The Problem with the Formula Milk Industry

hello everyone and a very warm welcome from a rainy london i'm chris van tullican and i'm uh i'm an infectious diseases doctor at the hospital for tropical diseases i'm a broadcaster for the bbc for children and adults and i'm also an academic at ucl where i study conflicts of interest and research integrity and that's one of the reasons i'm the moderator for these two webinars today and are in exactly three weeks time on september 29th that's the thursday put it in the diary and we're talking about the problem with the formula industry these two webinars are co-hosted by the world health organization the british medical journal the partnership for maternal newborn and child health and cat 2030 and today we're looking specifically at the influence of the formula industry on healthcare professionals i want to start with the story i just bought a new knife sharpener now i already own a knife sharpener but i saw an ad for this one online it was incredible the ad said that this new knife sharpener makes knives so sharp that until recently it was illegal for anyone who wasn't a professional chef to buy one it wasn't until the product arrived at my health and started making all my knives a lot less sharp but i started to question the whole idea in that ad whether or not it was true that chefs needed licenses to buy knife sharpeners i am susceptible to marketing and even the fact that i study how conflicts of interest affect the behavior of healthcare professionals with some of the people you're going to hear speak today it didn't protect me from a clever ad if you think you're not susceptible to marketing just look around your own house at uh at the brands that you wear the brands you eat and the brands you drive we all think we can remain unaffected in 2001 just as people were starting to get twitchy about the relationships between doctors and the pharmaceutical industries and doctors in san francisco did a survey of their colleagues about how we all thought we were influenced by industry marketing and they found that while most of us believe that our colleagues are affected other people are affected most of us also believe that we ourselves never would be well we're wrong to think that marketing does work and especially when it's dressed up as medical education or a sponsored study or a funded guideline we now have libraries of evidence that conflicts of interest change our behavior in ways that we ourselves can't judge so wherever you're watching healthcare professionals we are amongst the most trusted members of our societies and that trust gives us enormous influence we create policy we create the evidence that informs that policy and of course we have a network of face-to-face influence in our clinics and in our wards the formula industry and lots of healthcare industries know this a report by world health organization in unicef published earlier this year detailed exactly how this industry capitalizes on that trust that everyone placed in places in us by specifically targeting us and so that report led us here today to ask a few questions are we all aware of the extent to which we are targets do we understand the strategies that are used to target this and what can we as individuals and as associations do to shield ourselves and protect the well-being of the people that we should serve because we've all signed up to ethical sometimes legal obligations that we will work entirely in the interest of our patients and that's a problem because of course we can't serve two agendas the formula milk industry which comprises some of the largest transnational corporations on earth has obligations in fact a single obligation for making money for shareholders everything they do is to serve that purpose it's not controversial that's a fact and the interests of our patients and of this industry may sometimes feel a bit aligned but they are totally different and frequently they're at odds i want to finish with two thoughts on framing before we begin this webinar is not about finger-pointing it's about becoming more aware and working on solutions our focus is strictly on the marketing practices of the companies who make formula and their relationship with us this is not a discussion about the best way to feed a child there are so many factors that inform feeding decisions so this discussion is about supporting all women and all families in their feeding practice and protecting them from marketing that is about profit not public health it's a hot topic please tweet and share on social media using the hashtag end exploitative marketing the events uh we're gonna all speak in english but but we have simultaneous interpretation in french and spanish if you click the globe at the bottom of the screen i can't see it um then you can you can choose that option and select your language the event's also recorded so it's going to be available on the bmj youtube channel by tomorrow so we're going to start in part one of our agenda with dr nigel rolling from rollins from the world health organization who's going to talk about why and how industry targets professionals and why it matters so over to you nigel thanks there chris um my name is nigel rollins and i work in the department of maternal newborn child and adolescent health and aging at who i'm a pediatrician trained in belfast northern ireland and worked in eastern southern africa for about 15 years and i want to give some context for today's discussion as health professionals we all know that infant feeding is important and every parent and mother knows the same is central to systems biology influences our lifelong health risks mortality and development and also impacts on maternal health there is high quality evidence that breastfeeding gives infants and children the best health outcomes and this is true in all income settings breastfeeding is not only a low or low middle income country intervention just earlier this year another an analysis of more than 3 million births in the us and 2017 find that starting breastfeeding reduced infant deaths by 26 percent and by 40 for late neonatal deaths despite this evidence there's been a progressive transition in global infant and young child feeding more children today than ever in all regions are consuming formula milk in the past 15 years the per capita sales of formula milk not just total sales but per individual child have increased by between two thirds and three quarters quite remarkable and it's not only the skills and practices that have changed there's been a shift in societal views and acceptance of breastfeeding with mothers feeling ostracized and even being asked to leave public buildings if they breastfeed their babies now there are many reasons other other reasons as well why women don't breastfeed personal preference work constraints per support from health systems but marketing of formula products is unquestionably a significant part of the story i should emphasize that today's discussions are not about the relative merits of breastfeeding and formal feeding nor the reasons or challenges that women face when making decisions as chris says we know that maternity protection and work environments are very commonly inadequate instead we are focused on how industry deploys sophisticated marketing strategies to influence policy understanding and beliefs and specifically how it targets health professionals and all this despite an international code of marketing that was adopted by the world health assembly in 1981 and that included specific provisions to protect health professionals from inappropriate engagement by industry and not surprisingly this is driven by finances in 2019 global sales of formula products were about 55 billion us dollars now to achieve this between three and five billion dollars is spent annually on marketing that's at least or more than the global budget of who for two years and this enormous budget gives industry huge power and sustained influence a report published earlier this year by who and unicef that documented interviews with more than eight and a half thousand women 300 health professionals in eight countries showed again the wide range of marketing approaches and all prohibited by the code the usual advertising free samples and gifts to mothers social media and digital platforms flooded with messages by formula milk solves life's problems and documented ways in which health professionals are targets of marketing strategies in every country health professionals were described as trusted sources of information and health professionals reported how commonly they were approached by industry representatives and times offered incentives all of us are familiar with the large and highly visible industry standard conferences the sponsor dinners the slides saying platinum sponsor the use of every public display to display brand identity an industry targets us through science and health claims however even a little scrutiny shows how thin the evidence is references from industries funded research and sometimes these are unrelated or contribute no relevant content but together they communicate a semblance of truth and scientific underpinning of the claim and the strategies are deliberate at a recent conference hosted by the british journal of midwifery an industry sponsored session tried to nudge health professionals towards approaches that dilute and undermine choices around continued breastfeeding industry also uses the credibility and reputation of health professionals to unfair authority trust and integrity of its brands for example they sponsor pediatric and midwifery associations to capitalize on the cool branding here an example from the british or from the brazilian society of pediatricians and in an upcoming virtual event on medical research ethics being hosted by the new york academy of sciences but sponsored by johnson and johnson they present themselves as curators of medical ethics and it begs the question who's the winner in these relationships and it goes much further for example in 2011 the south african national department of health issued a major declaration of support for breastfeeding shortly after a marketing consulting company produced for one of the global formula producers a map of key opinion leaders leading academics researchers ngos government officials and evaluated their influence and their susceptibility to influence this was much more complex than just dinners or stands at a conference all this matters because nurses midwives dietitians doctors community health workers are trusted and relied upon for impartial and honest support yet in the multi-country study that reported that reported between 17 and 57 percent of the eight and a half thousand women interviewed received recommendations from health professionals to use a formula product this is industry's return on their investment what does this mean for us today we are all influenced by marketing in every sphere of life but now there's strong evidence that marketing impacts public health is true for the promotion of sugar sweetened beverages alcohol gambling and noy infant formula products i want to reiterate because industry will try to reframe the issue this is not about the availability of formula products or trying to restrict choice this is about the unethical strategic and manipulative marketing that undermines public health these approaches by industry may seem innocuous but they create conflicts of interest that can influence our understanding and views and therefore how we interact with our patients industry knows this and it's exactly why it invests to engage with us in all manner of ways answer the question for today how do we as trusted and influential professionals protect and prioritize child health over shareholder benefits chris back to you nigel thanks very much indeed i think everyone will be particularly struck by uh the growth of the formula industry over the last 15 years and particularly with that child individual child volume growth as well um thanks so much for that i want to call on katie gilbert who's a managing director at m c saatchi world services and her work focuses on social and health issues katie you're a communi communications and behavior change specialist with lots of experience in commercial marketing can you give us a window into the mindset driving this marketing why do these companies put so much value on targeting health professionals yes and thanks to introduction chris so first of all just to say at world services msc saatchi i work on social and health impact issues but before that i had a decade working in commercial marketing and i think really the perspective i bring today is talk a little bit about how marketing works and why health professionals and associations are so valuable to the marketing strategy of formula milk companies so i think the first thing to say is just how prolific marketing is so in the 1970s there were predictions that the average person saw between 500 and 1 600 adverts a day in 2021 that's now grown to between 6 000 and 10 000 ads every single day across the different media and so that's a huge change in those years so i think coming on to how marketing works the first thing i wanted to say is i am a marketeer and i'm a proud marketeer i believe in the power of marketing for good um but like any other tool marketing isn't inherently good or bad it's just at all and it depends on how it's used and to what ends and really i think the big focus here is to try and look at raising our awareness of unethical marketing and understanding its practices so that we can call it out when we experience it but also be as resilient as possible to its effects i still feel the effects of marketing and i've been working in marketing for 15 years and so one of the things i'd like to do is actually talk about one of the seminal texts in marketing so i'm going to get up a slide and talk to you a little bit about books some of you may have heard of it called how brands grow um it was i'm talking about the second part here published in 2016 by the two people you can see on the slide and that was really about sharing evidence-based views on how to grow brands and one of the things from it that i really wanted to focus on today was the framework on the right which is called category entry points and when brands grow what they're looking to do is create positive associations between uh their brands and products and the rationales for usage and the sort of feelings in the category and these are the five entry points that brands tend to use and once you've seen this model you can't help but now look at every advert you see in this lens so thinking about some brands use the y so in my former life uh i used to work on frozen uh frozen fast food brands and it was really interesting because one of the things that marketers are really understood at understanding is why are you buying in the first place so for frozen ships moms aren't buying chips they're buying happy meal times where children don't grumble because they like what's on their plate and if you have had a stressed out day as a mom a sort of relaxing peaceful meal time is what you're looking for so there's brands that are great at focusing on the ultimate why the when so i'm sure there's lots of people on this call that might know the coca-cola holidays are coming at us and they're designed so that we associate that when or if we see pizza advertising on football matches that's because they want you to when you think football think pizza um and with whom so if you look at alcohol advertising you never really see people drinking alone because they know the brands that do best the ones that show with mates because the with whom is so important to alcohol so that gives you a little bit of a framework about how some of these formula milk companies will be thinking and i think the really important message here to land is you are a category entry point you will be a category entry point on someone's strategy document and that is how they will be thinking about you and one you will be a category entry point to reach um caregivers particularly the top four um i think uh in terms of the why when where and with whom uh health professionals and associations often have a role in that so for example with whom if you're a midwife in the hospital you might actually be there for the first usage occasion for example so as well as being category points yourself you're also being targeted by your own capturing entry points so some of the things that nigel talked about the event sponsorship etc that's because they're trying to get you to you through those category points too so we've established that you are a category entry point now it's nothing good to talk about why you're so valuable and i think there's four key reasons to take away so one is the trust as nigel mentioned so health professionals you're highly trusted to provide impartial evidence-based advice brands know that the messenger is important as the message so your work words are literally worth their weight in gold and i do mean gold because your words will be translating into cash for the companies when um people use formula milk so that's one of the ways they'd be thinking of you the other thing is vulnerability so i think one of the quite frightening things actually from the report that wha and usf uh commissioned was seeing how falling milk companies are targeting caregivers in moments of vulnerability the 3am feeds in online support groups where they're not declaring that the brands are present um and one of the most acutely vulnerable moments is in the hospital post-birth tired exhausted parents often first time parents that haven't done it before and that's a really stressful moment and if they can get their product use tied into that stressful vulnerable moment then that's their chance to get people hooked onto that product so they'll be massively interested in picking that moment of vulnerability and the fact that as a category entry point you're present in those moments i think the third point is timing so we know that a level of formula milk feeding can interrupt breast milk flow so if they can get a mum or dad using formula milk um in the first couple of days that's far more likely to disrupt milk supply which makes it more difficult to do and therefore creates the need for their product so again that's why you're so crucial because if they can get um children on that in the first sort of week or so it's more likely they're on it for the next year or so um so in crude marketing terms you are the frontline salesforce where the free samples the first usage that is a vital tool in any category entry point plan and then the last point is the code so the code is a fantastic thing and it's amazing that it's been created but i think the facts from nigel show that that hasn't necessarily diminished marketing or the impact of marketing in terms of usage so um the your role as a category entry point will have probably only increased in terms of importance as the codes um as the codes come about and i guess the last thing just to touch on is what can we do about it because as nigel said this isn't about restricting the product any caregivers should have access this project product if they choose it's more about an awareness of unethical marketing and being aware of how you're being targeted through category entry points but also how you're being used as a category entry point and one of the things that we've found helpful um talking about this issue is to find the right analogy that helps health professionals decide where the line is between what is marketing and that's fine women and men should have access to information about formula milk and why it's useful um but also unethical marketing where it feels like we're playing on emotions and other things that don't feel appropriate when it's so linked to child survival i hate comparisons between the former milk company and the tobacco industry because i don't think it's fair the tobacco industry doesn't benefit anyone in terms of people's health whereas formula milk is an important tool for caregivers whether that's norms because of legislation or maternity or issues of breastfeeding so some of the ones that i like that i've heard is comparisons with asthma pumps or antibiotics where of course you'd want to make that available for children who need that and make sure it's readily available but you wouldn't give out free samples of antibiotics or free samples of of asthma pumps so i'm not necessarily saying that's the right analogy i'm not a health professional so i think you might have better analogies but i think the main thing is if we can create that analogy between formal milk companies and another um sort of health product that might help us judge where the line is and help health professional judge where they think something has crossed the line from marketing to unethical marketing casey thanks very much for those insights it's an incredible idea of us all as the frontline sales force i'm sure i've been part of that when i've worked in maternity the kind of outrageous thing maybe people might think of is that none of us are paid for this we're doing this sort of unpaid work um as well as it not being in the interests of our patients um thanks so much for the second part of the agenda we want to now hear from some healthcare professionals on their own experiences and first up is maeve keller who's a consultant in pediatric allergy at children's health ireland and she's joining us from dublin maeve the recent um who unicef study on formula marketing quotes a health professional from london who says the formula companies they absolutely love allergy they're the biggest funders of the meetings does that resonate with you can you tell us about some of your experiences great hi chris and hi everyone and delighted to be uh on this webinar today it's such an important topic so yeah i think that goes from you know a profession no in london uh back then probably you know i could see why they might have made that assessment but i think um what it does show how we can actually make change and have already made change even within the allergy community so i thought i just wanted to give a little bit of a chat about as one pediatrician and my kind of journey along uh milk marketing and how it influenced you know how i was influenced by it potentially so i suppose prior to in my very early career i didn't really think about it i just thought oh they've turned up when it's a free lunch and i got on my job's in the hospital and that was it but in 2012 um i started as part of my training i started researching into pediatric allergy and specializing in that area and i suppose the first thing that i came across was um you know i got offered sponsorship to go to a conference like the main allergy conference and i thought great you know i get my flights and accommodation paid for i get to meet collaborators i get to learn more about allergy um and you know this is going to be a good thing so am i supposed i would say you know there are other ways to get to conferences you know certainly after that i won scholarships free uh afterwards but to be honest you kind of need your profile to be increased to start off with and that's where it began for me so then kind of from over the next two years um you know my impression was you know i attended lots of meetings and lots of just you know uh you know sessions of education sessions and that were sponsored by um formula companies and i suppose i had this opinion that if i didn't support if they didn't support it it wouldn't be done you know it was a la uh particularly in ireland where i was working there was a lack of specialists in in energy and you know the education that was there you know it was really good out of education trying to get people you know done by you know people with the best of intentions to learn more about allergies so patients can be treated better and i suppose they were july you know in a way we're happy with sponsorship in that the expense of organizing back pre uh covered pre-webinars you know getting a room getting people together getting food and the effort of it all was done by someone else and i then moved in 2017 to london i suppose that's my really kind of kind of my own journey and along the journey kind of changed so um i was asked at that stage i was coming you know had more expertise and energy was becoming more known and you know i was asked to give talks um you know at sessions or health care professionals that were sponsored by formula companies and i wasn't the only ones i was also talking at you know healthcare uh you know at patient advocacy groups and stuff but i was thinking you know what you know they never asked for my slides i would never be ready in time anyway you know they never added content you know and i was like well i'm not conflicted and i'm educating others and this is all good and then you know i got a stage where you know you'd be given maybe 200 pounds for like one talk for an hour which you put a lot of work into and i said you know what i'm not comfortable with that and i said look i'm not being paid and so i'm not conflicted but there i suppose i was naively still turning up with the signs in the background from the formula companies given my education trying to get better energy education out for parents and for patients um so then i suppose it was a about 2018 probably around the time where the b j themselves came out with you know not using uh not getting sponsorship from former companies i said look i need to separate completely and i suppose i was also doing a big review for cochrane looking at preventing allergies and cochrane has very specific hundreds of interest rules and i wouldn't be able to be first off there if i if i continued but i think you know just the people i've met along the way london helped me towards this journey um and looking back and reflecting i think it was probably easier for me to do that at that stage and it's much harder as a younger professional you know i had a research position i had a fellowship that was sponsored by the nh or i need any more sponsorship i had a standing within the community and in that way i felt that it was easier for me as i became more senior to step back um then i think um moving to ireland in 2020 i realized i was probably further along that journey you know of moving away from foreign companies than others um i started back and you know we held a webinar series that you know that was independently ranked by really good intentions to get great allergy education out there to professionals but i rely i signed up and then realized as a speaker realized that you know the education was you know the organization was been run by a former company i said no and i was able to say no because i had a permanent job i was able you know i didn't need any more collaboration right then but i did get a few friends contact me and said i thought you had an allergy job why aren't you on this you know so stepping away can be hard at times um and then i suppose uh going back to the original point about um energy education you know the bfa side which is the main uh group of allergy uh as has you know as members have elected to step back and form their company and even in ireland ifan have done that in december 21. so i think you know things have changed and we can make some improvements so um i just want to say you know i suppose to some people thinking who are thinking wow you know i would never taken any of that money i can't believe you did that and then there's other others out there listening to what i'm doing and thinking you know that does resonate with me and maybe they'll step away from funding so i think as a healthy professional it's really about a journey i'm ahead of some people and maybe behind some people and others and it's just how you know we naively think we can't be influenced but unfortunately we can be as we heard from the first speaker thanks maeve thanks so much for sharing that uh so openly it takes real courage i think you speak to this idea of cultural change don't you that that the conflicts are deep and we can be conflicted by simple friendships where someone has some money from formula that their career is kind of built on and they've got they've got bills to pay and it it can be an allergy i think seem almost as a bit odd to not turn up at these conferences so so thanks thanks for for being so straightforward of that we need to work on sensitizing people to marketing and and and how we can all as a community start to kind of walk away from it um i want to turn now to professor caroline homer um she's talking to us from australia and where as ever it's the middle of the night she's midwife with over 30 years of experience she's joining us from melbourne uh and caroline's the co-programme director for maternal child and adolescent health at the burnett institute and the chair of who's strategic and technical advisory group of experts for maternal newborn child adolescent health and nutrition caroline i know you've seen this issue of formula milk marketing firsthand as a midwife you've studied it as a researcher do you think that we understand the scale of marketing do you do you think we really have grappled with this thanks chris uh really delighted to be here on this really important topic and i guess the first thing to remember is that midwives are also consumers we are we are influenced by marketing in our personal and our professional lives as much as the families that we care for and i suspect we've all become a bit immune to the impact of marketing like everyone and and katie's described it so beautifully just before and companies take advantage of this um so so we're part of the mix the second point i'd make is that while midwives are important and critical we may not have contact with women when they're being bombarded with marketing materials so so we may meet women in the second trimester of pregnancy or even later or sometimes we don't meet them until in the postpartum period so that means that by the time we come in touch with them they've already been heavily marketed uh social media uh proper targeted product marketing emails from their chemists or their supermarkets very early on in pregnancy as well as other baby related products so this makes unraveling misinformation or influence really hard later on especially when you don't know the woman and you haven't had an ongoing relationship i know that midwives work really hard to support women in the best way they're trying their best to provide the best care but they may be swimming against this tide of marketing the third thing to remember is and katie's already touched on this the early postpartum period is a time when women are at their most vulnerable they are recovering from giving birth they're usually tired and often really uncertain as they're working out how to parent this new baby women really want to do the best for their baby but this can make them vulnerable to suggestions that are posed by marketing and can you explain the science behind this moment of vulnerability this category entry point which i think is super useful for us to think about when women give birth in hospitals they often go home quite quickly now and so they may lack support from midwives in that really important time to get breastfeeding established to work out how to be with their baby and know what they're doing and to have some rest we know that breastfeeding takes time to get right and needs support but when women do go home early it means they are potentially without that support and then potentially at risk of taking up the option that can be marketed as a quick fix especially if they go out in the world and visit hospitals in those early days and we all know in places like pharmacies or supermarkets there's a lot of formula milk marketing pressure and a lot of pretty careful product placement that we can be exposed to and this is really seductive especially when women are tired feeling stressed and vulnerable and finally midwives and other health care providers are often members of professional associations and this makes us vulnerable to formula milk marketing for funding to survive and maeve has touched on this as well already we are a classic category point category entry point as katie explained many professional associations and i'm the president of one at the moment have limited funds to do the work we want to do including holding education sessions putting on conferences and the companies know that and they come to us offering sponsorship and incentives sometimes it's quite obvious that this is a formula milk marketing company but often it's quite subtle and it's not always clear that it is one of these marketing companies or part of a formula company way back somewhere in the organizational chart so if even when we as a professional association say no we make mistakes as the marketing is subtle and it's a challenge to get this right and i know that's going to be discussed at another webinar but just to say that this is a big issue for healthcare provider associations and and midwifery um as one of those key providers so i think they're my key points chris and i'll go back to you thanks so much for that and and it's really useful to have a little taster there of of of the view from a health professional association the challenges they face especially around industry sponsorship caroline thanks so much and uh and sorry it's so late for you um i want to now turn to uh dr melis kulkazan who's a pediatrician and an assistant professor of pediatrics at hajj tepe university children's hospital in ankara turkey melis you've come face to face with formula milk industry funding including medical training you work in adolescent medicine tell us about your experiences if you can um thank you chris it's a great pleasure to be here um yes like you said i like to start with why i was invited to this important webinar since i'm an adult medicine specialist and have i decided to participate i am the co-chair of the international association for adolescent health and professionals network and iah is a multidisciplinary non-governmental organization dedicated to improving the health and well-being of adolescents and young adults ah is also a member of the international pediatric association which represents 1 million pediatricians caring for more than 1 billion children worldwide age involves young professionals like me in leadership and supports the inclusion of young people's voices in governance public health and advocacy being a young professional interested in heart advocacy i was delighted to be invited to this significant webinar but at the same time i felt hesitant to accept invitation because my expertise is primarily in the care of adolescents after i started reading the recently published who and unicef report my hesitancy grieve even more as i realized how little i was aware of the scale of the formula in marketing however i also realized how similar most of the stories in the report were and that many pediatricians and other clinicians have been unmovingly exposed to exploitative marketing just like me from the adolescent medicine perspective health professionals caring for adolescents we should be extra sensitive and mindful on this matter because unfortunately nearly one in every six young women give birth before the age 18 and adolescent mothers are the most vulnerable to the effects of unethical formula milk marketing and most in need of breastfeeding support these are all why why i wanted to be a part of this webinar to share my experiences both as a professional and the mother and to help raise awareness on this crucial subject i'm a pediatrician and i live in turkey but i gave birth to my son in the u.s so i had the opportunity to experience two different settings with similar problems during our first newborn visitor a pediatrician he saw an exhausted mother and recommended with all his good will that i should not try too hard for exclusive breastfeeding he advised formula milk to help with the baby's sleep to involve my partner more in the feeding process and for all of us finally to have some rest if i was not a pediatrician and mother with partner support i would have been easily tempted from the turkish health professionals perspective turkey has long established breastfeeding policies and programs and improving breastfeeding is a very important matter in turkey although most health professionals promote breastfeeding reports demonstrate that the early introduction of formula milk is still a common practice similar to turkey governments institutions and associations especially in low and middle-income countries have limited financial resources to support researchers and clinicians on top of that global economic inequality is a reality and unfortunately not enough attention is paid to overcome these inequalities in science therefore most health professionals regard formula milk industry as a valid source of funding for conferences courses other scientific events and unfortunate even clinical trials health professionals are visited on a very frequency by formula company representatives bought in public and private hospitals some hospitals especially university hospitals have strict policies on not allowing these visits but most do not during these visit information on different fermental products is shared and brochures on feeding basics and feeding problems with the name and logo of the visiting band are given to help professionals to distribute to their patients along with other gifts and samples company presentations are also common these presentations usually include how formula ingredients promote child growth and development and how specialized formula products offer solutions to common infancy problems without much supporting evidence as a young professional i strongly believe that a more targeted breastfeeding training that raises awareness about formula milk marketing and provides country strategies to limit its impact on infant feeding practices is most needed worldwide to conclude family milk marketing in all its forms is a serious problem not only for women but also for health professionals every woman has the right to decide how she would like to feed her baby but this decision should only be based on what is best for the mother and the child and should be free of all commercial interests and risk items especially by the hands of our most trusted health professionals aids and other healthcare professional associations stand ready to partner with who unicef and other stakeholders to help bring these messages to all of our colleagues melis thanks so much for those reflections the statistic that um one in six mothers i think you said give birth before the age of 20 is so much starker when we think of it in the light of what katie gilbert was saying earlier about the idea that we're potential markets we're customers and that the companies know our vulnerable moments and who who could be possibly more vulnerable than a young mother in the in the early stages after having given birth thanks for those insights especially for the personal ones people i love hearing pediatricians reflect on their own experiences at parenthood it's really useful um so thanks maeve thanks caroline thanks melis for sharing all your experiences with these very tangible examples of how formula milk marketing infiltrates our professional lives through medical education through training through funding research medical educations publications guidelines many of these approaches are really subtle they feel very hard to avoid and i think lots of us today are going to see ourselves in in the stories that we're hearing now in some settings marketing strategies are not very subtle formula milk reps have targeted health professionals with commissions from sales with ambassadorial rolls even gifts all expenses paid promotional trips and in some countries formula milk companies have agreements with private hospitals as their sole providers of formula milk women have reported that they're separated from their babies from the first 24 to 12 to 24 hours after labor during which time formula is introduced to the newborn and as health professionals we should be deeply concerned about this while with a sometimes invisible hand industry is playing this very powerful role in the lives of our patients which include mothers and of course the new children at their most vulnerable moments the first step is going to be to recognize the nature and the scale of the problem but we then need to take the following step we need to start thinking about solutions things that we as healthcare professionals can do and that's the third part of the agenda an agenda for action we've got three speakers we've given them a challenging brief we're looking for these three to four minute elevator pitches on some of the things that professionals can and are doing to protect the integrity of our professions from this onslaught of marketing there's not a silver bullet but we hope this will be a positive start and to make a really positive start i'm going to turn to dr haroon saluji who's a professor of community pediatrics at the university of vietnam in south africa harun medical education is this key target of the marketing of the formula industry how can it be used instead to counter uh to equip us to counter this undue influence can conflicts of interest be addressed through education uh hello chris and uh hello to the audience i'm going to be sharing a few slides and i think i believe two set of activities are required firstly we need to strengthen lactation education and training and secondly we need to catalyze medical health science students advocacy to combat the influence of industry on their education so there are at least there are at least two systematic reviews offering evidence on education and training related to breastfeeding for healthcare professionals and four conclusions emerge and let me summarize them quickly first there's a lack of standardization currently across guiding frameworks course content and assessment strategies secondly the evidence we have is limited and of low quality however training resulted in small but significant improvements in breastfeeding knowledge attitudes towards breastfeeding and demonstration of breastfeeding to women thirdly there's a paucity of skills-based training and finally while training has a role uh it exists within a wider cultural environment environmental factors that influence breastfeeding in healthcare centers and these have to be addressed simultaneously so i've suggested three different ideas that uh that sorry four different ideas that the action recommendations that may be helpful firstly i suggest that we develop an online platform for under and postgraduate students in evidence-based lactation support and care and we need to use innovative techniques to engage the students but i am suggesting that we use this this learning platform for health science schools globally the curriculum should include theory skills training and assessment components and this curriculum could be developed by the who academy academies of pediatrics or an individual or consortium of universities and institutions the main challenge will be getting buy-in from health science faculties since curricular space is often limited available educational material include those produced by the who that support 10 steps a breastfeeding curriculum for residents developed by the aap and competency frameworks for free modules by various universities a good example of what is required is the nutrition of science initiative which offers a comprehensive online medical nutrition curriculum primarily directed at medical students it has been widely adopted by universities in the us and globally including my own the second point i'd like to suggest is that health professionals already in clinical practice also need opportunities for education and so webinars and moocs and perhaps even conferences offer the best reach currently my third idea is that recognizing that assessment drives learning and also training we develop an online assessment repository for students and trainers we should probably specifically focus on multiple choice questions but also add available tools assessing clinical and counseling competencies and finally i suggest i propose that we counter formula milk industry influence through targeting the medical education field and health science students are the best change agents to lead the effort although faculty also need attention and so a good example is the farm-free campaign conducted by the american medical students association to reduce conflict of interest at academic medical centers and one of the actions was to get students to sign a pledge committing themselves to avoiding undue influence from the pharmaceutical industry and i my feeling is that adding formula milk companies specifically to the fledge could be considered and the international federation of medical medical students association represents about a 1.3 million medical students in over 130 countries globally and i think we could get them motivated to get a similar pledge endorsed by students worldwide medical students were prominent in getting the u.s medical schools to review and tighten their conflict of conflict of interest policies including getting faculty to openly declare their funeral their financial year earnings and so studies have shown that both students and faculty support stronger conflict of interest conflict of interest policies at academic medical centers and so i believe this path can and should be pursued internationally scientific forums such as this webinar and publications could be the medium through which we alert health professionals about how best to recognize prevent and manage conflicts of interest so i trust that the ideas i've suggested may be of some value thank you lauren thanks so much i love the areas you're drawing joining examples from and just as the formula industry likes to get us when we're young and vulnerable so um similarly targeting young uh medical students while they're still idealistic and they have maybe slightly fewer bills to pay i'm not sure that's true but you know they're they're vulnerable to our marketing too so thank you thank you so much uh haroon next we're going to turn to uh kelly kampuche it's campus i beg your pardon a midwife with many years of experience working with the health system in laos kelly you've worked with the ministry of health there and with the medical community give us your pitch for how accreditation systems like the baby friendly initiative or others can be leveraged to shield professionals from the marketing thanks i'm so excited because this is exactly what we've been working on so much here in lao is recognizing that bfhi or in our case a national accreditation system is a powerful tool but only if you use it really strategically we have to not pretend this is going to be easy the way that we've seen accreditation work at protecting health professionals and therefore families is by admitting that we have to change a norm we have to make breastfeeding an essential part of health care not a nice to have not an add-on but actually get everyone on the ward to to come together around agreeing that optimal infant feeding is what we're trying to achieve but that's what we need for improved neonatal outcomes what i've seen is you can get health professionals to really key into that identity as the protectors and the defenders and the health providers we can create that energy created by it and that then gives us the inertia and the power and the willingness in the backbone to fight against bms in our facilities when we start getting into protector mode when we feel that the peers it's so important to create group norms right nobody wants to be an outlier so we've got to create peers we've got to make that the normal feeling of us as doctors or midwives or nurses is that we shouldn't be supporting a company we should be protecting families we should keep exploitative marketing out of our words once we do that then we're ready to hit the hard work which is to admit that we're all susceptible to marketing i love what's been said already in the seminar and it's so important that even doctors even doctors get hit by marketing and we are affected even if we don't want to admit it if our peers admit it we can admit it and once we admit it we can then identify why we have to change what's happening in our own facilities once we know that we then talk about why we seem to think it's okay and we can start to break down the fact that formula companies are selling us easy solutions they're selling as time savers when postpartum care is not easy and not time saving and supporting establishing breastfeeding especially for brand new moms or families or challenging birth like carolyn mentioned is such hard work but it's essential so once we get that maya and we agree that this is hard we agree to admit that we're all susceptible we can start breaking down these messages that we're taking away choice and we can start admitting that formula is not helping we're supposed to be the helping when so that's how we use have used accreditation schemes here in lao to beef up the implementation of the who the code and to really get breastfeeding professionals um whether you're obs whether you're nurses nurse midwives doctors to not just admit it or not just go along with bfhi or not just comply i really hate that term but rather to see themselves as owners of it and leaders of it when we take people away from being reluctant to actually owning changes that bfhi calls for or other accreditation systems for example in lao we don't use bfhi but we've actually institutionalized it as part of essential newborn care kpis for the country so once we take it out of just come on go along with it come on comply but actually we need you to champion this then we can see so much more change the crucial thing here is let's not pretend it's let's not pretend it's easy and let's not jump to enforcement because that's where doctors put barriers that's where nurses zone out when you state when you jump straight to enforcement you show them that you don't understand how hard their job is and yet formula companies are making all of it about how hard their job is and how much they need help so we have to make sure we don't fall into that trap that industry has created we don't jump straight to enforcement we make everyone aware of how they're marketed to and get a little bit annoyed and maybe a little bit mad about it and then we get everybody on board and we can work together to keep bms out it's everyone's job and we can really see change thank you so much kelly i love that this is like it's like therapy it's meeting people at the right moment in the cycle of change it's allowing people to own their change and i think i hope that our audience today are hearing from all the speakers this this this isn't a hectoring tone it's not uh coercion um it's not about compliance i love that it's about changing culture and and making life easier and meeting them where they are thank you thank you so much as you say no silver bullet but some examples of counter marketing now we're going to shift to um a totally different idea and one i'm very close to uh rebecca combs is joining us from the bmj uh the bmj has taken a really strong editorial stance rejecting all funding from the formula milk industry rebecca's going to speak to us about a different idea altogether tell us about your pitch for a register of health professionals in the uk what's that all about thanks chris yeah so i'm rebecca coombs and i'm head of journalism at the bmj and as you say we stopped carrying ads for breast milk substitutes back in 2019 because we were so concerned about the substantial harms caused by their promotion so we've ridden ourselves of our conflicts before campaigning on this issue so why do we need a of health professionals in the uk um as a parent should i have the right to know whether the doctor treating my child is receiving payment from the formula industry and if that doctor diagnoses my child with say cow's milk allergy and prescribes a specialist formula how do i know that they aren't conflicted um and if a healthcare professional is carrying out training on feeding infants and young children shouldn't we know whether they are a paid consultant of a former company this would at least let us know whether corporate interests are at play in the u.s i would be able to look up my child's pediatrician online and find out if they had a financial relationship with a formula company and to me and to the bmj that's that's important information when getting medical advice and treatment so you know nobody gives presents to doctors for no reason and the evidence is that even small gifts change behavior so we've heard today the numbers and the incentives dished out to healthcare professionals by big form formula so last year in the us for example abbott gave more than nine million dollars to physicians in consulting fees that's nearly 6 000 individual payments so if it's happening on that scale how do you know that your doctor isn't a recipient in the uk there's been a clamor for greater openness for many years now and the idea of a register of doctors interest hit the news again in 2020 when it was recommended by a government commissioned inquiry into healthcare safety which is chaired by baroness julia cumberland and she was leading an investigation into the harmful side effects caused by the hormone pregnancy test primados the anti-epileptic drug sodium evaporate and pelvic mesh and during the review um the panel heard from you know patients who were really concerned that clinicians had been paid or otherwise incentivized by manufacturers in a way that might influence their practice and a key recommendation of that inquiry was that patients should have the right to know if their doctor has links with you know pharma or medical device companies and the inquiry report called for the general medical council the gmc the doctors regulator in the uk to expand its register to include a list of financial and non-pecuniary interests for all doctors and working with baroness last year the bmj hosted a public meeting to call for a central register of interest that would be mandatory and also publicly accessible so what difference would a register make currently we have a really patchy view of doctors interests in the uk it's really very random and they are often collected by their employer although they are hard to impossible to find online while an organisation called sunshine uk hosts a voluntary register of doctors interests and the association of the british pharmaceutical industry also has its own voluntary database called disclosure uk but under data protection laws healthcare professionals can refuse to have their name published on it and many many do so with a mandatory register which is annually updated patients and parents are just a couple of online clicks away from knowing who pays their doctor and declarable interests would include any kind of financial interest a doctor might have in a device or a health product so formula and any financial support for travel or for educational activities we've heard a lot about those today and far from being afraid there's increasing support from the medical community for a central register we did a the bmj did a survey um and found that nearly 90 of medical professional bodies agree that the uk should have a mandatory and public register of doctors interests and we think it's essential actually that the register should start with doctors so ideally the register would be light touch with a single annual declaration major appraisal time and logged with the gmc so i just finished with the worlds of words of fairness convolution she said doctors are the principal decision makers in patient care they determine treatment perform surgery so it's with doctors that we must start and then roll it out to other health care professionals thanks rebecca thanks uh very much and um that that idea is so well evidenced and i love your point that essentially in the uk it's not possible really to find out who pays your doctor whether you're being treated directly by them or you're watching them on television or getting some information from them on tick tock or instagram or channel four it doesn't matter where we are no one can find out who pays me with any degree of certainty so i'm i'm a big supporter of this and i i feel very strongly that the only people that can hold these registers of interest are the central um regulators of medical professionals whether it's the nursing council or the in our case the general medical council um so thanks very much for making uh that plea now we've got a um a few minutes so we may be able to um answer some uh questions uh there are so many points to reflect on here i think one of the crucial things is that uh the disclosure of conflicts of interest whether it's at the end of a paper at the end of a guideline um or uh with a with a midwife treating a patient in hospital is just the first step that we know we have lots of evidence from the states that um while sunshine is really important it is not quite the disinfectant that everyone thought it would be so disclosure's the first step because it allows us to conduct research and to understand who is paying who and whether or not that influences them uh but after that there needs to be more and more steps then to really mitigate against those conflicts of interest because what we know is that a conflict of interest doesn't describe whether or not you are actually influenced by a promotion a small payment a gift a guideline it describes whether or not money has changed hands it's not up to you to decide whether you were influenced so conflicts of interest just simply exist they're very objective legal situations and when they do exist we know that they do influence our behavior i want to reflect a little bit everyone else has told these quite personal stories about the ways in which um they've been influenced one of the reasons um uh uh i'm hosting this webinar was an investigation i did of the infant formula industry in 2018 for the british medical journal working closely with rebecca coombs and many of the other people on this call and what i found was that when it came to cow's milk protein allergy the guidelines the charities um all the information that any patient or clinician could possibly get was coming from industry from the basic scientific research through to the clinical research through to the actual guidelines themselves were funded and then the the social media sites were also their industry people on there so it was very complete that's one of the things that contributed toward the bmj turning down uh infant formula sponsorship which i was very proud about so i published this piece of work it made the cover of the bmj i was very proud and i went online and boasted about it wrote about it in the national press and i noticed that many of my friends and family started to feel extremely judged in private conversation they sort of confided this later that i was judging them for their use of infant formula that my attacking the industry or my speaking about the industry's practices made them feel judged and they felt ashamed and defensive and angry and there was another group that felt very ashamed defensive and angry who were my colleagues who had conflicted relationships sometimes with the formula industry or sometimes with the pharmaceutical industry and that's when i started working more with unicef who and nigel who were really focused on specifically communicating about this marketing about communicating without shame saying how vulnerable we all are to it whether it's for novel knife sharpeners or infant formula milk um i'm just going to check my little messages here i'd love to throw back to nigel before i sum up who's going to just address a few ideas that are going on in the chat nigel we've got about 10 minutes and i'm sure maybe some of the other speakers would chip in as well thanks chris um i think you've really identified a i think a failing on our part within public health because as i tried to say in my slides there are many many reasons why women choose decide not to breastfeed for for all those reasons and what happens is that the criticism and kind of the revealing of strategies and approaches taken by industry to influence views and values and behavior is very rapidly conflated and turned around to somehow be a criticism of women and of course this is this is absolutely not the case but this is what happens and i think the public health community probably has been clumsy we haven't adequately separated these issues about the the needs of women and families in terms of their decisions on instant feeding practices and a critique and an identification of the strategies of industry in a whole range of ways we've been focused on a couple of small parts of a jigsaw puzzle rather than taking a step back and seeing the entire picture because um as we're hearing today health professionals are as much the target of marketing as our women and families but politicians are the targets of marketing you know through lobbying through other political influence the sheer amount of money that is deployed in marketing as caroline has mentioned or rebecca mentioned um and that is you know understood it means that everybody is trying to deal with life's complexities and industry and the marketing approach presents formula as a simple solution so for example one recently actually in ireland uh a lobbying company for the dairy industry um uh cautioned government about uh revisions to maternity protection saying that this would be a very expensive um option so you know where the loyalties and words that uh what is the justification for uh cautioning against better paternity except to protect the the product that the lobby group were you know employed to support so there are many ways in which marketing is implemented it works through science it works through health professionals it works by creating brand identity and trying to build brand identity integrity or the appearance of integrity you know by sponsoring things within communities so that the name of the brand becomes more and more familiar within a community all of this is marketing all of it is about promoting the product and ultimately about familiarizing and changing values in the multi-country study that i referenced earlier a great number of health professionals simply assumed that even though they would have acknowledged the value of breastfeeding there was generally an assumption that formula milks would be needed the biggest area of growth is after in the follow-on milks and you know who does not you know there is no need for the follow-on milks certainly cause milk with adequate complementary feeds you know from 12 months on and yet the idea that these follow-on milks are essential is is kind of what is coming through in much of the research so um there were several questions and first of all just a simple logistics uh the youtube uh the repeat of this webinar is available on youtube it'll be posted tomorrow um the powerpoint presentations from who will be available on the who site i can't promise tomorrow um there's the second webinar at the end of the month which is really going to be looking at the responses from associations and how it really how associations should be protecting their own membership but also protecting the public health interests going forward uh in that um but i think the one big message that i would take away that as health professionals we have got to separate marketing and the practices of marketing from uh the discussion about you know the support that women need for their infant feeding decisions and practices they are separate issues and we shouldn't conflict the two chris thanks nigel that's such a clear summary you've massively influenced my method of communication about this and i think lots and lots of other people as well it's great to have that that kind of clarity i want to finish with just another a personal story i think these these personal stories have been so so useful um this investigation i was doing of um cow's milk protein allergy i was investigating guidelines that gave very long lists of symptoms to diagnose cow's milk protein allergy including in exclusively breastfed infants and the symptom lists were predictably very very generalized so they would be you know diarrhoea and or constipation rashes crying not crying um irritability sleeping too much sleeping too little and so it was very hard to exclude any child from having the problem and some of the guidelines advised that in the context of exclusive breastfeeding if a child had these very common symptoms that almost every child would have fairly continuously they advised that the mother should totally exclude dairy from her diet now this obviously makes breastfeeding challenging breastfeeding is challenging for many people and adding a dietary exclusion on top is is hard there isn't so much of what we eat so even as i was investigating these guidelines their links to industry and unpicking with uh real experts like nigel like many others at who and institutions in london and around the world i was unpicking their illogicality and bias and the way they weren't particularly well evidenced i found that my wife who we'd given birth a few months earlier um who was trying to breastfeed we we agreed that she would go dairy free such was the persuasiveness of these guidelines and that advice becomes very infectious so the guidelines become a form of marketing themselves they are we must see them as marketing if they're funded by industry directly or if the people who write them are funded by industry they are marketing and then i became a marketing agent an unpaid marketing agent uh that made it even harder for my wife to continue breastfeeding so uh i want everyone uh to understand none of us are immune it doesn't matter if you're a physician who studied this stuff none of us is immune we should all stay a little bit angry perhaps i think anger is somewhat useful but not too angry and not uh not ever with each other um i want to finish up by saying thank you to everyone who's tuned in everyone who's engaged uh online there's a great hashtag i've just seen communicating without shame which i think is a perfect way of summing up save the date it's exactly three weeks time september 29th um and thank you very much to all our speakers uh today from all around the world thanks to the world health organization to the british medical journal um to cap 2030 um and of course to uh uh pmnch as well thank you all very much

Channel: The BMJ

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Length: 71min 8sec (4268 seconds)

Published: Fri Sep 09 2022