Longtime Code Champion Dr. Susanna Harutyunyan Advocates for the Health of Infants and Young Children in Armenia through Breastfeeding Protection

On 20 November 2014, the Law on Breastfeeding Promotion and Regulation of Marketing of Baby Food was adopted by the National Assembly of the Republic of Armenia. The new Law covers all provisions of the International Code and relevant WHA resolutions, and in some aspects, even goes beyond them.

Below are excerpts of an exclusive interview with Dr. Susanna Harutyunyan, Paediatrician, President of the Armenian IBFAN Group (Confidence Health NGO), and Lecturer at the State Medical University of Yerevan. Susanna is one of the core advocates who lobbied for the International Code to be implemented as national law of Armenia. It is hoped that sharing this experience, will serve as an encouragement and testimony to other countries which aspire to adopt good laws to protect breastfeeding and hold companies accountable.

ICDC: Were there any specific events that prompted you on this journey?
SH: Yes, prior to the dissolution of the Soviet Union, we did not have advertising of infant formula. After the dissolution in 1991, the market opened up, and companies started violating the Code seriously.

ICDC: Can you share with us the beginning of your journey on Code advocacy and the role IBFAN played?
SH: In 1997, I attended the Regional Course on Implementing the Code in Almaty that was jointly organised by IBFAN-ICDC and UNICEF, and learnt about IBFAN and its work on breastfeeding protection. That course was a turning point in my life, as protecting the health of infants and young children has always been my passion. After that I decided my country needed a draft law, and I contacted the lawyer from the Ministry of Health (MoH). With his support, a new article on the existing Law on Advertisement was adopted in 1999. Although the initial article had no penalty, it was a start – and with the help of IBFAN, we were able to stop a lot of violations.

ICDC: What were the subsequent steps after the initial article?
SH: I felt that the initial article was not effective enough. Aggressive marketing practices of baby food companies was one of the main obstacles in achieving optimal infant and young child feeding in Armenia. I continued to attend a number of other Code trainings organised by IBFAN. In 2003, I was able to participate in a training on law drafting held in Penang, Malaysia, where the ICDC office is based. A year later, with support from MOH and UNICEF, I started drafting the Armenian law based on the model law [2]. Although the draft law was then submitted to the MOH, but for a number of years, there was not enough political will to push it through.

ICDC: What exactly happened with the draft law in those years?
SH: To make matters worse, the draft law on “Marketing of Infant Food and Related Products” was severely weakened – the ban on health and nutrition claims was removed, so did the requirement for labels to warn users on potential contamination of infant formula [3]. Furthermore, the ban on advertisement of complementary foods was removed after being circulated in Parliament in 2011. The 2012 Parliament even stopped circulating the draft altogether and thus the process was halted. All the while, training on infant and young child feeding for healthcare professionals was insufficient, let alone education on the Code.

ICDC: How did the draft law get from being severely weakened to a comprehensive law that is tailored to the social framework of Armenia today?
SH: I persevered for many years and eventually, I was able to garner support from Dr. Ara Babloyan, Head of the Committee for Mother and Child Health of the National Assembly, and a paediatric surgeon himself. He was an avid supporter of breastfeeding, and he contributed greatly to re-drafting the Law. With his knowledge in paediatrics and his influence in the Parliament, we managed to submit the law to the Parliament. At the time the law was still slightly weakened. For example, it said that children who were living in poor socioeconomic conditions could receive free infant formula. But almost half the children in Armenia were in that category. The political support allowed us to keep on fine-tuning the draft to reflect the spirit of the Code and WHA resolutions, and contextualise it with the situation in Armenia.

ICDC: To our knowledge, the law now has provisions that go beyond the International Code?
SH: Yes! And I am proud of that. The new law has a scope up to 3 years for formula milks and complementary food. It bans any advertising and cross-promotion, conferences organized by companies, sponsorship, and any equipment donated to healthcare facilities. It is very much of a safeguard against today’s corporate marketing climate. It even bans the sale of infant food in the territory of health facilities.

ICDC: What was the critical catalyst in your lobbying for the law to be adopted?
It was when Dr. Babloyan demonstrated his support. He also happened to be my professor back in University, and at one point the Minister of Health. In retrospect, we worked very hard to push the law through two different paths. The first was through MoH, and not much headway was made. Once we garnered support from Dr. Babloyan, a member of Parliament, we were able to tap into the political will of those who can influence policy. As advocates it is important to be politically-savvy.

ICDC: How does your experience as a paediatrician influence your Code advocacy work?
SH: I can see firsthand the difference between children who were breastfed and those who were fed with formula, or worse, cow’s milk. In one case, an infant was born at 4kg, and was fed with sweet condensed milk. A year later, he weighed less than 6kg. He was suffering from severe malnutrition, and that is very rare in Armenia.

Our national statistics on the duration of hospitalization of infants and young children and the number of hospitalized children also reflect the health disparity between those who are breastfed and those who are not. Majority of children who were hospitalized were artificially fed. In another study in Armenia, looking at infants and young children who had died, the number of artificially fed babies were about 4 times the number of breastfed babies.

ICDC: So now that the law is implemented, what are the implications?
SH: The adoption of the law is timely because increasingly we are seeing more company infiltration into the healthcare system. Marketing strategies are becoming “better”, meaning they are misbehaving even more than before. They are approaching doctors, and we see free supplies at maternity hospitals. The law is new, so we really need to scale up monitoring to assess the effectiveness of the law and how we can improve. Sadly to say, our last monitoring was done in 2011. I think it needs to be done more regularly.

ICDC: What are some of the challenges in monitoring and how it is carried out?
SH: Human and organizational resources are always a challenge; hopefully with the law, the government and civil society can share the responsibility. In the past years, IBFAN group (Confidence Health NGO) was the main organiser for monitoring, mostly by volunteers with many working in the healthcare system themselves. However, sometimes we had to hire people to assess the hospitals and interview mothers because healthcare professionals cannot take up that role. Besides, it is very difficult to prove that doctors are involved in bringing free supplies into hospitals or taking money from companies. But because of social media, it is easier for us to see what companies are doing in promotion and at conferences.

ICDC: In the contemporary social context, how can working mothers be better supported to breastfeed?
SH: I think policy-wise, maternity protection is very critical. Certain aspects of that are incorporated into the law, for example appropriate conditions in the workplace for breastfeeding. Currently in Armenia, the duration of maternity leave is 70 days before and 70 days after giving birth, with benefits amounting to 100% of salary, paid by the government.

ICDC: In your vision, what are the important elements in breastfeeding advocacy?
SH: We have to think holistically in terms of protection, promotion, and support, as you see in our law, breastfeeding promotion and marketing restrictions go hand-in-hand. Educating healthcare professionals on the Code is important. We have now integrated Code training into the curricula for medical students. As with any advocacy, relationship building with relevant organisations is important, for example Confidence (our NGO) has been a strong supporter of the adoption of the Law, spearheading two campaigns to raise public awareness on the necessity of the Law -“Advocacy for Legislative Promotion of Breastfeeding and Regulation of Infant Food Marketing” in 2011and “Supporting the Adoption of the Draft Law on Breastfeeding Promotion and Regulation of Baby Food Marketing” in 2012. The Armenian Mother and Child Alliance has lent much support to our work, because of them we had multiple public hearings on the law, in collaboration with MoH and the American University of Armenia. We even organised a flash mob to promote breastfeeding with their support.

ICDC: Thank you Dr. Harutyunyan. It’s been a pleasure for ICDC to have worked with you all these years. We hope to see your efforts bear fruit and you can count on our continued support.

[1] In summary, the Law has a broad scope covering all baby foods including infant formulas, young child formulas and complementary foods for infants and young children up to 3 years of age; as well as related products such as feeding bottles, teats and pacifiers. There is also a wide range of prohibitions in relation to promotion to the public, in health facilities and to health workers, including an absolute ban on sponsorship and donation of equipment, supplies and services in health care facilities which is a major improvement on the International Code. Labeling provisions are extensive and include a ban on claims and a prohibition against labels of other products being similar to labels of infant formula in order to prevent cross-promotion. The provisions of WHA Resolution 58.32 (2005) are also covered – the ban for health and nutrition claims in the law and the warning on powdered formula beeing potentially contaminated – in regulations on labeling (the law refers to the regulations). The Law also includes detailed provisions on information and education with a ban on any reference to names and logos or products and those of manufacturers and distributors.

[2] The Model Law was developed by ICDC as an instrument to assist governments in translating the International Code into national legislation.

[3] As required by WHA Resolution 58.32