Initiatives of Change - Detailed view of For A Change Articles

Though it was fully 20 years ago, I remember clearly the post-natal ward of Nair Medical College Hospital in central Bombay (Mumbai). The long rows of beds were so close to each other that a child could practically crawl the entire length of the ward, from bed to bed. No-one was refused entry.

So many babies. Yet there was not a feeding bottle anywhere in the department, Dr Raj Anand, then Associate Professor of Paediatrics at Nair, told the international visitors he was showing round.

In the section of the ward for critically ill infants, we discovered why. I can still picture the look of dull despair on a mother's face as she watched over her son. She had two older children, both healthy daughters, both breastfed, Anand told us. But she had given her first son special treatment; she had wanted him to look like the fat babies pictured on the tins of formula milk. Now he was dying: another victim of malnutrition and disease caused by bottle-feeding.

Earlier this year The Times of London quoted a World Health Organization (WHO) estimate that 1.5 million infant deaths per year could be averted through effective breastfeeding. But breast-milk substitutes are big business. The global market in 1991 was $6 billion; and the Indian market was expanding by 6 per cent a year.

The dying baby and the statistic are 20 years apart. In the intervening period, Anand, who is now senior paediatrician at Bombay's prestigious Jaslok Hospital, has become well-known as a champion of breastfeeding-and a thorn in the flesh of the companies which produce and market alternatives.

Anand's campaign goes back to his medical training in 1962 in Sheffield, England, where Professor RS Illingworth was ardent for the cause. It was already accepted that breastfeeding produced healthy babies. It aids emotional bonding, helps to regulate the spaces between children and, most important of all, prevents infection.

Anand says that even a malnourished mother can produce enough milk for the first six months, but that aggressive advertising often persuades poor and illiterate women to turn to milk powders. When these are diluted for the sake of economy, or mixed with dirty water, children can die.

Some colleagues are sceptical of 'this whole breastfeeding business', he admits. Many textbooks carry conflicting advice, even though worldwide evidence supports the value of breastfeeding. Anand's resolve has a touch of patience to it. 'We would like to see most newborns exclusively breastfed for the first four to six months of life, and breastfeeding sustained into the second year,' he writes in Breastfeeding Review. In response to accusations of fanaticism, he concedes, 'In our eagerness to win a battle, we have on occasion lost the war by being abrasive.'

In 1980, the Indian government set up a committee to consider adopting an international code on milk substitutes drafted by WHO and UNICEF. Nestlé were promoting an alternative code. Anand discovered that the company had offered the Indian Academy of Paediatrics a donation for an Oration on Social Paediatrics, through one of the Academy's officers who was on the committee. At the Academy's national meeting, Anand pointed out the conflict of interest. Despite some outspoken opposition, the Academy voted overwhelmingly to refuse the gift.

In 1994 the Academy turned down a half million dollar contribution from Nestlé when it hosted the 8th Asian Congress of Paediatrics. It stopped the company's sponsorship of an annual undergraduate paediatric quiz. And finally in 1996 it voted to refuse all financial support from the baby food industry.

Pressures also came from Indian companies. One well-known manufacturer complained of unfair competition from Nestlé, but at the same time vehemently opposed the draft legislation, claiming to 'have all the MPs in our pocket'.

During the 1980s, Anand and his colleagues struggled to educate their compatriots about the risks of powdered milks. They helped to found the Association for Consumers' Action on Safety and Health (ACASH), and a coalition under the Breastfeeding Promotion Network of India. They ran workshops on consumer protection and lactation management.

Finally, in 1992, after a long decade of delays, the Indian Parliament voted for a unique law on Infant Milk Substitutes. This bans all advertising of infant milk substitutes and feeding bottles, limits the giving of free samples or supplies, and rules that labels on all infant milk and food products must warn, in both English and Hindi: 'Important Notice. MOTHER'S MILK IS BEST FOR YOUR BABY.' (Large capital letters to be used, by law.)

In addition to its own official inspectors, the Indian government has authorized four voluntary organizations, including ACASH, to take companies which violate these regulations to court. ACASH has initiated criminal action against Nestlé, Johnson & Johnson and a number of other companies.

Internationally Nestlé has twice had to face the pressure of boycotts. But in India, it has launched a case against the Government charging that its legislation is arbitrary. The battle continues.

In 1993 Johnson & Johnson (India) launched a new feeding bottle, with a 'liquid silicone, anti-colic nipple'. Their methods of promotion contravened Indian law. Anand fired off letters to government ministers, public authorities and consumer groups, in India and overseas. His letter to Johnson & Johnson brought a self-righteous denial.

Within months, Anand was threatening that ACASH would organize a boycott of all Johnson & Johnson products. Three years later, threatened with convictions involving possible imprisonment or fines, Johnson & Johnson and its Indian associates gave a sworn affidavit in court and apologized for their mistakes. Johnson & Johnson completely withdrew from the bottle-feeding market in India, and various Indian companies have had to follow suit.

Last year the British Medical Journal published an editorial by Anand, in which he quoted a company which said it aimed 'to make the physician a low-pressure salesman' of its products. Incentives to the medical profession are part of the culture of the pharmaceutical and baby food industries. Besides sponsorships, companies offer free samples, assistance with research funds and advertisements supporting professional journals.

Anand stopped taking such contributions back in 1978, on the grounds that 'there's no such thing as a free lunch'. His decision was part of a deeper personal change which motivated his campaigning. As an ambitious young doctor, he hated his head of department because he felt he was holding him back. 'We were at loggerheads,' he said. 'Even when I was examining a patient, his figure would come into my mind and I would start wondering how to take revenge.'

A doctor from Ireland, whom he met through MRA, challenged him, on the basis of the Hindu scriptures, to face his anger. Through 'inner listening', Anand found the words to write an apology to his chief. 'I became a free man,' he said. 'I refound the dreams of my childhood-to be available to the poor in the slums and villages.'

He embraced a simpler lifestyle and cut down on the number of fee-paying patients he treated so as to devote more time to voluntary work. He quit drinking alcohol, because of its effect on India's poor. Once a fortnight, on his free Sunday, he joined a busload of doctors running a free clinic in a village an arduous two hours' journey from the city.

He also organized a conference for his highly-qualified city-based colleagues to interact with rural health workers-including illiterate village midwives and Gandhian workers devoted to digging latrines. Some 80 per cent of India's doctors work in cities, while three-quarters of the population live in rural areas. After the conference, a number of doctors began to shift their focus.

He says that his motivation comes from two sources: 'Scriptures and MRA. Both complement each other. The scriptures teach me that to become a fit student I must first assimilate austere values in my life. The values of the Bhagavad Gita are the same as MRA outlines-purity, honesty, unselfishness and love. If I follow those values I can get clear messages from within on how to use my life and how to go about fighting the battles that need to be fought.'

Early morning meditations have been part of his spiritual discipline for years. Twice a week he and his son Sunil, a successful homeopathic practitioner, go to a discourse on the Hindu scriptures with a swami (teacher).

Though he would probably not make any such claim, he demonstrates Gandhi's satyagraha-the 'soul-force' of spiritual disciplines and of non-violence. Earlier this year, the managing director of an Indian company, whom ACASH had confronted with a legal challenge, was welcomed into the Anand home with respect, almost affection, as they negotiated a settlement.

Writing to his co-campaigners in the Breastfeeding Network, Anand urges them not to forget 'the age-old dictum that love is the greatest thing in the world', especially when they face opposition. 'Let us not lose our respect for our colleagues if they tend to differ with us. They may have something important to tell us.' It is an echo of the reconciliation he had, years ago, with his own head of department.

He quotes two verses from the Hindu scriptures: 'Ishwar arpan budhi' which he interprets as 'whatever you undertake, do it as an offering to the Lord', and 'Prashad budhi-after you have done your bit, whatever results come, accept them as a gift from the Lord.'

With people like Raj Anand 'doing their bit' India's social development may yet match its economic growth.

Mike Brown