Minutes after Keo Somaly gave birth to her first son, a female representative from
the France Bébé company was in the room to suggest her brand of infant
formula for the baby.
Staff in the private Sophear Maternity clinic were quick to tell the new mother that
the small amount of milk she produced and her sore nipples meant that breast milk
substitute was necessary. They provided the first tin free, but now the family spends
$36 a month on infant milk products, while their 11 month-old baby has been in and
out of hospital with fever and diarrhoea.
Six months after a draft law on the marketing of infant foods was submitted to the
Ministry of Health (MoH), little has been done to curb the unethical promotion of
breast milk substitutes in Cambodia, say NGO health workers.
In a country where 13.5 per cent of children will die before the age of five, Cambodia's
traditional high breast-feeding rates have been considered a rare strength in infant
health and one that needs to be protected, says Mark Thomson, communications officer
Breast milk is considered the best available source of nutrients for children, but
experts say the growing use of powdered milk substitutes in Cambodia increases the
risk of diarrhoea from unsafe water and unsanitary feeding practices. Poverty and
poor education also play a part, leading some mothers to over-dilute the powdered
formula or use condensed milk in the belief it is better for their baby than breast
"The consequence of not getting the breast milk is the child isn't getting the
nutrients which he or she needs to fight things like acute respiratory infections,
to fight the effects of diarrhoea, so it's really a two-pronged evil," says
A series of articles on child survival published in The Lancet in 2003 concluded
that "infants aged 0-5 months who are not breastfed have a significantly greater
risk of dying from diarrhoea and pneumonia compared to infants who are exclusively
This lack of nutrition is particularly crucial soon after a baby is born when the
mother's enriched first milk, or colostrum, gives what is in effect a natural vaccination
against disease. Only 24 per cent of Cambodian babies are breastfed within their
first day of life, according to the Cambodian Demographic Health Survey 2000 (CDHS).
While 96 per cent of Cambodian mothers breastfeed, only two per cent breastfeed exclusively
for the baby's first six months, which is the recommendation from doctors, says the
The National Pediatric Hospital in Phnom Penh has seen the rates of infant sickness
and mortality increase in recent years as more mothers return to work in garment
factories a month after giving birth, leaving relatives to feed their babies with
milk substitutes, says Dr Chhin Lan, an infant nutrition expert at UNICEF.
Doctors and health officials say the reasons behind this move away from breast milk
include the increased availability of alternatives, a reluctance to breastfeed while
working in offices or markets and the belief that infant formula is more nutritional
than breast milk.
This belief is strengthened by product advertising, say a range of nutrition experts.
The draft law to regulate the promotion of infant foods was written in 2001 by a
working group made up of the World Health Organization, UNICEF, Helen Keller International
and the Ministry of Health's National Nutrition Program and Communicable Diseases
Control departments. Representatives from the working party say Nestlé, one
of the three major suppliers of infant formula in Cambodia, asked to join the group
but was refused.
After two years of international feedback and refining, the working group eventually
produced a document similar to the International Code of Marketing of Breastmilk
Substitutes adopted by the World Health Authority in 1981 as the "minimum requirement"
to protect infant health. To date, only seven countries - Switzerland, the Philippines,
Zimbabwe, Malaysia, Singapore, Australia and New Zealand - have set up formal monitoring
bodies to enforce the code.
If the law is passed, the Cambodian Ministry of Health would be responsible for its
implementation with breaches attracting fines of up to 10 million riel and three
months in prison.
When the draft legislation was submitted to the Ministry of Health in July 2003,
they showed "strong support" and forwarded it to the MoH legal department,
but there has been little progress in the political vacuum that has followed last
year's election. Health Minister Hong Sun Huot requested that Professor Koum Kanal,
director of the National Maternity and Child Health Hospital, answer questions about
the progress of the regulations, but repeated efforts by the Post to speak to Kanal
by phone and in person were to no avail.
Women's Minister Mu Sochua is a strong supporter of breastfeeding and says she was
appalled at what happened to Keo Somaly, whose husband is Sochua's driver.
"To me I see it as a crime," says Sochua. "Especially for a poor country
like Cambodia, there's no way you can afford to promote formula because it is so
Sochua says unethical marketing of infant formula is widespread in private clinics
and in some state hospitals throughout the nation, and that the MoH is not doing
enough to promote a natural approach. Although she hadn't read the proposed breastfeeding
legislation, she questions the legal approach.
"I'm sure the law will say you can only market this to certain mothers with
certain problems but who will monitor that?" asks Sochua.
"The Ministry of Health should discourage [the use of infant formula] so totally
by having a huge campaign...for natural milk [and] breastfeeding."
That education role has been taken up in part by the BBC World Service Trust, which
will launch a wide-ranging education program in March tackling child and maternal
health as well as HIV issues. Giselle Portenier, the head of projects in Cambodia,
said their research found companies continued to breach internationally accepted
marketing standards and as such were an important part of the solution.
"We really want to work with the baby formula companies," said Portenier.
"This is all about saving children's lives and if we can get the baby food companies
to help us we've done a great job."
Nestlé, one of the main targets of criticism from advocacy groups such as
the International Baby Food Network (IBFN), has distributed its products in Cambodia
since 1998 and says it welcomes stronger legislation on marketing breast milk substitutes.
"We need this law," said Bertrand Sigwalt, the general manager of Nestlé
in Cambodia, saying the lack of a legal framework makes it more difficult to do business
in the country.
Sigwalt said all his staff received training about the ethical promotion of their
products and that Nestlé's company policy on marketing was stricter than the
internationally accepted World Health Authority document.
Nestlé's policy on implementing the 1981 WHA code states that "where
the national implementation is weaker than our own internal rules, we implement our
Nestlé is the only brand that labels its under-six month formula tins with
Khmer language warnings and instructions. Of the two most popular products, Dumex
carries a detachable Khmer label under the lid of the can, while France Bébé
formula only has instructions in English and Chinese.
The Cambodian representative for France Bébé, Bou Maly, declined to
comment. Questions put to Abbot Laboratories, the maker of Dumex infant formula,
via their Phnom Penh business manager Avinash Kulkarni a month ago have not been