Dr. Susanna Harutyunyan: Pediatrics and Infant Nutrition in Armenia

Dr. Susanna Harutyunyan works at the Chair of Pediatrics in the National Institute of Health in Armenia, an independent organization supported and financed by the Ministry of Health with the mission to improve the health of the population by providing a high level of postgraduate professional and academic training.

She is involved in the sphere of Primary Health Care in Pediatrics, the publication of updated literature, and in the training of health care professionals on Primary Health Care issues. She is also the Executive Director of Confidence, the Armenian International Baby Food Action Network (IBFAN) Group, and a medical consultant with the emergency relief agency Family Care.

In cooperation with IBFAN, Confidence seeks to prevent violations of the WHO/UNICEF International Code of Marketing Breastmilk Substitutes.

Onnik Krikorian: Let me first start by asking about your professional background and your involvement in the promotion of breastfeeding in the Republic of Armenia?

Susanna Harutyunyan: I'm a pediatrician, and as such, I worked in various pediatric polyclinics before moving to the Republican Center of Perinatology, Obstetrics and Gynecology in 1993. I worked there for six years and during this time, we established the breastfeeding support center for the whole of Armenia. The Ministry of Health started the National Program of "Protection, Promotion and Support of Breastfeeding" towards the end of 1993 because at that time we had a very bad rate for breastfeeding in Armenia. Twenty percent of mothers were predominantly breastfeeding at four months, and there was no exclusive breastfeeding at all.

This was very unusual for Armenia because we are traditionally a breastfeeding nation. However, after the 1988 Armenian Earthquake, rates for predominant breastfeeding dropped from 65 to just 20 percent in 6-7 years. This drastic decline was blamed on the shortage of food, economic hardship, and continuous stress that had endured since the collapse of Soviet Union. The majority of mothers with young infants were reporting insufficient breastmilk, and were requesting infant formula, because they lacked confidence in their breastfeeding capabilities under such hard living conditions.

During the early 1990s Armenia was provided with infant formula as humanitarian aid, and the availability of free infant formula was one of the most obvious reasons for the dramatic decrease in breastfeeding. Other factors included unfavorable hospital practices such as the late initiation of breastfeeding, scheduled feeding, routine prelacteal feeding with water, glucose water, donor milk and formula, use of bottle-feeding and pacifiers, the lack of trained medical staff capable of helping mothers with common breastfeeding problems, and the lack of knowledge among the population and primary health care providers regarding the advantages and techniques of breastfeeding.

After the National Program for the "Protection, Promotion and Support of Breastfeeding" was started, the rates for breastfeeding improved and it continues to increase. We understood that infant formula was undermining breastfeeding although it did prevent a rise in infant mortality because mothers did not switch to cow's milk. However, because infant formulas were distributed freely through polyclinics, mothers that could breastfeed started artificial feeding instead.

By a decree of the Ministry of Health, five out of ten steps towards the WHO and UNICEF Baby Friendly Hospital Initiative (BFHI) were implemented in maternity wings with the gradual implementation of the remaining five steps conducted in parallel with training for healthcare professionals. Immediately implemented were steps such as the early initiation of breastfeeding, rooming-in, feeding on demand, no drinks and food to newborns except breastmilk, and the exclusion of bottles and pacifiers. The flood of freely distributed formula stopped at the end of 1995 due to the policy adopted by the Ministry of Health and a change in donor strategies by aid organizations. The lack of freely available formula reinforced other breastfeeding promotion activities.

After the Republican Center of Perinatology, Obstetrician and Gynecology, I started work in an emergency relief agency, Family Care, as a health consultant, in addition to the National Institute of Health. Family Care is a local NGO that was formed three years ago and until now, it has worked mainly in Karabagh. We have just started a new mother and infant health promotion project in the Maralik region. In 1997 our breastfeeding team established the NGO, Confidence. Our main aim is to improve mother and child health by supporting breastfeeding. We are also the Armenian International Baby Food Action Network (IBFAN) group.

IBFAN is a worldwide network of more than 140 public interest groups working to improve the health and well-being of infants, young children, mothers, and families by promoting and supporting breastfeeding and the elimination of the irresponsible marketing of infant foods, bottles, and teats. IFBAN was one of the four recipients of the Right Livelihood Award, often referred as the "Alternative Nobel Prize." IBFAN was honored "for its committed and effective campaigning over nearly 20 years for the right of the mothers to choose to breastfeed their babies free from commercial pressure and misinformation with which companies promote breastmilk substitutes."

Confidence collaborates closely with other IBFAN groups, such as IBFAN-GIFA, Baby Milk Action, WABA, and Wemos. We also collaborate with LaLech Ligue International (LLLI). Four of us are ABM (Academy of Breastfeeding Medicine) members. Many Confidence members including myself are trainers for UNICEF on breastfeeding as well as other issues and external assessors for BFHI global assessment. Three of us are members of the "BFHI implementation procedure coordinating and awarding Committee" at the Ministry of Health. We have visited many regions, conducting training, distributing our booklets, consulting mothers, and working in the hospitals on the baby-friendly initiative.

We are involved in almost all the work done in the area of promoting breastfeeding in Armenia, including the mass media. There are seven on the Board of Confidence and approximately 25 members mainly involved in the medical profession. I am the Executive Director and I'm the main coordinator of the network of Confidence with IBFAN groups.

OK: What are the figures for exclusive breastfeeding now?

SH: Armenia doesn't have governmental statistics for exclusive breastfeeding. However, there was a survey in Yerevan and some regions that reported that 45 percent of all infants are exclusively breastfed until four months of age. This does not include those mothers who are breastfeeding but giving additional teas or water.

OK: Is breastfeeding the area of most concern to Confidence or just one concern regarding infant health?

SH: It's the main area of concern.

OK: You said that 45 percent of mothers exclusively breastfeed their children up until the age of four months but WHO guidelines now say that infants should be exclusively breastfed up until the age of six months.

SH: Yes, but we don't have these statistics. The governmental statistics just shows that in 2000, 60 percent of infants are fully, i.e. exclusively and predominantly, breastfed util the age of four months.

OK: Why is exclusive breastfeeding so important?

SH: Many studies show that exclusive breastfeeding up until the age of six months provides the best nutrition and protection from illnesses for an infant. Breastfeeding could prevent the death of two million babies throughout the world each year if promoted sufficiently.

OK: Many of these infant deaths occur in countries such as India, Pakistan, and other developing countries because of inadequate water supplies and the need for antibodies and immunities to be passed from the mother to her baby through breastfeeding. Concerns with water supplies seem to be a main concern in particular. Are these issues important in a country like Armenia?

SH: Yes, but it is not only the water supply that affects infant health if mothers are not breastfeeding. Studies from developing countries such as the Philippines show that infants that are not breastfed are nearly 20 times more likely to have diarrhea than infants that are breastfed, while another study from Scotland suggests that infants who are not breastfed suffer from five to six times the amount of diarrhea.

So it's not only water and hygiene. Mothers in Armenia mainly boil water before making formula and we do have some sources of uncontaminated water. However, even if water is uncontaminated, diarrhea is several times higher in babies that are not breastfed and infants are susceptible to other infections and non-infectious diseases.

OK: One argument against exclusive breastfeeding, however, is that disease can be passed to an infant through breastfeeding, and one area of concern is HIV.

SH: I don't think that HIV transmission by breastfeeding is a problem in Armenia. I'm not sure if there will be a problem in the future but it is true that HIV is the main concern regarding diseases that can be passed through breastfeeding. However, there are very few medical arguments against breastfeeding.

Mothers infected by HIV should be fully informed before they make their decision about the way they feed their infants. Not exclusively breastfeeding, and especially mixed feeding, increases the risk of infecting the infant but there are some studies that suggest that exclusive breastfeeding does not. Mothers can therefore exclusively breastfeed until the age of six months and then switch to other nutrition.

Other options are to feed the infant with pasteurized mothers or donors milk. In any case, this is an area that need more research and maybe for now it is better to advise HIV infected mothers against breastfeeding until we have more data on how likely it is that HIV can be passed on to infants.

OK: If a mother has HIV while breastfeeding her infant it's likely that she had HIV during her pregnancy and therefore it's also likely that the infant already has HIV?

SH: HIV can be passed to infants in the womb but not always. However, an exclusively breastfed baby is no more at risk than an infant artificially fed, although there is no doubt that the HIV virus would exist in the breast milk.

OK: I'd guess that some of what is now taught to doctors is new to them, like exclusive breastfeeding. Is there resistance to new ideas?

SH: There is some resistance, especially from those working in hospitals. It's not only an issue with age.

OK: When our infant son became ill, doctors prescribed HIPP teas and infant formulas along with antibiotics so it shows that new approaches are not prevalent among all health workers.

SH: This is a lack of knowledge. We are of course speaking about exclusive breastfeeding as the best possible nutrition for an infant until the age of six months, but if HIPP tea is sold in the shops labeled for infants from one week of age some doctors and mothers think that this is fine, but it is not.

OK: Do you think that it's possible that whoever is responsible for importing and distributing HIPP tea in Armenia is meeting with doctors and telling them that because a child in Europe is receiving HIPP tea from one week of age [HIPP market their products in Europe as weaning foods suitable from the age of 4-6 months but in Armenia as suitable from the age of one week--O.K.} infants in Armenia should? Are they giving free samples to doctors and hospitals?

SH: I haven't heard much about whether this practice exists but some doctors are interviewed on television suggesting that parents give their children certain products, including HIPP teas, purees, and other foods, all from a very young age. If you enter the shops, advice and leaflets will be given to you that promote HIPP tea from the age of one week, and it's the same with many other products.

OK: Is all of this a violation of the International Code?

SH: Yes, sure. No products other than breastmilk substitutes are suitable for feeding an infant less than (at least) four months, so they should be marketed correctly. When we speak about violations we are speaking about the Code and subsequent resolutions because the International Code of Marketing Breastmilk Substitutes and the WHA resolutions have the same power.

World Health Assembly (WHA) Resolution 54.2 passed last year recommends exclusive breastfeeding for about six months. IBFAN has been writing letters in support of Resolution 54.2 asking companies if they will change the labels of complementary foods to comply with this resolution so as not to undermine the global health recommendation of exclusive breastfeeding.

Many manufacturers such as Gerber and Dumex have indicated that they will ignore the resolution while others like Abbott and Nestle say they need time to change the labels. Exclusive breastfeeding for six months is a "global public health recommendation" which is undermined if products are labeled and promoted for use before six months of age.

The recommendation does not prevent health workers supporting and advising mothers who need or wish to introduce complementary foods earlier than six months, but attempts to instead ensure that this is free of commercial pressure from companies with a vested interest in selling more baby food.

OK: Why is the Code so important?

SH: The Code is important because it protects infant health. Many of us know about the advantages of breastfeeding and how it reduces infant mortality and the fact that artificial feeding has many hazards associated with it. Companies however, can make significant profits from the sale of infant foods and they are trying their very best to increase their sales. If there was not a Code they would advertise their products on television and they would pay the doctors to promote their products. The Code prevents all these things to protect infants from commercial pressure.

OK: How should these products be marketed in Armenia?

SH: Breastmilk substitutes should be marketed as infant formula and infant foods meant for infants less than six months of age should carry a warning that breastfeeding is best. Everything should comply with the Code and subsequent WHA resolutions and products such as teas should be marketed as complementary food and not labeled for use before six months of age.

OK: We just bought some Malish and the packet carries information that this brand of infant formula is suitable for infants whose mothers are unable to exclusively breastfeed and that it can be given to infants over the age of four months old. However, you have said that it wasn't always like that.

SH: Yes. There used to be a nice photograph of an infant on the label that was later changed because it is forbidden by the Code. I informed Baby Milk Action, we made complaints and they changed the labeling.

OK: Because it promotes something healthy?

SH: Article 9.2 states that "neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula." Article 4.2 says "information and educational materials, whether written, audio or visual dealing with the feeding of infants should include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods, and, in particular the health hazards of unnecessary or improper use of infant formula and other breastmilk substitutes. Such materials should not use any pictures or text which may idealize the use of breastmilk substitutes."

While all educational materials provided by companies and infant formula labels might explain more or less the superiority of breastfeeding, none of them explain the health hazards associated with artificial feeding.

OK: You can understand their reluctance to use such language, otherwise manufacturers wouldn't sell anything. However, some countries have adopted the Code into law.

SH: Armenia hasn't adopted such a law but has added an article to the law on advertising. The article says that it is forbidden to promote or advertise anything for infant feeding below six months of age including breastmilk substitutes, feeding bottles, and teats. It also prohibits the marketing of breast milk substitutes without text on the tins that emphasize the advantages of breastfeeding and the free distribution of breast milk substitutes with the purpose of advertising the product.

OK: Isn't there legislation dealing with the health and rights of children that specifically refers to this?

SH: Until now there has been none, and there is no mechanism under the advertising law to fight violations. Therefore, it isn't possible to ensure that the law functions.

OK: The only way to fight violations therefore is to take the company to court.

SH: We can take companies that violate the law to court but it's difficult. It's a tool for us but it's not perfect. Some countries such as India have a very strong law on the marketing of breast milk substitutes and maybe in the former Soviet Union, Georgia has a good law.

OK: But does it function?

SH: I have seen many violations of the Code in Georgia.

OK: The real issue then, is that companies aren't marketing their products correctly in the former Soviet Union. Nestlé for example was in trouble a few years back but has since cleaned up its act.

SH: I can't say that because we are closely watching what Nestlé is doing. They are constantly trying to violate the International Code of Marketing of Breastmilk Substitutes but are more careful because of the [worldwide] Nestlé boycott. If we allow them to violate they will surely do so, and they are trying all the time.

OK: It's very concerning to think that a company that produces goods to improve the lives of infants thinks more of profit than infant health.

SH: Of course. When they started to produce infant formula at the end of the 19th century the aim was to improve infant health, especially for those who didn't have mothers or whose mothers were unable to breastfeed. However, it can now be very profitable for them.

OK: When the Soviet Union collapsed, barriers also collapsed and many companies saw this region as a huge market.

SH: This was an unprotected market and we didn't have many advertisements on television before independence.

OK: From cigarettes to shampoos there are all these images of young, fashionable Western people and it's very obvious that Western advertisements will have an effect, especially if you say that ten years ago there weren't many ads at all.

SH: There is the tendency for mothers to see the pretty colors and beautiful pictures on packaging and think that everything from the West is good. Some mothers thought therefore that Western infant formulas were a very good thing and that they should give it to their children, whether they could breastfeed or not.

OK: In some cases Western goods might be better, but there is one point here. In the West there are laws that, while not perfect, function to some extent, while in Armenia the law generally doesn't function at all. There not only needs to be legislation, but there needs to be legislation that can function and the mechanisms by which to ensure that it functions.

However, a lot of this is also linked to the economy, isn't it? There are cases elsewhere in the developing world where companies visit hospitals giving free samples or their products, and it is very easy for this practice to gain acceptance. For example, at the hospital in Yerevan where my son was treated there was a display case full of Nestlé, Nutricia, and HIPP products.

SH: This is a new thing and I have never heard of it before. However, I will be checking it. They are breaking the International Code.

OK: If there's a display case in a hospital, is that in itself a violation of the International Code, or do doctors have to recommend that mothers use these products?

SH: If the display case exists it is already a violation.

OK: Even the Nestlé advertisements on Yerevan's trams were a violation?

SH: They were undermining breastfeeding and we were very lucky to stop it.

OK: Maybe Nestlé, Nutricia, or HIPP say to the hospital if you promote our products we will supply finance or equipment for your wing?

SH: Of course, they can give gifts to pediatricians, some sponsorship, or an invitation to a scientific conference but we have regulations at the Ministry of Health that restricts any kind of promotion in hospitals.

OK: In other countries there are financial incentives and conferences on cruise liners.

SH: I haven't heard of this in Armenia.

OK: But is it likely that to some extent it's happening somewhere?

SH: We haven't conducted Code monitoring in Armenia because we don't have the necessary funding. Therefore, I can't say that it doesn't exist.

OK: I know that you're not totally happy with Nestlé, but even though they tried to get away with violating the International Code of Marketing Breastmilk Substitutes they changed their marketing strategies after complaints were made. It's not good, it's not justifiable, but in the case of HIPP tea you've made many complaints and they've constantly refused to change their labeling. In this case there really is a major violation of the Code because they are advertising their tea for infants from the age of one week.

SH: IBFAN complained to the company and they said they don't produce any tea for infants one week of age. When we sent them the tin of the tea they responded that the Armenian government must complain in order for them to change their packaging.

OK: So why can't the Ministry of Health complain?

SH: They didn't.

OK: They can't or they won't?

SH: They haven't.

OK: If not the Ministry of Health, why can't WHO or UNICEF complain either on a local or international level?

SH: I have raised this issue in several international meetings and I think something will be done. It's not only in Armenia, the situation is the same in all former Soviet republics.

OK: Why is HIPP tea so bad?

SH: Because it is not suitable to give any tea to an infant, and as a pediatrician I can certainly say that it is not recommended. It is recommended that children under the age of six months are exclusively breastfed and giving HIPP tea undermines this.

OK: Is this only if it is given in a bottle?

SH: Even if it is given by spoon it still undermines exclusive breastfeeding. HIPP tea also contains a lot of sugar and is very dangerous for infants even if the child hasn't started teething. You can find a lot of information on HIPP tea and the dangers on the Internet.

OK: Breastfeeding can also help the development of infant teeth because it helps the formation of the jaw muscles and helps the development of healthier, straighter teeth.

SH: Yes.

OK: Although you said that it was traditional for Armenians to breastfeed, it is also very traditional for Armenians to give water and juices to a baby.

SH: We now know this was promoted by our grandmothers who were taught by medical professionals when they were young.

OK: Is there a concern with swaddling?

SH: Yes. Swaddling is an old Armenian tradition but this is not very good for the child. This is actually a sign of poverty because if you don't have enough clothes, it is easier to swaddle.

OK: I've heard that there was some concern raised in a report released by UNICEF but the response of many Armenians is don't you want your children to grow up with straight limbs.

SH: I know that a lot of mothers will say that but it's just the opposite. Swaddling provocates hip dislocation and the infant cannot move, restricting the development of the muscles. However, in the West they don't swaddle yet their children have straighter limbs.

Swaddling also "switches off" the baby and is not good for his development. They sleep more but it is not always good to shut down the baby for sleep. Even in some regions, they cover the baby's eyes and this shuts down the baby even more. This might make life easier for mothers but it is not good for the baby.

OK: Is this another area of interest for Confidence?

SH: Yes, we are interested in this and in fact, all aspects of mother and child health.

OK: Are there other concerns as well? There now seems to be many expensive baby stores opening up in Yerevan that sell Western products like pacifiers and bottles and I've also noticed that they've started to sell canned baby foods imported from the West. Are there any concerns with this? Is labeling on these products correct?

SH: From time to time these shops violate the Code, but we are not fighting against the sale of infant food if it is labeled adequately and is not promoted otherwise.

OK: Or even the sale of HIPP tea?

SH: It's a different issue with HIP tea. Even if they sell HIPP tea it's a violation of the Code because this is an unsuitable product for an infant and they label it as suitable for a child from the age of one week. This is already violating the Code, but we do not have any concerns with the sale of infant formula because it is the mother's choice whether she breastfeeds or not.

OK: The issue is whether that decision is being influenced by advertising, recommendations from doctors, or marketing.

SH: Mothers have the right to be fully informed, free from commercial pressure when they make their decision. We are concerned with the choice of the mother and I'm sure that if infants were given the choice they would choose breastfeeding. The child also has the right to receive the best nutrition so why do we always forget about this? However, if we are not informing mothers about the benefits of breastfeeding and the hazards of artificial feeding before they make that decision, this is undermining breastfeeding.

OK: I also get the impression that when new ideas come into Armenia, and exclusive breastfeeding is a new idea given that traditionally, Armenians have always given soups, teas, or water, there tends to be some resistance to those who suddenly tell mothers that not only have they been doing things wrong but they've been doing them incorrectly for the past 70 years.

SH: Of course. Some grandmothers, relatives, and even some doctors and nurses say this. For example, when I was breastfeeding my son in 1988 my mother was also telling me to give water to him because he might be thirsty. However, it was instinctive for me to exclusively breastfeed even though in Medical University I was taught that you should give water and breastfeed by schedule. However, I don't want to blame this on the Soviet system. It was the same all other the world.

OK: Of course. I mean, in the West they gave thalidomide to mothers and had children born with extreme physical disabilities. It was one of the biggest mistakes ever made along with DDT. That destroyed much of the environmental food chain. There were good things during the Soviet era and there were bad things. There are good things in the West and mistakes have also been made.

SH: The tins and the ads are coming from the West.

OK: You mentioned the other day that growth charts show that Armenia is where America was 20 years ago. Is it fair to say that this is because of mistakes made during the Soviet years regarding swaddling, nutrition or is it all unrelated.

SH: I can't say that the growth pattern for the population is the same as that in America 20 years ago because we don't have the studies that prove this. We use these old charts however because we don't have our own. We really do need to rectify this.

Regarding the effect of nutrition on growth it is one the factors but not the only one. Genetic factors and the overall health and well-being of the child are the most important, but growth is also related to nutrition.

OK: There's apparently been an increase in infant mortality. Why?

SH: Maybe it's better to ask this question to the authorities in the Ministry of Health.

OK: The Ministry of Health launched an initiative to promote Baby Friendly Hospitals with UNICEF and WHO in 1993. How is that progressing?

SH: There are four baby friendly hospitals in Armenia now, two in Yerevan one in Gyumri and one in Abovian. There are two hospitals that are ready to become baby friendly in 2002. The Gavar maternity is already assessed and Goris maternity hospital will be assessed in February and the Hospital in Erebuni, Yerevan, has passed all their training and is working towards becoming baby friendly.

Hospitals apply to the Ministry of Health and UNICEF and the initiative comes from the medical staff of the hospitals themselves. However, we do not have the resources to deal with all their applications and so we started with the two largest maternity hospitals in Yerevan. Gyumri maternity hospital was also considered very important because it was the largest in the region.

It's also good to implement the BHFI in big clinical hospitals where medical professionals learn and study rather than small ones.

OK: At the end of 2001 therefore, there are four baby friendly hospitals in Armenia with two ready to become so. By the end of 2002 how many will there be?

SH: Depending on our resources there should be six others by the end of 2002.

OK: Are there incentives to become baby friendly?

SH: The hospital will gain because what is the objective of a maternity wing? Healthier infants. Improvement of mother and child health care is the main incentive. They don't get any money, just prestige for the hospital.

There are ten steps to becoming a baby friendly hospital but also one of the main things is that the hospitals should comply with the Code. They are not allowed to receive free samples from companies or have any advertising materials and if we find that that happens in hospitals that have become baby friendly we will take their award away.

OK: No hospital is allowed to do this.

SH: This is a violation of the Code.

OK: This is what I don't understand. If a hospital breaks the Code what happens?

SH: We have means of fighting against violations.

OK: How?

SH: Firstly, someone needs to discover that they are breaking the Code and we are trying to monitor this but as I said before we don't have the funding to conduct a real monitoring project in Armenia. If we find violations we can of course apply to some international organizations as well as to the company directly.

OK: There are also cases of advertising and misinformation on Armenian Television.

SH: Yes, for example the program "Blitz" on Channel Armenia gave misleading information about the study "Duration of breast feeding and arterial distensibility in early adult life." Channel Armenia also recently ran advertisements for infant formula that went against the International Code but complaints from IBFAN stopped them.