Juan Perez III is a doctor of medicine specializing in public health, engaged in work on breastfeeding and child health, health services organization, infectious diseases and health information systems. His email is j3pere@yahoo.com.  This article was published in the Opinion Section, Yellow Pad Column of BusinessWorld, December 4, 2006 edition, page S1/5 & 6.

For the first time in Philippine history, milk companies are suing a government agency for coming up with strict rules that may impact on the way they have been doing business among Filipino health practitioners and the general public. The Pharmaceutical & Healthcare Association of the Philippines (PHAP) filed a petition with the Supreme Court on June 27, 2006 against the DOH’s new IRR on EO 51, the Philippine Milk Code.

To recall, President Cory Aquino’s revolutionary government issued Executive Order 51 in 1986, effectively making the World Health Organizations; (WHO) International Code on the Marketing of Breastmilk Substitutes the law in the Philippines, one of the first countries to do so.

For the last 20 years that this law has been in effect, companies have circumvented the Philippine milk code’s implementing rules and regulations (IRR) through various tactics:

Companies have interpreted the code to refer only to breastfeeding in the first six months.
Companies have come up with a variety of milks aimed at promoting supposed factors in their follow-on and other milks that they claim would make Filipino children more intelligent or cultured, etc.

Companies continue to promote this array of copycat milks to the public through print, radio and TV ads that saturate the prime times of mass media.

Rather than giving outright donations to hospitals and clinics, companies now sponsor medical and midwifery society/association meetings and send health workers all over the country and the region to attend continuing professional education seminars; even government campaigns have sought milk company sponsorships for their campaigns on child health

It is quite understandable that the Department of Health (DOH) decided some time ago that the Milk Code IRR needed to be updated in order to overcome the milk companies’ tactics. But even the hint of a change in the rules was enough to send the companies to Congress to stop DOH from doing its job to protect public health. But when Congress realized that they had no business interfering with the executive branch, the companies went to court.

So now we are treated to the spectacle of milk companies that are better known for taking care of their profit margin suddenly showing an interest in the Philippine National Demographic and Health Survey (2003), simply because the companies would like to show that they have not harmed breastfeeding in the Philippines in the last 20 years. The companies would have the courts believe that their product is safer than breastmilk, by alluding that HIV passed through breastmilk is more dangerous. Companies would like to make the Supreme Court believe that pathogens in infant formula are a rare occurrence, nothing that Filipino mothers and DOH should worry about.

What is the truth behind all this? Can we believe milk companies when they claim that they have a better product?


Debunking milk company claims

The milk companies thus far have only succeeded in mobilizing community and NGO support for DOH’s new IRR on the milk code. In the last few weeks, discussions have centered on the preposterousness of the milk companies’ arguments before the Supreme Court. In a paper entitled “The Ties That Bind Filipino Mothers to Milk Companies: Time for a Break,” the breastfeeding advocates refute the milk companies’ claims.

The milk companies claim that their products are the next best thing to breastmilk. That is wrong.  The next best thing to a biological mother’s breastmilk is another lactating woman’s breastmilk. Surrogate breastfeeding is more practical in Filipino communities where close family and ethnic ties prevail. Milk formula is only the third-rate product.

Moreover, in the interest of public welfare and safety, we need to ask how safe infant formula is.  Is it really a sterile product? Or is it possible that infant formula on the Philippine market may actually contain organisms like Enterobacter sakazakii, found in several cases among infants in Europe and the United States?

The truth is that the Codex Alimentarius allows up to 10 coliform bacteria (like E. sakazalii) in powdered milk, making infant formula a non-sterile product. Yet the milk industry argues that this is a “gross overstatement” on the issue of Enterobacter sakazakii in infant formula, saying that “the number of case reports of any illness approximates one per year worldwide.”

This again is false. For example, in April 2001 alone, Mead Johnson was implicated in the cases of 10 infants in the US found with Enterobacter sakazakii in stool and urine samples, leading to the recall of the product the following year (INFACT Canada Newsletter. Case reports of E. sakazakii infections and powdered infant formulas. Spring 2002).

For a broader view, let us quote the WHO report on E sakazakii (Enterobacter sakazakii and other microorganisms in powdered infant formula. Geneva, FAO/WHO, 2004):  “The magnitude of the problem is generally described in terms of frequency and severity. The frequency of the disease in infants appears to be very low, yet the disease is devastating.”

Another WHO document (Questions and answers on Enterobacter sakazakii in powdered infant formula. February 2004) presents a disturbing report: “Mortality rates for Enterobacter sakazakii have been reported to be from 20% to >50%. Significant long-term effects in the form of neurological deficiencies can result from the infection, especially among those with severe meningitis and cerebritis.”

In this light, the INFOSAN Information Note No. 1/2005-Enterobacter sakazakii, issued by the WHO and the Food and Agricultural Organization in January 2005, makes this point: “Given the large quantity of the product (infant formula) consumed and the fact that even one contaminating bacteria is capable of growing to large numbers, a combination of risk reduction measures may be required for the effective management of the risk.”

Still in the interests of public safety, we should ask what other secrets lie under the aluminum foil of infant formula tins. Salmonella, perhaps? Botulism? Klebsiella? All have been reported in recent literature.

The task of the Bureau of Food and Drugs (BFAD) is to have milk companies certify that their products are free of contaminants before they are cleared for sale to the public. This has to be done, not as an exercise of police power, but as a defense of public welfare and safety.

Worse, the milk companies denigrate breastmilk when they state “there are more cases of transmission of pathogens in human milk, including the human immunodeficiency virus (HIV) than there are of E. sakazakii formula.”

But the fact is the risk of vertical transmission of HIV is higher during late pregnancy and childbirth (20 percent risk) than through breastmilk (14 percent risk).  Further, the risk of death from diarrheal disease among artificially fed infants in conditions where sanitation is inadequate and families are poor can go up to an astronomical 14 times, compared to breastfed infants living under the same conditions. Studies done by WHO and academics show that the incidence of diarrhea among artificially fed infants is several times higher than breastfed children.  The UNICEF (State of the World’s Children 1998) fears that the deaths from diarrhea and respiratory infections vastly outnumber those from HIV.

In conclusion, the milk companies should be made to think more about Filipinos’ right to true and accurate information, and most of all, safe products. Moreover, it is high time they focused on and actually practiced business ethics in a country where business has been good for them.

Juan Perez III is a doctor of medicine specializing in public health, engaged in work on breastfeeding and child health, health services organization, infectious diseases and health information systems. His email is j3pere@yahoo.com.