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Lord McIntosh of Haringey: My Lords, since the order is brought forward with the approval of the United Nations Commission on Narcotic Drugs and the Advisory Council on the Misuse of Drugs, we are satisfied with it.

On Question, Motion agreed to.

Breast Milk Substitutes

6.47 p.m.

Lord Rea rose to ask Her Majesty's Government why, in the Infant Formula and Follow-On Formula Regulations 1995 (S.I. 1995/77), they have disregarded the World Health Organisation code on marketing of breast milk substitutes by allowing brand name advertising to the public through the healthcare system.

The noble Lord said: My Lords, this evening I shall try to focus my remarks quite narrowly on the words of the Unstarred Question. Of course, there is a much wider issue at stake; that is, the increasing recognition by both government and the health professions of the health benefits of breast feeding and the need to promote it. There is steadily accumulating evidence that human breast milk has health benefits not only in the developing world, where the use of formula milks can be a virtual death sentence, but also in the United Kingdom and other industrial countries.

I shall go into more detail later about the health benefits for both child and mother. But I believe that the Government are fully aware of the evidence which supports the benefits of breast-feeding and they have stated repeatedly that they wish to promote that further. In fact, the whole tenor of the regulations which we are discussing is to control the composition, advertising and marketing of alternatives to breast-feeding in the spirit of the WHO code of 1981, which regulates the promotion of artificial feeds for babies and young children. The implied aim of the regulations is to protect and promote breast-feeding. The regulations implement Commission Directive 91/321 of the EC, now the EU, which was itself the result of prolonged discussion by the European Commission, the European Parliament and MAFF with the overall aim of complying, as far as possible, with the WHO code.

The first United Kingdom version of those directives—the draft version of the regulations in question tonight—was issued in December 1993 by MAFF for consultation. It called for comments from interested organisations and individuals, as is the norm with proposed new legislation. It was enthusiastically backed by 60 organisations concerned with health, including the British Medical Association, the British Paediatric Association, the Royal College of Nursing, the Health Visitors' Association, the Royal College of Midwives and the British Diabetic Association, as well as some 160 individuals. Some of them called for strengthening of the draft regulations further to restrict

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promotion. The draft regulations were opposed, at least in the part dealing with advertising, by 10 organisations, all of which were manufacturers, promoters of distributors of infant formula preparations, as well as just three individuals.

Despite the large body of responsible professional opinion backing the draft regulations, or asking for them to be strengthened, the final version is now law and is more lenient than the draft version instead of being tighter as the professional organisations wanted. To be specific, Regulation 17, which is concerned with restrictions on advertising of infant formulae, has been greatly watered down compared with the draft. Regulation 17 reads:

    "No person shall publish or display any advertisement for an infant formula except,

    (i) in a publication specialising in babycare and distributed only through the healthcare system; or,

    (ii) in a scientific publication".

It then goes on to cover some areas with which I am not concerned tonight. In the draft version which preceded it, which was backed by the health professions that I have mentioned, Regulation 17 started by saying the same:

    "No person shall publish or display an advertisement for an infant formula except .... in a publication specialising in babycare... or in a scientific publication".

The wording, up to then, is identically followed by the current regulations. But, after that, the draft law goes on to say,

    "publications of which in either case the intended readership is one of independent persons qualified in medicine, nutrition or pharmacy, or having a professional qualification in maternal or childcare".

Those words have been eliminated from the regulations now in force, and the words,

    "and distributed through the healthcare system",

have been substituted.

The Minister must surely realise that that is an entirely different proposition. Mothers can be, and are, reached directly through,

    "publication[s] specialising in babycare distributed through the healthcare system".

The noble Baroness, Lady Cumberlege, has said that the new regulations put into statutory form the current voluntary agreement with the baby food industry to restrict advertising to the general public. However, the draft regulations, in line with the WHO code, would have tightened up and further restricted advertising to mothers—for example, through the healthcare system. At present that is quietly going on in quite a big way, despite the voluntary agreement. For instance, Bounty Packs, sponsored by the baby milk industry, giving information about baby care, including breast-feeding and also formula milks, to mothers and offering tokens in exchange for usual baby care items such as shampoos, soap and nappies are being given to mothers in maternity units. Indeed, the sponsors pay 70 pence per patient to those hospitals which allow Bounty visitors to see newly-delivered mothers when they are still at a very vulnerable stage. That income is modest, but, in a maternity hospital which receives 2,000 patients a year, it is a useful, small extra item of income.

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The names and addresses of the mothers seen are collected, thus allowing further promotional material to be sent to them by the Bounty sponsors. As the Minister knows full well, the advertising industry is highly ingenious and will use the provision allowing promotion "through the healthcare system" to the full.

Again, the noble Baroness, Lady Cumberlege, stated in a television interview that promotional material under the new regulations will not be going directly to mothers; it will only do so via health professionals. That contradicts her repeated statements, and those of other Ministers, that the new regulations represent the continuation of the present voluntary agreements, which are in fact widely circumvented—or perhaps circumnavigated. I gave your Lordships one illustration, but there are other cases. It appears that the Government have not taken the majority opinion of responsible health professionals who responded to the call for consultation, but have taken the minority opinion of the baby milk producers in watering down the draft regulations issued for consultation in 1993.

I personally feel a sense of déjo vu when asking tonight's Unstarred Question. At about this time last year, I was asking your Lordships to support an amendment which would have restricted the advertising of tobacco products in much the same way as the draft regulations in question would have restricted the advertising of infant formula milks. Then, as now, the Government opposed the proposal while accepting fully the health arguments. In fact, the reduction of smoking was actually a target of The Health of the Nation White Paper. In my view, the Government's position is manifestly hypocritical in both cases.

However, there are still some ways in which the regulations could be made to help control infant formula promotion better than the current voluntary agreement. At present the guidelines for the implementation of the regulations are being drawn up. I hope that the Minister or his colleagues will listen very carefully at these consultations to the views put forward by representatives of the health professions who are on the working group which is drawing up the guidelines. Perhaps the Minister can give me some indication of how soon those guidelines will be available.

In comparison with artificial feeding, breast-feeding has been shown in very careful studies to decrease infections, improve intelligence, decrease subsequent diabetes and reduce pre-menopausal cancer of the breast in women who have breast-fed. The cost to the National Health Service of treating the excess gastroenteritis alone caused by bottlefeeding has been calculated to be about £18 million per annum.

Britain still has a low breast-feeding rate compared with some other industrialised countries. Only 62 per cent. of women start breast-feeding at all and only 25 per cent. are still breast-feeding when the baby has reached three months of age. That rate has actually decreased over the past 10 years, whereas in Norway virtually all mothers start breast-feeding and 90 per cent. of them are still partially breast-feeding when the baby is three months old.

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Norway has a strict advertising ban on baby milk promotion, as has Holland, France, Denmark, Luxembourg and Spain. However, Norway has also promoted breast-feeding in many other ways; for example, it has made it compulsory for firms to allow women time off while at work to breast-feed. Not surprisingly, the perinatal and infant mortality rates in Norway are both better than ours, despite the fact that Norway has a scattered and remote population many of whose members live out of the reach of health services.

It would be possible to continue further. Indeed, the subject is complex and there are many lines of argument that I could follow further. However, I believe that I have said enough this evening to amplify the printed words in the Unstarred Question and to give the noble Earl food for thought—a description which could well apply to breast milk itself.

7 p.m.

Lord Monkswell: My Lords, we are all indebted to my noble friend Lord Rea for his excellent introduction to this mini-debate. His contribution this evening has been so extensive that it leaves me with very little to say. I should like to stress one aspect of the subject and introduce a slightly different idea that may be considered.

I believe it to be generally accepted that breast is best and that breast-feeding is beneficial to both mothers and babies. However, it has become public knowledge only through research which has been conducted which has shown that it is beneficial to mothers and babies. It is unfortunate that more publicity has not been given to research which shows that mothers who breast feed suffer a reduced rate of breast cancer. We need to publicise that fact time and time again to get it across to the public at large.

My noble friend referred to déjo vu in terms of the debate last year on tobacco advertising. It is interesting to note that tobacco products carry a health warning. One of the suggestions that I make tonight is that breast milk substitutes should carry a health warning similar to that relating to tobacco products. I believe that it would be sensible for breast milk substitutes to carry words to the effect that the use of those products would increase the risk of breast cancer. It has been elucidated through scientific research that this is a fact. It seems only sensible that we through government action should ensure that that fact is widely publicised. It seems logical that, using the precedent of the health warnings placed on the packaging of tobacco products, we should use a similar system for baby milk formulas and like products.

One of the matters that emerged strongly in the remarks of my noble friend was that, on the one hand, those in the health field in a professional capacity recommended one course of action and, on the other hand, the commercial interests recommended another. It is a little disturbing, but not surprising, that the Government have sided with the commercial interests. I believe it is only sensible that we in Parliament recognise the problems of commercial imperatives. It is

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a little sad that the Government seem to be able to listen only to the commercial interests and not to professional reports and concerns.

One wonders whether the problem should be viewed in a slightly different way. I draw an analogy with the defence industries. We all know that one of the problems facing those industries is the reduction in demand caused by the peace dividend following the end of the cold war. For a number of years my party has called for a defence diversification agency to ensure that the talents, commercial acumen and abilities of the commercial enterprises that produce defence products can be harnessed to produce peaceful products. I believe we have to recognise that, like the defence industries, here is a whole industry that produces breast milk substitutes. We need to recognise the importance of those commercial interests. They provide employment and economic activity. Perhaps it is sensible to consider the creation of a baby milk diversification agency to look at and develop ways in which the commercial interests, which at the moment produce baby milk formulas, can be harnessed and used in a more beneficial manner. I have been considering this matter for only a short time. The idea came to me a week or so ago. For example, instead of these commercial interests providing a product that is harmful to mothers and babies, perhaps they can produce a product, which may be similar and may use the same technology and raw materials, for use in the pet food industry. Instead of providing a product that is harmful to human beings, perhaps they can provide a product that is beneficial for pets which the British public love so dearly and for which they want to provide nutrition.

That is only one suggestion for diversification of the commercial interests away from the anti-social activities in which they are engaged at the moment into more socially beneficial areas. I notice that my remarks have brought smiles to the faces of some noble Lords who sit on the opposite Benches. But I hope that this matter can be considered seriously. This matter has immense implications for the health of both babies and their mothers. By stressing the risk run by both mothers and babies due to bottle feeding, the fact that breast-feeding is healthy for mothers, and the possibility of the diversion of the commercial interests into a socially responsible activity which will not deny them their operation entirely, we may go forward on this subject.

7.7 p.m.

The Viscount of Falkland: My Lords, I thank the noble Lord, Lord Rea, for introducing this subject in his Unstarred Question. It is a pity that as well as having a qualified medical practitioner speaking in the debate we do not have a noble Baroness to speak also. It is unfortunate that on a subject which involves so much the interests of women and their children it should be an all-male debate. But I am quite sure that, given the usual care and concern that noble Lords give to their speeches, it will not be that much weaker.

My reason for speaking in this short debate is that I have been aware that for a number of years the World Health Organisation has taken a fairly strong line on the

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whole business of the worldwide marketing of breast milk substitutes. Of course, in the third world they have created considerable problems, not just because of the nature of the products themselves but because of the radical changes in behaviour, particularly in tribal areas; for example, the mixing of milks with dirty water on some occasions and so on. One hopes that that kind of problem does not prevail in a country such as ours, although it may.

In 1981 when the argument was raging on a worldwide basis, the British Government signed up to the World Health Organisation's international code in relation to the marketing of breast milk substitutes. That draft code was concerned with the dissemination of totally impartial and non-commercial information to nursing mothers. That is an admirable aim. It did not preclude the passing of authorised information to health professionals in this area.

In 1990 the Government signed up to a European declaration—the Innocentri Declaration—which had two aims. They were to take action to give effect to the principles and aims of the articles of the code and also to stimulate imaginative legislation by European governments to protect the breast-feeding rights of working women. The Government saw no difficulty in signing up to that declaration.

Then in the early 1990s we had draft regulations on the subject. They were followed in 1995 by a statutory instrument. All of those came close to the requirements of the World Health Organisation. Then the Government published The Health of the Nation, which gave great weight to the encouragement of breast-feeding by nursing mothers.

The present regulations which we are discussing represent an important departure from the principles of that international code to which the Government acceded. Quite correctly, the Government sought the views of a number of organisations. A list of 48 organisations has just been shown to me by the noble Lord, Lord Rea. The majority advised that we should not change the practice of excluding commercial advertising to nursing mothers but should adhere closely to the original guidelines laid down by the World Health Organisation. There was a small number of those who felt that the rules should be relaxed. Not surprisingly many of them represented commercial interests in the artificial milk manufacturing industry. That is where the anxiety lies.

The manufacture of breast milk substitutes is a very profitable business. Between £5 million and £7 million a year is spent on advertising these products. I do not know how much the Government spend on their literature encouraging and recommending to nursing mothers that they make every attempt to continue breast-feeding as long as possible. (The noble Lord, Lord Rea, has just whispered in my ear that the figure is £100,000. That is derisory in comparison with the large amounts spent by commercial interests on advertising their products.) It is curious that, against all the advice of non-commercial organisations, the Government have decided that the views of the commercial lobby should prevail in this way.

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I do not want to go into detail, because the noble Lord, Lord Rea, has given us a good and succinct account of the benefits of breast-feeding. After all, mothers have been breast-feeding since the beginning of time and we are all here. In those countries where breast-feeding is still the norm a very high percentage of mothers continue breast-feeding until a late stage. As the noble Lord, Lord Rea, indicated, in the Scandinavian countries the figure is between 95 per cent. and 100 per cent. However, they have the social security support necessary to enable them to do so. That is an important point which was rather surprisingly raised somewhat obliquely by other noble Lords. If one is seriously to encourage women to continue breast-feeding, one has to create the financial circumstances in which they can do so. That may well have been one of the considerations that the Government had in mind in arriving at their decision to allow the further dissemination of information.

I am sure that when he rises to answer the Question the noble Earl will tell us that the Government are seeking to increase the quality and amount of information available to nursing mothers. I hope that he will not say that because I shall not believe a word of it. I do not believe that other noble Lords will either. We all know that everything that is advertised is advertised selectively and, to use the words of the noble Lord, Lord Rea, highly ingeniously. Any sensible person would come to the conclusion, as did many of the 48 bodies that advised the Government, that what is needed is appropriate information provided by professionals so that women can make an informed choice rather than being fed modern promotional information by way of videos, information packs with free gifts and all the paraphernalia of modern commercial advertising.

Here again the Government have lost sight of the main issue. It is not the interests of commercial groups or the interests of doctors; it is not even the interests of mothers. It is the interests of babies. Have the interests of babies been properly considered? The question of whether if one is breast-fed for three months one is less likely to have migraine, gastro-enteritis or whatever is far too technical for me. However, it seems to me that the Government have moved too far on the side of commercial interests. I shall be very interested to hear how the noble Earl will explain the swift decision to come down so strongly on that side.

7.16 p.m.

The Parliamentary Secretary, Ministry of Agriculture, Fisheries and Food (Earl Howe): My Lords, this has been a useful debate. I am grateful to the noble Lord, Lord Rea, for initiating it, and I welcome the opportunity to reply to some of the points raised by noble Lords who have spoken.

First, I should like to emphasise the Government's commitment to the promotion of breast-feeding as the best means of nurturing a baby. That is based on medical advice which is quite unequivocal about the advantages of breast-feeding for both mother and baby, as the noble Lord, Lord Rea, rightly pointed out.

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Government policies have consistently supported breast-feeding. That is reflected in the steps that we have taken and are still taking to promote it. To take two examples, in 1988 the Government set up the very successful Joint Breast Feeding Initiative as a pilot project to assess new ways of supporting mothers who choose to breast-feed; and in 1992 the National Breast Feeding Working Group was set up. Fresh guidance on breast-feeding based on its good work has been issued to the NHS.

The noble Lord, Lord Monkswell, stressed the importance of getting the message across to mothers of the importance of breast-feeding. The guidance recently issued to the NHS on breast-feeding lists the benefits of breast-feeding to mothers as well as to babies. The guidance has been widely circulated among healthcare professionals.

We do not believe that the new Infant Formula and Follow-On Formula Regulations 1995 weaken our commitment to breast-feeding. All noble Lords who have spoken today have criticised the Government for not implementing the WHO code. They should remember that the code has been developed to meet the needs of a large number of countries which inevitably have very different economic and social conditions. The code consists of aims and principles despite its rather legalistic wording. It states that governments should implement its principles and aims in a way that is appropriate to their social and legislative framework. That is what we have done.

I turn now to the specific points about advertising. The WHO code effectively prohibits advertising of infant formula, although it allows some information and supply of product samples to the healthcare system. The UK has never gone so far as that recommendation. Since 1983 our industry has operated in accordance with a code of practice which was drawn up in consultation with government departments and health professionals. It allows advertising in the healthcare system where it is under the control of the healthcare authorities.

The EC Directive 91/321 also did not go so far as the WHO code. It allows advertising in publications specialising in baby care and in scientific publications and lays down detailed rules about the content of the advertising. It also allows member states to be more restrictive if they wish. Indeed, the UK's code of practice is more restrictive than the EC directive.

Before draft implementing regulations were issued for consultation, the Government made it clear that the UK's existing restrictions would be maintained. Nevertheless it was open to us to explore the reaction to a more restrictive option. Therefore, in the draft regulations it was proposed that the controls on advertising should be quite far reaching, allowing advertisements to appear only in magazines where the intended readers would be professionals involved in maternal and baby care. It was no surprise that these proposed controls generated a considerable number of responses to the consultation, split between two opposing views. One view was that, while supporting the advertising controls proposed, the Government should go even further and use the directive's option to its full extent to ban all advertising of infant formula.

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The opposing view was that we should not use the option at all and we should stick to the minimum controls required by the directive. The latter view drew attention to the Government's policy of deregulation and the thrust of my ministry's legislative programme: only to introduce regulation where there is no viable alternative.

There was also very strong feeling, and it is one that I share, that such strict controls would impinge upon a mother's right to have access to information. Those mothers who are not able to, or choose not to breast-feed, have a right to decide for themselves what is best for themselves and their children. Who are we to say that a mother cannot make a judgment for herself? She should also have sufficient information so that her decision is an informed one.

Industry takes the view, and many agree, that advertising of infant formula is not about persuading mothers not to breast-feed, and to bottle-feed their babies instead. Rather, it is about giving mothers, who have already decided to bottle-feed, information about the infant formulae available so that they may make their own choice about the product they wish to select for their baby.

However, while not denying the validity of such views, the Government are, as I have already said, fully committed to supporting the promotion of breast-feeding. We were therefore very conscious that to adopt only the minimum in the directive would have meant controls that were less restrictive than those already in place under the voluntary agreement with the industry. This, we decided, did not provide the support which the promotion of breast-feeding deserves.

It was only after very careful consideration that we concluded that the option which best served this dual purpose was the one that has been operating voluntarily and successfully in this country since 1983. This means that advertising of infant formula will continue to be allowed but only in baby care publications distributed through the healthcare system and in scientific publications, and in certain trade journals not seen by the general public. Although it may be seen to ignore the majority, to paraphrase the noble Lord's words, the force of the argument was with the minority.

This does not mean, as some have argued, that manufacturers will have even more access to advertise. The wording of the regulations also specifies that such publications must be

    "distributed only through the healthcare system."

Furthermore local healthcare units will continue to exercise their own judgment about the baby care publications, containing permitted advertisements, which they wish to accept for distribution by them or to be available in places such as waiting rooms or pre-natal clinics.

I am aware that during the debates on these regulations in another place and indeed in your Lordships' House tonight, figures running into millions of pounds have been quoted as the amount the baby milk industry spends on advertising. This amount has been set alongside expenditure by the Government on information about breast-feeding, as if to show a

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difference in commitment towards ensuring that mothers receive appropriate advice. Quite apart from the fact that the industry produces information on breast-feeding and baby care—some of which is quite excellent and unbiased—I would also point to a source of advice for mothers that is not only beyond the ability of infant formula manufacturers to imitate, but also something that they cannot buy—the on-going face-to-face contact with healthcare professionals. No leaflet or magazine can substitute for the opportunities women have to talk through their expectations, concerns or experiences with an appropriately trained healthcare professional. Advertising breast-feeding is an integral part of the day-to-day work of midwives and health visitors. This is why the Government have decided to commit some of the money they spend on supporting breast-feeding to the Royal College of Midwives and the Health Visitors' Association's joint programme Invest in Breast Together—to help improve the quality of advice and support these health professionals are able to give mothers and mothers-to-be.

Much has been made of the fact that during the consultation health professional bodies expressed support for a total ban on advertising. But the results of at least one independent survey would seem to suggest that some of their members think differently. This survey suggests that a ban on advertising of infant formulae is opposed by the majority of health professionals involved in the care of mothers and babies. It seems, from the survey, that professionals at the sharp end agree with the Government that a limited form of advertising should be available. This is the best way to ensure that mothers who wish to choose not to breast-feed make that choice in informed circumstances with professional advice readily available to them.

The noble Viscount, Lord Falkland, pointed to the breast-feeding rates in other countries. The basis of the collection of statistics like that can vary enormously from country to country. That makes it extremely difficult to compare the true rates of breast-feeding. A range of complex social, cultural and psychological factors influences a woman's choice on how to feed her baby. Such things as the attitude of friends and family, public attitudes, the particular difficulties which a mother may experience and what best suits her lifestyle all play a part.

What I do not accept is that the limited and restrained amount of advertising of infant formula that we allow in this country overrides all those other considerations and plays a vital part when a woman makes her decision on how to feed her baby. But what is not in dispute is that our breast-feeding rates are lower than we wish them to be. We must do what we can to improve the situation.

The noble Lord, Lord Monkswell, suggested that infant formula was harmful. Infant formula is harmful in the sense that it can cause an increased incidence of gastroenteritis but the healthcare professionals should make mothers aware of that. At the end of the day, it is for mothers to make their own decision. That is brought out clearly in the Government's publications.

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The noble Lord, Lord Rea, pointed out that Bounty pays hospitals for access to new mothers—something that I learnt at first hand in the past few months. If health professionals are so concerned about Bounty's access to new mothers, they are perfectly free to take steps to withdraw that co-operation.

The noble Lord, Lord Monkswell, said that there should be a health warning on formula products. He said that the product will increase the chance of breast cancer. There is already a requirement in the regulations that the packaging must include a statement, as follows:

    "recommending that the product be used only on the advice of an independent person qualified in medicine, nutrition, or pharmacy or having a professional qualification in maternal or child care".

It is difficult to see how we could go much further than that. It is the professionals who should be pointing out to mothers the risks of not breast-feeding.

The noble Lord, Lord Rea, asked what progress was being made by the working party implementing the—

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