Ensuring exclusive breastfeeding for the first 6 months of an infant’s life with ongoing breastfeeding to 2 years of age could decrease child deaths by 13%. The inappropriate marketing of infant formula and breast milk substitutes can present a challenge to meeting this critical goal, which is why, in 1981, the World Health Organization (WHO) adopted the International Code of Marketing of Breast Milk Substitutes (the Code). The Code remains today an important yet deeply divisive piece of international policy intended to prevent inappropriate marketing and promote breastfeeding globally. In his paper in this issue of the Journal of Public Health, Stewart Forsyth argues that the Code has instead had the opposite effect because it has driven a wedge between the various sectors needed to dialogue and collaborate to promote breastfeeding. This criticism could also be heard in the hallways at the 65th World Health Assembly in Geneva this past May, and it reflects more broadly, the general atmosphere of mistrust between stakeholders in the infant and young child nutrition (IYCN) community. As a way forward, Forsyth proposes a Memorandum of Understanding (MOU) to be established between key agencies to set out common understandings, express a convergence of will between the parties and indicate an intended mutual line of action. The proposal is a good one. What is missing, however, are the concrete steps to convince various actors from the public and private sectors to actually come together to discuss challenges and build trust. From our program, Singh et al. proposed a set of shared principles of ethics for IYCN in the developing world—derived from relevant existing laws, trade regimes, international codes and international goals—from which stakeholders may be able to begin dialogue around establishing an operational framework for cooperation, collaboration and oversight. In addition, Singer et al. have suggested that stakeholders in IYCN explore a multi-stakeholder initiative, somewhat analogous to the Ethical Trading Initiative, which was established to address sweatshop violations in the international labour industry. There is a need to explore how these and other proposals may complement and strengthen one another and be implemented in practice. There is also a need for key leadership to initiate the process of building the trust necessary to implement them. For example, the WHO along with other key international agencies could act as a neutral arbitrator to negotiate the terms of an MOU between stakeholders, incorporating conflict of interest guidelines and the set of shared ethical principles for IYCN. The negative impact of the lack of dialogue between stakeholders in the IYCN community, specifically over the Code, should not be underestimated—of particular concern is that despite these deep divisions and perceived ineffectiveness of the Code, some stakeholder groups continue to hold that it ought to be extended to include complementary foods in addition to breast milk substitutes. Such a move will only further exacerbate international efforts to tackle infant and young child undernutrition. The various proposals mentioned here recognize the complex nature of these relationships and offer key agencies and stakeholders opportunities to begin dialogue that can lead to solutions collectively addressing the lack of Code compliance, establish partnerships, prioritize IYCN globally and ultimately save children’s lives.
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