In the 1970s, Nestle and other formula manufacturers aggressively marketed infant formula in developing countries where most families lacked access to safe water and sterilization equipment. When mothers diluted expensive formula with contaminated water, infants died from diarrheal diseases. The 1981 WHO International Code of Marketing of Breast-milk Substitutes was adopted to stop these practices. Four decades of monitoring data show Nestle has systematically violated nearly every provision of the Code across dozens of countries.
In the early 1970s, a mother giving birth in a hospital in Nigeria, Kenya, or the Philippines would typically receive a visit from a woman in a crisp white uniform who looked like a nurse. The woman would explain that infant formula was modern, scientific, and better for the baby than breastfeeding. She would provide free samples — enough to last several weeks. By the time the samples ran out, the mother's breast milk would have dried up from lack of stimulation, making continued formula use necessary.
These women were not nurses. They were sales representatives employed by Nestle, Abbott, and other formula manufacturers. The companies called them "milk nurses" or "mothercraft advisors." By 1978, Nestle alone employed an estimated 4,000 to 5,000 of these representatives across developing countries in Asia, Africa, and Latin America. They operated in hospitals, clinics, and made direct home visits to new mothers.
The practice worked because it exploited a basic biological reality: breastfeeding functions on supply and demand. When a mother nurses, her body produces milk. When she stops nursing and uses formula instead, milk production ceases within days to weeks. The free samples provided by company representatives were enough to interrupt this process. Once the samples ran out, mothers had to continue purchasing formula regardless of whether they could afford it or had access to clean water for safe preparation.
Dr. Derrick Jelliffe, a pediatrician working in Jamaica and other Caribbean countries in the 1960s, began documenting what he termed "commerciogenic malnutrition" — illness and death directly caused by commercial promotion of products. His clinical observations showed that mothers were diluting formula to make expensive tins last longer, sometimes extending a one-week supply to a month. They mixed the powder with contaminated water because they had no access to safe water or fuel for boiling. The resulting diarrheal infections killed infants at rates that would have been considered epidemic if the cause had been biological rather than commercial.
In 1974, War on Want, a British anti-poverty charity, published a 28-page report titled "The Baby Killer" by journalist Mike Muller. The report documented formula marketing practices across multiple developing countries and presented evidence linking those practices to measurable increases in infant mortality. It included interviews with doctors, mothers, and healthcare workers, along with analysis of company marketing materials and sales techniques.
A Swiss activist group translated the report into German and published it under the more direct title "Nestle Tötet Babies" ("Nestle Kills Babies"). Nestle responded by filing a libel suit against 13 members of the activist group in Swiss court.
The 1976 trial in Bern became an international event. Nestle's legal strategy required the company to defend its marketing practices in detail. Activists brought medical experts, including Jelliffe, who presented clinical evidence of infant deaths associated with formula use in populations lacking safe water. The defense documented Nestle's "milk nurse" system, its advertising campaigns portraying formula as superior to breastfeeding, and its distribution of free samples in hospitals.
"The need ensues on the producer to ... fundamentally rethink their advertising practices in developing countries concerning bottle feeding, for its advertising practice up to now can transform a life-saving product into one that is dangerous and life-destroying."
Judge — Bern District Court Decision, June 24, 1976The judge found the defendants guilty only of the technical charge that the pamphlet title constituted defamation, assessing a fine of 300 Swiss francs (approximately $120 at the time). But the written decision criticized Nestle's practices extensively and called for "fundamental" changes. International media coverage of the trial brought the formula controversy into public consciousness across Europe and North America.
On May 23, 1978, Senator Edmund Muskie convened hearings before the Senate Subcommittee on Health and Scientific Research titled "Marketing and Promotion of Infant Formula in Developing Nations." The hearings produced three days of testimony from activists, medical experts, and industry executives.
INFACT representatives, who had launched a consumer boycott of Nestle products in July 1977, presented documentation of the company's marketing practices. Medical testimony established that in countries where formula was heavily promoted, breastfeeding rates had declined by 50 to 75 percent over two decades, while infant mortality from diarrheal diseases had increased.
Nestle's presentation was led by Oswaldo Ballarin, a company executive, who defended the company's practices and characterized boycott organizers as having "Marxist" motivations — a statement that dominated media coverage and became a public relations disaster for the company. Internal Nestle documents later made public showed the company had been aware of concerns about its marketing practices for years but had treated the issue as a public relations problem rather than a substantive health concern.
The hearings created political pressure that contributed directly to WHO's decision to develop an international regulatory framework. They also expanded the Nestle boycott from a small activist campaign to a movement involving churches, universities, and health professional organizations across ten countries.
On May 21, 1981, the World Health Assembly — WHO's governing body, composed of health ministers from all member states — adopted the International Code of Marketing of Breast-milk Substitutes. The vote was 118 in favor, 1 against (the United States), and 3 abstentions.
The Code established a comprehensive framework prohibiting:
The Code applied to infant formula and all products marketed for feeding infants under six months. It was not legally binding but served as a minimum standard that countries were urged to implement through national legislation.
Nestle announced it would comply with the Code "to the fullest extent possible." The company commissioned the United Methodist Church to establish an independent monitoring commission. In 1984, after finding Nestle had made meaningful changes to its marketing practices, the commission recommended suspending the boycott. INFACT and most participating organizations agreed.
In 1988, INFACT relaunched the boycott after monitoring revealed that Nestle and other formula manufacturers had systematically violated the Code across dozens of countries. The violations followed a consistent pattern: public statements of compliance combined with marketing practices that violated nearly every Code provision.
The International Baby Food Action Network, founded in 1979, established a monitoring system that produced biennial reports documenting Code violations. The "Breaking the Rules" series, published from 1991 through 2020, documented over 2,000 specific violations by formula manufacturers across 69 countries.
The monitoring documented that violations were not isolated incidents but systematic practices adapted to local regulatory environments. In countries with strong Code legislation and enforcement, companies would comply while violating in countries with weak or no legislation. Within countries, companies would cease traditional advertising while shifting to digital platforms, healthcare professional sponsorship, and "educational" programs that functioned as marketing.
In 2017, a Nestle internal audit was reviewed by the Access to Nutrition Foundation, a Netherlands-based research organization. The audit examined Code compliance in 116 countries where Nestle sold infant formula. It found compliance failures in 107 of them.
The audit documented practices including:
The audit's existence became public through a leaked summary. Nestle has never released the full document. The company stated it was taking corrective action but provided no specific timeline or verification mechanism.
By 2015, formula manufacturers had largely ceased traditional advertising in markets where Code implementation was strong. They shifted resources to digital marketing platforms that existed outside traditional regulatory frameworks.
A 2018 investigation by Save the Children documented systematic use of:
Research published in The Lancet in 2020 estimated that formula companies were spending approximately $8 billion annually on marketing. The study surveyed mothers across six countries in Asia, Africa, and Latin America. It found that 84 percent reported exposure to formula advertising in the previous six months despite living in countries where such advertising was theoretically prohibited.
The research documented that digital platforms allowed targeting with precision impossible in traditional media. Companies could identify pregnant women through data purchasing and target advertising to them specifically. They could serve different content in different regulatory jurisdictions from the same platform. They could use influencers who appeared independent but were paid to promote products.
Formula manufacturers developed a second strategy for circumventing Code restrictions: heavily marketing formula products for older infants and toddlers (typically labeled for ages 6 to 36 months) while using the same brand names, packaging design, and visual elements as their infant formula products.
These "growing-up milks" or "toddler formulas" fall outside the WHO Code's strict definition, which covers only products marketed for infants under six months. But pediatric nutritionists and WHO itself have stated that such products are nutritionally unnecessary — toddlers can receive adequate nutrition from breastfeeding, regular cow's milk, and family foods.
A 2018 investigation by Changing Markets Foundation found that formula companies spent significantly more advertising these products than they had previously spent on infant formula before Code restrictions. The investigation documented that brand architecture was deliberately designed to drive sales of infant formula through advertising of related products.
"The evidence is clear that the promotion of breastmilk substitutes directly impacts on breastfeeding practices, and that the marketing of toddler milks and follow-up formulas is being used by companies to get around the restrictions on infant formula marketing."
Dr. Nigel Rollins — WHO Department of Maternal, Newborn, Child and Adolescent Health, 2020In the Philippines, for example, data showed that after strong infant formula restrictions were implemented, advertising of toddler formula increased by 240 percent over a five-year period. Market research showed mothers perceived the heavily advertised toddler products as indicators of brand quality and reliability, driving purchasing decisions for the entire product line including restricted infant formula.
As of 2023, only 44 countries have enacted legislation that substantially aligns with all WHO Code provisions. Another 97 have partial implementation, typically covering some but not all provisions. The remaining WHO member states have no Code implementation.
Countries that have attempted strong implementation have faced direct pressure from formula manufacturers and, in some cases, their home governments. The Philippines, which enacted comprehensive Code legislation in 1986, documented sustained efforts by industry to weaken enforcement. In 2006, pharmaceutical and formula industry lobbyists pushed for exemptions for toddler formula. In 2016, they lobbied for reduced penalties for violations. Philippine health officials reported receiving direct communication from embassies of countries where formula companies are headquartered, arguing that regulations violated free trade agreements.
Similar patterns occurred in Thailand, India, and South Africa. In each case, initial strong legislation faced sustained industry opposition seeking to weaken provisions, create exemptions, or reduce enforcement mechanisms.
The economic incentive for violations is substantial. The global infant formula market was valued at approximately $55 billion in 2023, with projected growth to $76 billion by 2028. Nestle holds roughly 24% of this market, Abbott and Danone each hold approximately 12%, and smaller manufacturers hold the remainder. Growth projections are concentrated in Asia, particularly China and India, where rising middle-class populations provide expanding markets.
WHO estimates that globally, only 41 percent of infants under six months are exclusively breastfed. The agency's target is 50 percent by 2025 — a target that will not be met. Research published in The Lancet estimates that optimal breastfeeding practices could prevent 823,000 child deaths annually from diarrheal diseases, pneumonia, and other infections.
The impact is concentrated in lower-income countries where both formula marketing is most aggressive and access to safe water is most limited. In sub-Saharan Africa, only 44 percent of the population has access to safely managed water services. In South Asia, the figure is 53 percent. In these environments, formula feeding carries the same risks documented in the 1970s.
A 2019 study in the Journal of Pediatrics examined infant mortality data from 74 countries between 2000 and 2015. It found that countries with weaker Code implementation had significantly lower exclusive breastfeeding rates and significantly higher infant mortality from diarrheal diseases, even after controlling for GDP, water access, and healthcare system quality. The relationship remained statistically significant across multiple regression models.
The Nestle boycott relaunched in 1988 continues as of 2023, making it the longest-running consumer boycott in history. It is coordinated internationally by IBFAN and nationally by organizations in more than 20 countries. The boycott's demands are straightforward: full compliance with the WHO Code in all countries where Nestle operates.
The boycott has never achieved the scale of participation it reached in the 1980s, when an estimated 5 million people were actively participating. But monitoring organizations report that it maintains pressure on the company and provides leverage for advocacy with policymakers. When Nestle executives meet with health officials, the existence of an ongoing boycott provides context for discussions of the company's marketing practices.
The broader significance extends beyond Nestle. The formula controversy established a framework for analyzing how corporate marketing of products that substitute for natural human functions can produce population-level health harms. It demonstrated that voluntary corporate compliance with health standards is inadequate when economic incentives favor non-compliance. And it showed that international standards without enforcement mechanisms will be systematically violated.
Forty-five years after the first Senate hearings, the evidence is clear: Nestle and other formula manufacturers have treated the WHO Code as a public relations problem requiring public statements of compliance while continuing practices the Code was designed to prohibit. The babies saved by the Code's partial implementation number in the hundreds of thousands. The babies killed by its incomplete implementation and systematic violation are uncounted but demonstrably real.