This paper was written in preparation for a talk I was asked to give at the World Alliance for Breastfeeding Action Partners Meeting in Salvador, Brazil on July 23, 2001. I was too late arriving for there to be time for me to give it, but here it is, presenting my thoughts on the international breastfeeding promotion “movement” today.

In some sense breastfeeding promotion is right back in the same crisis situation is faced 20 years ago: there is too little money to do much. Indeed, the basis for undertaking powerful actions on behalf of breastfeeding may in some sense be weaker now. We’ve lost the sheen of being something new, “sexy.” In many countries policy makers are content with current levels of breastfeeding, not realizing how important and rare exclusive breastfeeding (EBF) is. The nutrition community, for one, perceives breastfeeding as having received if anything too much money and attention compared to other issues. And media attention now comes only when something anti-breastfeeding comes along.

Is there some kind of backlash against breastfeeding among elite women who resent being told so often now that they are raising their infants in an inferior way? Maybe they more often have positions of power or influence in the media than they did 20 years ago, particularly in North America where they have so little support and yet so much reach in the communication media and cultural impact. Maybe we need a project with high visibility to shame the US by providing “development assistance” to American women in key positions!

All joking aside, WABA needs to lead the way toward a new dawn for breastfeeding action. But how? That is a question for discussion at the meeting, but I will take the opportunity of pushing my personal agenda for your consideration! But to start with, let’s look at the successes and lessons of the past.

A history of global breastfeeding promotion

Breastfeeding promotion used to consist of local or at best national-level efforts. The seeds for global cooperative efforts to promote breastfeeding were planted in UN work starting in the late 1960s that led to the International Code of Marketing of Breast-milk Substitutes; the activist work that began on that issue in the mid-1970s; and a series of meetings in Scandinavia among international experts in the late 1970s and early 1980s linked to research projects in three developing countries on “Breastfeeding policy under changing socio-economic conditions.” Those meetings led to a Lancet article castigating donor agencies for not doing anything for breastfeeding but giving lip service, even suggesting that the B in UNICEF’s GOBI (growth monitoring, oral rehydration, breastfeeding and immunization) should be a small b: GObI.

In December 1985, USAID held a meeting with participants from all over the world on breastfeeding promotion where the head of the nutrition unit, the late Marty Forman, announced that they were intending at last to start spending money on breastfeeding, and would be happy to do so with international partners. A few developing country participants came up to me and asked if Sida could not take the lead, since at that time the US was still actively opposing the Code. I talked to Marty privately about it and he welcomed the idea, but warned me that if Sida did not act quickly he would go ahead alone.

Sida was not willing to do that, but over the next couple years Marty must have gotten the message and waited. Then at a lunch gathering at an ACC/SCN meeting, the idea was raised of several agencies joining together to do something to raise the position of breastfeeding on the international agenda. This led to the formation of International Group for Action on Breastfeeding, IGAB, a temporary collaboration of WHO, UNICEF, USAID and Sida. It was open to all, but no other agency was willing to participate (it being understood that this also meant join in funding it). Georgetown University was chosen as the Secretariat for the group and a series of planning and technical meetings were held from 1987 right up the time of the Innocenti Meeting in July-August 1990. The key one perhaps was a Sida-funded expert meeting at WHO in June, 1990 where some of the basic wording for the Innocenti Declaration was hammered out, including the insistence on “two years” as the duration, breaking with WHO/UNICEF language up to that time (“well into the second year”).

A history of the first Innocenti Target: the breastfeeding advocate

At a 1980 meeting in Oslo, I was the rapporteur for a workshop that was tasked with looking at non-health worker related aspects of breastfeeding promotion and, inspired by it, wrote a paper called “Ideas for Action Programs for Promoting Breastfeeding.” Though never published, it was sent to the IGAB Secretariat when they asked for unpublished papers on breastfeeding promotion. It thus appeared to have inspired the first Innocenti target: appoint a national breastfeeding coordinator of appropriate authority and establish a multisectoral national breastfeeding committee composed of representatives from relevant government departments, non-governmental organizations, and health professional associations.

The idea was based on the fact that what happens in society is in part informed by vested interests. And in any country there are many times more people whose jobs have to do with X-ray technology or anesthesia, say, than with breastfeeding. That is, one reason breastfeeding never gets much further than lip service is because no one is hired to work on it, and there is no accountability anyplace if it declines. When people complain that hiring people just to work on breastfeeding would cost government money for something of seemingly narrow interest, we need to remind them that many more human lives are in the balance related to how well breastfeeding is done than how well X-rays are taken.

Thus the Innocenti Declaration at least implies that countries need to hire someone as a breastfeeding coordinator. This person needs to work in an inclusive way, getting inspiration from others in the many relevant sectors and helping them understand the issues from a breastfeeding perspective, leading to the idea of an intersectoral committee.

But actually I originally suggested an advocate rather than a coordinator and the most important groups I suggested that the advocate develop close working relations with were women’s groups. “Intersectoral committee” sounds like the death knoll of action!

In any case, I doubt that this target has been achieved in many countries and even then may not have had the intended affect. This is because it needs to be preceded by effective advocacy. Someone in government needs to feel the need for a person, backed by a powerful committee, to take responsibility for breastfeeding rates in the country, to report annually on how the work is going, and to be accountable for the its effectiveness. If breastfeeding decreases, then new people or at least new ways of working must be found. That kind of accountability only exists where those with power care about something.

The second target: BFHI

The late Jim Grant, Executive Director of UNICEF at the time, was always looking for quick fixes, exciting things that could be done quickly, get a lot of attention and money, and hopefully lead into broader ways of tackling more complex problems. Thus he went for a small part of the health professional portion of what is needed for breastfeeding to work well. I was lukewarm toward it in the early years.

But in time I realized that BFHI was for the first time reaching the industrialized world about a child health issue. And it was for the first time reaching someone in every country with the message that EBF was possible, important, and rare, and thus required attention. Kudos to UNICEF. Sadly, as we all know and UNICEF admits, the HIV issue has knocked out much of its attention to BFHI. Sida recently stopped funding it, for reasons that are unclear to me, so it may also have serious funding problems, as I do not know how important the Sida funding was. The original idea was that governments would themselves take it over, which of course they have done in richer ones that cared about it and in China, but probably not in many other countries.

There have of course been other problems along the way. What to do about step 10 in places where women’s groups do not already exist? What to do in places where it was implemented only superficially and where even the industry has secretly come in and undermined it, as has happened in the earlier huge success in China? Or in places like Yemen where it is dead in the water.

Much thought needs to be given to how to achieve the attention and concern needed to get access to increased resources for breastfeeding and then how to use them: what should be prioritized now? IF BFHI deserves to be resuscitated, then I suspect it needs to be taken on at a broader level in countries where it has not been successful, to build broader knowledge and consensus within the health care system. For example, the WHO course (not just the 18-hour course) may need to be held for dozens or hundreds of health workers, not just a few.

The third target: the Code

The work of IBFAN, including BMA in the UK, GIFA, and country level collaborators, continues to be a joy to see. Breaking the Rules continues to make a key contribution to keeping the movement to protect breastfeeding alive. This is complemented by important ongoing training from ICDC and David Clark’s efforts at UNICEF, both funded largely from Holland. WABA has played a role in awareness-raising through WBW and its publications, and in helping to create an international norm for ethical behavior among health professionals and researchers.

But let’s be honest. Without continued funding from donors to IBFAN, particularly Sweden and Holland, we would have won only round one and by now it would be back to business as usual. The various activists are understandably busy with their work, obtaining and reporting on grants and still have not been very successful in broadening or making permanent their base of financial support. But the companies will never go away, never stop needing to promote their products, and never lack money to do so.

Of course one way of institutionalizing protection of breastfeeding is laws. I am a big believer in going to the huge additional effort it takes to make the Code’s key provisions law. Here in Sweden I warn that the voluntary agreement will only be good as long as no new companies decide to enter the market, pointing out that the US had the first voluntary code which worked fine for over 60 years until two new companies decided to enter the market. It’s not wise to wait until this actually happens to act, because then you will have local vested interests working against you. How simple-minded the argument originally made in 1982 against passing a law now sounds: it would take several years to change the Swedish constitution regarding freedom of speech.

Breastfeeding, even more so than nutrition, falls between all the cracks and has no real home in any country, let alone internationally. Even the ACC/SCN is now going to die and is struggling to decide how to re-establish itself.

Without some kind of institutionalization, all the companies really have to do is wait us out. The day Sweden and/or Holland tires of being the ones to shoulder this burden is the day every country will experience what I recently heard has happened in China: the companies are back. Apparently they are establishing a system there like in North America: taking turns paying hospitals for the right to exclusively be the one to give out the free samples for a period of time. Though there is little evidence that the overall duration of breastfeeding has declined since the late 1970s, there is no natural law saying that we cannot lose much of the ground we have gained since then.

How sad that the world still does not recognize the need to institutionalize, “permanentize,” some kind of institution with acknowledged international credibility to promote breastfeeding policy and research-a think tank, a center of excellence, a source of inspiration, ideas and contacts for action, and if possible even a source of funding for critical research and action like the Micronutrient Initiative has been in its field. Such institutions exist for virtually any kind of food you can name, from wheat to cassava, but not for human milk, since no one makes money from it.

I have raised the idea in many international forums, but the only really enthusiastic response I got was from WABA. Sadly, the Bill and Melinda Gates Foundation was not willing to entertain a formal proposal for establishing one. I think if some substantial seed grant could be found, Sida would be willing to contribute, especially if it were based in Sweden. Let’s keep thinking about this and trying to find money for it.

Target four: support to working women

Work on this issue has progressed from naivete in the first meetings in the late 70s and early 80s to pessimism a decade later (thus explaining the Declaration’s vague reference to “imaginative legislation,” lacking anything more concrete to recommend), to a whole new set of opportunities yet another decade later. Two factors are particularly positive: the growing awareness of and agreement on human rights (outside the USA) and the new ILO convention MPC 183 and Recommendation 191. Three cheers for the magnificent efforts that the Maternity Protection Coalition made at two ILO Conferences to bring about these improved instruments! Their major success was rather invisible though, consisting of avoiding the weakening of these documents that leading industrialized countries, employers and the ILO Secretariat wanted.

However, in this case, I am not so positive about laws as I am in the case of the Code. This is because I do not think we know enough yet about the various constraints and how to overcome them. Laws have a way of causing unexpected side effects. There is always a risk that stronger laws will result in more discrimination against women and we must always be careful about the effects of our actions on women and on the attitudes towards us and towards breastfeeding of the women’s movement. Thus my main interest in the ILO was actually for its potential normative effect. That is, the new convention, but almost equally so, the new recommendation, could have provided us with just the tool we needed to promote social change, both structural and in our thinking, to provide women with the support they need to achieve six months of EBF.

I was not involved in the lobbying efforts at either ILO Conference, and thus do not have any right to be critical. Nor do I know if a different outcome would have been possible if a different strategy had been employed. It is completely understandable that one gets deeply involved in the acute issues of the day and may lose sight of the forest for the trees.

In hindsight however, once the lobbyists had established their presence and proven their power to deliver votes, I wonder if it might have been possible to arrange a negotiating session at which certain aspects of the convention were “traded” for substantial strengthening of the recommendation. For example, now we see that we may lose Scandinavia due to such a minor issue as pay for the breastfeeding breaks. What if we could have “traded” a weakening of that (say, by adding that they were to be paid “according to national law and practice”) in return for support for six months’ paid leave in the recommendation-which would cost no one anything and not threaten any ratifications?

As it is, I am uncertain what is the best thing to concentrate our efforts on now. The Recommendation’s 18 weeks may seem like goodness and light compared to the previous 14, but it’s closer to four months than six. Ratification has its own value and gaining credibility and partnership relations with unions, exemplary employers, and even the ILO itself is at least as important. But how far will all this take us toward creating the support working women really need? Women, as always, are and will continue to be caught in the middle. If they really believe in 6 months EBF, they face 8 weeks of pumping at work even where the Recommendation is implemented.

What is clear is that we have only a short window of opportunity to exploit the ILO ratification process for our own purposes. WABA needs to think strategically about how to make the best use of this in the coming year or two, particularly what its role should be in relation to others in the coalition. Then when that opportunity has played itself out, we need to put our heads together, see how far we have gotten, who our best partners are, what lessons we have learned, and decide where to go from there. Maybe a shift of attention to informal workers would be the best way ahead at that point.

A fifth target?

At the workshop in Oslo, referred to above, there was a debate about what deserved greatest priority: efforts to educate health workers or community-based efforts. I was among those who pushed for the latter because I believed and still do, that the major thing required for breastfeeding to work well is to enable and empower mothers to do it. When women have access to information and social support (including at the workplace), the role of the health care professions becomes minor. Indeed, the major task will be to remove them as an obstacle, something which empowered women can do. If however, we begin from the wrong end and ask the health care professionals to be the vanguard of breastfeeding protection, support and promotion, I am afraid we will be in for a disappointment. If there is one generalization I think we can make about health professionals all over the world, especially doctors, it is that empowering others is not their modus operandi.

The Innocenti process did not include NGOs. As far as I know this was more an oversight than a policy decision. At the actual Innocenti meeting, when a couple of them showed up, WHO was upset, UNICEF embarrassed and Sida and USAID seemed to stay out of it. WHO told them they could attend but not be involved and definitely not do any lobbying inside or outside the meeting room. This embarrassment on UNICEF’s part may have been the real seed for the formation of WABA. This lack of NGO involvement is also a possible explanation for the inadequate attention in the Innocenti Declaration paid to the role of civil society itself and of empowerment.

I am particularly moved by the example most of you have read about from Gambia-their Baby Friendly Community Initiative. When they learn about the importance of exclusive breastfeeding, any community can take steps to support and enable women to practice it. Something as simple as temporarily working on each others’ fields, so that for six months after delivery no woman in the village has to walk a long distance from home to work on her fields. How about WABA making a field trip with some crack journalists and photographers and see if you can turn this into a world-wide movement: a fifth target could be the establishment of baby-friendly communities!