Infant formula pushers: round two

Metro Express
February 4, 2010

This is not a good week for domestic milk powder. In the latest round of a melamine contamination scandal that everyone thought was put to rest more than a year ago, Chinese media reported today that three people have been arrested in Shanxi for selling melamine-tainted milk. This follows reports last December of a company that repackaged and sold milk powder that was supposed to have been destroyed in 2008.

And the English-language edition of the Global Times reported today that demand for foreign milk powder is picking up.

A Xinhua investigation printed in today’s Metro Express and other newspapers across the country is hard not to connect to the current scandal. Two Xinhua reporters spoke with the former employee of an infant formula manufacturer who said that the company enticed doctors and other medical staff to promote its products in their hospitals.

The source used in the article provided inside information that echoes the account told to a Mirror journalist in August 2008, just before the first melamine scandal broke. That article’s focus was on how the privacy of new mothers was violated by hospitals that sold their personal information to formula producers; the Xinhua journalists chose to emphasize the role unscrupulous doctors have in pressuring new mothers to use formula instead of breast feeding their babies.

Although melamine is not mentioned by name, the final paragraphs of the article allude to vague “quality problems” that could come back to haunt doctors who promoting a particular brand of formula for no special medical reason.

“Whenever they provide a new mother’s personal information, they will receive a 10- to 30-yuan ‘handling fee’. If they successfully promote the company’s products, they will receive a 60-yuan ‘continuation fee’.”

For medical personnel, instructing new mothers in breast feeding is a duty, yet in the interest of profit, some of them have abandoned that duty and have become “spokespersons” for infant formula. What is behind this relationship between formula producers and “angels in white”? Our reporters recently conducted an investigation to find out.

A hidden “profit chain”

“Companies give doctors money, take them to dinner, and give them gifts. Some doctors are tempted, and providing a list of expecting mothers is not difficult.” The former “medical administrator” of a domestic milk powder producer recently made a report claiming that beginning two years ago, the company had selected the city of Taiyuan to launch a trial program to obtain the personal information of maternity patients by offering rebates. After distributing literature and promotional material for the company’s products, the company could realize substantial returns. The “medical administrator” claimed that she had been in charge of more than twenty “medical agents” who were responsible for cultivating relationships with doctors. The company would even devote a budget to “key” doctors in order to maintain its old client list and add new ones.

The company reportedly had a full set of regulations that prescribed detailed rules for “medical communications”: the company’s goal was to “fill all available space.” It fought to established a “friendly” relationship with the medical staff in the departments of prenatal, ultrasound, maternity, pediatric, and preventative medicine at hospitals at all levels, using them to market milk powder to maternity patients. Products were held on consignment in those wards and sold “at a discount,” or samples were distributed by hospital staff for free to new mothers. Doctors who handed out the formula samples or discount cards were required to say things like, “Mothers and children are all drinking XXX milk these days. Children who drink this brand grow up cute and clever.” Companies held their own “parenting salons” and asked their “medical agents” to “choose the most well-known pediatricians in the area, or well-known specialists from partner hospitals” and, one week before the event, “talk over content with the lecturers to make sure that it was in line with the products.” This served to “increase the follow-up consumption rate.”

Hurry up with the milk powder, we’ve got another good client!

Company training session materials provided by the “medical administrator” showed that discount cards, nutrition books, and parenting handbooks were classified as company promotional materials and were to be distributed to new mothers by hospital staff; a note read, “beneficial for improving doctor recommendation of milk powder.” “Before I resigned, the company I worked for had established partnerships with nearly 400 medical and health care organizations in Shanxi, and its particular brand of milk powder had achieved a continued purchase rate of more than 30%. Some hospitals even made it the only brand they admitted. The immediate profitability of this method led the company to expand the practice to eighteen provinces.”

“An infant’s first mouthful of milk is taken at the hospital, so a massive market share can be won by occupying medical channels,” the informant said. Even if a mother nurses her baby, she should add supplements at four months and wean the child after roughly one year. The company can influence the parents through medical channels, guiding more of them to choose its products for supplements and post-weaning food. “The commission paid out to doctors is passed on invisibly to the consumer.” The informant said that because medical channel expenditures were so high, the price of formula would continue to rise the company sought to stabilize profits. Price adjustments in recent years were due in part to this reason.

The true meaning of “300 grams”

An industry insider revealed that for the majority of newborns, once they become accustomed to a particular brand of formula it is difficult for them to adjust to any changes. In addition, once they feel that it is easier to drink formula, they will refuse to nurse. Some formula companies will therefore distribute free samples of their product, amounting to 300 grams — typically what a newborn will consume in a week — to cement the infant’s preference and rule out as options both mother’s milk and other formula brands.

This reporter recently visited a number of hospitals and pediatric preventive medicine facilities to explore the situation described by the source. The result was a shock: the informant’s company was not the only formula producer traveling this road. And it was not only formula: some medical staff also actively promoting a wide range of children’s health products.

At a childbirth class run by a “baby friendly hospital” (a UNICEF designation), an eloquent doctor was giving a free session for a dozen or so expecting mothers, explaining all kinds of childbirth and parenting-related questions. As he was speaking about infant food and nutrition, the doctor emphasized the unique properties of a particular brand of formula. After the session, every mother was given a free bag of that brand of formula. On another occasion, the reporter accompanied a parent to a Class III-A hospital on East Shuangta Street in Taiyuan for a pediatric checkup. An older doctor on duty asked whether the parent was nursing or using formula. Learning that the child was given formula, the doctor became interested immediately: “What brand are you using?” But when the parent responded, “I don’t want to switch brands,” the doctor stopped speaking and bent down to write out a prescription, and then pointed to the pharmacy opposite: “Give your child a calcium gluconate supplement. Go to that pharmacy and pick up this brand, and then come back and I’ll tell you how it should be taken.”

“Even though there are posters in every room in the hospital promoting breast feeding, not a single member of the medical staff gave me any instruction in nursing during the seven days after I gave birth,” said Ms. Qin, who had become a mother just three months before. She had continued nursing for just a few days before switching to formula. Afterward, she received follow-up calls from a formula brand, always asking how she came to learn of “our” formula, and offering her two choices: was it on the recommendation of a friend, or of a doctor? This reporter learned that most women do not immediately start producing milk after giving birth, and they need an infant’s suckling to stimulate their milk secretions. Some formula producers take advantage of the time when new mothers are in the hospital after giving birth but before they learned how to properly nurse to have medical personnel provide them with free samples, which are then fed to the newborn under the “supervision” of those same medical personnel.

Fines cannot be the only punishment

Laws already exist barring the barring sellers and producers of breast milk substitutes from using hospitals and other health care facilities to distribute free samples of their products, so why have they continued to do so? Interviewees said that medical personnel acting as “spokespersons” is not merely a question of profit; it is an issue of responsibility that must be investigated and exposed to the rest of society. The [Implementation Measures] for the Law on Maternal and Infant Health Care says that medical and health care institutions shall not promote or recommend breast milk substitutes to expecting mothers or the families of infants; producers and marketers of breast milk substitutes may not provide samples to medical and health care institutions or offer them equipment, funding, or informational materials conditional on such promotion.

“Hospitals do not have the responsibility to hand out formula, and besides, the country does not permit medical personnel to give out formula. Doctors can only make a medical diagnosis as to whether a newborn requires artificial feeding, but giving parents formula is definitely not a medical necessity,” said Guo Zhanying, director of the Department of Maternal, Child, and Community Health Office at the Shanxi Provincial Department of Health. “We found in our investigations that some medical personnel have indeed violated the law and ethical principles and have to some degree been engaging in marketing for the manufacturers.”

Experts say that medical personnel are not quality inspectors, so if quality problems crop up in a particular batch of milk, they cannot evade responsibility. As for the existence of medical personnel acting as “spokespersons” for formula, the public health administrators should toughen up examinations and management. Fines should not be the only means of punishment; there ought to be stronger ethical and legal constraints as well.