This month, Corporations and Health Watch focuses on the role of corporate practices in producing or maintaining socioeconomic, racial/ethnic or other inequities in health. In our interview, Stephen Thomas [pdf], the director of the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health and founding co-chair of the new Academy for Health Equity, describes the ways corporate decisions contribute to health disparities and assesses various strategies for putting this issue on the agenda in Black, Latino and other low income communities. In the second feature,Martha Lincoln, a PhD student in anthropology at the CUNY Graduate Center, tells the story of Bidil, a prescription drug approved by the US Food and Drug Agency in 2005 for treatment of congestive heart failure. Bidil is the first “race-specific” pharmaceutical to be awarded federal approval. Lincoln describes the ethical, health and financial issues raised by “racial targeting” of a specific population with a specific drug. The third contribution is a selected bibliography and abstracts of recent scientific publications on the role of corporate practices on health disparities. Finally, Alexandra Lewin examines the impact of rising food prices on the school lunch program, suggesting that these price hikes may further reduce access to healthy food for vulnerable populations.
In this commentary, I review some of the pathways by which corporate practices may contribute to health inequities, describe some of the strategies advocates have used to reduce harmful corporate practices or policies and suggest some directions for research and advocacy.
Pathways: How corporate practices contribute to health inequities
How do corporate practices influence the differential burden of disease on different population groups? In previous work, my colleagues and I have identified four business practices that influence health: product design, marketing, retail distribution and pricing. 1, 2 Let’s examine how each contributes to disparities in health.
By designing products to appeal to specific groups, producers hope to increase sales to these markets. When the product harms health or the targeted population has other vulnerabilities that can magnify its adverse impact, this practice can lead to differential disease profiles. For example, the tobacco industry added menthol to tobacco products in the belief that African-Americans preferred mentholated cigarettes.3 Some research suggests that menthol cigarettes increase the risk of dependence and tobacco-related illnesses.4, 5, 6 As a result, concludes one researcher, menthol “may be partly responsible for the disproportionately high tobacco-related disease and mortality among African Americans generally and African American males particularly.”3 Similarly, the production of malt liquor, characterized by high alcohol content, a sweet taste and often sold in 40 ounce containers, is designed to appeal to male African-Americans, where it has been associated with higher rates of binge drinking and alcohol-related health and safety problems.7 In both the case of menthol cigarettes and malt liquor the problems associated with a product designed to appeal to a specific population were aggravated by heavy marketing to that group.
Tobacco, alcohol, and food companies target advertising at Blacks, Hispanics and low-income communities, leading to greater exposure to health-damaging messages.8, 9, 10 In some cases, differential media exposure further exacerbates the adverse impact. Since African-Americans watch more television than whites, they are more exposed to unhealthy food or alcohol advertisements. One study found that 52% of food and beverage advertisements in magazines for Hispanic women were for unhealthy foods and drinks compared to only 29% in this category in mainstream women’s magazines aimed mostly at white women.11 Other forms of marketing such as product promotions and corporate sponsorships also often target vulnerable groups,12, 13 contributing to the health burden these groups experience.
Corporations play a role in deciding where to locate retail outlets for their products. The density of such outlets results in differential access by socioeconomic status and race/ethnicity to unhealthy products such as tobacco, alcohol, and high fat foods and less access to healthy products such as fresh fruits and vegetables.14, 15 For example, a study in Detroit found that the nearest supermarket was, on average, 1.1 miles further away from neighborhoods in which African Americans resided than from White neighborhoods.16 Decisions to preferentially locate retail outlets selling unhealthy products in Black, Latino or low income communities and those selling healthy products in better off areas may result solely from an assessment of where opportunities for profit are highest or also from implicit or explicit racial prejudice. The motivation, however, does not change the impact of these decisions on health.
Corporate decisions on retail distribution are also a consequence of patterns of racial segregation. Kwate argues that housing segregation drives out supermarkets, which often sell healthier foods, and attracts fast food outlets, which sell calorie dense but nutrient low foods at an affordable price.17 In this case, housing and real estate policies and corporate decisions intersect to create food environments that contribute to obesity, now increasingly concentrated in low income and Black and Latino neighborhoods.
By developing pricing policies that make unhealthy products more accessible or healthy products less available to low income, Black, Latino or other ethnic populations, corporations contribute to health disparities. In some cases, this differential pricing is the result of impersonal market forces, e.g., super markets cannot offer volume discounts on products for which a strong demand already exists, making some healthy foods more expensive in poor neighborhood than better off ones. In other cases, big companies choose not to confront pricing practices in the informal or black market economy because they are ultimately profitable. The easy availability of unregulated inexpensive handguns (“Saturday night specials”) in poor communities served as a profit center for many gun manufacturers, even though it also contributed to higher rates of homicides and gun injuries.18, 19 Similarly, the ubiquity of “loosies”, single cigarettes, and untaxed black market cigarettes, helps the tobacco industry to attract and keep young and poor customers and also serves to concentrate tobacco-related diseases on the lower end of the socioeconomic spectrum.20
Corporations make decisions that can contribute to maintaining or increasing disparities through these four business practices, but also through their opposition to stronger government regulation. Weak public health regulation adversely effects all populations but especially those with fewer resources to escape or protect themselves from harm. For example, the automobile industry’s success in avoiding more stringent air pollution standards may have a more detrimental effect on low income and Black and Latino populations since these communities are less able to block or move away from highways or other high traffic areas.21 The tobacco industry’s global success in delaying enforcement of laws against illegal sales of cigarettes contributes to the differential impact of the illicit tobacco market by income and race/ethnicity. For example, one California study found that underage Black and Latino youth were 2.5 times more likely to be sold cigarettes than their white counterparts.22 Finally, vulnerable populations may have less access to public health campaigns that provide the knowledge and skills to reduce the impact of health-damaging industry practices.23 When corporations and their allies advocate privatization of public health services, oppose increased taxes to improve public services or sponsor media campaigns that emphasize individual responsibility for health, they may further undermine the capacity of poor Black or Latino communities to protect themselves from harmful corporate practices.
In sum, the pathways by which corporate decisions may create, maintain or widen socioeconomic or racial/ethnic inequities in health suggest that these business practices can be viewed as a significant determinant of health disparities. In the next section, I describe some of the advocacy strategies that have been used to reduce these disparities.
In recent years, many organizations and individuals have mobilized to change the practices of the industries that contribute to ill health.25 In some cases, these campaigns have targeted industry practices that contribute directly to health inequities. For example, in Philadelphia, a coalition of African American, community, church, and health organizations led a campaign to force R.J. Reynolds Tobacco Company to drop plans for test marketing Uptown cigarettes, a brand aimed at African Americans. 26
Similarly, a coalition of Chicago Black and Latino groups and the attorneys general of several states worked together to force R.J. Reynolds to modify its Kool Mixx, a tobacco promotional campaign that used hip hop music to appeal to young Blacks and Latinos.27 A neighborhood coalition and a university in Chicago joined forces to advocate bans on alcohol and tobacco billboards in low-income communities of color.28 Many communities have used land-zoning regulations to reduce the density of alcohol, tobacco, and fast food establishments.29
In other cases, community or health advocacy organizations have launched counter-advertising campaigns using African American or Latino images and themes designed to counteract industry’s use of similar elements. In schools across the country, including many in big cities with high proportions of low-income students, parents and advocacy organizations are working to force food companies to end marketing of high-calorie low-nutrient foods within schools.30
In sum, public health campaigns to modify health damaging industry practices are a promising strategy for the primary prevention of health inequity. Using social justice and health equity as themes for community mobilization and policy change may help to bring new constituencies into the effort to reduce disparities.25
A Research and Policy Agenda
For researchers, considering corporate practices as a social determinant of health inequity raises many challenging questions:
- What is the differential impact of business practices such as product design, marketing, retail distribution and pricing on health disparities?
- How does the relative impact vary by health condition, industry and population characteristics?
- What is the attributable risk for business practices in producing health disparities? How do business practices compare to (and interact with) other determinants such as poverty, social hierarchy, and social stress?
- What policy and programmatic interventions are most effective in reducing the harmful impact of business practices?
- How do strategies for reducing harmful business practices compare in the preferential benefits they bring to disadvantaged groups?
- How do the business practices that contribute to health inequities in the United States and other developed nation compare to those operating in the global south?
By focusing attention on these and related questions, conducting systematic studies of the efficacy of various intervention strategies, and better documenting the many existing efforts to change industry practices, researchers and health professionals can bring evidence-based lessons to policymakers that would assist them in selecting policies to maximize the potential for the reduction of disparities.31
For policy makers and policy advocates, framing corporate practices that harm health as a cause of health inequity opens the door for new alliances among those working across industries, e.g., food, tobacco, and guns; across political levels, e.g., local, national and global; and across issues, e.g. corporate reform and responsibility, human rights, and consumer protection. Recent calls for the development of social movements to reduce disparities32 create opportunities for dialogue on these issues. To date, however, more attention ahs focused on public rather than corporate policies that contribute to disparities. By expanding our understanding of the causes and solutions to health inequities, public health advocates can help to move from description of disparities to action to end them.
Nicholas Freudenberg is fonder and Director of Corporations and Health Watch and Distinguished Professor of Public Heath at Hunter College, City University of New York.
1. Freudenberg N. Public health advocacy to change corporate practices: implications for health education practice and research. Health Educ Behav. 2005;32(3):298-319.
2. Freudenberg N, Galea S. The impact of corporate practices on health: implications for health policy. J Public Health Policy. 2008;29(1):86-104.
3. Gardiner PS. The African Americanization of menthol cigarette use in the United States. Nicotine Tob Res. 2004; 6 Suppl 1:S55-65.
4. Garten S, Falkner RV. Continual smoking of mentholated cigarettes may mask the early warning symptoms of respiratory disease. Prev Med. 2003;37(4):291-6.
5. Richardson TL. African-American smokers and cancers of the lung and of the upper respiratory and digestive tracts. Is menthol part of the puzzle? West J Med. 1997;166(3):189-94.
6. Wackowski O, Delnevo CD. Menthol cigarettes and indicators of tobacco dependence among adolescents. Addict Behav. 2007;32(9):1964-9.
7. Time to reclassify malt liquor and flavored malt beverages as a distilled spirit? Available athttp://www.corporationsandhealth.org/malt_liquor_product_profile.php
8. Moore DJ, Williams JD, Qualls WJ. Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethn Dis. 1996; 6(1-2):83-98.
9. Alaniz ML. Alcohol availability and targeted advertising in racial/ethnic minority communities. Alcohol Health Res World. 1998;22(4):286-9.
10. Balbach ED, Gasior RJ, Barbeau, EM. R. J. Reynolds’ targeting of African Americans: 1988-2000. Am J Public Health. 2003; 93:822-827.
11. Duerksen SC, Mikail A, Tom L, Patton A, Lopez J, Amador X, Vargas R, Victorio M, Kustin B, Sadler GR. Health disparities and advertising content of women’s magazines: a cross-sectional study. BMC Public Health. 2005;18;5:85.
12. Rosenberg NJ, Siegel M. Use of corporate sponsorship as a tobacco marketing tool: a review of tobacco industry sponsorship in the U.S.A, 1995-99. Tob Control. 2001;10(3):239-46.
13. Kuo M, Wechsler H, Greenberg P, et al. The marketing of alcohol to college students: the role of low prices and special promotions. Am J Prev Med. 2003;25(3):204-11.
14. Schneider JE, Reid RJ, Peterson NA, et al. Tobacco Outlet Density and Demographics at the Tract Level of Analysis in Iowa: Implications for Environmentally Based Prevention Initiatives. Prev Sci. 2005; 15;1-7.
15. Harwood EM, Erickson DJ, Fabian LE, et al. Effects of communities, neighborhoods and stores on retail pricing and promotion of beer. J Stud Alcohol. 2003; 64(5):720-6.
16. Zenk SN, Schulz AJ, Israel BA, et al. Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. Am J Public Health. 2005 Apr;95(4):660-7.
17. Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place. 2008;14:32-44.
18. Wintemute GJ. Ring of Fire: The Handgun Makers of Southern California, 1994. Violence Prevention Research Program. 19. Wintemute GJ. The relationship between firearm design and firearm violence. Handguns in the 1990s. JAMA. 1996 275(22):1749-53.
20. Smith KC, Stillman F, Bone L, Yancey N, Price E, Belin P, Kromm EE. Buying and selling
loosies in Baltimore: the informal exchange of cigarettes in the community context. J Urban Health. 2007;84(4):494-507.
21. American Lung Association. Urban air pollution and health inequities: a workshop report. Environ Health Perspect. 2001; 109 Suppl 3:357-74.
22. Landrine H, Klonoff EA, Campbell R, et al. Sociocultural variables in youth access to tobacco: replication 5 years later.Prev Med. 2000 May;30(5):433-7.
23. LaVeist, TA. Disentangling Race and Socioeconomic Status: A Key to Understanding Health Inequalities. Journal of Urban Health. 2005;82:iii26-iii34(1).
24. An earlier version of this section appeared in: Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008;19(1):26-40.
25. Freudenberg N, Bradley SP, Serrano M. Public Health Campaigns to Change Industry Practices That Damage Health: An Analysis of 12 Case Studies. Health Educ Behav. 2007 Dec 12. [Epub ahead of print]
26. Robinson RG, Sutton C. The coalition against uptown cigarettes. In: Jernigan D, Wright PA, eds. Making news, changing policy: case studies of media advocacy on alcohol and tobacco issues Washington, DC: U.S. Department of Health and Human Services, 1994; 89-108.
27. National African American Tobacco Prevention Network (NAATPN). National African American Tobacco Network demands that Kool’s stop targeting the hip-hop generation. Press Release. Summerville, NC: NAATPN, 2004 Apr 8.
28. Hackbarth DP, Schnopp-Wyatt D, Katz D, et al. Collaborative research and action to control the geographic placement of outdoor advertising of alcohol and tobacco products in Chicago. Public Health Rep. 2001;116(6):558-67.
29. Ashe, M., Jernigan, D., Kline, R, et al.. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003; 93: 1404-1408.
30. Peterson KE, Fox MK. Addressing the epidemic of childhood obesity through school-based interventions: what has been done and where do we go from here? J Law Med Ethics. 2007;35:113-30.
31. Gibbs BK, Nsiah-Jefferson L, McHugh MD, Trivedi AN, Prothrow-Stith D. Reducing racial and ethnic health disparities: exploring an outcome-oriented agenda for research and policy. J Health Polit Policy Law. 2006; 31(1):185-218.
32. Prevention Institute. Laying the Groundwork for a Movement to Reduce Health Disparities Report II. Prevention Institute, Oakland, CA, April 2007.