CASE CRACKED: Glico-Morinaga

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The incident in 1955 is best outlined in the report named: "The Morinaga Milk Arsenic Poisoning Incident: 50 Years On."

In part, it reads:

At the end of June in 1955, a strange illness spread among bottle-fed children in the western part of Japan.

According to their mothers, those children started suffering from fever and diarrhea without showing any other symptoms beforehand.

They were also throwing up the milk that was fed to them and doctors were not able to identify a specific reason for their sickness.

It was on August 10th when this illness was reported for the first time, appearing in Okayama’s Sanyo newspaper. The writer of the article, Mr. K, was himself a parent with an 8-month-old daughter.

The newspaper headline read "Babies affected by the summer heat; Many occurrences in the southern part of Okayama prefecture. Some serious cases with anemia."

The article went on, "Due to the continuous heat during summer, babies, particularly in the southern part of Okayama prefecture are suffering from anemia. This has resulted in some infants in a critical condition in Okayama University Hospital and Okayama Red Cross General Hospital in the past week. Extreme cases are exhibiting symptoms similar to those of leukemia sufferers. In these instances patients have lost up to a quarter of their blood and have required treatments such as blood-forming medicine or blood transfusions."

Mr. K had been covering Okayama Red Cross General Hospital at the time and was told by one of the nurses that "a ‘black’ baby has been coming for examinations recently".

He became curious and enquired about this to the head doctor, to which the response was "I think it is Molinia. Some antibiotic medicines, such as penicillin, cause the whole body to become moldy and the skin to turn black."

At the time of the first report, Mr. K’s brother and 10-month-old niece were visiting from Tokyo.

Both Mr. K’s own daughter and his niece were bottle-fed babies who had consumed Morinaga powdered milk.

Soon after they were fed the milk, they started suffering from diarrhea. When they were presented at Okayama Red Cross General Hospital, their doctor said "You do not have to worry, but stop using the Morinaga powdered milk and change to one from another company."

It was not until twelve days later, on August 24th that the powdered milk produced by the Morinaga Milk Company was found to be mixed with arsenic.

Mr. K’s daughter and niece recovered as soon as they stopped consuming Morinaga powdered milk. Mr. K started to wonder about this incident and frequent Okayama Red Cross General Hospital.

On August 19th, he found the letter "M" on the records of 16 patients who had been hospitalized there. It turned out that all those who had been marked with an "M" were patients who had consumed Morinaga powdered milk.

Mr. K wrote a draft article which was due to be printed on the morning of August 10th.

Its content included a reference to "infants who had been fed Morinaga powdered milk" but this draft was not published in the morning edition, rather it appeared later that day, in the evening edition.

Moreover, during the editing process "fed Morinaga powdered milk" was changed to "bottle-fed".

It is claimed that this change was made "for a reason ordered by the company", according to Mr. K’s memoranda.

It had been clear "since around August 5th" that something was wrong with Morinaga powdered milk products.

In the publication, A Report on the Occurrence of Arsenic Poisoning by Powdered Milk in Okayama Prefecture, a diary entry written by Dr. Eiji Hamamoto, pediatrics professor in the Okayama University medical department, makes reference to this date.

All of the pediatricians at Okayama Red Cross General Hospital were pupils of Dr. Hamamoto and some doctors from Okayama University Hospital had sought help there.

This meant information about the recent events reached both hospitals immediately.

This begs the question, what if they had announced the danger of Morinaga powdered milk in early August when it was first detected?

Furthermore, had they made an announced on August 12th when Mr.K presented his baby, the damage would have been significantly less.

Instead, the announcement was postponed until August 24th, when arsenic was found in the Morinaga powdered milk products tested at the forensic medicine laboratory within Okayama University medical department.

August 24th 1955, this incident was given extensive coverage in every newspaper. The Asahi newspaper headline read "Strange illness occurring in bottle-fed babies. Three dead in Okayama", however, the word "Morinaga" did still not appear in the headline of Okayama’s Sanyo newspaper.

As a result of this, readers were not aware that consumption of Morinaga powdered milk was the cause of illness unless they read the whole body of the article.

It was assumed by many that the issue was common to all bottle-fed babies.

Numerous mothers who became upset by the article rushed to hospital and lined up outside in spite of the hot weather to present their babies.

Out of 197 bottle-fed babies who were presented to Okayama University Hospital on August 25th, 94 were found to be suffering arsenic poisoning from Morinaga powdered milk.

In Okayama Red Cross General Hospital there was not enough room for all the patients so some were forced to occupy beds in the halls.

A newspaper article on August 25th reported the number of patients in Okayama prefecture to be 216, and more than 100 in each prefecture of Kinki, Chugoku, Shikoku regions. In Okayama, five patients had officially died from the poisoning and even more deaths were estimated.

It was reported that patients were showing symptoms of high fever, diarrhea, darkened skin, and their abdomens had swollen up. The following day, the number of patients nationwide reached 1463, and 23 were dead.

The medicine used to treat the arsenic poisoning was British anti-Lewisite (BAL). BAL was originally discovered in the United Kingdom during the Second World War as an antidote for arsenic gas used in combat.

Who could ever have imagined that such a virulent poison was being mixed with powdered milk designed for babies? The information about why arsenic was present in the powdered milk was the cause of much confusion.

Arsenic had only been found in a powdered milk product called "MF Can" which was produced at a factory in Tokushima. While thirteen of the elements added to the powdered milk were taken to Okayama University medical department for examination, no trace of arsenic was detected in any of them.

It was actually the Morinaga factory in Tokushima who announced that arsenic had been found in sodium phosphate, a chemical being used as a stabilizer.

The stabilizer had not been sent for examination so all of the tests performed during the investigation had effectively been done so in vain.

It had not been known to anybody but producers that a stabilizer was being used in the powdered milk.

At the time, there were no refrigerated tanker trucks for transportation, so the milk was becoming oxidized on the long trip from the farm to the factory.

The quality of the milk used was a major factor.

If milk of low quality is used for powdered milk products, it is difficult to dissolve in water for consumption.

This problem does not occur if good quality milk is used. In the case of Morinaga, the milk being used was almost rotten therefore they needed to add sodium phosphate as a stabilizer.

According to the press release by Morinaga, they had been using this stabilizer since 1952.

Sodium phosphate can be classified into three grades of purity, known as reagents, these are: the first reagent, the second reagent, and the grade suitable for industrial use.

Believe it or not, the type of sodium phosphate that Morinaga had been adding to their milk was the one for industrial use, which is more commonly used as an insecticide or for cleaning boilers.

In fact, during the time in question, the scales at the factory were broken so the stabilizer was not measured before being added.

This is why the amount of arsenic found in each product was different depending on the date of production and lot number. The sodium phosphate in which the arsenic was found was actually produced from industrial waste.

This particular waste was generated during the process of refining bauxite into aluminum at the Nippon Light Metal Company, Ltd. factory in Shimizu.

It was first delivered to Japanese National Railways but was returned due to the presence of arsenic.

This sodium phosphate was delivered to Morinaga factory in Tokushima after being rejected by many medicine companies.

The Nippon Light Metal Company made an inquiry to the Ministry of Welfare via Shizuoka Prefectural Sanitation as to whether this "medicine" would constitute as a poison, in accordance with the "Poisonous and Deleterious Substances Control Law" of November 1954.

They did not receive an answer from the Ministry of Welfare until November 1955, the following year.

If their response had been completed much earlier, this incident would never have occurred.

Aside from these details, it is needless to say that all producers have a responsibility to their customers when it comes to product quality.

Including components that are best used for cleaning trains, as demonstrated by Morinaga, is nothing short of irresponsible and dangerous.

Nothing can excuse the actions of Morinaga.

It is clear that they neglected both their duty of care as well as security practices, which in turn lead to this incident.

In contrast, once the investigation was underway Morinaga insisted in criminal court that they had been "deceived by the medical company".

Morinaga claimed to have thought the medicine was the same as what they had been using before, and therefore did not check for quality.

They claimed this was an offence by the medical company against "the principle of trust".

The response from the medical company was mixed. On one hand they accepted the fact that they had actually delivered a low quality product.

On the other hand, they stated, "if Morinaga had made it clear what the medicine was to be used for, we would have delivered the proper product."

The medical company did not ask about the usage of their medicine because Morinaga wanted it to remain confidential.

The reason Morinaga chose to use low quality milk as a material was due to a sudden increase in their share of the powdered milk market.

This growth was the result of an effective marketing campaign, which included a baby contest and commercials featuring well-known personalities.

Their market share had exceeded 50% by 1955. The amount of milk Morinaga collected increased by 3.1 times over the period between 1950 and 1955.

Morinaga had outdistanced their competitors, Yukijirushi and Meiji, by 2 times and 2.6 times respectively.

As previously mentioned, there would have been no need to use a stabilizer at all if only Morinaga had used fresh milk as a material.

Although they had been advertising that Beta Dry Milk, a higher-ranking product than MF Can, was safe, it turned out not to be true according to a recent thesis.

Morinaga was found not guilty at the first trial in Tokushima district court on October 25, 1963.

At a review by an appellate court in Takamatsu high court on March 31, 1966, the original decision was reversed and remanded. Following this, at a hearing in the Supreme Court, a final appeal was rejected on February 27, 1969.

Eventually, it was through Tokushima district court that the head of factory production at Morinaga, Tokushima was sentenced to three years’ imprisonment.

It was one of the top ten longest lawsuits in history.

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