Letters

Nestlé's violation of international marketing code

The auditors respond

Nestlé responds

Audit report fudges the issue

Similar practices take place in Europe

The auditors respond

EDITORYamey did not give an accurate summary of the findings of our audit of Nestlé's infant food marketing practices in Pakistan.¹ It should be clarified that we did not investigate the allegations made by Syed Aamar Raza. What we undertook was an audit of policies, procedures, and operational systems, cross checked by internal and external surveys. Whereas we concluded that Nestlé Milkpak's operations are in compliance with the letter and spirit of the World Health Organization's code of marketing of breast milk substitutes, Yamey focused on the violations of the code that we did find, implying that our conclusion is not justified by the facts.

We found that Nestlé Milkpak had in place a consistent framework of policies, procedures, and work instructions to ensure compliance with the code, that the code is embedded in the culture of the company, and that Nestlé tried to mitigate pressure from the marketplace that may have led to code violations.

Yamey did not discuss the nature of the three instances of violation identified in our audit. The gifts offered to health professionals amounted to a jar of instant coffee and some non-medical books. The failure to disclose financial assistance to health professionals was actually a failure to disclose such assistance to the heads of their institutions. The bonuses that were provided to sales staff were from one distributor that had failed to separate infant formula products from other products when calculating staff bonuses and whose sales account for less than 2% of Nestlé Milkpak's total infant formula sales.

In the article Anna Taylor, an adviser to Save the Children, stated that the audit suggests that Nestlé uses health system facilities to promote its products. What she is referring to is the practice of medical detailing, by which Nestlé medical delegates inform doctors of the properties of Nestlé products. This is scientific information that conforms fully to the relevant articles (4.2 and 7.2) of the code.

The marketing of breast milk substitutes is an important issue; a serious study of the marketing practices of a company such as Nestlé Milkpak deserves accurate reporting.

Sunil Sinha, director. 
Emerging Market Economics, London E14 9XP sinhas{at}emergingmarkets.co.uk

Nestlé responds

EDITORYamey totally misrepresented the findings of the independent audit.¹ The executive summary of the audit report, written by the respected international auditors Emerging Market Economics (EME) and which can be read on our website, stated: "it is clear that the WHO code and the Nestlé instructions are embedded in the policies, procedures, structures, and resource allocation of all the company's functions and work processes." The audit found three instances of violation of the WHO code, but the auditors stated that "these violations appear to be of the letter rather then the spirit of the code."²

Part of Nestlé's commitment to the code is to thoroughly investigate alleged violations and make changes if necessary. The three breaches, one of which was a gift to a doctor of a jar of coffee and some non-medical books, have been corrected. Yamey's article on the alleged violations does not reflect the generally positive tone of the report of the external auditors, especially in the light of the scope and nature of the allegations made against the company.

The photograph accompanying the article is unclear, and it is understandable that Yamey qualifies its use by saying that it "allegedly shows mothers in Pakistan carrying free Nestlé samples." If the mothers do have Nestlé samples, these will be of Cerelac, a complementary food product, which is not marketed as a breast milk substitute and is thus not covered by the code. As Emerging Market Economics reported, the audit found no evidence of inappropriate gifts to mothers.

David Hudson, communications and corporate affairs director. 
Nestlé UK, Croydon CR9 1NR d.hudson{at}nestlegb.nestle.com

Audit report fudges the issue

EDITORThe external audit report on Nestlé's infant food marketing practices in Pakistan, as discussed by Yamey, is a whitewash.¹ The report was undoubtedly commissioned in response to former employee Syed Aamar Raza's allegation that Nestlé had violated the international marketing code. How could the auditors possibly have ignored the damning evidence that Raza put in the public domain? I have analysed Raza's evidence and question how any independent audit could manage not to find anything that would either corroborate or refute the existence of the practices he highlighted.

The audit uses the international code of marketing of breast milk substitutes (inaccurately referred to as the World Health Organization's code) and the Nestlé instructions as the benchmarks to measure compliance. The instructions differ sharply from the codewere the auditors not aware of these differences? And were they not aware of subsequent World Health Assembly resolutions that clarify the code? Did they know that these subsequent resolutions enjoy the same status as the code? As the audit was commissioned by Nestlé, how much was it circumscribed by perimeters set by Nestlé?

A statement in the report claims that the Nestlé instructions were developed in consultation with the WHO. Neither the WHO nor Unicef has ever endorsed or refuted any company's interpretation of the code.

In an analysis comparing the Nestlé instructions and the code, I found Nestlé's interpretation to be incompatible with the letter and spirit of the code and subsequent World Health Assembly resolutions in many ways. (The analysis is available from me.) If the Nestlé instructions were the guiding instrument in auditing the activities of Nestlé in Pakistan, then perhaps the auditors were right in finding only three instances of violation. But the auditors' conclusion that Nestlé is in compliance with the letter and spirit of the code is inexplicable.

I take issue with the auditors' statement that poor awareness of the code among health professionals has resulted in an uneven playing field in Pakistan. The auditors are shifting the burden of compliance to third parties, whereas the buck should stop with the company itself. The auditors' recommendation that health professionals should undertake courses on the code (with the explicit understanding that training would be funded by Nestlé) is equally untenable. Instead the auditors should have recommended that Nestlé train its staff in the code, not in its flawed instructions, and that they should do it well. Good training, however, would entail Nestlé teaching its staff not to put profit before the wellbeing of young children in Pakistan.

Yeong Joo Kean, legal adviser. 
International Code Documentation Centre, PO Box 19, 10700 Penang, Malaysia ibfanpg{at}tm.net.my

Similar practices take place in Europe

EDITORYamey reported Nestlé's violation in Pakistan of the World Health Organization's international code of marketing of breast milk substitutes.¹ We should look at what happens in Europe, too. In a survey on the financing of continuing medical education of paediatricians in the Naples area, I interviewed 136 paediatricians (17% of the total) concerning the support they received from the baby food industry to attend national and international meetings during 1998 (table). One hundred and twenty (88%) reported that their travel or hotel expenses, or both, had been paid fully by the industry; 60 paediatricians had received medical or computer equipment for their office.

The main baby food companies were recently condemned by the Italian Competition Authority because of their refusal to sell their products through the usual market: in Italy, infant formula is at present sold only in pharmacies and at a much higher cost than in most European countries.² Moreover, the authority reports cases in several Italian hospitals of gifts of formula milk and medical equipment to maternity wards. The authority notes that it is not surprising that when a neonate goes home a formula milk is prescribed, even if the mother is breast feeding. (The words "if breast milk should not be enough" are usually written on the discharge card.) The type of formula that is prescribed changes every 2-3 months, as do the discharge cards, which are printed and distributed by the baby food companies.

The baby food companies have nevertheless found a way of complying with the WHO code. Furthermore, they have a strong influence on paediatricians, who usually prescribe a formula during transitional lactational crisesthe most frequent reason for interruption of breast feeding during the baby's first three months.³

Alfredo Pisacane, senior lecturer. 
Department of Paediatrics, University of Naples, Naples 80131, Italy pisacane{at}unina.it