Sponsorship: Dangerous Health Worker–Industry Relations in Cameroon

One of the most effective ways in which companies are building goodwill is by sponsoring health professionals by way of fellowships, study tours, research grants or attendance at professional conferences, etc.

Companies portray sponsorship as part of their corporate social responsibility to show that they are contributing to the society. In reality, this practice is an effective marketing strategy. It links the company name to respected health professionals and prestigious health professional associations. This form of association provides companies with outrageous and continuous returns on the money invested.

Lately, many reports have come in about health professional events being sponsored by Nestlé Nutrition Institute Africa (NNIA) in Central and West Africa. NNIA is described on its web page as “a multidisciplinary, educational organisation dedicated to the science of nutrition for people of all ages on the African continent. As one of its 13 chapters and the oldest outside of the USA, the NNIA forms part of the global structure of the Nestlé Nutrition Institute”. It is in fact a Nestlé-owned and Nestlé-funded entity according to documents unearthed by the Botswana Gazette back in 2011.

Examples of what companies are doing in Cameroon, show how NNIA sponsors health professionals in events disguised as ‘continuing medical education’ or ‘scientific information’ in Cameroon. These activities give rise to concerns about conflicts of interests which a number of World Health Assembly resolutions and the 2016 Guidance have warned against. (2016 Guidance on ending the inappropriate promotion of foods for infants and young children)

Is sponsorship permitted under the International Code of Marketing of Breastmilk Substitutes?

Article 7.5 allows companies to make contributions to health workers. The only safeguard provided is the need for manufacturers and distributors and recipients to disclose the contribution to the institution to which the recipient is affiliated. It is only afterwards that WHA resolutions amended this lack of safeguards. The assumption that disclosure is sufficient to avoid conflicts of interest is unfounded, because:

  • Health workers may have a different understanding of a conflict of interest, and therefore not disclose all.
  • Declarations of conflict of interest are usually unverified, casting doubts on accuracy.
  • Disclosure may be used to “sanitise” a problematic situation, suggesting that no ill effects will follow from the disclosed relationship.

Article 7.5 is a weakness in the Code. To overcome some of the shortcomings of the Code on this topic, three WHA resolutions caution against conflicts of interest, namely resolution WHA 49.15 [1996]; resolution WHA 58.32 [2005] and resolution WHA 61.20 [2008]. The 1996 resolution calls for caution in accepting financial support for health professionals working in infant and young child health which may create conflicts of interest. The need to avoid conflicts of interest is repeated in 2005, and expanded to cover programmes. The word “programme” is not explained, but using its ordinary dictionary meaning, would cover a planned series of events or on-going services. In the context of infant and young child nutrition, these can include support for research, community out-reach activities and multiple, projects implemented within schools and colleges, medical or health education. The need to avoid conflicts of interest was reiterated in the 2008 resolution in the call for Code implementation by scaling up efforts to monitor and enforce national measures to protect breastfeeding.

Recommendation 6 of the 2016 Guidance is also couched in the context of avoidance of conflicts of interest to prevent health professionals and health facilities from being targeted and influenced by manufacturers and distributors through relationships and incentives that can result in the loss of independence, integrity and public credibility.

What is a conflict of interest?

The concept of a conflict of interest has its origin in the law used to regulate fiduciaries- individuals entrusted to serve the interest of another party or to serve a designated mission- who are held to the highest legal standards of conduct. The law does not permit fiduciaries to promote their own interests, or the interests of third parties. It requires fiduciaries to be loyal to the party they serve, to act prudently and diligently, and to account for their conduct. There are two broad types of conflicts of interest: 1) conflicts between an individual’s obligations and their financial or other self-interest; 2) conflicts resulting from an individual’s divided loyalties, dual roles or conflicting duties, sometimes referred to as conflicts of commitments.[1]

Health professionals possess specialised knowledge and hold the trust of their patients. As patients are not in the position to determine if health professionals are acting solely for their benefit or have been influenced by some personal interest, a duty to avoid conflicts of interest is implied. When health professionals attend conferences sponsored by companies that market products in ways which undermine breastfeeding and child health, that gives rise to a conflict of interest.

[1]Rodwin, Marc A., Attempts to Redefine Conflicts of Interest (2017). Accountability in Research: Policies in Quality Assurance (December 6). Retrieved from https://papers.ssrn.com/sol3/papers. cfm?abstract_id=3084307

Look what they are doing in Cameroon!!

  • November 2017 – A clinical trial on Cerelac and similar infant cereals, funded by Nestlé, was conducted by a team of researchers from the University of Yaoundé I. Thomas Caso, Director General of Nestlé Cameroon said “We are proud that our Cerelac brand helps support healthy physical and intellectual development in Cameroonian children”. Unsurprisingly, the results of the clinical trial showed that iron fortified complementary foods can help fight anaemia in children under five. In spite of the recommendation in WHA resolution 54.2 [2001], this finding will doubtlessly be exploited for marketing purposes. (Resolution 54.2 urges Member States “to improve complementary foods and feeding practices by ensuring sound and culture specific nutrition counselling to mothers of young children, recommending the widest possible use of indigenous nutrient-rich foodstuffs.”) Indigenous, not imported or ultra-processed.

Banner proclaiming the benefits of fortification of complementary foods at an event organised by Nestlé (Nestlé Nutrition Forum, 16 October 2018)

  • November 2017 – NNIA sponsored two scientific symposia in Yaoundé and Douala. A total of 106 Cameroonian paediatricians and general practitioners from health facilities in different areas were informed about the role of nutrition in optimal growth and immunity, deficiencies in micronutrients, nutritional management of diarrhoea in children, and paediatric obesity. They were part of the 650 healthcare professionals “trained” across Central and West Africa. Thomas Caso, Director General of Nestlé Cameroon stated that “through this program, the Institute wants to contribute to reinforce training in pediatric nutrition and give the medical system effective skills in this area”. NNIA plans to “train” 10,000 more healthcare professionals in the next three years.Imagine having all these health care professionals consciously and unconsciously acting as Nestlé’s marketing agents throughout the country. The other concern would be the emphasis that Nestlé normally gives to various formulations in their products and their unsubstantiated benefits. Promoting expensive commercially fortified complementary foods to communities that are ill-prepared to handle the social and financial implications of using such products is quite inappropriate.
  • March 2018 – NNIA organised the first African Course on Paediatric Nutrition (CANUP) of the year in partnership with the Association of Midwives and Assimilated of Cameroon (ASFAC) and the Ministry of Public Health in Douala. CANUP is part of an action plan implemented pursuant to a partnership agreement between Nestlé and the Ministry of Public Health. A total of 40 health professionals attended the two-day course. The aim of the training is purportedly to develop and strengthen the knowledge of health professionals in paediatric nutrition to improve well-being of children and fight against malnutrition in Cameroon but in actual fact CANUP serves as a ready platform for the promotion of Nestlé products.
  • April/May 2018 – Similar CANUP trainings were conducted in Garoua and Bafoussam for health professionals from various cities in the Western and Northern region of Cameroon. They include midwives, nurses specializing in reproductive health, paediatric and immunization services and midwifery nurses. A total of 225 health professionals attended.

The Director General of Nestlé Cameroon, Thomas Caso, is ambitious: via CANUP sponsorship, NNIA seeks to “allow families to live more healthy and happy lives, notably by helping 50 million children to live in better health by 2030.”

Nestlé Cerelac samples on display at the Nestlé Nutrition Forum (16 October 2018). Helping children or establishing a market for Nestlé products?

Conclusion

Despite the multiple warnings about conflict of interest, Cameroonian professionals pulled into these NNIA programs cannot pride themselves on fair and independent continuous medical education.

The Cameroon government voted for the Code in 1981. It also joined the consensus for each and every subsequent resolution at the World Health Assembly. The Code and resolutions have the same legal value and must be jointly implemented whenever possible.

If and when Cameroon upgrades the Ministerial Decree of 2005, by adding sanctions as intended, it may be a good idea to study the resolutions on sponsorship and on conflict of interests.