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2 M i l k i n g P r o f it s

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Milking Profits:How Nestl puts sales ahead of infant healthis published byTheNetwork --Association for Rational Use of Medication in Pakistan60-A, St. 39, F-10/4, Islamabad, PakistanPh: +92-51-281755 Fax: +92-51-291552, E-mail:[email protected], December 1999

Any part of this report may be reproduced on the condition that the source i-

tioned. No part of this report, however, can be reproduced, quoted or used in anway for direct or indirect commercial purposes.

Price: Rs. 75, overseas US$ 8 (including handling and postage)

4 M i l k i n g P r o f i t s
mailto:[email protected]:[email protected]

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5M i l k i n g P r o f i t s

Profits Before Health . . . . . . . . . . . . . . . . . . . .6

A Prick to the Conscience . . . . . . . . . . . . . . . . .8

Perks & Persuasions . . . . . . . . . . . . . . . . . . .12

Targets & Sales-Based Incentives: . . . . . . . . .20

Free Supplies/Samples . . . . . . . . . . . . . . . . . .24

Public Relations . . . . . . . . . . . . . . . . . . . . . . .26

Contents

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report * released in April 1998 revealed that

not a single company in Pakistan was market-

ing baby f oods or feeding products in a responsible

w a y. All compan ies were found to be violating the

WHO/ UNICEF Internat ional Code o f Marketing o f

Breastmi lk Substitutes, adopted in 1981 to p rotectmothers and babies f rom the co mmerc ial influences

of this industry.

Milking P rof its of f ers a ra re inside r's view of the hid-

den but common sa les pract ices of a giant t ransna-

tional company. Syed Aama r Raza, a former sales-

man o f Nestl Milkpak Ltd, revea ls concrete evidence

of the systematic and routine manner in which the

company buys the loyalty o f doctors, persuadingthem to p romote commercial products rather than

lif e-saving b reastmilk. His earlier attempt - in the f orm

of a Legal Notice issued on November 12, 1997 - to

conf ront his f ormer employe rs elicited threats to h is

lif e and the sa f ety o f his f amily.

This is not the f irst time the unethical marketing prac-

tices of the baby f ood industry, including Nestl, have

been documented (and it won't be the la st time ).Independent surveys to monito r International Code

compliance all over the world have produced similar

f indings, revealing ho w this company (and others)

markets its products in ways that underm ine breast -

f e e d i n g

In f act, because o f its "prof its-be f ore-health "

approach, Nestl has been the ta rget o f two interna-tional Boycotts. Thousands of individuals and organi-

sa tions in 19 countrie s pledge not to pu rchase the

company's best se lling product Nescaf (many stop

buying other Nestl p roducts as well) until the com-

pany ends its irresponsible marketing of breast milk

subs titutes and abides by the International Code. T h e

Boycotts focus on Nestl, the world's largest f ood

m a n u f a c t u r e r, because it controls about 40 % of the

world market in baby mi lks and u ses its inf luence toset ma rket trends and company behaviour and to

interf ere in government ef f orts to regulate the indus-

try's marketing pract ices.

This is the f irst time, however, that such explicit and

irref utable evidence has come f rom ins ide this mas-

sive co mpany (231,881 employees, 500 factories in

more than 80 count ries, turnover of US$52 bi llion

(1998) - "Are the re countries in which Nestl p roductsare not ava ilable?- Not to ou r knowledge " (Nest l

webs ite) ).


ProfitsBefore Health

* In March 1997,TheNetwork --Association for Rational Use of Medication in Pakistan conducted a nationwide survey to monitor the baby food industrys compliance with the International Code of Marketing o

Substitutes and the SAARC Code for the Protection of Breastfeeding andYoung Child Nu trition.The resulting report, Feeding Fiasco: Pushing commercial infant foods in Pakistan, was released in April 1998.Alarmingly, not a

single company marketing baby foods or feeding products in Pakistan was abiding by the International Code or the SAARC Code in their entirety.Available fromTheNetwork (see pg..4 for address) for US$ 15 (88pp).

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Nestl, having received much o f the evidence docu-

mented in this repo rt as attachments to Aamar Raza's

Legal Notice, has no doubt had its damage control

team scour each ite m to come up with ways to

explain everything a way. They won't be ab le to. T h eevidence (all provided in original by Aamar) is too

explicit, the v iolations too blatant. But let them try -

past experience has sho wn their ef f orts to expla in

their actions, only revea l more wrongdoing.

As is always the case when monito ring comp liance

with the International Code, the f indings repre sent

only the tip of the iceberg. The evidence contained in

this report has been accumulated ove r only 29months in the district surrounding a sma ll town. By

the time o f Aamar's resignation, Nestl employed 52

medical delegates to car ry out similar activities (on an

even large r scale in city centres whe re the potent ial

f or sales is greate r and the s takes higher).

Unholy AllianceAnd what o f the doctors? Are they not also partiallyrespons ib le for the deaths of these innocents?

TheNetwork believes that the doctors too must share

the blame. For in accepting (or in so me cases even

reques ting) the bene f action of the baby food industry

and igno ring the importance o f mother's m ilk f or

babies, many doctors have put the ir own interes ts

ahead of those o f their small patients. In exam ining

evidence o f Nestl's Code vio lations , so me truly crim-

inal cases o f doctor bet raya l also su rfaced. WhileNestl's unethica l marketing p ractices remain the

f ocus of this report, TheNetwork also wis hes to b ring

to light the wrongdoing o f the medical profession.


Why is Breastfeeding Important?The lives of 1-2 million babies could be saved each year if their mothers were enabled to breastfeed optimal-

ly (i.e. exclusive breastfeeding for about 6 months, continued along with additional foods for two years or

beyond). Not only does m other's milk provide all nutrients necessary for infant growth and development, it also

contains unique anti-infective properties which protect the baby against common childhood illnesses. Where

clean drinking water is not available, a bottle-fed baby is 25 times more likely to die of diarrhea and four times

more likely to die of acute respiratory infections than an optimally breastfed baby. Even when bottles are pre-

pared properly under sterile conditions the risk of illness and death is greater than among breastfed babies.

Mothers, too, benefit from breastfeeding. Not only is breastfeeding less time consuming and more convenient

than bottle feeding, there are also health benefits. Breastfeeding helps the uterus to return to its pre-pregnancy

state and reduces the risk of post-partum haemorhaging. It also reduces the risk of breast and ov arian can-

cers and of fers protection against subsequent pregnancy.

But breastfeeding - a simple, inexpensive and traditional practice that has the potential to save hundreds of

thousands of infant and child lives each year in Pak istan alone - is being endangered by the aggressive and

unethical marketing practices of the manufacturers of artificial baby foods and feeding products.These com-

panies go to great lengths to com e between a baby and its mother's breasts. Breastfeeding babies are bad

for business.

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yed Aamar Raza joined Nestl Milkpak Ltd. on

December 3, 1994 as a "medical delegate" con-

cerned only with products within the scope of the

International Code. He had seen the position adver-

tised in the newspaper. After a two-day interview

process,Aamar was selected out of about 50 appli-cants. He resigned with immediate ef fect onApril 30,

1997, ending a promising and envied career with a

multinational company. Heres why:

I was on a routine visit to a

doctor in a hospital in Sialkot.

While I w as there a critically ill

infant was brought into the clinic

with chronic diarrhea and severedehydration. The doctor I was visit-

ing rushed off to begin emergency

treatment. But th e baby d ied.

"The detailed medical history

revealed that this four- m o n t h - o l d

baby had been breastfed for his first

month but was then started on for-mula milk by a local doctor. The

mother had been assured that formu -

la milk would help the baby to gain

weight and become healthier and

chubbier. She was also directed to

stop breastfeeding and was told that

her milk was not suitable for her

baby. The baby was being fed formu-

la milk with a feeding bottle and had

been having episodes of diarrhea for

the last tw o months.

"The doctor I had been visiting and

wh o attend ed the baby is trained as a

preventive pediatrician who in his

practice actively pro m otes bre a s t-

feeding. Over my next several visits

he explained to me how formula

feeding was affecting the lives of thousand s of children in Pakistan. I, a

father at that time expecting my sec-

ond child, understood the role I was

playing in this crime and decided to

leave my job.

Syed Aamar RazaDavid takes on GoliathOnce removed f rom the pres sure and compet ition with-in Nestl, Aamar soon decided he s hould do something

to try to change the company s behaviour in Pakistan.

Six months after his res ignation, Aamar issued his f or-

mer employers a Legal Notice (dated 12-11-97), attach -

ing nearly 80 pages o f evidence o f the company's

unethical ma rketing practices. This evidence had been


A Prick tothe Conscience

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gathered over h is 29-month emp loyment with the com -

pany not systematically with the intention o f taking any

f uture lega l action, but as a job requirement. He had

been told to maintain records o f incent ives to docto rs

so that he could later us e them to p ressure the doctorinto p rescribing more Nestl p roducts. Document s f rom

his super iors, mean while, were kept a s a record of their

directions to him.

Advised by his fathe r in vie w of his legal experience,

Aamar demanded in h is legal notice that the compa-

ny "stop its business o f inf ant f ood manu f acturing in

Pakis tan and withdraw all its infant food products

f rom the Pakistani market within 15 days o f rece ivingthis legal notice ". He also directed the company to

"terminate the se rvices o f sta f f involved in

non-professional and uneth ical practices o f

promoting and selling in f ant f ormu las within the same

period o f 15 days ".

First Bribes, then ThreatsAfte r Aamar is sued the Legal Notice, two senior

employees o f Nestl (Specia l Project Manager/G roupBrand Manage r (GBM) who had come f rom Karachi

and the Area Detailing Executive (AD E) re sponsible

f or A a m a rs district) visited the home o f the pediat ri-

cian who had s hown Aamar the error o f his ways.

They told h im to stop Aama r pursuing the Legal

Notice and th reatened anyone involved in this matter

with him. The pediatrician contacted A a m a r, who

refused to bo w down or to meet with the Nest l sen-

ior employees.

Having failed to deter Aamar through this indirect

approach, the Nestl senior employees contacted a

doctor who had been on the receiving end of N estl's

largesse (see CoolTrade pg. 16) and asked him to call

Aamar to his office the next day on any pretext. Not

suspecting what awaited him, Aamar arrived at the

doctor's office to find his former seniors also there.

The GBM said N estl was such

a giant company that I couldnot harm it. He asked me to

withdraw the legal notice and said

that if the company's interests were

damaged with legal action, I would

s u ffer serious consequences ( I s k e ytumey sunge en nataig bhukatnainpharain gey ). Nestl is a m ultinationalcompany, he reminded me, and has

money to do anything to me. My

ADE off e red m e any a mou nt of

money I like ( Hum tumey moon mongi

rukum company say dila sekhthy hain.Jis say sary omer ash car o gey.) I did n otaccept.

The GBM said that if I continued to

be stubborn, the comp any w ould filecases against me in many different

cities. They said anyone from my

family could be kidnapped ( Tumar eykhandan kay kisi bhi shuks ko aghwa carlia jai ga ), or I could even be killed(Tumey zindagi se bhi hatth dhona pharsekhthy hain ). They said there are lotsof gangsters in Karachi and Lahore

read y to kill for money. I told th em to

go ahead and do what they wanted

to do and I would d o what I wanted

to do.

Syed Aamar Raza9M i l k i n g P r o f i t s

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The Campaign Begins...The respon se f rom Nestl Milkpak Ltd made clear the

company' s intentions. Though shaken and concerned

about his f amily's saf ety, Aamar resolved to perse-

ve re, this time with the help and support o f other

groups working on this iss ue. Aamar had ea rlie r sent

a copy of the Lega l Notice to TheNetwork and sub-

sequently wrote a rev iew for Feeding Fiasco (see pg.

6). (Interestingly, Nestl co rrespondence with Nestl

Boycott supporte rs revealed that the company had

incorrectly concluded that the "former Nestl

employee " anonymous ly ref erred to in Feeding


It was not u ntil,

up on the expiry of

15 days, Aamar

notified Nestl that

he would hold a

pr ess conference to

reveal the compa-

ny's "malp ractice

and unethical

measures" that

Nestl responded

officially, acknowl-

edging both his

legal notice and

subsequent letter

(dated November

29, 1997). In a letter

(dated 2 December

1997, Nestls lega l

advisor denied all

adverse allegations

and threatened

with legal action

for breach of trust

and d efamation

should

Aamar make them

public.

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Fiasco was Aamar Raza). Now he contacted

TheNetwork aga in, seeking gua rantees of security

and f inancial support f or taking the company to

court. Both requests were out o f our scope, but we

promised to help him make his evidence public

whenever he was p repared to do so.

After many months of contemplation and meetings,

Aamar decided to proceed and took precautions to

protect his family's and his own safety. This report is

the outcome of that decision.


Redundant and IllegitimateThe Nestl Charter -- Nestl's infant formula policy in developing countries" is the company's own code of con-

duct, which it implies is the same as the International Code. However, there are significant dif ferences betweenthe two - most notably, the International Code covers all breastmilk substitutes in all countries, while the Nestl

Charter applies only to infant formula in developing countries.

Not only was the International Code adopted by 118 countries, its text was prepared by the World Health

Organisation after consultations with governments, NGOs, health workers and the baby food industry itself.A

company-prepared code of conduct such as Nestl's Charter is nothing more than a public relations exercise

and is w ithout legitimacy.

In any case, Nestl's marketing has been sho wn to break even its o wn Charter as well as the International Code.

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ll the support s are with you as usual, " reads a

handwritten note signed by Aamar's immediate

s u p e r v i s o r, an Area Detailing Executive. He is ref er-

ring to the company's un written po licy of "keep ing the

customer happy " through gif ts of products , equipment

and othe r mate rial and f inancial inducements. T h e"custome rs " in this case aren't necessari ly the direct

buyers o f the company's product. They are, mo re

i m p o r t a n t l y, in a position to in f luence th rough their

prescriptions the purchases o f their hundreds and

thousands o f patients. The understanding is that i f

the company gives the doctor something, s he or he

will f eel obligated, or in the very leas t willing, to give

someth ing (i.e. prescriptions f or the company's prod -

ucts) in return.

It is a classic case o f "you-scratch -my-back-and- I'll-

scratch-yours ". The question is , who scratches f irst?

Bribes are not on ly of f ered by the baby food industry,

but also de manded by the many docto rs . Even when

Classification/Contact Data cardsOf course not all doctors are created equal in the eyes of the baby food industry. Number of patients, private practice and-

ernment service and teaching positions determine a doctor's potential to influence and therefore, their value to the ba

industry. The number and value of gifts and services a doctor receives from the company is determined by her or his cl-

tion.The more valuable the doctor (i.e. the more her or his potential to influence), the more the company is willing to "i

her or him.

Nestl's early contact classification system divided all health workers into three classes (A, B and C) according to -

ber of children they see or deliveries they handle, and considering their qualification (i.e. pediatrician, gynecologist/obs

general practitioner, para-medical staff, etc.). Specialists who are professors, assistant or associate professors or influent-

ion leaders areA-class, irrespective of their volume of practice.A new system of contact classification considers practice size

patient income level (considering doctors' fees, patients approximate per month income and area of practice) and in

Doctors were then divided into four classes (AAA,AA,A and B).

A data card is maintained for each contact. Information collected includes date of birth, wedding anniversary, year o-

ation, graduation institution and interests. Gifts and cakes are routinely delivered on birthdays and anniversaries.These vary in

price from Rs. 250 to Rs. 600, depending on the doctor's classification. Data cards are also maintained for hospitals, m

homes and clinics. They are also classified accordingly. These cards record the services provided, number of paeds and gy/

wards, number of beds, w hether there is a pediatric nursery, number of incubators, occupancy, number of children in out-patient

department per day as well as information about the heads of departments and ab out nearby pharmacies.


PerksPersuasions&

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13M i lk i n g P r o f i t s

the demands are not blatant and acco mpanied with

f lattery of Nestl, a docto r's openness to the co mpa-

ny's largesse and persuasion is perceived as a will-

ingness "to do business " and is quickly exploited by

the medical de legate. Responsibility for theseexchanges lie s with both partie s, the baby f ood

industry and the docto rs - a f act the International

Code clea rly establ ishes in saying that inducementsshould be neither o f f ered by the baby f ood industry,

nor accepted by health workers .

Bribing DoctorsAamar was reimbursed monthly for "promotional

expen ses" or "impres s money". This amount varied

f rom month to month, but could be over Rs. 10,000(e.g. Rs. 12,549, Rs. 15,750).

This budget is used to fulfill

the demands of doctors. The

money is spent according to

the potential of the doctor and is

solely on the Medical delegate's dis-

cretion. The medical delegate is also

authorized to freely use telephone

and courier services for prompt ful-

fillment of doctors' dem and .

Syed Aamar RazaOne gynecologist in f ormed Aamar that she had t rans-ferred her practice and she required a ne w signboard.

Article 7.3No financial or material inducements to promote productswithin the scope of this Code should be of fer ed by manu -facturers or distributors to health workers or members of their families, nor should these be accepted by health

workers or members of their families.

I N T E R N AT I O N A L C O D E

Bank slip sh ow-

ing reimburse-ment of impress

expenses for the

mon th of March

97, amou nt

Rs 12,549.

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When Aamar f orwarded the request to h is supe rvisor,

the reply was: "Is it plastic sign or tin board? Kindly do

it as you feel eas y f rom your budget. " Earlier (27-9-

95), her husband, also a docto r, received a cheque

f rom Nestl f or Rs. 10,000. Another doctor was p ro-vided Rs. 4,500 with which he was to pu rchase his

own signboard.

Nestl a lso provided lunch f or a f ree medica l camp,

f or which one o f the o rganizers received Rs. 4,000

"with a bundle o f thanks ". The same doctor later was

also pleased to accept ("with thanks ") the donation of

a nebu lizor with tubings and accesso ries . On the

request o f another doctor, Aama r's supervisor himsel f

purcha sed a baby weighing s cale to be de livered

by A a m a r.

Another doctor acknowledged receipt of a clinical pa-

diatric nebulizor and stethoscope for the paediatrward of Memorial Christian Hospital, Sialkot.The

director of the hospital was unaware of the "donation

Among other g ifts distributed by Aamar were 1996

Nestl Milk Pak Lt. Diaries and 25 Cerelac

dispense rs /table clocks f or A-cla ss pediatricians.

Routinely he supplied Nestl products (co f f ee, tea

w h it e n e r, etc.), tongue depressors, printed p rescript ion

pads and anyth ing else the doctor needed or requested.


Goodwill GoodiesUnde r Article 6.8 o f the Internationa l Code, baby f ood companies may donate equipment such as nebu li-

zors and weighing scale s (and these may even bear the company name or logo), but Article 7.3 states No

material and f inancial induce ments to promote products cove red within the scope of the Code . The end

result of such g ifts, espec ially in resource-tight Pakistan) is an inc reased sense o f goodwill to wards the

company and an ob ligat ion to return the favour in the shape o f presc riptions (see "No uncertain terms ",

opposite). As such, all such donation s can and should be considered as financial or mate rial inducements

and the ref ore disallo wed.

Courting CooperationNot on ly doctors, but also nurses a re wooed by Nestl's marketing team. Samples o f the company's prod-

ucts (Milo, Nesca f , yakhni, Cere lac) were regularly supplied to the nu rsing sta f f . Gif ts of lips t ick, nail polish

and pe rfume were also purchased out o f Aamar's "impress money ". Clea rly, s uch items are not f or prof es-

sional use, but mater ial inducements, banned under Article 7.3 of the Code.T

he nurses, in return, p rescribed

Lactogen 1 f or ne wborns rathe r than helping the mothers to breast f eed and admitted Aamar to the wards and

nurse ry outside o f f ice hours to give him d irect contact with the mothers. Whereas doctors may spend on ly a

few minutes with a patient, the nurse s are in the ward for the entire day and have much more contact with

the mothers.

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No Uncertain TermsSometimes the arrangement works subconsciously, with doctors denying

having been influenced by company inducements. Sometimes the deal is

spelled ou t in no uncertain terms.

On April 9, 1996 Aamar wrote to his supervisor, seeking guidance. He

wrote that he had been "asked for the sponsorship of an air conditioner

(A/ C) by [a doctor] who is a child specialist in DHQ Hospital Sialkot and

also private practitioner

as a consultant". He wrote

that he had told the doctor

he would have to ask his

sup ervisors as to "whetherthere is such type of policy

of sponsorship or not".

Aamar's supervisor, the

Area Detailing Executive,

wrote to the Group Brand

M a n a g e r, "Sir, as you

know he is a district pedi-

atrician. We have verbally

talked to him. I strongly

recommend for Rs. 10,000

instead of full payment

that would be around Rs.

20,000/ -. Rest am ou nt

would be sponsored by

any pharmaceutical com-

pany."

To w hich th e Grou p Brand

Manager replied to

Aam ar, "O.K. But N an an d

al110 sales should go up."

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Cool T rade for Company LoyaltyAmilitary doctor at Combined Military Hospital, Sialkot, on 5 July 1996 requested two air conditioners (a-

vided specifications) "for the comfort/better care of ... patients".The letter was addressed to ZahidAshfaq, who

he assuredAamar was an old friend of his. Aamar sent the letter to his senior.

Later, when he still hadn't received his air conditioner, the doctor

asked m e to inquire from m y seniors about it. My seniors told me that

the doctor should first show w hat he could do for the comp any in the

form of prescriptions.

Syed Aamar RazaB yAugust, Aamar had secured almost a monopoly over the hospital, and the Field Operations Executivs e n t

him a letter o f apprec iation, detai ling the hospital's large purchase o f Nestl products. The lette r was cop ied to

the Group Brand Managers, Brand Managers and Area Detailing Executives throughout the count ry.

On 16 September 1996, the same doctor issued a circular stating that only Nestl products were to be

The circular, having not been signed by the Commanding Of ficer, is also contrary to military service norms.

Aamar forwarded the circular to his seniors.

My seniors then told me to provide them a receipt amounting to the

price of an air cond itioner (abou t Rs. 24,825) so tha t they could release

the m oney. I could not find anyone w illing to issue m e a fake receiptfor such a large amoun t. When I told the d octor this, he said it was no p rob-

lem and he would take care of it. He phoned his friend and asked for a

blank receipt. I went to his friend's home and collected a blank receipt

stamped w ith his company's official stamp . I took it back to the doctor and

we made out the receipt for a hospital bed (which this company does not

even produce) costing Rs. 24,825.

After sending this receipt to my seniors, a cheque for Rs. 24,825 was

issued ("as per Brand Manager's instructions") on N ovember 14, 1996

in the name of the doctor's friend's company. The friend then wrote

back that he did n ot have an accoun t in Pakistan in the compan y name, and

asking that it be re-issued in his own nam e. I was sent the revised cheque

on January 15, 1997 and asked to pass it on.

Syed Aamar Raza16 M i l k i n g P r o f it s

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Outside the CodeNestl takes full benefit from its wide range of prod-

ucts, using products not covered by the International

Code to promote the company name and at the same

time create a sense of goodwill among doctors andother health care workers.

Before Eid at the end of Ramazan (the Islamic month

of fasting), the sales delegates receive packaging

material at their homes and products from their distrib-

utors for Eid gifts.Aamar was to give gifts to 20A-class

doctors and 10 to B class doctors, the contents of

which were as follows:

Among the supplies the company regularly de liveredto A a m a rs home were infant cereal sachets,

Eve ryday (tea whitene r) and Yakhni (chicken stock ).

These supp lies were provided f ree o f cost to the

d o c t o r s .

A circular f rom A a m a rs s uperviso r, the A D E

Faisalabad, dated J an 11, 1997, noti f ies the detailing

team that "f rom no w onwards nobody is a llowed to

purchase any company p roduct f or docto rs [except

in] special ca ses. You will have to take pr ior app roval

f rom undersigned."

This indicates that such purchas-es were pe rmitted o f f icially up to that date, and will be

cons ide red in future on a case-to -case basis. Such

purchases were above and beyond the supplies dis-

patched by the company.

Sponsoring LoyaltyA group o f 12 doctors and sta f f nurses f rom Memorial

Christian Hospital reque sted permission to visit the

Nestl plant near Sheikhupura. The letter sa id,"

Ours t a f f looks f orward to visiting your plant and d is-

cussing the va rious products which you o f f er " .

When PPA Gujranwala held a " one-day clin ical meet-

ing" on 27-04-97, Nestl printed invitation cards, dis -

tributed them to doctors and covered all the expense s

18 M i lk i n g P r o f i t s

Nestl is unique

in presenting

doctors with Eid

gifts of compa ny

products.

Verm icelli, trad i-

tionally preparedfor Eid, w as to be

pu rchased from

the market, as

Nestl does not

produce this

product.

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(break f as t, lunch, co f f ee/tea and excu rsion). The p ro-

gra mme revea ls it was more an excu rsion than a" one-day clin ical meeting " and its purpose f ar f rom

a c a d e m i c :

Nestl took care o f regist ration and accom modation

for a number o f pediat ricians to attend the

8th Nat ional Paediatric Con f erence,

26-28th Februa ry, 1997.

Families w ere a lso a ble to

accomp any the ped iatricians to

the conference. In at least one

case, the doctor's whole family was

issued air tickets as well. These tick-ets were returned unused to Nestl

and the doctor was given cash

instead.

Syed Aamar Raza

Invitation card

to PPA

Gujranwalas

"one-day clinical

meeting" held on

April 27, 1997

and directions

for Aamar to

deliver them to

doctors.

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Targetsales targets are calculated according to birth

rates and morbidity/mortality rates of a particu-

lar area.The minutes of anAnnual Delegate's Meeting

state that "Targets of Al-110 must be rationalised

according to the real potentiality of the towns."

Mo n t h l y, brand-wise (f or Cerelac, Lactogen 1 &2, A l

110, Nan, Neslac, P re-Nan and Nestum) target

sheets are prepa red by the ADE and hand written on

a Nestl writing pad or any pla in piece o f paper. In

Pakis tan Nestum (r ice cereal that has since been

renamed Nestl Rice ) and most flavours o f Cerelac

are marketed for use f rom four months and a re the re-

f ore within the scope o f the Code (see Living in the

Past, page 25). In se tting targets or calculating sales-

based bonuses, the re is no dist inction made between

cereals intended f or use f rom 4 month s or f rom 6

months. Target sheets a re al ways signed by the A D E .One target sheet also advises Aama r to se ll the items

on a 3 -5% discount.

Pressure to PerformThe sales team is continuously re minded of these tar -

gets and the impo rtance of meeting them. They are

unde r pressure to per f orm. Anotice f romAamar's super-

visor informs hi m, "Please receive your last quarte r

achieve ments report against target. Your small to wnsneed a lot of improvement in all products and special

emphasis is needed in Sialkot... " It adds, "Af ter very

heavy sa mpling your Ce relac sales a re decreasing day

by day. " And to keep the pressure on: "Also receive your

targets for April. I hope you understand that you are in

problem. " Another target sheet directs Aama r to meet

his targets f or Neslac "at any co st and without excuse ".

With his city- wise targets f or Nestum, Aamar was told,"Please take these ta rgets very se riously and positively

and take max imum advantage o f the season ". "The sea-

son" ref ers to the start o f hot weather and increased

incidence of d iarrhea. Anothe r time (March 1996) A a m ar

was in f ormed, "Your most concern area is Cere lac as

well as Nan also special ly in Sialkot. And start tak ing Rx

Tar gets & Sales-Based Incentives:

Brand-wise

and city-

wise target

sheet for the

month of

Ap ril 1996.

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of A l - 110 also. " A month later special emphasis was

needed in Sialkot on Neslac and Ce relac.

Team SpiritW hile there is stif f competition between medical dele-gates, the company places importance on creating a

sense of "team spirit" and a common goal of increas-

ing sales as a service to the babies of Pakistan.The

sales force is appointed as "medical delegates", in a

single move medicalising the company's infant feeding

products and raising the sales force above the rank of

common salesmen. Addressing the salesmen as

"tigers" incites promotional aggressiveness.

The company is generous with p raise whe re de served

and mora le boosting talks where required. "You are

doing good job. Keep it up with same tempo and dedi-

cation," encourages the note belo w ta rgets f or Sept. 95.

Another ta rget sheet note say s, "These a re your target s

f or the month o f March 96. Now ball is in your 'cou rt'.

This is the right t ime to prove yourse lf. At this time no

product is short and all the supports are with you as

usual. " ("Supports " are discussed in Perks &

Persuasions, pg. 12)

The successes of individual medical delegates were

circulated throughout the country and held out as

examples to be followed (see CoolTrade for company

loyalty, pg. 16)

Article 8.1In systems of sales incentives for marketing personnel, thevolume of sales of pr oducts within the scope of this Codeshould not be included in the calculation of bonuses, norshould quotas be set specifically for sales of these pr od -

ucts. This should not be understood to prevent the pay -ment of bonuses based on the overall sales by a companyof other products marketed by it.


Below: Morale is

kept high and

promotional

aggressiveness

encouraged

through a sense

of team spirit

and a common

goal.

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Fruits of Their LabourA letter from M arshall Rolland, M arketing M anager,

provides the break up of Aamar's salary (1996 Salary

Revision).The letter states: "Please also note that a

level adjustment of Rs. 200/- has been included in yourgross salary which is in addition to your performance

increment." It also informsAam ar that he "will also con-

tinue to be entitled to participate in the Performance

Incentive Scheme", details of which were to be provid-

ed separately. It goes on to say, "Please remember

your actual performance is regarded to be of key

importance and has therefore been duly considered

when revising you r sala ry." A similar letter was

received the following year (1997 Salary Revision)except the "Performance Incentive Scheme" had been

renamed the "Sales Incentive Scheme".

On 12.3 1996, Aamar received a Performance Bon

Payment (Including 10-C) amounting to nearly on

months salary. This was one of four bonuses received

in 1996.

Early salary slips consistent ly list "Fix Pay " and

"Incentive to Salesmen". Fix pay, as its name implies,

remains unchanged. Incentive to salesmen varies fro

slip to slip but is sometimes nearly as much as th

fixed pay. On later salary slips, where fixed pay is bro-

ken down into basic pay and various allowances, th

incentive to salesmen is sometimes more than doub

the basic pay.

The entire sales team is invited to annual sales co-

ferences at the luxurious Pearl C ontinental Bhurban


Below: Aa mar s

salary and ad di-

tional bonuses

were calculated

according to

his sales

performance.

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The invitation letter informs that the winners of the

Tiger Cup will receive their award during this event, aswill the winne rs of the Achievement and

EncouragementAwards. Awards are given to the

Medical Delegate of theYear. Winners receive plaques

and cash awards of as much as Rs. 25,000. Winners

are determined by their sales performance.

A review of targets vs. achievements and target s vs.

expenses also p laces emphasis on sales per f ormance.

The invitation letter also sets a goal o f sales worth Rs. 8billion by the end o f the year 2000, which presumably

includes sales o f products cove red by the Code.

Local musicians are brought in on the last evening as

the medical delegates dance the night away, in reward

for a job well done and providing incentive for the year

to come.


Incentives to

Salesmen on

Aamars salary

slips were some-

times as much as

the fixed pay or

more than doublethe ba sic pay.

Awar ds and

entertainment:

reward for a job

well done and

providing incen-

tive for the year

to come.

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24 M i l k i n g P r o f i t s

henAamar forwarded one doctor's request

for 10 packs of Lactogen 1 for free, he was

advised by the GBM to pay for the stock.

The distributor supplied the

doctor and billed me. I paidf rom my imp ress m oney,

which was reimbursed by the com-

pany

Syed Aamar Raza.

A special form was to be filled out for request for fr

or low-cost supplies.The form quotes extracts from the

WHO International Code and the WHO Guidelin

concerning circumstances under which infants need

be fed on breastmilk substitutes. Doctors are to sig

that they have read the extracts and that their reque"is consistent with the same". "In practice, docto

signed without reading anything." - SyedAamar Raza

The extracts quoted ignore subsequent, relevant res-

lutions adopted by the WHAthat specifically address

the issue of free and low-cost supplies, namely (WH

39.28 (1986), WHA43.3 (1990), WHA45.34 (1992

WHA47.5 (1994). Concern over free and low-cost su-

plies intensi f ied unti l resolution WH A47.5 (1994),which clearly states: "..no donations of free or subs-

dized supplies of breastmilk substitutes in any part

the health care system."

The sales representatives are submit these requisitio

forms duly signed by doctors along with an "Al-110

Free Sample Detail" form, which list s the total

received, previous balance, total in hand, month, tot

consumed and closing balance.

Cereal SerialMarch 9, 1995

A circular announced that the Cerelac Wheat 40gm

sachets would soon be "relaunched".This was seen

as a way to improve sales by increasing the number

Free supplies/ Samples

A special

form was to

be filled ou t

for request

for free or

low-cost

supplies.

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people trying the product and "help to fight against

Farex in small towns where Farex's 150 gm pack is

making ground".

The sachets were to be made available at doctor'spharmacies and sold for Rs 6/-.As "the shelf life of 40

gm sachets is very limited" the "medical delegate/sam-

pling team" was to "generate enough prescriptions to

get it moved from the shelves within 2 months".

August 31, 1995

A circular said:

" Within t wo o r three months you would be ab le to

receive the f ree sa mples of Cere lac 3-Fruit also.Kindly use s amples more ef fectively as you are

already doing. "

April 1, 1996

A letter toAamar dated says, "After very heavy sam-

pling your cereal sales are decreasing day by day."

April 17, 1996

A follow-up note dated says, "I have written an infor-mation to you dated 1-4-96 regarding mention of

Cerelac sachets in front of every doctor but till today

you are not mentioning. Why? I need your written

explanation."

Aam ar regularly collected from the local distributor car-

tons of Cerelac sachets for distribution among doctors.

Sachets were also distributed directly to mothers dur-

ing baby shows arranged by Nestl at local hospitals

(see Public Relations below).A circular informed themarketing team that Cerelac was to be the "first priori-

ty for prescriptions during 1995".

Article 5.2M a n u f a c tu rers and dis t ributors should not provide, d irectlyor indir ectly, to pregnant w omen, m others or m em ber of theirfam ilies, sa m ples of produ cts w ithin the scope of this Code.

Article 7.4Samples of infant formula or other pr oducts within thescope of this Code, or of equipment or utensils for theirpr eparation or use, should not be pr ovided to health work -ers except when necessary for the purpose of pr ofessionalevaluation or resear ch at the institutional level. Healthworkers should not give samples of infant formula to pr eg -nant women, mothers of infants and young children, ormembers of their families.

WHA47.5 (1994)Member States ar e ur ged "to ensure that there ar e no dona -tions of fr ee or subsidized supplies of breastmilk substi -tutes in any part of the health car e system."


Living in the PastComplementary foods marketed for use before they are nutritionally required are unnecessary and potential-

ly dangerous. When marketed for use below six months of age, they fall within the scope of the International

Code as they necessarily replace a baby's intake of breastmilk and are therefore breastmilk substitutes.The

World HealthAssembly (in Resolution 47.5, 1994) and the National Breastfeeding Policy of Pakistan recom-

mend complementary feeding "from about six months".

Nestl, however, prefers to live in the past, when it was recommended that complementary feeding begin

between four and six m onths of age. Given that age bracket, m others and doctors were inclined to begin cere-

als earlier rather than later, resulting in more sales. So while science has established that most babies thrive

on their mother's milk alone for about six months, the company ignores changing national policies and inter-

national recommendations and markets its cereal products openly as though they are not covered by the

International Code at all.

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organized baby shows in schools

and hospitals, where the winners were given

free gifts and plaques. Sample sachets of cereal were

distributed directly to mothers and children.The area

where the baby show is held is decorated with posters

promoting Nestl products. There are also prominentdisplays of Nestl products, including cereals and for-

mulas (pre-mature, regular and follow-up).

I conducted 13 Baby Shows in

Sialkot during my time with

Nestl, 12 were in schools and

one in a hosp ital. The 13th show was

a gran d finale, where the "Baby of the

Year" was selected from the winners

of all the previous show s.

During these baby shows w e wou ld

promote the company's produ cts and

motivate mothers to buy them. In

direct interaction with the mothers

we w ould ask w hat milk their baby is

drinking and encourage them to useLactogen and Nan. We also gave out

free samp les.

Syed Aamar RazaThese shows were seen as a public serv ice of sorts.

Indeed, an ex- Mayor o f Sialkot handed out prizes and

presented a plaque to Aamar's supe rvisor f or his

service to the c ity. Doctors , too, were pleased to par-

ticipate and had their photograph taken with the prod-

uct display.

Aamar received a letter o f apprec iation f rom a doctor

at the hospital that hosted one baby sho w that said:

"My team members and I ... are grateful for your kin

and sincere cooperation regarding "Baby of theYear

Award, 1995".Your active participation and devotion

was a great honour for us. We hope that your coope-

ation in this activity, launched for the promotion of

PublicRelations

Right: Direct inter-

action with m oth-

ers and d isplays of

products covered

by the Code

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health and well of the children of this city and aware-

ness of their mother regarding their care and health

needs, will continue in future as well.

"We will always be looking for your comp any with us."

Other direct contact with mothers took place in the

doctors' waiting rooms.

We would talk with mothers

while they were waiting to see

the doctor. We gave free sam-

ples of Cerelac, especially to the

mothers of very young children, butif others requested we would give

samples to them also. The mothers

themselves would ask us about the

benefits of the product and how to

prepare it. We, of course, took full

advantage of this interaction to pro-

mote the company's products.

Syed Aamar Raza

It was not uncommon for medical delegates to visit

hospitals outside office hours. Aamar used to visit the

nursery and wards and ask m others whether their doc-

tor had recommended Nestl products.The nurses

collaborated with him by admitting him to the ward and

writing prescriptions of Nestl products (See Courting

Cooperation pg. 14 for their rewards).

Article 5.1There should be no advertising or other form of promotionto the general public of products within the scope of thisCode.

Article 5.2Manufactur ers and distributors should not pr ovide, dir ect-ly or indir ectly, to pr egnant women, mothers or member of their families, samples of pr oducts within the scope of thisCode.

Article 5.5Marketing personnel, in their business capacity, should notseek direct or indir ect contact of any kind with pr egnantwomen or with mothers of infants and young childr en.

Article 6.2No facility of a health car e system should be used for thepurpose of pr omoting infant formula or other pr oductswithin the scope of this Code...


Hand ing out sam-

ple sachets of

Cerelac, labelled

for use from 4

months of age.

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Nestl must abide by theInternational Code andsubsequent WHAresolutionsNestl must abide by the International Code of

Marketing o f Brea stmilk Subst itutes and subsequentWorld Hea lth Assembly Reso lutions on infant feed-

ing. The company must ful f il its responsibility ( Artic le

11.3) f or taking steps to ensure that it s conduct at

every level conforms to the principle s and aim o f the

Inte rnational Code.

At the 1998 W HA , D r. Tomris Turmen, Executive

Director of Family and Reproductive Health, WHO

said: Infant-food industry needs to be more active andmore responsible to monitor its own marketing prac-

tices and respond promptly to correct all the violations

that are reported.

Though not binding, WH Aresolutions carry moral or

political weight, as they constitute the judgement on a

health issue o f the co llective membership o f the highest

international body in the f ie ld of health. (Shu b b er, S. Th e

International Code, Digest of Legislation, Vol. 36, No.4, 1985. pg. 884).

Nestl must reveal resultsof internal audits andcorrective action takenNestl clai ms to strictly and at all times act in accor-

dance with and cont inuously strive to adhere to the

Internationa l Code o f Marketing o f Brea stmilk

Substitutes (and the Nestl Charte r, which it believes

to be con sistant with the Inte rnational Code). It says

a ll employees are required to adhere strictly to the

Nestl Charter -- but notably not the International

Code. It also s ays that any breach o f the Nest lCharte r -- again, notab ly not the International Code -

- entails ser ious disciplina ry consequence s. Nestl

must make public all cases whe re disciplinary action

was taken as a result o f a breach o f the International

Code (o r even the Nestl Charte r).

M r. Peter Brabeck, worldwide CEO of Nestl, say s that

he has pe rsonally revie wed any hint of wrongdoing

uncove red dur ing 130 internal aud its conducted overthe past 5 yea rs. Nestl must make publ ic the result s of

these audits and the co rrective measures taken).

Nestle must also bring its Instruct ions to sta f f on the

Code into line with the Internationa l Code and sub -

sequent WHA R e s o l u t i o n s .

Nestl must abandon its

CharterAcompany-prepared code of conduct such as N estl

Charter is nothing more than a public relations exe-

cise and is without legitimacy.

Nestl must openly admit and accept the signi f icant di f -

f erences bet ween the International Code and the com

28

What mustbe done?

M i l k i n g P r o f it s

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p a n y s redundant Cha rter. Where gove rnments have

not enacted legislation to regulate the baby f ood indus-

t r y s marketing pract ices, the Internationa l Code and

subsequent, re levant WHAResolut ions should serve as

the company s code of conduct in A L Lc o u n t r i e s .

PPA must take disciplinaryactionDoctors are not innocent bystanders, but in some

cases willing and active accomplices. They should be

held accountable for accepting and even requesting

favours from the baby food industry.

The Pakistan Pediatric Association must be pro-active inensuring that doctors a re aware of their responsibi lities

under the International Code. Se rious notice shou ld be

taken of the role o f its members in the unethical promo-

tion of baby milks and f oods. The membership o f doc-

tors involved in this cruel a lliance should be cancelled.

Nestl must issue a publicapologyFor too many years , this massive co mpany has beenrak ing in prof its while contributing to the su f fering a nd

even dea lth o f the babie s of this country (and many

others ) .

Nestl must issue a public statement accepting that

their promotional push into an inappropriate market

has been unethical and apologizing for its contribution

to infant suf fering and death.

GoP must enact legislationThe text of the proposed Protection of Breastfeeding

and Young Child NutritionAct has been finalised. It

now needs to be enacted without f urthe r delay.

Pakistan, as a signatory to the International Code

nearly 19 years ago, is obligated to enact legislation

implementing the International Code in its entirety.

Such legislation is also in line with obligations under

other international agreements, notably the

Convention on the Rights of the Child.

The Government of Pakistan first drafted the proposed

legislation in 1992, but because of internal debate and

external pressure from the baby food industry, it has

yet to be enacted.

nestle - zaka (63)

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