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Benefits of breastfeeding are scientifically proven and widely known, but exclusive breastfeeding is no longer a norm in many communities. In the free market economy of Hong Kong, concerns that a legislation would go further than most international standards are indication of a call for the formulation of a more suitable regulation that places a top priority on children’s health and finds a balance while protecting the rights of the trade and consumers

By Channy Lee

According to Transparency Market Research, the infant formula market in Asia Pacific was valued at US$10.3 billion in 2013, and is predicted to expand to be worth US$18.2 billion by 2020. China’s presence is particularly notable in the region, a growing market which has bought an estimated 40 percent of the world’s baby milk formula in 2014.
The market for formula milk is correspondingly large in Hong Kong. While shopping in any one of Hong Kong’s supermarkets or local drug stores, one can expect to face a plethora of choices of formula milk. The options available range from Japanese brands to those of Australia and New Zealand, formulated specifically for infants between six and 36 months old.

But concomitant to the continuously increasing demand for formula products are concerns in a dynamic market where early cessation of breastfeeding is encouraged and consumption of formula milk over breastmilk is endorsed. The formula milk market is often characterized by prevalent and extensive promotion of breastmilk substitutes, and that is precisely the area around which heavy restrictions have long loomed.

The “Hong Kong Code of Marketing and Quality of Formula Milk and Related Products, and Food Products for Infants & Young Children” is a major part of the government’s effort to regulate breastfeeding over formula milk, placed under persistent scrutiny from parent groups and workers in healthcare and formula companies.

Basis of claims

Benefits of breastfeeding are scientifically proven and widely known. Beyond its nutritious superiority to formula milk, many research reveal that breastfeeding also nurtures infants in the optimal immunological and emotional environment for growth while contributing to prevention of chronic conditions. It is therefore recommended by the World Health Organization (WHO) that infants be breastfed exclusively in their initial six months post-partum for the well-being of both mothers and their children.

But exclusive breastfeeding is no longer a norm in many communities. Over the past few decades, trends have turned from primarily breastfeeding to some deeming formula more nutritious and well suited for children’s health. Based on an annual survey conducted by the Hong Kong Department of Health in 2014, breastfeeding rate stood at 80 percent on leaving hospital, but fell to 22 percent after a month, and below five percent after six months.

As the burgeoning need to promote breastfeeding became evident with diminishing inclination towards exclusive breastfeeding, WHO adopted the International Code of Marketing of Breastmilk Substitutes in 1981. Commonly referred to as the Code, the unbinding health policy framework prohibits unethical marketing of formula as well as provision of free samples to parents and health facilities.

Many jurisdictions since then have followed suit of the WHO guidelines. Within three years after the Code was passed, 130 countries either passed legislation or formulated policies in varied forms to restrict advertising. To develop a version of the Code that is suited for Hong Kong, the Hong Kong Department of Health also set up a taskforce in June 2010 and subsequently issued a draft of the Hong Kong Code in 2012.

Concerns raised

With the purported aim of eradicating factors that contribute to low breastfeeding rate in the region, the Hong Kong Legislative Council responded to what it refers to as aggressive marketing of formula milk, with regulations in two parts: The larger framework being the Hong Kong Code enforced as a voluntary guideline; and two legislations concerning nutrition labelling and advertising claims on product packaging.

Once implemented, the Hong Kong Code will serve as a recommendation for manufacturers and distributors of formula products as well as workers in the healthcare facilities, targeting not only advertising of formula milk but also formula-related products such as bottles manufactured for feeding infants. The two food laws, on the other hand, are intended to regulate provision of inaccurate information through labels and overselling of benefits that breastmilk substitutes bring about.

So far in Hong Kong, only the former of the two laws has been implemented, and only a draft of the Hong Kong Code has been released. Public consultation results were reported to the Legislative Council Panel on Health Services in July 2014, which inferred that the delay may be due to policy debates that are especially contentious in the context of Hong Kong.

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A research from The Lancet, a medical journal in the UK, states that the compound annual growth rate (CAGR) predictions for milk formula in China and Hong Kong from 2014 to 2019 were 15.9 percent and 12.8 percent, respectively, compared to the world average of 9.5 percent. Such a large market in the Greater China Region is explained with the huge local demand for breastmilk substitutes from working mothers in Hong Kong and those from the Mainland.

For mothers in Hong Kong, the dire need for formula milk arises from the number of hours they invest into work, leaving them deprived of the time and resources to breastfeed their children as recommended. For those from the Mainland, high costs of formula milk products in China followed by subsequent upsurge of parallel trading have increased the product’ market value in Hong Kong.

Despite the two-can limit on the amount of infant formula a person can take over the border between Hong Kong and Mainland China – which aimed to curtail parallel trading – Mainland consumers still account for the majority of sales. It is a key concern among formula producers that the Hong Kong Code will mostly affect these 70 to 80 percent of consumers that are not the primary targets – the local mothers – of the administration’s goal of encouraging breastfeeding.

Exemplified by concerns as such, it further fuels the debate that the city is branded as a free market economy. Limiting free flow of communication between the business sector and consumers may be of detrimental damage to the free market, undermining the freedom of business operations. Results from public consultations about the administration’s proposals imply that the general public’s primary concern is consumers’ right to make informed choices, also a key value in a free market economy.

Any excessive ban on marketing and promotional practices could limit access to legitimate information to which all consumers are entitled – and could potentially lead to inaccurate information from unofficial sources, undermining parents’ capacity to make choices based on information about food for their children.

Manufacturers and distributors should be required to act morally responsible, but the responsible industry players who comply with all relevant regulations in Hong Kong should also be respected for their right to communicate evidence-based information.

Larger context

The government continuously reiterates the importance of aligning local policies concerned with formula marketing to international standards. An important aspect in which they differ, is the range of products covered by the code.

The WHO Code recommends exclusive breastfeeding for infants during their initial six months after birth. Regarding follow-up formula which is intended to be a part of the weaning diet, the Code declares that “products covered by this standard are not breastmilk substitutes and shall not be presented as such,” excluding follow-up formula from the range to be covered by a ban.

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Similarly, the Hong Kong Code targets products sold for not only those under the age of six months but also up to 36 months. This is another point in the trade’s argument that the administration is pushing for overachieving policies that goes beyond a merely effective strategy in encouraging breastfeeding and intervenes in interactions between the trade and consumers.

The argument sets forth that such large demand for formula milk in Hong Kong should be noted not just as an indication of low rate of – or unwillingness to – breastfeeding, but rather as an indication of mothers’ inability to breastfeed due to external barriers laid upon them.

As for the blanket ban on nutrition and health claims, many practices in developed economies place a strong emphasis on scientific substantiation and evidence-based claims, following established procedures to evaluate nutrition and health claims. The European Union, for instance, allows for nutrition and health claims on infant and young child formula given that expert panels approve of the claims after an extensive review procedure.

Furthermore, the United States only enforces bans on a specific type of nutrition claims, those that compare the nutrient content of products to others. Conversely, there is a blanket ban on advertising of formula products in the Republic of Korea, but there are now talks of lifting the ban in recognition of the population educated enough to judge for themselves what is best for their children, and for the sake of inducing more economic opportunities.

There are factors other than marketing of breastmilk substitutes contributing to a low breastfeeding rate, and it is questioned whether banning certain marketing strategies – either with a voluntary or a legislative approach – will serve as an effective method of encouraging breastfeeding. In fact, a survey conducted by Hong Kong Infant and Young Child Nutrition Association and the University of Hong Kong Public Opinion Programme in 2012 found that over 50 percent of respondents disagreed on that low breastfeeding rate is a result of formula advertisements in the locality.

It is essential that more effort is put into improving Hong Kong’s poor breastfeeding rates and securing an appropriate level of nutrition for children. But claims presented on both ends of the policy debate are reasons of significant implications. In the free market economy of Hong Kong, concerns that the Hong Kong Code is more trade restrictive than necessary and goes further than most international standards are calling for the formulation of a more suitable regulation that places a top priority on children’s health and finds a balance while protecting the rights of the trade and consumers.