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should be undertaken; and although a population withconsiderably more deaths would be needed for a refinedstatistical analysis, it is possible to draw useful conclu-sions from these data since the increase in mortality withdecline in nutritional status is so large.The fact that the majority of children died in the 6

months after the initial nutritional survey has obvious

implications. Rapid intervention after identification ofthose at risk is essential to lower mortality rates. Thevariation in mortality with season suggests that in ruralPunjab nutritional need, and therefore mortality, is

actually highest when food is potentially available. LateMarch to mid-May is wheat harvest time when mostable-bodied adults and older children are in the fieldsfrom dawn to dusk, leaving the care of infants andtoddlers to their siblings (often barely a few years older)or to the infirm and elderly. In addition to child neglectat this time of the year, especially among the lowercaste, the climate is at its worst, with temperatures oftenat or above 40 °C for days or weeks. During this seasondiarrhoeal illness is more prevalent among toddlers and,if complicated by dehydration, takes a heavy toll in childlives, especially among the undernourished. From Jan-uary to March the climate is pleasant yet food stores, es-pecially of the landless, are exhausted thus resulting inincreased mortality of those already underweight.The observation that there was no seasonal variation

in mortality among children with good nutrition is im-portant and requires further investigation. Sanitationwas not considered to be appreciably better among thesefamilies, and it appears that good nutrition gave thesechildren very great protection from seasonal attacks ofdiarrhoea and other infections.

These findings indicate that malnutrition contributesto the deaths of most infants below 80% of the Harvardweight-for-age median and to most deaths of those aged12-36 months and below 70% of that standard. Thedegree to which low weight contributes to mortality andthe extent to which a contributing cause becomes theprimary cause appears to be inversely related to thechild’s weight-for-age. When we compared child-mortal-ity rates from four southern European countries (in1970)8 with those of "well-nourished" (over 80% ofHarvard weight median) Punjabi children, we foundthat Punjabi children had about equal, if not lower,rates.

We thank Dr C. E. Taylor, Dr W. A. Reinke, Dr R. L. Parker, MrA. D. Robertson, and Mr C. Ajello for their help during the investiga-tion, Mrs M. S. List for preparing the graphs, and Mrs P. Bremer andMiss C. Buckley for typing the paper.

This work was partly supported by The World Bank.Correspondence should be addressed to A.A.K., Department of In-

ternational Health, School of Hygiene and Public Health. The JohnsHopkins University, 615 North Wolfe Street, Baltimore, Maryland21205, U.S.A.

REFERENCES

1. Gomex, F., Galvan, R. R., Frenk, S., Cravioto-Munoz, J., Chavez, R., Vas-quez, J. J. trop. Ped. 1956, 2, 77.

2. Ascoli, W., Guzman, M. A., Scrimshaw, N. S., Gordon, J. E. Archs env.Hlth, 1967, 15, 439.

3. Scrimshaw, N. S., Taylor, C. E., Gordon, J. E. in Interactions of Nutritionand Infection, World Health Organisation, Monograph No. 57, 1968.

4. Puffer, R. R., Serrano, C. V. in Patterns of Mortality in Childhood (Wash-ington, D.C.: Pan American Health Organisation/World Health Organisa-tion), Scientific Publications no. 262. 1973.

5. Waterlow, J. C. in Nutrition m Preventive Medicine; p. 530. Geneva, 1976.6. Sommers, A., Zoewenstein, M. S Am. J clin Nutr. 1975, 28, 2877 Kielman, A. A., Taylor, C. E., Parker, R. L. ibid. (in the press).8. World Health Organisation Report on the World Health Situation, 1969-72,

pp.196, 207, 209, 234. Geneva, 1975.

Controversy

Has the infant-food industry achieved too dominant aplace in the moulding of infant-feeding practices, par-ticularly in developing countries? The debate continues;and some of the comments on the industry’s practiceshave been vehement. As The Lancet has uttered itsshare of the less strident criticisms, some representativesof the industry have complained that they have been un-justly treated by us—and by others. We therefore in-vited the International Council of Infant Food Indus-tries to prepare the following statement on the Council’spurposes and plans. An editorial appears on p. 1240.

INTERNATIONAL COUNCIL OF INFANT FOODINDUSTRIES

Its Aims and Progress

THE role of the infant-food industry has been the subjectof intensive debate in the light of the recent findingsabout the protection afforded by breast-feeding and theconcern about reports claiming that the unnecessarysubstitution of breast milk by infant formulae is widelypractised in communities where artificial feeding can bemisused. These concerns led to contacts between repre-sentatives of the infant-food industry and of the interna-tional agencies and organisations involved in maternaland child health. Initial discussions in Bogota at a

seminar sponsored by the Pan American Health Organ-isation and UNICEF in 1970 led to further contacts andthe publication of a P.A.G. statement.1 This was the firstofficial statement containing recommendations directedto professional groups, governments, and governmentalorganisations and to the industry. Discussions betweenindustry representatives attending a P.A.G. regionalseminar held in Singapore in 1974 finally led to the for-mal constitution of the International Council of InfantFood Industries in November, 1975.

OBJECTIVES

Much needs to be done to improve the state of knowl-edge about infant-feeding practices, particularly aboutthe part which breast-feeding can reasonably be

expected to play under varying cultural and economiccircumstances. At the same time, an industry organisa-tion such as I.C.I.F.I. must analyse criticism of manu-facturers’ promotional policies in order to correct irregu-lar practices where they do exist and to attempt to

develop and to encourage its member companies to im-plement, procedures which lead to the maximum pos-sible benefit to mother and child.

I.C.I.F.I. aims to obtain recognition as a self-regula-tory body, representative of the infant-food industrythroughout the world, and thereby recognised as spokes-man in all matters where the industry can make a con-tribution towards improving infant-feeding practices.To achieve these objectives I.C.I.F.I. offers coopera-

tion with leading scientists and academic institutes, with

1. United Nations Protein Calorie Advisory Group. Statement no. 23. RationalPromotion of Processed Foods. July, 1972.

2. Code of Ethics and Professional Standards for Advertising Services forBreast Milk Substitutes. I.C.I.F.I., 1975; amended 1976.

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the international health agencies, and with govern-ments.

ACTIVITIES

The first action was to draw up a code of ethics2 defin-

ing the minimum standards to be accepted by any manu-facturer wishing to adhere to the Council. Since thiscode has been the subject of comment4 it must againbe made clear that the members of I.C.I.F.I. are

obliged to observe laws which preclude any agreementsthat would have the effect of restricting free and opencompetition in international trade.5 Although nothingprevents member companies from expanding on theI.C.I.F.I. code to reflect their individual policies, theU.S. anti-trust regulations require that the code canmake no reference to restrictions in individual advertis-

ing or marketing policies.Clearly, the credibility of any code will depend on the

way in which it is implemented. The executive com-mittee of I.C.I.F.I. has therefore established a working-group whose task is to monitor business practices withinthe infant-food industry (both member and non-membercompanies) and to recommend steps designed to elimin-ate practices which are in conflict with the spirit and theletter of the code. The executive committee has agreedto recommend to the General Assembly of I.C.I.F.I. thatin the case of any member persisting in a clear contra-vention of the code, membership can be terminated bya three-quarters majority of the Assembly.The business-practices working-group organises

regional meetings between I.C.I.F.I. representatives andlocal authorities on the implementation of the code. Twoother working-groups have been established: the scien-tific group and the communications group. Their tasksare in line with the objectives. The studies carried outby these working-groups seek to answer the questionswhich can be roughly summarised as: to what extent isthe use of specially formulated milk for babies justified(particularly in the developing countries)?; and how canthe risks associated with the weaning period in vulner-able communities, be reduced?To answer the first question, a strictly scientific and

objective approach to the measurement of lactationalperformance is necessary. The literature on the naturalhistory of breast-feeding, is too often biased by the atti-tude of the observer and marred by poor research de-sign and especially by inadequate methodology.7.8 Thebasic problem of how to measure breast-milk quantityand quality in a way which allows meaningful compari-sons to be made in different communities has not yetbeen solved. This question is so fundamental thatI.C.I.F.I. has given a research grant to a independentgroup of distinguished academics, who are attempting todevelop new methods for making these measurements. Ifthese efforts are successful then it is hoped to apply themethod to field studies.

Other studies now being carried out by the scientificand by the communications working-groups are aimed atreducing the risk of misuse of infant foods. For example,

3. see Lancet, 1977, i, 1067.4. Acta pædiat. scand. 1977, 66, 129.5. Bauer, E. S. Lancet, 1977, ii, 44.6. Thomson, A. M., Black, A. E. Bull, Wld Hlth Org. 1975, 52, 2.7. Cole, E. International Conference on Human Lactation. Lactation Review,

vol 2, no. 2, p. 5. Human Lactation Center, 666 Sturges Highway, West-port, Conn. 06880, U.S.A.

8. Jelliffe, E. F. P. Ciba Foundation Symposium no. 45. Excerpta Medica,1976.

an attempt is being made, in cooperation with healthauthorities, and with technical support from a feeding-bottle manufacturer, to develop a new feeding utensilwhich will be easier to clean than the traditional feedingbottle, and which will eliminate the practical disadvan-tages of the "cup and spoon" method advocated by someauthorities.

Another important study arises directly from the fol-lowing P.A.G. recommendation to industry:’ "Industryshould give special attention to the importance of unam-biguous and standard ways of making up dry and liquidpreparations for child feeding to minimize misuse. Theneeds of illiterate as well as literate persons should beconsidered in designing labels. Label design and litera-ture should foster hygienically-orientated practices suchas the use of boiled water and the proper cleansing ofutensils." Further details of this work, and on the analy-sis made by the Council of published criticisms of the in-fant-food industry, are given elsewhere.9.1U

THE SITUATION TODAY

Looking back over the past two and a half years,I.C.I.F.I. has reason both for encouragement and disap-pointment. New applications for membership have

brought the total of members to 12,* and other manu-facturers showed their interest by sending observers tothe I.C.I.F.I. General Assembly in Haslemere in Septem-ber, 1977. It is hoped, therefore, that I.C.I.F.I. will soonrepresent more than 90% of free-enterprise sales of in-fant formulas.Progress has also been made in establishing regular

working contacts with international health agencies,notably with the W.H.O. I.C.I.F.I. will apply for non-governmental organisation status in official relationswith W.H.O., which it hopes will be granted in January,1979. This will greatly facilitate the continuation of thedialogue between the industry and the health profes-sions.On the other hand, campaigns against the infant-food

industry continue to be mounted. Recently such cam-paigns have spread from Europe to North America.Efforts are made to influence public opinion by the useof a film, made in Kenya, which attempts to give the im-pression that successful bottle-feeding in that country isimpossible.One aim of such campaigns seems to be to restrict the

distribution of the industry’s products by making themavailable only on medical prescription. Those who advo-cate such restrictions fail to recognise that the resultwould almost certainly be a swing back to the use of lesssuitable products, like sweetened condensed milk, avail-able widely as an ordinary household product, andwhose use for infant feeding was generally condemnedby specialists in tropical paediatrics more than twodecades ago. Alternative supplements, such as tradi-tional gruels, which are of little nutritive value (except

9. I.C.I.F.I. Infant Feeding in the Less Developed Countries. PAG Bull. 1977,7, 62.

10. I.C.I F.I. A Review of its Objectives and Activities. September, 1977.

I.C.I.F.I. Secretariat, Nordstrasse 15, 8035 Zurich, Switzerland.* The present members are: Dumex Ltd., Denmark; Meiji Milk7Pro-

ducts Co., Ltd., Japan; Morinaga Milk Industry Co., Ltd., Japan; Nes-tle Products Technical Assistance Co., Ltd., Switzerland; Snow BrandMilk Products Co., Ltd., Japan; Unigate Foods, Ltd., Great Britain;Wakodo Co., Ltd., Japan; Wyeth International Limited, U.S.A.; BSNGervais Danone S.A., France; Coop. Condensfabnek Fnesland, Neth-erlands ; B.V. Lijempf, Netherlands; Nutricia Nederland B.V., Nether-lands.

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to bacteria), would also figure more largely in the infantdiets if sales of more properly formulated foods werelimited to medical prescription.By the same token, the pendulum seems to be swing-

ing back from the time when far too little attention waspaid to the benefits of breast-feeding to a situation whereclaims are being made for breast-feeding which cannotbe substantiated. For example, in a Canadian Broadcast-ing Corporation television documentary a public-healthnurse in Jamaica was shown addressing a group ofmothers in the following terms: "Breast-feeding has allthe necessary ingredients for the growth and develop-ment of your young child up to the age of one year".Such unqualified statements can lead to much misunder-standing.

I.C.I.F.I. members are committed to efforts aimed at

encouraging breast-feeding. They are concerned thatover-selling the benefits of breast-feeding may haveharmful effects in the long term, and they therefore wishto encourage a balanced approach which will ensurethat appropriate supplements are given at the right time,and that instructions relevant to the circumstances ofthe mother are given. It is this problem to whichI.C.I.F.I. has addressed itself; and its solution requiresa cooperative approach by the industry, academic insti-tutes, the health authorities, and governments.

Round the World

ItalyTHE NEW ABORTION LAW

ABORTION has become legal in Italy. On May 18 the Senateapproved a Bill that had previously passed successfullythrough the Chamber of Deputies, thus making Italy one ofthe countries where pregnancy termination is permitted andregulated by law. Some might find it odd that the vote of theItalian Parliament has come at a time when other countries are

stepping back from or reconsidering the issue of abortion, butthe clock in Rome is always rather slow. After a referenduma few years ago made it clear that Italians did not like theChurch’s ban on divorce, the country began to move awayfrom Catholic obedience, and it has now acquired one of themost liberal laws on abortion. The vote in Parliament came

shortly before another referendum, scheduled for June 11, thatwould have had to decide on whether to retain or do withoutthe old laws prohibiting pregnancy termination. IThe new law permits abortion on demand in the first 90

days of pregnancy. The phrase "on demand" does not appearin the text, but this is what the spirit of the law says. Abortionmay be obtained if one of the following conditions is met: ifto continue the pregnancy would pose a serious danger to thewoman’s physical or mental health, if the woman is in unstablehealth, or if there are poor social or economic conditions, un-usual circumstances of conception, or a chance of abnormali-ties in the fetus. The pregnancy may be terminated after thethird month if there is a serious danger for the woman’s healthor if the fetus is abnormal and this may reasonably causedamage to the woman’s physical or mental health.The procedure for obtaining an abortion is simple. The

woman applies to a community health centre or to her family f

doctor, whose duty it is to discuss with her the reason why shewants an abortion and to offer help in case she wants to con-

1. See Lancet, May 6, p. 981.

tinue with her pregnancy. If she is determined to have her

pregnancy terminated, the doctor signs a certificate statingthat the woman on that particular day has decided to abort.7 days later, the woman can be admitted to a hospital or otherauthorised clinic to have the abortion performed. If the womanis past her ninetieth day of pregnancy, the decision rests withthe doctor who is to perform the abortion. As all hospitaladmissions are paid for by the health-insurance schemes, abor-tions will be free if performed in hospitals.The only problem is who will perform the abortions. Most

Italian doctors oppose pregnancy termination except wherethere is real danger to the woman’s physical health. In fact, theold laws that made abortion a crime stated that it was a crimenot punishable in cases where it had been performed out ofnecessity to save the woman’s life or wellbeing (a very vaguewording that made doctors the sole judges of their own deci-sions). But despite the vagueness of the old law, almost noabortions were performed; probably not many more will beperformed now.

United States

NEGATIVISM ON HEALTH COSTS

EvEN those not too kindly disposed to the American MedicalAssociation felt a stab of sympathy when that organisation wasrecently denounced by the President, who in his tour of wes-tern states had harsh words about doctors and lawyers. Thegravamen of the charge against the A.M.A. seemed to be thatit was too largely concerned in looking after the interests of itsmembers. But that is just what it was set up to do, and it hasdone pretty well by its members. Some may well feel that itsopposition to the socialisation of medicine was overdone andperhaps not in the best interests of its members. After all, onceA.M.A. opposition to Medicare and Medicaid was overcome,the day of the present affluence of the medical profession inthis country rapidly dawned. The President did pay tribute tothe individual medical practitioners and was much more politeto the doctors than to the lawyers.

Probably these are political sighting shots to herald the on-coming of some sort of national health programme, and pressand radio and, of course, television have begun to explore thepossibilities. In the forefront are the "cost factors". Healthcare is "the third largest industry in this country", as our

H.E.W. official put it, second only to the food industry and theconstruction industry (an unfortunate analogy, for if healthmatters are to be considered an industry, the legislative resultswill not be happy). We have had a spate of books dealing withthe rising costs of medical care, and health spending is nowsaid to be about$200 billion per annum. Astronomical figureslike this can be regarded with some suspicion; but it is a factthat the cost of an average day in a hospital bed is now closeto$200 and we used to be horrified when we thought it mightreach half this figure. It is equally obvious that these costs arerising more rapidly than are prices generally, and, moreover,the public has not benefited proportionately. It is also clearthat much of the rise in health costs has developed out of thefederal and states government’s own actions; and the govern-ments try to cut costs by day-to-day interference between phys-ician and patient. Much of the rise is due to better pay for thepreviously underpaid hospital staff and much of these costs ismet not out of the patient’s pocket but out of government andinsurance or other funds.The measures which now seem to be favoured in the cutting

of costs are the negative ones, such as a mandatory ceiling onannual increases in hospital operating revenues, restricting thenumber of hospital beds, limiting technological advances,expensive equipment, body scanners, and the like. The eli-mination of fraud and mismanagement can be approved byeveryone, but most other proposals are purely negative andwon’t go far in altering the present state of affairs, though,