Children suffer as formula milk companies circumvent law

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The government should ensure Vietnam is not a place where "anything goes," Dr. Marjatta Tolvanen-Ojutkangas, Chief of Child Survival and Development Section, UNICEF Vietnam, and Dr. Jean-Marc Olivé of the World Health Organization told Thanh Nien Weekly.

Four years after the government decree on Marketing and Use of Nutrition Products for Young Children, how would you assess its impact on the breastfeedingpromotion campaign in Vietnam?

Jean-Marc Olivé (L), World Health Organization representative for Vietnam; Marjatta Tolvanen-Ojutkangas, Chief of Child Survival and Development Section, UNICEF Vietnam

Marjatta Tolvanen-Ojutkangas: The decree is action in the right direction but there are obvious obstacles to its implementation. Firstly, there is a gray area in the decree regarding the definition of support groups and associations, such as Pediatric Association, Mid-Wives' Association and Nutrition Association. The companies have effectively used the gaps to their marketing benefit, which has weakened the contribution of this decree. Secondly, the tools required to implement the decree need to be updated to make it more effective.

Jean-Marc Olivé: Currently, the breastfeeding rate in Vietnam is very low; only 17 percent of mothers breastfeed their children during the first six months. How the decree contributes to protect breastfeeding among mothers in Vietnam very much depends on compliance to this decree by health sector and milk companies and content of the decree itself.

However, from the report by the Health Inspection Unit of the Ministry of Health, there are a number of violations of the decree by health facilities and milk companies. By this, I want to say that the compliance with this decree needs to be enhanced. On the other hand, promotion activities on breastfeeding should be conducted more intensively through different channels including through mass media, health system and medical professional associations.

How have the companies cashed in on the gaps [existing in the decree]?

Jean-Marc Olivé: The gaps that do not cover role of medical professional associations, applications limited in health facilities, silence on promotion of breast milk substitutes in shops, and public places; age limits of children for whom the products are advertised can allow milk companies to cash in on these gaps.

[For example], the decree limits the selling or advertising breast milk substitutes for infants less than 12 months to health facilities. There is silence on promoting milk formula in shops and public places. The age of children for whom the decree strictly regulates selling or advertising breast milk substitutes is under 12 months. This allows milk companies to sell and advertise their products for children more than 12 months old. However, in reality, as many products are branded, it is not always clear for what age the milk product is advertised.

The decree bans pictures or text that encourages bottle feeding; (labeling) words that describe a product as equivalent or superior to mother's milk: photographs, drawings [used in labels] of children below 12 months; and donation and acceptance of materials bearing names or symbols of milk for children below 12 months in health facilities. But many milk companies violate these regulations.

Marjatta Tolvanen-Ojutkangas: Since there has not been any improvement in screening of the advertisements by the Communication Department of Vietnam Food Administration, the false advertisements in TV continue, and many violations continue also in the facilities. No formula company is unaware of the decree, in my opinion, for the International Code is some 30 years old, and many national Codes are passed and implemented. The companies often choose to ignore them or try to use their ignorance as an excuse. It is the responsibility of the government of Vietnam to enforce the decree to protect the best interests of the Vietnamese children from the false advertising and marketing of the companies, and make them aware that this is not the country where "anything goes." This is now the case with the nutrition products for children, but with increasing integration with global markets the same phenomenon can be true with so many other foods, unless the new Food Law that is now being finalized is fully enforced and implemented.

Is it realistic to have a complete separation of Vietnamese health professionals from infant formula milk companies at an organizational level in order to deal with the conflict of interest?

A mother bottle feeds her child at her house in Ho Chi Minh City. Formula milk companies are using legal loopholes to promote their sales and undermine the health of children, experts say.

Jean-Marc Olivé: The way to improve compliance by health professionals is to raise their awareness of the national code and enhance monitoring of code violations among health professionals. There is need to limit contact of individual health inspectors with companies to prevent intimidation by companies, and corruption and abuse of power on the part of government officers. Dealings with companies should always be committed to writing and central and provincial authorities must be encouraged to inform each other of the actions and decisions taken to ensure consistency and uniformity. A monitoring report on marketing practices which violate the decree should ideally be prepared as a shaming device and circulated widely so that companies, health workers and shop owners will refrain from blatantly violating the decree.

Marjatta Tolvanen-Ojutkangas: Since Vietnamese women have a very high attendance of ante-natal care clinics and give birth in the health facilities, close to 100 percent, we obviously cannot separate the health professionals from breastfeeding promotion. At organizational level we do need to be able to separate them from the influence of the companies, otherwise the advice that they give and task that they are expected to perform in ante-natal care clinics and maternity hospitals will be compromised. We need to ensure that the basic training of health professionals includes a good knowledge base on benefits of breastfeeding, so that the health professionals know what the best practice is, and with that information be prepared to stand against the false information of the companies. The financial incentive for the health personnel by the companies is one of the main reasons for them to ignore the best practice. Increasing the pay for civil servants would obviously be the best way to make that incentive disappear. Finally, in order to achieve this goal, revising the decree is a must.

Has there been any headway in enforcing the decree?

Marjatta Tolvanen-Ojutkangas: After the launch of breastfeeding awareness campaign last August there has been increasing exposure of the violations, thanks especially to journalists and the media. The process of reviewing the decree and respective tools is now included in the UNICEF supported annual work plan for this year. What is needed is commitment by the relevant MoH departments to speed up the process that in any case is time-consuming. But we believe that this will proceed in 2010.

Can the latest hike in formula prices be considered an opportune moment to talk Vietnamese mothers into exclusive breastfeeding?

Marjatta Tolvanen-Ojutkangas: We need to update our calculations of the cost of formula per child - it is a huge sum of money! This year there will be substantial communication campaigns coming up, so we need to use also this information for awareness rising. When a family knows of the better option, of breastfeeding, one would expect that rational behavior is to save the money for something else and at the same time improve the child's health and nutrition.

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