The Infant Formula Scandal

Hi everyone, I’m Becca.

S: & I’m Sarah! And you’re listening to Unsavory. 

I want to start off by asking you a question. If you have a baby and you are unable to breastfeed, what do you do?

S: Ooo, right into it! I would use baby formula. 

Right, it’s not the only option. But it is often the first and sometimes the only thing that comes to mind. 

Today we are going to cover a story of corporate greed that rocked the world in the 1970’s. It’s a story of white collar crime, conformity bias and the diffusion of responsibility. It has been referred to as the darkest chapter in corporate history where profits were prioritized over people…and we’re covering the Nestle infant formula scandal. 

I think this might be the biggest true crime story we have told on the podcast thus far. It’s another one of those - like Herbalife - where once I got into the research I couldn’t believe we hadn’t covered it yet. And where the information was endless. 

S: Ooouuff

Do you know much about this one?

S: Not a single thing. Not only about this story, but also about baby formula. It’s not my area of expertise. All I know is that I was formula fed and I think I turned out pretty great! 

Okay, are you ready?

S: I’m ready! Let’s do it.

Intro music

Shout out to my sources for today’s episode which are all listed in the show notes at unsavorypodcast.com. A paper called “A history of infant feeding” by Stevens, Patrick and Pickler; a video by Into the Shadows ______

Massive trigger warning before we get started. This episode will discuss instances of infant malnutrition and mortality. 

I want to kick off this story by very clearly stating that the way you feed your child is your choice. Even though we will be discussing some of the extreme effects and criticisms of the use and misuse of infant formula, it in no way represents our views. 

S: Agreed.

Creation of infant formula

OK so as we touched on in our intro, if you weren’t breastfed as an infant, you were likely formula fed. But prior to the end of the 19th century, infants who were not breastfed by their mothers either had a wetnurse or were fed animal milk. So I naturally read up a bit on wetnurses and it’s so so interesting. From the 15th - 17th centuries, being a wetnurse was a desirable profession among women from lower income families because it paid really well. It wasn’t uncommon for women to get pregnant, have a child, get rid of it, and become a wetnurse.

S: Ouff tough times, but I bet you could make so much money doing that! There really wouldn’t be any other option for mothers who couldn’t breastfeed and they would be desperate to feed their babies. 

Ya, but authorities picked up on this and the profession became surprisingly regulated. So the women had to have a physical prior to being hired and they were forbidden from breastfeeding other children until they were 9-months post-birth. Kinda forcing people to keep and nurture their own children. These women were often hired by wealthy, aristocratic families, where it was seen as unfashionable to feed their own child. But they were also hired by some working women, where it was cheaper to hire a wetnurse than it was to hire someone to help with their husband’s businesses.

S: It’s interesting the different pressures women have faced throughout the years, probably since the beginning of time really, about how to feed their children. Like in certain societies 150 yeras ago, it would have been uncool to breastfeed your own child and at the same time in other circles, women were probably getting shamed for not breastfeeding. 

Bottles were also used to feed infants either human or other animal’s milk. But during the early 19th century, they didn’t really know to properly clean the bottles. And that combined with the improper storage and sterilization of the milk led to the death of about ⅓ of all non-breastfed infants within their first year of life.

S: OMG 

With the discovery of germ theory in the 1860’s - which we talk about in our Typhoid Mary episode - came better sanitation practices, as well as modern improvements on bottles, and the availability of animal milk - mainly cow’s milk. And bottle feeding started to become a more popular choice. 

But studies that compared the composition of human milk against animal milk found that human milk was the best source nutritionally for infants. It has certain antibodies that can help protect infants from infections and diseases early on AND it can have positive effects on children into adulthood. Which is why it is recommended to breastfeed exclusively for the first 6 months of life, if you can. 

S: Right and now they don’t even recommend introducing dairy milk unti 9-12 months. (Alerbta Health Services, 2022)

B: So, researchers took what they knew about breastmilk and tried to mimic it.

(Stevens, Patrick & Picker, 2009).

It was pretty obvious that cow’s milk was the most similar to human milk and the best canvas to work with. But some modifications had to be made to make it easier to digest, more palatable, and safer for infants. So they did things like remove some of the animal fat and replace it with vegetable oils. They diluted the protein content and adjusted certain nutrient compositions like adding iron and adjusting the calcium/phosphorus ratio (Institute of Medicine, 2004).

In 1865, a chemist named Justus von Liebig created and marketed a liquid formula consisting of cow’s milk, wheat flour, malt flour and potassium bicarbonate.

S: Justus Von Liebig… that name sound so familiar?

Funny you ask…I can’t remember if we talked about him in the Organic Foods episode, but he was also known for his discovery of nitrogen as being essential to plants. He came up a lot when I was researching for that episode - since he’s best known as “father of the fertilizer industry”.

S: wow, he really had a diverse portfolio of projects

So with Liebig’s success with the product others started to follow…and by 1883 there were 27 infant food brands. One of these brands was Nestlé’s Food.

S: So Liebig’s formula must have been safe then, if it caught on and other companies started to follow suit. Even though sanitation was likely still a big concern. 

In the 1870’s, Nestle launched their product called Farine Lactee which in English literally means “milky flour” I think…unless I’m reading it wrong. It was made from malt, cow’s milk, sugar and wheat flour and it was deemed the first COMPLETE artificial formula available on the market, since it required no milk to prepare…it was a powdered formula that you just added water to. And this was right around the time evaporated milk was invented, so they used that in the formula which helped with its preservation. 

S: Coool

The formulas in general continued to improve with vitamin fortification and they even created soy-based versions for infants allergic to cow’s milk. With that being said, I feel like the infant formula industry had very savory beginnings. It seemed like they were motivated by the wellbeing of children…at first. 

S: Ah savory, before it became… Unsavory

By the 1950’s, doctors and mothers around the world regarded the use of formula to be a safe substitute for breastmilk. And as a consequence, breastfeeding steadily decreased until the 1980’s. 

S: what happened in the 80’s?

Oh we’ll get to that very soon. So the formula wasn’t just being used by mothers who couldn’t breastfeed, but mothers going into the workforce and others who simply chose not to breastfeed. At the time Nestle was selling the bottles for 50 cents a pop…which in today’s money is around the $10 mark. But when I looked up the Nestle formula cost today it ranges from $20-50 online. I read somewhere that you go through about 40 tins of formula (500g) during the first 6 months with an infant. So that’s an extra $800 minimum in addition to the MANY other expenses that come with having a baby (Stevens, Patrick & Picker, 2009).

So it should come as no surprise to hear that baby formula is one of the most stolen items from stores, accounting for 13% of all stolen items (Kavilanz, 2021). I do think that stolen formula should be a complete write off. I hope no one ever gets prosecuted for a crime like that…

Nestle Marketing

Now is where shit gets sinister.

Nestle sales spiked in North America in the 1950’s following the post World War II Baby Boom. But this new customer growth couldn’t last forever and in the 1960’s birth rates began to decline. With profit to maintain and stakeholders to satisfy, Nestle had a problem - they needed to find more babies. And the answer was pretty clear - they would look for a new customer base in countries that had been fairly untapped by their influence - developing countries.

So in the 1970’s they brought their products into Asia, Africa and South America. But they had another issue. Only about 1 in 5 women were unable to breastfeed. So very few actually needed access to formulas. Plus it’s so expensive, meaning that in many of these countries, families would be required to use up to 40% of their income to purchase it. It didn’t really make sense. But they persisted.

There were a few things they needed to break into the new market: they needed to create a need, to provide free samples and to link their products to a desirable lifestyle. The last one was easy…they had ads and billboards plastered everywhere, almost all of them using imagery of healthy white babies. They tried to glamorize their products by implying that westernized mothers were all using it and that their children were stronger and healthier because of it.

But how do you create a need for formula where there isn’t a need? You make breastfeeding seem inferior, of course. They used their advertisements to do this, including one headline that stated “when breastmilk fails…”; they would even send sales women dressed as nurses into hospitals to talk to patients. At one point, they had over 5000 saleswomen on the ground in these lower-income countries. When this practice was ultimately banned in hospital settings, the fake nurses were instructed to gather the home addresses of families from maternity wards to visit them once they were discharged; and to campaign the streets looking for homes with drying cloth diapers outside. They would then knock on doors, provide free formula samples and discuss its benefits with anyone willing to listen - all while presenting themselves as medical health professionals. This promotion was intended to create fear around breastfeeding and to increase any levels of anxiety these women had about motherhood. And guess what anxiety does?

S: 

Yep, it can impact lactation. Increased levels of stress can decrease milk production, meaning these mothers may actually end up needing the formula whereas before even knowing about it, they may have been fine.

Nestle also set up shop in maternity wards, providing lots and lots of free products and baby bottles. They wanted to get the attention of mother’s within the first few hours after they gave birth. To provide them with free samples and allegedly with the intention of interfering with the mother’s initial milk supply. The first hour postpartum is especially important and if an infant does not take to the breast, the supply slows down fairly quickly (Into the Shadows, 2022). 

Nestle also sent sales reps in to talk to doctors and nurses - they would shower them with gifts and in turn hospitals began giving them more pull. They even became involved in the infrastructural design of some maternity departments, funding the creation of wards that were apparently a further distance from the maternity rooms, making it that much more difficult for mothers to get to their babies to breastfeed. But Nestle wasn’t the only one guilty of this, Abbott helped design over 200 maternity wards in hospitals across the US and as of 2017, they were still involved in the infrastructural design of maternity departments in parts of Africa and Asia (Changing Markets Foundation, 2017).

Malnutrition, infection 

There was nothing actually wrong with the formula itself - as I mentioned, it was nutritionally adequate when compared to breastmilk. And millions of infants who had relied on formula in North America had already grown up to be healthy children and healthy adults. So there was nothing technically wrong with the products themselves…if they were prepared with uncontaminated water.

In the 1970’s - and still today - many of the lower income communities in these countries did not have access to safe drinking water. Often surface water was used that contained harmful bacteria. Sanitation practices weren’t as well recognized and therefore weren’t prioritized either. For instance, in West Africa, some kitchen stoves were set up to cook over a campfire with three stones to support one cooking pot. With this setup it was almost impossible to boil water for each feeding AND to sterilize the feeding equipment for every feed AND to cook food for themselves and the rest of their families. Plus newborn babies apparently eat between 8-12 times a day. So someone would be at that stove all dang day. One study found that about 80% of all bottles at this time had some level of bacterial contamination.

Another major issue that we briefly touched on was the price of formula. Since many of the families who needed or had the perception that they needed it were spending around 40% of their income on it. Many mothers began diluting the products to make it last longer. In Barbados, one study conducted in 1969 found that 82% of mothers were diluting 4-days worth of formula to last between 5 days and three weeks. This obviously resulted in many instances of chronic malnutrition, and a condition called merasmus becoming more common. This is a condition associated with a deficiency in energy and protein, and was often referred to as “Lactogen Syndrome” which was the name of another Nestle product on the market at the time.

In other instances, mothers would add sugar water and cornstarch to the formula to stretch it out. This resulted in another disease called KWA - SHE - OH - KOH /kwashiorkor, which is associated with a severe deficiency in protein; so not necessarily energy, just protein. Infants suffering from malnutrition are more vulnerable to infection and diarrhea. And ultimately one of the of the greatest predictors of infant dealth became these formulas. An infant using formula in conditions without safe sanitation practices was 25 x’s more likely to die from diarrhea (and dehydration) and 4 x’s more likely to die from pneumonia than their breastfed counterparts. And even those who survived experienced and continue to experience many of the permanent effects that were caused by malnutrition during this critical developmental stage.

When these issues were brought up to Nestle, their argument was that the issue was of the misuse of their products and not the products themselves. Which is technically true. But should they be held accountable for advertising in areas where they knew the conditions were not appropriate? 

S: Absolutely.

Most of the instruction and nutrition labels were printed in English. Meaning if you didn’t know how to read English, you wouldn’t know how to prepare the formula properly. Even when the instructions were printed in an appropriate language, many of the developing communities targeted had low literacy levels.

What were perhaps unintended consequences at first, became very much expected as corporate greed took over and their promotion and sales continued.

A study by the National Bureau of Economic Research estimated that in 1981 - at the peak of this controversy - the mortality rate that could be linked to the availability of Nestle formula was 66,000 infants. Today that number ranges from 800,000 to 1.5 million deaths a year. Although these numbers are estimated based on infant formula in general - not just Nestle’s. Nestle was just one of the biggest players in the game (Anttila-Hughes et al., 2018; Into the Shadows, 2022). 

The Baby Killer report & 1977 Nestle boycott 

But the sales overseas didn’t continue without pushback. 

In 1974, a 12-page report titled “The Baby Killer” was released by an anti-poverty organization based out of London, England called The War on Want. In this report they hold Nestle accountable for the deaths of infants around the world due to their manipulative marketing tactics - promoting formula as superior to breastfeeding - in developing countries. Nestle figured they had a defamation case on their hands so they sent two representatives to a pediatric ward in Nairobi, Kenya - I think to gather information for a lawsuit. But when the representatives arrived, they witnessed an infant who was fed on Nestle formula lose their life right in front of them. And they ended up leaving the hospital without completing the task they were sent there to do.

The Baby Killer report was then later translated in Sweden and the translated title was quite literally “Nestle Kills Babies”. Nestle tried to sue the organization for 5 million dollars, but apparently, when they saw the evidence that the other side had against them, they withdrew most of their complaints…except for their complaint of the title of the report - “Nestle Kills Babies”. Unfortunately, because the groups could not prove that Nestle had intentionally killed any babies, the judge was forced to side with them. But they only made the group pay $400 in charges in addition to changing the report name. The judge also told Neslte that they must change their publicity methods. So they weren’t really seen as a victim here (Into the Shadows, 2022). 

In 1977, after more awareness and public disapproval, protests began breaking out and a boycott was formed called the Infant Formula Action Coalition (or INFACT). Their sole purpose was to protest against Nestle’s unethical marketing practices. Nestle’s own website today addresses this whole thing and states “this boycott was dropped in 1984” (Nestle, n.d.). So I think formally, maybe it was. But there are still live INFACT websites and work being done around these issues. 

New regulations (WHO)

One of the reasons I think the boycott was “dropped” was because of a new set of regulations called The Code. In 1978, following the start of the boycott (which is important to remember), Senator Edward Kennedy brought the issue of infant formula to the senate. The World Health Organization and the United Nations then finally stepped up in 1979 to create The International Code of Marketing of Breast-milk Substitutes AKA The Code. The Code prohibited certain practices including: 

• Promoting formula products in hospitals
• Giving out free samples
• Giving gifts to medical professionals
• Providing misleading information; using misleading images or text
• Promoting products designed for infants under 6 months
• As well as requiring all labels to be written in a language that is understood in the country it’s being promoted in; and 
• Including a prominent health warning label

But remember that the peak of this crisis was in 1981 - two years after The Code was created. Because the code was seen more as a set of recommendations to follow - not rules. Many of the American formula companies considered these practices to infringe on their free speech and their ability to trade. So they would do things like translate the instructions in the appropriate languages, but keep the warning labels in English…After more pushback, in 1982, Nestle finally created their own policy to reflect SOME of what was in the code. And they updated it in 1984 after consulting with the WHO, UNICEF & some outside organizations (Nossiter, 1981). Why that took 5 years, I can only imagine was due to significant profits.

Conclusion

Today, issues of infant formula continue. Earlier this year, it was reported that a few infants had died due to the consumption of contaminated Similac products going back as far as early 2021. This is an Abbott product btw, not Nestle. But one of the major plants shut down, contributing to global supply chain crisis and associated baby formula shortage.

These stories are so bizarre to me because we continue to fail one of the most vulnerable populations and not take better precautions with their lifesaving meal replacements. I couldn’t find anything that said Nestle was punished any way other than financially, which doesn’t seem like enough in my opinion. 

But anyways, that is the story and the pretty unsatisfying ending of the Infant Formula Scandal.