as you can see we've covered a lot in this series and each paper has its own set of recommendations but they can be more or less boiled down to the following first parents health professionals in society more broadly must be empowered with correct information about infant behaviour and breastfeeding and the support needed to breastfeed.
Second, there must be stricter regulation of marketing. Indeed we call for an end to the commercial marketing of all food products for children, whilst also calling for the continued strengthening of code implementation. Third, everyone should have a better understanding of the formula industry as a whole. including the sophistication of its political and marketing strategies and its broader social, economic and environmental negative impacts. Fourth, we know that baby-friendly, woman-centered and culturally appropriate maternity care will improve breastfeeding rates, so proper investment in trained and empowered health professionals with the elimination of conflicts of interest is a must.
Fifth, it's wrong that so much of the work and responsibility for breastfeeding is left on the shoulders of mothers and women. The value of care work must be incorporated into economic accounting systems and policies, the unbalanced gender distribution of care work must be corrected, and investment in maternity protection and baby friendly work environments must be prioritised. But finally, unless the imbalance in power between actors with an interest in expanding formula consumption and those with a duty and mandate to protect the rights of children and mothers is corrected, little will change.
Now correcting this imbalance is ambitious and may be considered by some as unrealistic, but we believe that it's possible. Thank you. feeding but it's not only about infant and young child feeding. It's about the impact of commercial interests on child development and society more generally.
It's about the economic power used by the formula industry and the detriment to health and rights. And so I'm sure we'd probably all join in a vision where we would long for a world where parents and families are really supported in the care of their infants and where breastfeeding is robustly promoted and supported and protected at all levels. Thank you very much. Thank you so much to Nigel and Dave for that powerful presentation and for distilling so much into that and all the core aspects of those papers and I heard a lot of hums of approval and a few silent fist bumps just to hear it being said out loud because it's important stuff.
So now I'm going to invite our expert panel on stage to hear their thoughts. You can pop up and let me introduce them as they are taking their seats. We have, first of all, from Durham University's Infancy and Sleep Centre.
we're joined by Professor Helen Ball. Next, from MNC Satchie World Services, we have Katie Gilbert. You're very welcome. Next, we have pediatrician, health campaigner and broadcaster, Dr. Goodie Singh.
And finally, MP for Glasgow Central and member of the All-Party Parliamentary Group on Infant Feeding and Inequalities, Alison Thewlis. You're all very welcome. You're here. And look, Nigel and David left us an extra two minutes.
Thank you. Helen, I'm going to come to you first. You're an expert in impaired infant sleep and a newborn pager.
And I suspect the first question you're ever asked by anyone when you introduce a stud is, how do you get a baby to sleep? I'm not going to ask you that. Thank you. I'm going to ask your thoughts on paper one and that cultural discordance between cultural and parent preferences for sleep and babies in age biology. Well I think the authors of paper one you know hit on a very pertinent example when they talked about how parents understand infant sleep.
So, you know, as an anthropologist thinking about babies from a biological and an evolutionary perspective, we know that they're kind of immensely immature at birth and their brains have got a huge amount of development to do over the course of the first year. And their systems for sustaining sleep, their circadian cycle, all of these kinds of things aren't developed for several months. Yet parents...
have been led to believe over the years that babies should be able to start sleeping for the night from a young age that babies aren't going to need feeding at night after the first few months and we know for breastfed babies that absolutely isn't true so it's about expectations and parents having realistic expectations and how are they supposed to get that information so you know one of the things that we have done in our work is try to make that information available to parents. via the web, but health professionals need to be trained in that. Health professionals get very little training around things like infant sleep.
So health professionals need to have this information in order to be able to pass it on to parents. But it's part of the cultural milieu in which we're embedded, that we have this set of ideas about what babies should be like that actually don't reflect reality. So what you were reading in paper one, were they familiar lines that you see in your research?
Very familiar. I mean, I've been working doing this kind of research for 30 years and in one of our very first studies I published quotes directly from parents saying we found that our baby was not sleeping well at night so we switched a formula. Breastfeeding wasn't allowing our baby to get a good night's sleep or for us to get a good night's sleep.
And it's, you know, it's about parents understanding that you will get as much sleep but you will, it will be more fragmented. and how to deal with that and how to put strategies in place to cope with that. Katie, I'll come to you. You're a behaviour change expert and communications expert.
In relation to paper two and the comments around marketing preying on parents'anxieties and aspirations, what were your thoughts on that? I was shocked, but I can't say I'm surprised. So I worked for a decade in the commercial sector before I decided to harness those skills just for working on health and social issues. And I think one of the things the commercial sector... teaches you is to unlock the ultimate why that can build the strongest bond between your consumer and the product or service so for example when you're selling beer you're not selling beer you're selling and bonding and belonging when you sell You're not selling chips, you're selling happy meal times where mum and dad can have a break because kids are fussing what's on their plate.
So I thought it was really interesting with what Nigel shared, talking about the CEOs saying what we're really selling is sleep here, or what we're really selling is peace of mind. sell it with the messaging and the little cues like quiet comfort it's well when do you sell that at 3 a.m. when mum and dad are exhausted that's when you message on social media or if a parent's desperate for some speak to who's on the other end with the helplines so I think it's really interesting for us to think about how they're doing it and as a result I think there's two types of conversations we need to have off the back of these papers one is how do we stop it how do we stop this unethical pervasive but the other thing I think is should be a reflection point for the breastfeeding community as well about why we're not doing some of these things in the same way I found moving from the commercial to the development sector is the development sector are full of lots of health professionals that want you to do the behaviors for the same reasons they believe that you should be doing it um and it's interesting we just did a project in unicef looking at early child development about getting people to do the behaviors because of development child development others was about doing it out of love and Love messaging performed better because if you're in a low resource setting, you're not necessarily thinking about next week or, you know, you're thinking about that day and you might not have enough food, that sea of love.
I think it's interesting thinking about the messages of sleep as well. Sometimes we neglect the immediate reasons. why people would be doing a behaviour.
So I think, yeah, those two types of conversations I think we have to have off the back of paper two. And Goody, did you see a lot of things that you recognised in terms of commercial milk formula marketing across the papers? Yeah, this is actually quite a personal thing for me because I recently became an auntie and my brother had his first baby a few months ago and of course, I've answered on everything from nappy contents to the shape of this baby's head.
Lucky you. I know. But I've also been asked about my baby. feeding of course and this is despite them living in a medium-sized city they gave birth in a university hospital and it turns out that the advice that's given to new parents feeding is either lacking it's inconsistent and in some cases it's downright dangerous and this is 2023 Now, this is a shame because I'm a neurodevelopmental specialist and I know that breast is best.
For almost every health and developmental outcome, breast milk confers huge benefits to newborns. The advice given by health professionals, particularly the biomedically trained doctors amongst us, is more about getting people home than it is about establishing breastfeeding. We've heard that worldwide, under half of women are given birth...
at birth are given breastfeeding counselling advice. Now doctors, even paediatricians like me, are taught next to nothing about breastfeeding. But we are from and courted by the pharmaceutical companies that are making infant formula. Now this is not to say Formula milk does not have an important role to play in neonatal health.
It absolutely does. But under the combined pressure of marketing and messaging from doctors and midwives, a partner could easily have caved in and used formula when there was no need. So what if it had been different? What if?
Like so many of my patients who are from some of the most deprived and marginalized communities, time, knowledge, and ease means that it is simply easier to go. Be clear, this is not about blame or shame or judging ordinary people because I don't think that's where the responsibility lies. I'm asking a very different question. What is the point of doctors telling their patients that breast is best if the conditions require to follow that advice?
Now, as a pediatrician who operates... single day. Now it turns out that children need to eat throughout their lives and not just in the first few months. So let's just think about what happens in terms of feeding beyond that time. In the UK right now more than a third of primary school kids that I will see in clinic will be overweight.
obese and research is showing that 96% of the most downloaded free apps for children under the age of five have commercial content most of which are food ads which promote high calorie low nutrient ultra processed foods which happen to be more affordable on average than whole foods, fruits and vegetables, and which are increasingly, and those things are increasingly hard to obtain for people who are living in poorer neighbourhoods in what we call food deserts. Meanwhile, studies are showing that fast food, sugary drinks and cereals are being advertised more in black and minority ethnic communities and in low-income populations. Commercial determinants affect every single aspect of a child's life from birth to adulthood, and I have seen inequalities widen into gulfs that are now becoming unbridgeable. You know, as a paediatrician, the job on the tin is to treat sick kids. But if I actually want to make a difference, I need to diagnose the problem accurately.
And a kid cannot be healthy if the context they are in is sick. Now, the launch of this Lancet series is important not only because it shines a light on infant feeding practices, but because it demands that the health community takes a political economy lens to get to the root of what is really making our patients sick. Yeah, I think that's really, I mean, you've hit the nail on the head.
Yes. It requires everything, doesn't it? I mean, and I think, and Alison coming to you then, I think we all recognise that politicians and elected representatives have responsibilities in terms of economic development and providing robust public health.
But, you know, there's a line in paper three which says that we have turned feeding babies into objects of commerce and trade. And it's like, I found it very emotional because you're like, we did that and how are we going to not do that? do that. Yeah and it's not even so much that we did it we've allowed it to happen and we've allowed that to develop over many many years to the point where we're now at a position where it's difficult to see how you intervene on that and I think these papers are a great contribution to how you intervene to that and I think there's an important point as well in paper three where it was talking about the the cost of women's labour and I haven't seen it set out as starkly as that that women's labour is worth 3.6 trillion dollars and I think it's really nice to have a figure to put on that because it's not valued it doesn't count up it doesn't count in GDP but formula does treating the symptoms does um but breastfeeding does not then I think it's important that that is recognized that that is rebalanced and you change that there was a comment about the kind of the negative externalities and companies not having to treat those things but the health services do have to pick those up pediatricians have to pick those up society has to pick those things up Actually increasing breastfeeding, investing in those services, protecting families from marketing, turns into a positive externality because you're improving the general health of the population by doing so and I think that's a good investment and I think having recognition of the cost and the missed opportunities of not acting is important. Counting the cost of not breastfeeding, counting all the data, valuing the care work, valuing the breastfeeding is part of the journey to get us to balance.
the books so to speak but then in terms of actually like the world's a mess I don't know if you noticed but how do we draw it how do we get the attention of legislators and politicians and all the people at these levels to recognize the importance of this issue and how do we do that as civil society organizations as health workers how do we capture people's attention well I think there is a role there for all of us as ordinary people out there in the world we all have people in the UK and others people watching from around the world we all have a Member of Parliament. We all have somebody we can pester the hell out of, because that is your job as a constituent and our job as an MP is to try and listen to that. And I know many people in this room do that a lot, because I know some of these folk in the room. And I love you all.
But the point of that is though, MPs don't always see these messages. Politicians don't always see these messages. We've got a million different things from potholes to very serious benefits. its case is in our inboxes you need to be a nuisance and you need to pester the hell out of us you need to make these issues seen to politicians and it's something that I cared about already so it was easier for me to get into this the space but pester the hell out of us that's that's your job as citizens and it's up to us to respond to that's the take-home message pester the hell out of your politicians that's one thing that we have to do but I do think that um like the competing um crises and issues that are out there like health campaigners and health professionals, I think you have a very important role in terms of leading change. Do you think so, Goodie?
Yeah, I do, because I happen to be doing a PhD on that topic. And exactly that question of, you know, what should doctors and health professionals be doing about these wider social, political and economic determinants of health? I will give you the real answer in about a year when I finish writing it up.
But until then, what is clear is that the health community cannot just acknowledge the social determinants with our words, but then fall back on all these biomedical solutions when it comes... comes to our actions. You know, it's one of those basic principles of medical science that if you want to cure a disease, you have to name it first, because you have to know what the cause is if you're going to deal with all of its consequences. So there's no getting around it. And Richard Horton mentioned the C word today.
It's capitalism, and we have to be able to say it. Now, under capitalism, human well-being is second to profit and growth. And not all politicians are even doing their job properly anymore.
And in fact, now democracy has been completely co-opted. Of the 100 largest economies on earth. 70 are corporations and not countries so who really is running the world right now and calling out the problem is important because it shifts the framing from being a health problem to being a problem of justice and infant feeding like so many of the problems that we're facing in the 21st century is really about power and so the health profession has to take this political lens to make sure that it doesn't become this technical apolitical problem anymore because these reductive responses that we've tried all this time just cannot these really complex problems. Now doctors get really uncomfortable if you mention politics and they claim that it's not their business but if politics is about who gets what, when and why then that's fundamentally about health justice and I would argue that is my business. So yes we need governmental regulation and we need limits on marketing but as we've said we all have a responsibility to hold those with power to account and to use our own power however small.
small it might be to help our patients. So I think of the way that health workers can actually intervene on this and then basically addressing social justice issues by thinking about what they can do inside and outside of health systems. Now within health systems we need to acknowledge the influence of corporate power in prescribing practices.
True professionalism demands that there can be no conflicts of interest and so our training and education has to reflect only the best evidence not the best kickbacks. But we can go further than that right? So health systems could model the world we want to live in.
Health leaders could create the conditions in which women's labour is recognised, where there's actually gender parity in pay, and where breastfeeding and career progression are not mutually exclusive, which I can tell you it is currently in the NHS. And outside of the health systems, well, we need intersectoral change, clearly, right? But given our privileged position, where we are at, where political economy and patients'lives collide, it behooves the health community to step up and to take leadership about bringing about societal transformation.
because you know what the other Sectors are looking to us for that leadership. They want us to speak out and they want us to be political. And failing to do so means that we are failing in our duty.
As doctors and health workers, we combine that moral power of civil society with that epistemic power of society. and we should be using that for social good. Now, neoliberal capitalism has not only created an unequal world through its economic policies, but it's also created a popular culture in which collective action, agency and empowerment are min... minimized in favor of a rhetoric of individual responsibility and self-interest. Yeah, we're individuals, but we're also collectors.
We're also professional associations. And we have to ask ourselves, what could we achieve if we organized around this issue? And if we made commercial practices like this unthinkable, who should we be lobbying? And how can we raise public awareness? And who in civil society should we be forming partnerships with and building solidarity with?
Now, I don't have all the answers. But what is clear from what we've heard is that this morning is that the status quo cannot continue and is not an option. I'm calling for the health profession to leap beyond the walls of our safe little clinics and to actually take that courageous stance against commercial influences in our patients'lives. If it is our ethical responsibility to take care of our patients and to protect them, then I think in this case, being ethical requires us to be political. Well said.
I think though, I totally agree with you, but I'm kind of thinking a health worker who's in the trenches in terms of what what they're doing on the front line every day in day out possibly don't have the capacity for that you know where where is the professional associations you think are the are the key to that leadership in terms of i think it's both i think you'd be surprised by the number of individual ordinary clinicians who really want to do good in the world and are not being supported by their medical institutions at the same time you know leadership comes from all sorts of areas right and it doesn't have to doesn't have to be like the lone clinician who's trying to change things you're absolutely right what are institutions like like the Royal College is doing on this? What are, what's the British Medical Association doing that? Not to mention the World Medical Association.
All of those things matter, but I think it's about us having a conversation and being allowed to actually stand up to the pharmaceutical industry and also questioning things like research funding and where we're getting support. I mean, it's really difficult to say no to these things, isn't it? Yeah, yeah.
And that whole thing that David brought up about the public-private partnerships and all that kind of thing is definitely worth exploring. Katie, I might come to you because like we're talking about an industry that spends 3.5 billion dollars and that's not just on TV ads that's on you know bespoke deep social messaging that's on all the and not even on all the lobbying everything how do we possibly tackle an ecosystem like that I think there's two ways I think the first thing for me is no one likes being misled and this is fundamentally about the fact that caregivers are being misled and I think it's really interesting if you compare other issues so we did work on hidden sugar in food and one of the things is that you have all those cereals that on the front say fortified iron etc so as a parent you think I'm doing good for my kid and when you look in the back and it says X many milligrams of sugar you don't really know what that means so we created an app where you scan the barcode and it showed the number or showed the sugar bit in sugar cubes and suddenly parents like oh no I know what sugar cubes are the 14 sugar cubes in my child's cereal and it made them angry and it got lots of media outrage created and it helped contribute to the sugar tax I think we need to raise awareness of how caregivers are being misled and encourage anger around that so that they do pester their politicians and representatives. So I think that's definitely something we need to look at, raising awareness of this issue.
I think the second thing though, as I mentioned in my previous question, is I also think as a breastfeeding community, we need to look at how we could be using some of these marketing techniques because marketing techniques aren't inherently good or bad. It depends on who's using them and for what ends. And I always think about if I had a breastfeeding brief land on my desk, I'd be thinking about what are the reasons to to believe in the product of breast milk that you could create the biggest empathy bond with the target audience.
So what mum and dad doesn't think their baby's special and unique and like no other child, yet you've got breast milk that is personalised to your baby. Messaging like only breast milk understands how unique your baby is. You know, that's the kind of things that marketeers would be doing or those, and again, I'm not a sort of health professional, so multi-purpose stem cells blow my mind.
Yes. and the idea that we can send a man to the moon etc etc but we cannot replicate that so this idea of almost nature or biological miracle that can't be replicated there's something really interesting that in terms of making it clear why it can't it's not the same as commercial milk formula so I think we can also think a bit more like marketeers when we're thinking about how we're communicating on breast milk as well it shouldn't just be that the best marketing practices are used by the commercial milk formula companies how do we give you loads of money so that you get a breast milk on your table on You're destined to go, I'm going to start tackling this now, that's what we need. But also I'd love to hear your thoughts about what that grassroots campaign or attention would look like in terms of feeling like you're being misled.
Have you any ideas about that? Well it's one of the things we've been talking about with partners in this. sector which is as we were saying this isn't an issue about the product the product has value for people that need it this is a consumer rights issue because this is about misleading advertising so that's why I mentioned the things like hidden sugar I think we need to be thinking about areas like that and how pro has been made. I really don't like comparisons to tobacco when people mention it. I think it's unhelpful because tobacco has no role in health whereas actually for some mums because of certain issues they need to use formula milk as well.
So I think we need to look at how progress has been made on those issues as well. Who's the best champions? How do we unite the civil society around this issue?
Because it's like yeah I totally agree with your point in relation to tobacco because you're it's more that you can have formula but it's not going to solve intense crying or your arching back problem. problem. And it doesn't help mums using formula to hear that they're being told this product is like tobacco.
I think you just go, I'm ignoring you because you don't get it from that mum's perspective. So I think we've got to find the right comparisons when we're talking about it. And this is so important too, even now in the middle of the cost of living crisis, because Alison, you were mentioning earlier that some of the work that you're doing at the all-party parliamentary group is about the cost of formula and that people are spending money on premium formula, which is exactly the same as the own brand formula.
nodding your head in. It's just outrageous and I think these are the kind of messages, it's not about the products we said, it's the marketing. Raise awareness of all this misleading claims and the fact that you're being missold, you're being told to buy premium when there's no difference in the formula.
I think people can get angry about this because this is about being misled and that is something that people get quite emotional about. Yeah but who's going to be putting out those messages? Well that's a question for the community as well.
I definitely think that there does need to be a sort of uniting on the messages that people are using. around these reports the advocacy ask that they're calling for one advocacy asked and I think my colleague Andy in the room was talking about this to me in the office of you shouldn't be allowed to use the same brand for the sort of nought to six months of the use for toddler milk just agreeing the advocacy ask that the global community is going to advocate to together so there's consistency of messaging I think is one of the steps that should hopefully come out of this report do you think Alison that that's very that's achievable those kind of like things about cross-marketing you know the regulation around the product and how it's sold? Do you think politicians could actually tackle that?
I'm going to say relatively easily, but like... Yeah. Some of these things are within the regulations at the moment.
It's the enforcement of these things. And the enforcement is the big gap for, in many different ways in many different areas in the UK, things are just not enforced. So moving towards enforcing these rules would be a huge big step.
Strengthening the rules, moving towards full implementation of the code, even better, because it would strengthen the protections that people have. from these rapacious companies marketing towards our youngest citizens. So there's a lot more there that could be done.
And the point around what we heard at the all-party group yesterday from Leicester Mamas, who'd done some research with some of the people that they work with, nobody was, you know, relative in the group that they surveyed, nobody was buying the cheapest supermarket value brand because it doesn't come with a marketing budget. Everyone was buying the premium brand because it's got a marketing strategy and you see the adverts on the television and you see the things on... on Instagram or on Facebook or on Twitter or whichever you're using, and you will see those and they will be marketed to you. So you think the most expensive is the best.
They're all exactly the same. And but people don't hear the other side of that message. They just see the premium advertising and think that they are buying into something better. Helen, do you think health workers can play a role in that communication around avoiding those marketing messages and also just appreciating what? normal newborn behavior is and it's not going to be solved by your product yeah i think what katie said is exactly right that that people need to have awareness we need to help people understand how their anxieties are being exploited around some of these issues um and and you know there are there are multiple ways to do that the baby friendly initiative is one of the ways it is trying to educate health professionals to to convey that information to to parents and and you know trained lactation consultants also but one of the things that has happened though over the course of the last decade is that the opportunities for parents generally to learn this information in antenatal classes, in postnatal groups, etc, has just evaporated because the funding has disappeared.
So you know the government needs to be investing in these kinds of services for families. There aren't the health practitioners out there to be able to to provide those services at the moment. Health visitors are kind of like dwindling. So we need to be pressing government to be reinvesting. in all of these things.
support families and babies. Yeah because if we don't do it like it's such a cruelty to tell somebody that they should breastfeed and they're not provide them with the support and the information. And also I think but what's heartening is that the research shows that if you do give the support groups if women and families have places to go where they get to share their stories they vent about how little sleep they've had they're told that's normal i'll make you tea give me the baby all that stuff counts you know that's valuable and we need more of us so and whether it's and it should be government who is funding that. But if it's not, then it needs to be done by our community groups and by...
Absolutely, because at the moment, the only places that... or the few places that exist you have to pay for, and then that increases inequalities. Yeah, yeah, yeah. So if we were to reconvene back here in 2020, how many...
what's the cycle that we're on? How many years later will we give... How many years will we give ourselves to have those six recommendations, I think, that David put up at the end were very...
You know, they don't seem... Like we could be we could do them. I think I mean, maybe I'm just a hopeless optimist.
But like, what do you think? Do you really want to see happen in the next five years if we're to turn this around? I would like to see us providing wraparound services for mothers and babies and parents generally.
But the education piece, I think, is really important to help with expectations about how newborns behave, about what to expect over the course of that first year. and then the support, the follow-on support, kind of when people hit crises and they have anxieties. Yeah, so it's for me, it's about services and support and information. How about you Katie, you've five years, what do you want to see happen in five years?
I'd like it to be that it feels odd to see marketing on formula milk, that it's there for people who need to use it and also I'd like to see that there is, in the same way that the because the full milk company are serving a need of empathy so like we mentioned before about helplines and things like that and I think you made the point about these services going I think we can't just take away here and then not think about the other side of it so I think I'd like to see a world where full milk company marketing is seen as an odd thing of the past but also like to see a world where those services of support lines etc are replaced by independent impartial advice very good goody I'd like to see a a world where health professionals are given the information that they need to be able to act on behalf of their patients um and also for it never to be acceptable that you know our financial interests would come above you know our patients and that should be the world that we're looking at in what five years so is that what we're saying five years i'm gonna lay it down all right alison i mean i think having politicians that are aware and informed of all of the all of these issues is vitally important so the right decisions are then made so not only that you have the code in law you have the code enforced and active and that people can rely on the types of services that they need rather than being marketed at and marketing essentially filling that void where the support isn't there so I think there's a number of things that have to happen but I think prioritizing infant feeding and making sure that the interests of our younger citizens are right there in policy all the way through I was incredibly proud that the Scottish Government put infant feeding support in their program for government you don't often see you know the first minister or the prime minister getting up and seeing that kind of thing that that was in the program for government of the scottish government and that increased spend on infant feeding it increased the prioritization of that as a policy agenda and it has increased breastfeeding rates as a result of that investment and that commitment so you can see it follow through but that's not the end of the story that has to happen every single time and it has to be a priority and politicians have to think that it matters because it does yeah well i think that's a really good way of thinking about you in terms terms of the election cycle is that if people are starting to campaign and advocate for this that they wanted this in this issue put into the program for government so that it becomes an action point and then especially now that well I don't know what the situation is in lots of European countries but you know the green movement are are in the greens are in Ireland at the moment and they're interested in putting this issue forward and I think that's probably been reflected across the world as well well listen I think we covered a lot there we could talk all day no doubt because this is one of our passionate topics but please can I have a very warm round of applause for our panel. As you probably know today's event was co-sponsored by CAP 2030 the children in all policies so to get some final thoughts on everything that we've discussed I'd like to give a warm welcome to professor of global health at University College London Anthony Costello Anthony, you're a professor of global health, you're a pediatrician, you're a father, you're very aware of everything that we've been hearing about. What are your thoughts in terms of how we can turn this around some radical thinking and action? Well I was interested in the idea that health is not political, you know, that some people suggest because it's completely political.
Actually if you go back to the 1890s, Rudolf Virchow who discovered the cell His proper biomedical pathologist said medicine is a social science and politics is just medicine on a large scale. And he rightly took apart the German government about the typhus epidemic and completely condemned them for everything they were doing, the political origins of this. And actually, before we come on to the breastfeeding...
If you look at the pandemic, the global vaccine inequity, 70% of people in low-income countries have not yet been vaccinated. And that was because of the political determination of companies to control. control, stop any patent waiver that was insisted upon by countries. And that was actually supported by Bill Gates, as well as all the rich governments, the UK, Canada, Japan, the EU, all blocked a patent waiver.
And we've seen the disaster of public health in the UK, USA, 200,000 dead from the pandemic, 1.2 million dead in the USA. public health was completely neglected and it was just again the medical industrial complex with their you know just pushing vaccines so not thinking still anyway let's not go on to that and then of course I could throw in climate change because Margaret Thatcher no don't please spare us that I was going to say Margaret Thatcher gave a great talk about climate change 32 years ago at the UN and yet we're now going to hit 1.5 degrees in two years so And the emissions are the highest ever. And this is the future for our children. So it's the same with breastfeeding.
I just want to make, I'm on to breastfeeding now. And we are interested, we're not stigmatizing or pressurizing or shaming women who didn't breastfeed. Because we're only interested in the influences and the ability of people to resist some of those influences. So they have a proper choice.
It is a woman's right and a woman's choice. about feeding. I just want to make three quick points. So number one, in 2016 I was at the WHO. I worked with Nigel, okay, and I've worked with Dave because he was at the Institute for Global Health, and I've worked with Goody, and I was called by my ADG, the Assistant Director General at WHO, an Agile Provocateur, all right.
Well, if I'm an Agile, these three are political terrorists who should be locked up probably, or our government will probably have read some. Anyway. At 2016, WHO, we had a policy resolution put up by 60 low middle-income countries about tightening the rules on what was then called breast milk substitutes, the inappropriate promotion. And I sat through a six-hour debate where everyone was quibbling about wording and stuff.
And in the end, United States, under Obama, not Trump... the EU, including the UK at that time, and New Zealand, all the dairy producers blocked it. They did not endorse it. And the following year, they did exactly the same. Well, not all of them.
The USA and Italy blocked the global obesity campaign. And when you're not unanimously endorsed, you've lost the ability. If you get full endorsement, then national lawyers can start to take action.
So that showed. how commerce always and the political backing of commerce triumphs over you know infant mortality basically. Secondly Children in All Policies arose out of a Lancet, another Lancet Commission, a future for our children question mark which was chaired by Helen Clark and Awa Kolsek.
Now Awa Kolsek is a pediatrician and she's Minister of State in Senegal And I remember in the first meeting, she said, I've sat in cabinet in Senegal for 10 years, and it's only just now that I've managed to persuade my political colleagues that investing in maternal and child health is the fundamental thing to do to develop. That's what the best countries have done. And politicians don't get it. And I've spent a whole career, many of you have spent a whole career, and you know politicians just don't get it. Some do.
There are exceptions. But an awful lot simply don't understand. You know, it's all about... Is that our failing, though? Is that because we haven't made it?
Is it just because you don't make any money out of breastfeeding? Exactly. It is about power.
It's about money, as Goody and Dave and Nigel have explained. They were fantastic presentations, by the way. I love them. So...
We, in Cap 2030, Children in All Policies, where's Sarah Dalgleish, our director back there, is, you know, they're working in nine countries and trying to get this idea of multisectoral collaboration. And it did some participatory work early on because we ran an expert meeting on commercial marketing about... a year ago and they interviewed a lot of young people and it was, I think her name was Natalie from Hong Kong, said I'm always seeing all these people endorsing breast milk substitutes on the telly. One of my own doctors that I knew was on there promoting all this stuff.
And they could see that this was wrong, just as gambling ads are wrong and all the rest. But, you know, they're kind of shocked by the adult world they're growing into. The final thing I just wanted to say was, just to remind us, 20 years ago, I was starting a, I had a PhD student in Bangladesh.
And it was the first time I'd done any kind of proper field work in Bangladesh. She had to follow up a lot of newborn infants that had been born in Mitford Hospital. And so we went out. We went into a fairly typical informal settlement. They're called now slums.
And knocked on the first door. And the woman was there holding a totally emaciated infant at death's door with watery diarrhea and a tin of lactogen. And it was the first one we went to. And we had to get. That child rushed into hospital, fortunately was rehydrated.
But it just brought home to me the scale of this population. But I think the figures actually are under estimates because in the poorest communities, you don't get out to really sample them in proper estimates of mortality. So I think this is an incredibly important...
Usually, I hate to say this, but can I just... I normally slag off Richard. This is your last point now, Anthony. Make it a good one.
Make it a good one. good one good one a compliment richard alone amongst global editors has spent the last 22 years defending mother and child health placing it at the top of uh the global agenda and i think that has been incredibly important and i salute you for that even though you men's playing a bit no no and actually i disagree with you about men's playing because i think we should be as vociferous as as women that we're all in it's a whole of society issue you exactly and so I mean what you're saying there about you know the 800,000 child deaths that could be prevented annually by optimum or recommended breastfeeding by the WHO that's what we need to get into the minds of politicians and forget and not the money and if you want if money is what make policymakers think then start adding up the cost of not breastfeeding and doing the sums on that and making that the argument because what has been going on for the last 20 years hasn't changed the direction Absolutely. And it's one aspect of it.
James Heckman won the Nobel Prize for Economics, showing that the earlier you invest in pregnancy, in infancy, for feeding, for all kinds of things, you get a huge return on your investment. All of the problems that we have today, you know, have origins in childhood and we need to defend that. But this was brilliant. I commend all the authors, all the editorial staff, all the people that were contributed to this.
And I'm going to read this, Richard. Richard. No, I'm going to read all of it because it looks really interesting. I mean most commissions, because he churns them out once every fortnight, you read the executive summary, but this is gold dust. It's got good stuff.
Thank you so much Anthony for sharing your thoughts. Well I'd like to echo what Anthony is saying in that I really do encourage everyone who's watching to read these reports and to use them as tools for advocacy because they are strong stuff and I think we are all in agreement that the tide is... to change direction. We are, and as Nigel said earlier, you know, we know what the vision is, a world where parents, all parents and families are genuinely supported in the care of infants and for breastfeeding to be robustly supported and protected.
There is a huge amount of work to be done. It's going to require political will and commitment, but it's up to all of us in the global community to speak up and advocate for change. And the great Nelson Mandela said, it always seems impossible until it's done.
Yes. We are now going to end the live stream. The recording of the event will be available on the WHO website in the coming days. I'd like to repeat...
Thanks to all the authors to the funding bodies to the supporters There's an enormous amount of work that has gone into this event and to these papers And I think we all need to recognize that and but we also want to thank especially the women who shared their experiences and participated in the research and so thank you all of you from watching all around the world and As we say in Ireland curve Magath August longer phone. Thank you and see you soon