Fifi and her baby at home in Jakarta. She spends half her husband’s monthly salary on formula milk. Photograph: Poulomi Basu Photograph: Poulomi Basu
This article originally appeared in The Guardian
With poor access to clean water, giving up breastfeeding is a serious health risk in this part of the world - but milk formula companies continue to sign up midwives
To get to the baby immunisation clinic in North Jakarta, the mothers of the slum pick through rubble and muck and the stagnant remains of the January floods. Towers of water-damaged mattresses and mildewed plastic sofas flank the main thoroughfare; it looks like Hell's Ikea. If gastrointestinal disease had its own smell, this would be it.
Fifi, who is 20, lives in a wooden room the size of a bathroom, with her husband and six-month-old daughter, Riska. We met her at the clinic, but only found out later that she wasn't there for jabs, she was there because her daughter was already sick.
She started feeding Riska formula, rather than breastfeeding her, when her daughter was two months old; she was on contraceptives, and thought it was interfering with her milk supply. The midwife agreed, and gave her a free sample of formula milk. Now she spends 400,000 rupiah (about £26) a month on formula, which is half of her husband's monthly salary. She seemed to be a pretty good example of one of the main problems of formula feeding in Indonesia. Even the cheapest brands punch a huge hole in a poor family's budget, and they end up over-diluting it, which leaves the babies malnourished.
But at Fifi's home, it became obvious that the sanitation problem towers over this one – 45% of Indonesians have no access to clean water. There are only two places in the capital where anyone can drink from a tap, and that's the American embassy and Jakarta international school. But Fifi can't afford gas to boil water either. She has no kitchen. She has to pay every time she goes to the loo, which is shared between 26 people, and sometimes she cuts a deal with a neighbour where one of them goes to the loo while another has a shower, to save money.
Clean hands, clean utensils, clean bottles, clean anything, it's all a total pipe dream. A paediatrician in a separate Jakartan clinic, Dr Asti Praborini, said: "Selling formula is like the killing fields, in my opinion. The babies will die of diarrhoea and they will die of malnutrition."
Here, all the statements about breastfeeding, which in the developed world are made hyperbolically – how it's the only safe choice for a baby – are true. Indonesia's child mortality rates, at 35 per 1,000, are high anyway, but in the lowest wealth quintile, mortality is nearly five times higher than in the wealthiest.
Some mothers formula feed because they're not eating enough themselves, and don't feel confident that they're producing enough milk. A Save the Children report due out on Monday will give details of breastfeeding rates and child nutrition across the developing world. Wahdini Hakim, senior programme manager, says that persuading mothers to breastfeed is a more effective intervention than efforts to improve sanitation.
But there is a looming influence, far greater than personal choice: that of the formula companies. The World Health Organisation (WHO) has codes on corporate selling of formula that go back to 1981. But this is big business for big companies – two thirds of their growth comes from Asia-Pacific. The Indonesia market is worth $1.1bn (£708m).
This is an example of how it works. Sari Husada, a subsidiary of Danone, has sales reps that build relationships with midwives. Up until 2011, it was purely financial – they would get a village midwife to sign up to a contract, which would involve selling a certain number of boxes of formula per month. Their rewards were pretty small – between 1m(£65) and 3m rupiah a year, depending on the number of deliveries the midwife's practice had, and how much formula they sold. This is in manifest breach of the WHO codes, as well as Indonesian regulations, which expressly ban free samples, as well as direct marketing to healthcare workers or new mothers.
According to Danone, this no longer happens, and has been replaced by a scheme which runs training for midwives. As Usman Tasya, who worked for a subcontractor to whom Sari Husada outsourced its sales, explained: "Basically, what changed was the price. Previously, they were given cash. Post 2012, they were given gifts in kind, once they'd signed a contract."
'Act of beneficence'
Paperwork seen by the Guardian detailing these contracts specifies the change from cash to gifts. Sometimes they'll get a gift, apparently for personal use, like a television or a laptop, but very often, it's something they need for their practice, such as an oxygen canister, a TENS machine or a nebuliser.
The spokesperson for Danone insists that there is no connection between these events – the gifts are just that, an act of beneficence to the midwife, to help her set up her practice, they are unconditional upon the sales of any formula. Asked why that would include a television, he said: "They use them in waiting rooms. To make them places where people would want to go, where they'd feel comfortable going." Asked about why sales reps have a relationship with midwives at all, the spokesman said: "We are permitted to have contacts with healthcare professionals, to tell them what's good about our products. Separate to that, we support midwives in setting up their practices. They're not necessarily separate people. But these are two separate activities."
Formula companies are not allowed to contact new mothers or pregnant women directly and yet, according to Usman, this is rife: "We get details of the mothers who are giving birth, pregnant women, through the midwife." But why would a midwife give out that information? "Midwives, when they get the samples, they really like it. They really like the gimmicks, even the small things. The patient data, they give it to Sari Husada because they think it's part of the programme they've agreed to."
The Guardian has seen a spreadsheet detailing the number of new mothers contacted, the amount of 0-6 months formula sold, and the proportion of their target this represents. Danone commented: "That may still be happening, that's something we need to address."
Sari Husada has legitimate links all the way up the chain. Doctors running seminars for midwives are in its pay. It sponsors professional bodies, conferences and midwifery awards (which are then bestowed by the minister for women's empowerment and the protection of children). The sponsorship element sounds innocuous, and is allowed under Indonesian law; but you can forgive the midwives, who do the grunt work for the company and get the smallest rewards, for thinking that everyone else is doing it, so why shouldn't they?
One young midwife in West Java, who didn't want to be named, insisted she would never sign a formula contract. "Recently, the health officer came to the houses of mothers and found out that some mothers purchased formula from the midwives. They called the midwives all one by one, and questioned them. They are all afraid. Then they were made to sign an agreement with local government that they wouldn't sell it any more. But senior midwives don't like being told what to do." The other midwives in the area disputed this, saying she had to be on a contract; she'd had more education than she could possibly have afforded on her own. Her bachelors degree would have cost her 25m rupiah, which is well over a year's salary.
It may sound counter-intuitive that Indonesia has the strictest breastfeeding law in the world – since 2010, all babies have had to be breastfed exclusively for six months, unless there were compelling medical grounds not to. Anyone hampering this could be fined 100m rupiah or spend a year in prison. But nobody has been jailed for misdemeanours and it is noticeable that only civil charges could be brought against the formula companies, while individuals could face criminal charges.
Nia Umar, who set up the breastfeeding activist group AIMI in 2007, said: "It's absurd that we would regulate something that we would do so naturally. It's like regulating, you, yes, you – you have to eat rice. The formula industry is a stakeholder in the law that tells women to breastfeed."
One of AIMI's more recent successes was to scotch a research project at the Faculty of Medicine at the University of Indonesia that would have taken newborns from the slums and fed them free formula for a year, to see how well they fared.
No provision was made for covering their medical bills if they fell ill. One of the many problems that AIMI had with the study was that there was no transparency about who was funding it – but that bit was rectified when someone accidentally copied them in on the consignment form from FrieslandCampina, a Dutch formula company that is a big seller in Indonesia.
More pressingly, though, the study was unethical in a number of ways, with big questions about using the poor as a testbed for the general population, not to mention generating conditions which are unsafe for a cohort of babies.
Wadhini, from Save the Children, is tactful – but not completely reticent – about the role of corporations: "I guess promoting breastfeeding is important, but behaviour change needs support at every level, the family, the community, the government … especially where we see that formula companies are a competitor to breastfeeding. That's what we are trying to emphasise, it's not merely about the mother and the baby, it's about engaging with the family, the community, the local government, the central government."
However, being a charity, it can't say what many activists think, which is that this is an outrage; public health networks, not hugely well established in this country, are just well established enough to act as capillaries for an industry whose profit motive runs directly counter to the interests of public health.
Inevitably, the story ends back in the slum, where Riska has diarrhoea, a rash and a fever. She's seen the clinic midwives. This story is crying out for a line like: "Riska is fine, for now. The next slum baby might not be so lucky." But none of us knows what will happen. She seemed pretty sick.
Some names have been changed