At the November 2007 meeting of the American Public Health Association in Washington, D.C., several sessions addressed the issue of trade and health. Many of these sessions were sponsored by the new Trade and Health Forum and address global economic policies that generate health disparities.
Presidential elections provide one opportunity to shine some light on how Big Business seeks to create a political environment favorable to its interests. Between now and November 2008, Corporations and Health Watch will include periodic reports on the positions of leading Presidential candidates on public oversight of corporate practices that influence health; the elections roles of the pharmaceutical, food, tobacco, automobile and other industries, and the prior legislative records and corporate involvement of major candidates. Our first report focuses on the role of money: what industries are contributing to the various candidates. Our focus here and in future reports is on the role of the industries monitored by Corporate Health Watch: alcohol, automobiles, firearms, food and beverages, pharmaceuticals and tobacco.
Using analyses conducted by Open Secrets at the Center for Responsive Politics, we can identify contributions made to the 2008 Presidential campaigns by both political action committees (PACs) and individuals affiliated with a particular industry (usually as a result of employment) through September 30, 2007. Final 2007 reports will be available at the end of January 2008. Our report covers the 3 major Democratic candidates and the 5 leading Republicans.
PAC and Individual Contributions by Selected Industries for 2008 Presidential Candidates
|Candidate||Registered Lobbyists||Pharma & Health Products||Health Profs||Tobacco|
|Rudolph W. Giuliani||$212,100||$138,850||$1,026,452||$77,400|
Totals on these charts are calculated from PAC contributions and contributions from individuals giving more than $200, as reported to the Federal Election Commission. Individual contributions are generally categorized based on the donor’s occupation/employer, although individuals may be classified instead as ideological donors if they’ve given more than $200 to an ideological PAC. Shows contributions through September 30, 2007.
Source: Open Secrets
As shown above, Hilary Clinton led the Democratic field in contributions from all four categories of contributors, although Barack Obama was a close second in contributions from the pharmaceutical industry and from health professionals and their organizations. On the Republican side, Mitt Romney led the pack in total fund raising form these four sources with Rudolph W. Giuliani a close second. Health professionals split their contributions fairly evenly among Republicans and Democrats as did the pharmaceutical industry and registered lobbyists. Only tobacco consistently favored Republicans, giving about twice as much to them as to Democratic candidates. Note that on the Democratic side, the level of contributions were somewhat similar to the level of support received from Iowa caucus goers and New Hampshire voters. For the Republicans, however, Iowa winner Mike Huckabee received few contributions perhaps because of his late rise in the campaign, while candidate Rudolph Giuliani won substantial support from contributors but not Iowa or New Hampshire voters.
Industry’s bipartisan approach to political contributions reflects both the heterogeneity of these categories, at least within mainstream American politics, but also the hedge- your-bets philosophy of special interests. No matter who wins, they want a friend in the White House. Registered lobbyists larger contributions to Clinton and McCain may demonstrate these candidates’ longer tenure in Washington and thus their established relationships with lobbyists.
While both the pharmaceutical and health products industry and health professionals (hospitals, medical associations, medical suppliers) provided substantial support to several candidates, these industries were not the major contributors to these campaigns. Donors from the securities and investment, legal, hedge fund and real estate industries were more significant donors to most major candidates than the industries shown in the table above.
Role of the Pharmaceutical Industry
As James Ridgeway and Joan Casella noted in Mother Jones recently, “Any candidate who genuinely plans to confront Big Pharma must be prepared to give up a boatload of cash”. Between 1998 and 2007, the pharmaceutical industry spent more on lobbying than any other industry, spending a total of $1.3 billion with $191 million in 2006 alone. Between 1990 and 2007, drug manufacturers contributed a total of $149 million to federal election campaigns. On the Democratic side, John Edwards has failed to raise significant contributions from Big Pharma, perhaps because of his prior life as a trial lawyer who won large settlements from pharmaceutical and health care industries.
Another perspective comes from an examination of PAC contributions to the Presidential candidates. According to the Center for Responsive Politics, as shown below, business PACS heavily favor Republican candidates and Labor PACS, not much of a presence in 2008 contributions to date, heavily favor the campaign of John Edwards. Single issue groups are organizations that span the ideological spectrum and support or oppose issues such as abortion, gun control, or gay marriage. They constitute a major component of Barack Obama’s PAC contributions but without analyses of the specific sources it is difficult to draw conclusions.
Finally, it is worth noting that PAC contributions constitute no more than 1% of total contributions to any candidate and do not play a major role in funding campaigns. Their value lies in showing how organized political interests are rating the various candidates.
Per cent sources of PAC Contributions for 2008 Presidential Candidates
The totals in these charts are calculated from PAC contributions, as reported to the Federal Election Commission. Contributions from individuals are not included in this breakdown.
Source: Open Secrets
View CHW’s coverage on Corporations, Health and the 2008 Presidential Race:
|Candidate||Business||Labor||Single Issue Groups||Total contributions|
|Rudolph W. Giuliani||70%||1%||29%||$265,992|
Imagine a mysterious but pervasive substance that contributed to tens of millions of deaths around the world. Imagine that simple new public rules limiting human exposure to this substance could prevent almost nine million deaths in the developing world in the next ten years. Wouldn’t you expect that governments around the word would implement such rules? Well, these facts describe the current scientific situation on salt. 
To answer the question requires a closer examination of the ongoing clashes on salt policy. On one side are health, scientific and advocacy bodies such as the American Medical Association, [2-3] the National Academy of Sciences,  the World Health Organization, [1,5] Consensus Action on Salt and Health,  and Center for Science in the Public Interest, [7-10] all arguing for global and national regulations to lower salt content in processed food. On the other side are groups such as the European Union Salt Producers Association and The Salt Institute, a U.S.-based salt industry trade association, who claim in scientific, policy and legal settings that excess salt intake is not harmful to human health. [11-13]
Late last year, the US Food and Drug Administration held a public hearing on this issue with a request for public comments.  (The transcript of this hearing will soon be available at http://www.fda.gov/ohrms/dockets.) If the FDA decides to reclassify salt (also known as sodium chloride) as a food “additive,” then it can place limits on the amount of sodium contained in prepared foods and foods served in restaurants.
In this report, Corporations and Health Watch reviews the evidence on the adverse health consequences of excess dietary salt, describes some of the policy proposals to reduce salt intake and the extent to which various jurisdictions have implemented such policies, and analyzes the political strategies that the salt industry has used to oppose or delay new limits on dietary salt.
The adverse health consequences of excess dietary salt consumption
How much salt does the average adult in the United States consume a day? Although many people consider only the amount of salt that they add to their food while cooking or at the dinner table, approximately 75% of the sodium we consume is already in the food we buy. The National Academy of Sciences recommends that adults consume no more than 2,300 milligrams of sodium daily, roughly one teaspoon of salt. The recommended maximum intake for people at risk of high blood pressure, such as adults over age 50, is 1,500 milligrams of sodium per day.
The average U.S. adult consumes about 4,000 milligrams of sodium per day—as noted above, about 75% of this intake comes from sodium added by food manufacturers and restaurants. Canned and processed foods often contain 1,000 milligrams or more per 8 ounce serving, and typical meals served in restaurants contain between 2,300 and 4,600 milligrams of sodium.  In addition, sodium is present in foods such as bread, diced tomatoes, and cereals,8 important sources of sodium intake often overlooked by consumers. Jeremiah Stamler, M.D., professor emeritus of Preventive Medicine, Northwestern University Medical School in Chicago, observed, “If we reduce our salt intake [at the table] that won’t solve the problem. There’s salt in bread, processed meat, cheese, canned vegetables—these are all hidden sources of salt.” 
Although experts debate the precise threshold for maximum daily salt intake, there is little controversy that excess salt intake is a major contributor to high blood pressure, a major risk factor for stroke, heart failure, heart attack, and kidney and vision problems. [16-18] In the United States alone, it is estimated that nearly 30% of all adults are affected by hypertension, with another third of adults affected by pre-hypertension.  One important way to control hypertension is to lower salt intake.
Policy proposals to reduce dietary salt intake
Many scientific and professional organizations have come to the consensus that the public would benefit from a reduction in the sodium in products sold by the food and restaurant industries. For example, in November 2002, the American Public Health Association called for a 50% reduction in the nation’s food supply over the next 10 years.  In June 2006, the American Medical Association also advocated lower levels of salt in processed food, observing “[i] n the continued absence of voluntary measures adopted by the food industry, new regulations will be required to achieve lower sodium concentrations in processed and prepared foods.”
Similar positions have been reached by the National Institutes of Health, National Academy of Sciences, U.S. Department of Agriculture, U.S. Department of Health and Human Services, and at least 40 other professional organizations in the U.S.  The American Medical Association states that “substantial public health benefits accrue from small reductions in the population blood pressure distribution.” The AMA noted that a 1.3 grams per day lower lifetime sodium intake is estimated to save 150,000 lives annually as individuals advance form age 25 to 55. 
Policy recommendations include: (1) broad public and consumer education on salt, new food labeling systems, e.g. the use of red, yellow and green traffic light symbols to show levels of salt in a product, (2) a requirement that some foods must be labeled as high sodium, or (3) regulations that would limit the amount of sodium in processed and some restaurant food.
What has been the national and international response to excess dietary salt consumption?
In the United States, the Center for Science in the Public Interest has petitioned since 1978 for measures to regulate sodium. In 1994, in a partial victory, the US Food and Drug Administration required that food manufacturers disclose to consumers sodium the amount of sodium and its percent of Daily Value.  The FDA also established guidelines for using sodium- and salt-related food claims such as “sodium free,” “low sodium,” “reduced sodium,” “salt free,” and “unsalted.” Back in 1982, the FDA had recommended that food manufacturers voluntarily reduce the amount of added salt in processed foods. However, despite these measures, it is estimated that salt intake has actually increased by in the United States by 55% from the early 1970s to 2000, [17,19] during which time the age-adjusted prevalence of high blood pressure increased substantially. 
Efforts are underway in several countries to reduce the amount of sodium consumed. For example, in the UK, The Food Commission has launched a campaign for safer, healthier food called the Healthy Hexagon, Eat less salt project.  This project aims to provide healthy eating education to more than 3,000 residents of the Hexagon Housing Association in south east London. Also, in the UK, the Sainsbury’s supermarket chain has voluntarily reduced the sodium content of its store brand products without protest by consumers. 
The government in the UK has divided foods into approximately 70 categories and has set target sodium reductions for each of these categories. The government hopes that sodium consumption in the UK will decrease by 33% in 5 years with these measures. The UK is also encouraging a “traffic light labeling system” for use by the food industry—with high sodium products being labeled with a red light, medium sodium products a yellow light, and low sodium products a green light.
The governments of Ireland, New Zealand, Australia and France have set similar standards to reduce the sodium intake in their populations. Finland’s government, which has focused on reducing sodium since the 1970s, has achieved a 30% reduction in average sodium consumption, from approximately 4,700 milligrams daily to approximately 3,300 milligrams daily. Researchers credit these efforts with decreasing deaths among 30 to 59-year-old men and women by 60%. [14, 21]
Strategies used by salt industry groups to oppose or delay new limits on dietary salt
The current FDA salt review was sparked by a petition filed in November 2005 by the Center for Science in the Public Interest (Docket No. 2005P-0450). [9,10] The petition seeks to have the GRAS (Generally Regarded as Safe) status of salt modified so that salt may be regulated. CSPI argues that voluntary measures over the past two and a half decades have not lowered the sodium content of foods and that more aggressive regulatory action is needed.
Under current law, sodium would need to be reclassified as an “additive” in order for it to be legally regulated. The CSPI petition further calls for food labeling requirements and ceilings on the amount of sodium in processed foods, among other measures.
Several salt industry groups, notably the European Union Salt Producers’ Association and The Salt Institute (a U.S.-based salt industry trade association) have argued against the scientific evidence and claimed that excess salt intake is not harmful to human health. [11, 12] In a clear conflict of interest, these salt industry groups have paid for medical and scientific opinions from “experts,” and they have used their popular websites to misinform the public. People without medical backgrounds may view their statements on salt and hypertension and make decisions that are contrary to medical advice. For example, the European Union Salt Producers’ Association, which represents salt producers in the EU who currently produce 45 million tons of salt per year, has issued several position papers on salt and health. In their position paper Salt and blood pressure: Controversial and misunderstood they state that “alarmist media reports and general recommendations to reduce salt intake” have the potential to cause harm. And The Salt Institute, which represents the interests of all major U.S. salt producers who produce approximately 46 million tons of salt per year, has similar statements on salt and health on its consumer website, including recommendations to adhere to a salty, Mediterranean diet.
In the December 2007 newsletter published by The Salt Institute, the authors comment on the proposed FDA regulations, likening them to the actions of Joseph Stalin, Adolf Hitler, Orwell’s “Big Brother,” and The Spanish Inquisition. In this newsletter, they denounce “pathological science,” quoting John Horgan who said: “Pathological science kills people and ruins lives. Such fake science is still peddled by the PC establishment in Europe and America.” The proposed federal regulations, which would impose labeling requirements and limit the amount of sodium in processed foods, would not interfere with the ability of consumers to purchase salt and use it as they wish. The proposed regulations would simply protect U.S. adults from processed foods that increasingly contain excessive amounts of sodium. By reducing hypertension, the new rules would also reduce the burden of chronic disease in the United States. [1, 17]
In May 2007, the European Salt Producers’ Association held a conference that promoted their scientifically questionable views on salt. David McCarron, a hypertension specialist, spoke at the European Union Salt Producers’ conference. He is the same person hired by The Salt Institute to request immediate access to the complete data from the DASH study.  The DASH study, published in the New England Journal of Medicine in January 2001, demonstrated that reducing dietary salt could lower blood pressure, even in people without hypertension.  The Salt Institute filed a petition under the Data Quality Act, claiming that the researchers must turn over their data so that a “qualified member of the public” can reconduct the analysis.  A district court dismissed The Salt Institute’s petition, and when The Salt Institute appealed to the U.S. Court of Appeals for the 4th Circuit the petition was again dismissed. [22,24]
In the case of salt, industry opposition has prevented governments from instituting simple policies that could, over the years, prevent millions of premature deaths. In the coming weeks, the FDA has an opportunity to change the ending of this familiar story.
1. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007; 15;370(9604):2044-53.
2. American Medical Association. “AMA calls for measures to reduce sodium intake in U.S. diet: urges FDA to revoke ‘generally regarded as safe’ status.” June 13, 2006. Accessed December 22, 2007 at http://www.ama-assn.org/ama/pub/category/print/16461.html
3. CRohack, JJ. Letter from AMA to Boston Globe: Cutting sodium beneficial to Americans’ health. July 3, 2006 (published).
4. Institute of Medicine, Food and Nutrition Board. Accessed January 9, 2008 at http://www.iom.edu
5. World Health Organization, Global Strategy on Diet, Physical Activity and Health. Cardiovascular Disease: Prevention and Control. Accessed January 9, 2008 at http://www.who.int/dietphysicalactivity/publications/facts/cvd/en/
6. Consensus Action on Salt and Health. Accessed January 9, 2008 at http://www.actiononsalt.org.uk
7. Center for Science in the Public Interest. Salt: the forgotten killer. . . and the FDA’s failure to protect the public’s health. Accessed December 22, 2007 at http://www.cspinet.org/salt/saltreport.pdf
8. Salt Assault: Brand-Name Comparisons of Processed Foods. Washington, DC: Center for Science in the Public Interest.http://www.cspinet.org/salt/updated_saltreport.pdf
9. Center for Science in the Public Interest. Petition to Revoke the GRAS Status of Salt, to Set Ceilings on the Amount of Sodium in Processed Foods, to Require a Health Warning on Packaged Salt, and to Reduce the Daily Value for Sodium (Docket no. 2005P-0450, U.S. Department of Health and Human Services Food and Drug Administration). Submitted November 8, 2005 by Michael F. Jacobson, Ph.D.
10. U.S. Food and Drug Administration (FDA). October 19, 2007 Notice of Public Hearing: Salt and Sodium. Petition to Revise the Regulatory Status and Establish Food Labeling Requirements Regarding Salt and Sodium. Docket No. 2005P-0450. Accessed December 22, 2007 at http://www.cfsan.fda.gov/~comm/registe7.html
11. EU Salt, European Salt Producer’s Association. Accessed December 22, 2007 at http://www.eusalt.com
12. The Salt Institute. Accessed December 22, 2007 at http://www.saltinstitute.org/2.html
13. The Salt Institute. December 2007 Newsletter. Accessed December 22, 2007 at http://www.saltinstitute.org/news07-dec.html#article1
14. Havas SH, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium. Am J Public Health. 2004; 94(1):19-22.
15. Greeley A. A pinch of controversy shakes up dietary salt. FDA Consumer Magazine, November-December 1997.
16. Food and Nutrition Board. Dietary Reference Intakes for Water, Potassium, Sodium Chloride, and Sulfate. Institute of Medicine, 2004.
17. Dickinson BD, Havas S, for the Council on Science and Public Health. Reducing the population burden of cardiovascular disease by reducing sodium intake. Archives of Internal Medicine. 2007; 167(14):1460-1468.
18. Cappuccio FP. Salt and cardiovascular disease: Reducing sodium intake improves cardiovascular outcomes but few countries have effective policies. BMJ. 2007; 334: 859-860.
19. Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004; 24: 401-431.
20. The Food Commission, Healthy Hexagon Eat Less Salt Project. Accessed December 22, 2007 athttp://www.foodcomm.org.uk/hexagon.htm
21. Krappanen H, Mervaala E. Adherence to and population impact on non-pharmacological and pharmacological anti-hypertensive therapy. J Hum Hypertens. 1996;10(Supp 1): S57-S61.
22. Kaiser J. Data access. Industry groups petition for data on salt and hypertension. Science. 2003 May 30;300(5624):1350.
23. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER, Simons-Morton DG, Karanja N, Lin PH; DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. NEJM. 2001; 344: 3-10.
24. Raeburn P. A regulation on regulations. Sci Am. 2006 Jul;295(1):18, 20.
Salt Shaker, Supa mb
Following recent efforts to address obesity by banning transfats and proposing a moratorium on the opening of new fast food restaurants, in late December of 2007 San Francisco Mayor Gavin Newsom proposed a tax on soda. The sweetened beverage fee would be applied to big box retailers who sell sweetened soda and other beverages; “Mom and Pop” stores would be exempt.
Newsom proposed the measure, which will be voted on by the Board of Supervisors early this year, as a means by which to address rising obesity rates and the attendant rising health care costs. Though the surcharge on sweetened beverages has yet to be defined, proceeds from the tax will support Newsom’s “Shape Up SF,” a program designed to encourage San Francisco residents to exercise.
Though the Mayor’s office argued that there was a well developed linkbetween obesity and the consumption of high-fructose corn syrup—a corn-based sweetener preferred over table sugar by the beverage industry because of its lower cost in production. Most researchers agree that carbonated sweetened beverages have played an important role in rising rates of obesity in the United States and elsewhere. Malik et al (2006) found evidence for this relationship in their meta-analysis of 30 publications. They state: “The weight of epidemiologic and experimental evidence indicates that a greater consumption of SSBs [sugar sweetened beverages] is associated with weight gain and obesity. Although more research is needed, sufficient evidence exists for public health strategies to discourage consumption of sugary drinks as part of a healthy lifestyle.”
Despite this emerging scientific consensus, the American Beverage Association (ABA), the trade association for the non-alcoholic beverage industry, argued that taxing soda would be ineffective given the complexity and multifaceted nature of obesity. An ABA press release stated: “It makes no sense to single out one food or beverage product to address an issue created by a lack of balance between calories consumed and calories burned. It would be just as silly to tax all the high-tech companies in San Francisco and blame them for contributing to childhood obesity through their video games, computer games and Internet search engines…This idea for taxing retailers sounds more like a thinly veiled attempt to raise revenues for more city spending than a sincere effort to reduce childhood obesity.” Others criticized the Mayor of behaving in a “Nanny State” manner, a charge that has been applied to other advocates of taxes on obesic foods and beverages.
In response to proposals such as Newsom’s, the beverage industry continues to fall back on the food industry’s stock line that obesity is caused by an imbalance of calories in and out and that all foods and beverages can have a place in a well-balanced diet accompanied by an active lifestyle. Yet according to an unreleased draft report by the San Francisco Department of Public Health, sweetened beverage consumption is the leading source of added sugar in children’s diets accounting for more than 10% of the total daily caloric intake for an average child. In addition, the consumption of sweetened beverages is more strongly associated with pediatric obesity than is high fat content or decreased physical activity.
While the industry publicly rejects any particular association between sweetened beverages and obesity, it is clear that beverage makers are concerned. In the spring of 2007, Coca Cola Company Chief Creative Officer Esther Lee described obesity as an “Achilles heel” and something that works against beverage makers’ marketing strategies. Although Americans spent$105 billion on “refreshment beverages” in 2007, US sales of soda are decreasing. During 2005, the number of cases of soda sold in the US declined by .07 percent. In April of 2007, Coca Cola first quarter profits report indicated that unit case volume had declined by 3 percent.
In response to declining sales and changing markets, Big Soda is shifting its marketing and distribution practices in two ways. First, the industry is promoting the sale of alternative beverages such as “enhanced” waters, juices and energy drinks. Sales of these products more than tripled in one year, from $80 million in 2001 to $245 million in 2002 and have continued to grow since. Odwalla juices and Glaceau Vitamin Water, (owned by Coca-Cola), SoBe’s Synergy Drinks, (owned by PepsiCo) and Snapple Juices (owned by Cadbury Schweppes) have become increasingly popular as Americans seek to substitute what they perceive as more healthful drinks for soda. However, critics such as Dump Soda, a global campaign whose goals include reducing soda consumption and eliminating the marketing of sweetened beverages to youth under 16, have illustrated that these “alternative” beverages are often just as sugar and calorie-laden as the soft drinks they seek to replace.
Second, as beverage makers promote “healthful” products in the US, they have refocused the marketing and sale of their traditional, sweetened soft drinks on the global south to maintain sales. According to Dump Soda, Coca-Cola has tremendously increased spending on non-US media, rising to $1,176 billion in 2000 from $500 million in 1994. Sales of Coke and Pepsi have also risen dramatically. In 2005, sales of Coca-Cola increased eleven percent in North Asia, Eurasia and the Middle East, case volume grew by seven percent in Latin America, and by four percent in Africa. In 2006, Pepsi’s international volume growth was up 9%.
With increasing sales comes increasing consumption, raising concerns about the spread of Western-style diet and disease in the global south. By linking local efforts such as those of San Francisco Mayor Newsom to tax high sugar beverages to global campaigns such as Dump Soda, public health advocates can ensure that a move toward a healthier US does not come at the expense of the global south.
Public health researchers seeking to focus greater attention on the role of corporate practices in health and disease often encounter the argument that the only significant modifiable determinant of health is lifestyle. In this commentary, social epidemiologist Sandro Galea, MD, DrPH, Associate Professor at the University of Michigan School of Public Health makes the case for a broader perspective.
The typical public health observational study goes something like this. We identify a disease of interest. We then try to figure out if an exposure is indeed associated with this disease. We conduct a study and collect data from participants. We then use a variety of increasingly sophisticated analytic tools to isolate the relationship between the exposure of interest and the disease. Once we have identified such an association with some confidence, we recommend a behavior change that will limit exposure to that particular factor. For example, here is the conclusion from a recent, well done study aimed at understanding several factors that may cause cardiovascular disease: “strategies should focus on reducing obesity, in particular through physical activity, elimination of cigarette smoking, and moderation of alcohol intake” (1).
In other words, to reduce heart disease, we need a lifestyle change, to eat less, exercise more, and smoke less, in order to become healthier. These types of conclusions come from peer-reviewed academic papers published in reputable public health journals. In many ways, these recommendations arise naturally and logically from the dominant public health paradigm. We understand the factors that make us sick and now all we have to do is to change the way we live so that we are no longer exposed to those factors.
Although it is seldom stated in this manner, the public health literature veritably shrugs in disbelief when contemplating these issues, suggesting “how could they possibly keep smoking (or drinking too much etc) when we tell them over and over how bad that is for their health?” Or, “how could they possibly continue having such an unhealthy lifestyle?”
Tobacco as a Lifestyle Problem
Let’s look back at one of the great triumphs of modern public health science to provide us with hints about our lifestyle and whether we truly can do something about it. All students of public health well know the details of what the Centers for Disease Control and Prevention (CDC) rightly identified as modern pubic health’s greatest triumph—the identification of tobacco smoking as a risk for disease(2). In the middle of the twentieth century a few physicians-turned-epidemiologists used follow-up cohort studies to show that cigarette smoking was associated with lung cancer and heart disease. These studies led to other comparable studies confirming these findings. There was opposition to this observation at first, primarily from cigarette companies, but, with the production of the surgeon general’s report on smoking in 1964, the fact that smoking causes poor health in many forms became accepted within public health circles. What followed of course was a dramatic burgeoning public health effort to help eliminate smoking. A large industry grew around health education programs to teach all of us about the adverse consequences of smoking and countless education programs aimed to help smokers quit.
Smoking prevalence dropped throughout North America from 42% in 1965 to 25.5% in 1990 to a current prevalence of approximately 20.8% percent (3).
Clearly, public health research and practice “saved the day”. Through careful empiric research, we were able to identify a health menace and we have, ever since, been devoting energy to help eradicate this menace. One cannot walk through any major US urban area without seeing a plethora of health education messages touting the evils of smoking, offering Quit-Lines and other aides to quite smoking and, increasingly, rather horrifying pictures of the pathologic consequences of smoking aimed at scaring us into not smoking.
But we, or at least 1 in every 5 of us, keep smoking. In fact, we keep participating in many of these factors that we surely must by now know cause poor health, including 1 in 5 of us drink too much on a regular basis, 1 in 3 of us are overweight, and 1 in 3 of us own firearms (4). All of these factors are well recognized to be among the leading causes of death in this country (5).
Why do people choose unhealthy lifestyles?
Which then brings us to the issue at hand. Why is it that so many patently harmful factors in our lifestyle continue despite public health’s valiant effort? The existing literature suggests three common answers. First, some posit that there are psychological reasons, including pleasure in risk taking and defying conventional wisdom, in continuing to embrace unhealthy lifestyles. Second, some argue that public health professionals are not as good as we need to be at conveying what unhealthy lifestyles should be avoided. A third explanation asserts that ultimately people do not care much about being healthy and would rather do as they please without regard for health. All these can be summarized to say that fundamentally, people choose the lifestyle they want, irrespective of what public health might say.
While these (and other) explanations all have some validity, they should matter little to us as public health professionals because a focus on lifestyle is simply not the most efficient or effective approach for public health to take. Why?
Perhaps another example, one that contrasts with the previous smoking one, illustrates the point. Another of the CDC’s great recent achievements in public health is the reduction in motor vehicle injuries and deaths (2). As the automobile took the US by storm by the middle of the twentieth century, the rates of motor vehicle accidents and deaths were soaring. There were 93,803 unintentional motor vehicle related deaths in 1960, for example (5). Clearly, our lifestyle choice to drive was also killing us. One approach would have been for the public health establishment to urge every American to drive less, to walk instead or take mass transit – to change their transportation life style. But that is not what happened.
Instead, a consumer movement emerged that demanded the automobile industry to make safer cars and Congress passed laws to make that happen, usually over the objection of the automobile industry and with significant compromises. For example, Ralph Nader’s Unsafe at any speed (1965) resulted in changes that substantially changed the contribution of motor vehicle accidents to our burden of disease morbidity and mortality. However, in stark contrast to the tobacco example, the focus of the changes aimed at reducing car-related disease was not on the “users” of the car but rather on the circumstances of the driving. Certainly driver education improved, but it is widely recognized that the greatest contributor to the change in car-related morbidity and mortality were safer cars, safer roads and better enforcement of traffic regulations aimed at making those collisions that were inevitable less injurious. As a result, although there are now more than 200 million drivers on the roads on a regular basis, compared to under 90 million in 1960, the rates of motor vehicle accidents in the US is less than 1.5 per 100 million vehicle miles traveled compared to approximately 5 per 100 million vehicle miles traveled in 1960 (6, 7). In other words, we did not really change our lifestyle (driving) at all (in fact, we are driving much more than ever), but still improved our health. We can argue about whether a different approach might have led to more sustainable and better environmental outcomes, but in this case changing corporate practices rather than lifestyle led to dramatic improvements in public health.
In contrast, until the last decade or so, tobacco control focused primarily on changing individual behavior. As new policies were passed to ban smoking in public places and increase tobacco sales taxes, the declines in tobacco smoking accelerated, showing the value of integrating strategies to change individual lifestyle and policy.
Both these examples in fact reinforce the observation that changing lifestyles is immeasurably difficult, requiring not only efforts to change deeply held beliefs and practices one person at a time but also to continue to “treat” the new recruits into tobacco use, or eating or drinking too much. Thus, perhaps changing lifestyles should not be the point of what we do in public health but rather changing circumstances should be. Perhaps it is time to recognize that changing lifestyles is in fact very difficult and that a more efficient and effective approach would be to change the political, economic, and social circumstances within which people live their life as they please, to the fullest. This strategy also acknowledges that people do not choose lifestyles in a vacuum but are influenced by corporate practices such as advertising and product design, by public policies, and by the “opportunity structures” of our market economy.
Objections to a critique of lifestyle
This argument can lead to complaints along three grounds. First, some would object to leaving individuals to their own lifestyle choices within a healthier environment as insufficient given that some lifestyles are inherently injurious to self or others. Second, some critics might assert that if public health were to take responsibility for the circumstances within which we live, it would contribute to a “nanny state”, highly unpopular in a country where individual autonomy is prized almost above all other virtues. Third, some public health experts believe that it is outside our professional domain to seek to change economic, political, and social circumstances. In my view, each of these criticisms is in fact wrong. Let us tackle each one.
We cannot avoid dealing with lifestyles; some lifestyles are always harmful. It may seem that some lifestyles are simply harmful in an absolute sense, but is this really the case? Let’s return to the cigarette example. We now know that tobacco companies worked hard to make cigarettes more addictive to increase consumption and therefore profit. From the point of view of addictiveness and carcinogenicity, they are harmful by design. To take another example, people choose high fat, high calorie food in part because that is what has been most advertised and made most available. In these two cases, the health consequences of lifestyle “choices” are the direct result of efforts to make a profit. With different food or tobacco policies, the default choices could be very different. So what do public health professionals work to change—the environments and policies that make some lifestyle choices unhealthy or the behaviors themselves?
Public health cannot tackle political, economic, or social circumstances because that threatens individual autonomy. Would a public health focus on changing the circumstances within which we live mean that public health would reduce individual autonomy? Of course it could but the critical point is that doing so would not be any different than what is already done to our individual autonomy by forces other than public health. We do not choose the cigarettes we smoke—we smoke cigarettes that are made for us by corporations acting under a set of their own incentives (primarily to maximize profits) that are often not aligned with the goal of improving our health. We often have little choice about the food we eat. Recent research shows that those living in poor neighborhoods have more access to unhealthy foods and less to healthy ones. Not surprisingly, they then eat those available foods. Similarly, for the most part drivers do not choose to drive in safer cars, on safer roads than we used to drive on 50 years ago. These choices are made for us by political, economic, and social forces that are larger than ourselves. It has always been so and it will always be so. Urging public health to tackle reshaping our circumstances would introduce a player among these forces that shape our circumstances whose interest is in the promotion of health rather than in the promotion of profit (as in the case of corporations) or electoral success (as in the case of political parties). The choice is not whether parents should have sole rights to make health decisions about their children – our world is too complicated for that. Rather, the question is who do Americans want looking out for their children’s health—public health professionals or McDonalds? Public health professionals should welcome an opportunity to argue they will better protect autonomy than Ronald McDonald.
Public health simply is not equipped to tackle changing contexts. This third objection is a plaintive one—but what can public health do? Public health arises from medicine, which is concerned with the health of individuals. The forces of public health are much weaker than are political, economic, or social forces. How could we possibly compete? It is self-evident that unless we try to compete we cannot succeed. It is also true that challenging contextual forces that shape health as a central focus would require substantial retooling of the public health profession. It would require re-thinking how we teach our students, the goals and methods of professional practice, and the value of being well-regarded by all sectors of society. But other professions have been able to conduct similar retooling. Why then not public health? For example, many US State Attorneys General were, in the 1970s and 1980s focused on the eradication of organized crime. This scarcely remains the focus on AG efforts nationwide today. In fact, AG efforts have been, in the past decade, much more focused on curtailing illegal financial sector activity than on what the AG offices used to work on a decade ago. Surely such focus shifting could not have been easy. But it happened, and arguably the law-abiding citizenry is better for it.
Another approach to public health is possible
Similarly, public health can decide that the old target, lifestyle, is no longer, or perhaps never was, such a fruitful target for our efforts, and move toward another target, the circumstances within which we live, the political, economic, and corporate practices that shape our environment, with the goals of effecting change here in order to promote the health of the public. The objections to such an approach rest primarily on a lack of imagination on our part that we can indeed achieve a change in focus in the profession. I argue that such a change is not optional, as much as necessary, for public health achievement in the twenty-first century.
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Neighborhood environments can both promote health (Ewing 2005) and encourage disease (Satterthwaite 1993). Differences in presence of health enhancing and health damaging messages and environments may account for some differences in health among neighborhoods with different socioeconomic and racial/ethnic characteristics (Kipke et al. 2007; Macdonald, Cummins, and Macintyre 2007; Pasch et al. 2007; Snyder et al. 2006; Stafford and Marmot 2003). In this pilot study, our hypothesis is that health-enhancing messages are more prevalent in wealthier neighborhoods and health damaging ones more prevalent in economically impoverished neighborhoods. For the purposes of this pilot study, we define “health enhancing” messages as messages which promote the consumption of whole grains, fresh fruit and vegetables, low fat dairy and meats or public health service advertisements (e.g., a smoking cessation ad) and “health damaging” as advertisements for alcohol, tobacco and high fat, low nutrient foods. In preparation for a larger scale study, our goal here was to test a methodology for comparing such messages across communities with differing sociodemographic and environmental characteristics
Disparate Urban Neighborhoods: Upper East Side, East Harlem
To carry out this study, we involved youth researchers in measuring the health enhancing and health damaging messages in two, disparate urban neighborhoods: the affluent and predominantly white Upper East Side of Manhattan, and the neighboring but economically impoverished and predominantly Black and Latino East Harlem. Lexington Avenue, a major thoroughfare, runs through both neighborhoods. The youth researchers worked in two phases measuring health enhancing and health damaging messages along Lexington Avenue in the two neighborhoods. The first phase included a class of thirty-three Hunter College undergraduate students; the second phase, a smaller group of three high-school-aged students recruited from Global Kids, a community-based youth organization. In each phase, the youth surveyed ten block segments of Lexington Avenue in the two neighborhoods.
Using Digital Technology to Measure Health Enhancing and Health Damaging Messages
Researchers at Hunter College partnered with the Fund for the City of New York (FCNY), a nonprofit research and policy group, to modify their ComNET software to measure health enhancing or damaging messages. FCNY developed the ComNET software to document problems in the urban environment and engage community members in notifying the responsible municipal agencies to address those problems in the urban environment. ComNET is designed for use on handheld digital devices, equipped with digital cameras. The use of ComNET and digital technology made this project possible and offered a number of advantages.
First, the handheld devices serve as an important incentive for the engaging the youth. Young people, most of whom have grown up immersed in digital technologies, quickly learn how to manipulate the devices and yet still see them as fun, innovative “toys.” It would be much more difficult to engage youth in this research without the use of digital technology. Second, the ability to quickly upload the data and have it almost immediately available for data cleaning and analysis is an invaluable asset of working with the ComNET software. The decade-long development of the technology by FCNY and the infrastructure that they have in place to ensure the smooth functioning of the devices, upload, cleaning and analysis of the data, provided a strong foundation for the methodology used here and obviated the research group from investing time and money in developing such a technology.
The hypothesis that health enhancing messages are more prevalent in better off neighborhoods and health damaging ones more prevalent in poorer neighborhoods appears to be supported by the data from our pilot study. Table and Figure 1 shows that in the 10-block segment our project surveyed, the percentage of health harming ads in East Harlem is 29% greater than in the Upper East Side. East Harlem also contains nearly 10% fewer health promoting ads than does the Upper East Side. Both neighborhoods have a higher concentration of health harming than health promoting advertisements. Tables 2 and 3 illustrate that tobacco and alcohol advertisements are more prevalent in East Harlem than in the Upper East Side where health-harming ads tend to be food-related.
The findings here are necessarily limited because this was a pilot study. First, the sample size (ten block segments measured by two groups) was too small to confidently generalize to all urban areas, all New York City, or even the two neighborhoods studied here. Further limitations include some challenges with digital technology. The ComNET software is very effective at measuring some types of problems in the urban environment, but needs further modification to accurately and efficiently measure health enhancing and health damaging messages. Specifically, the addition of a feature that would allow for multiple features for one entry would speed up the process considerably. The limitations of this admittedly small and suggestive pilot study can be addressed in a larger and more systematic follow-up study.
New York City neighborhoods of East Harlem and the Upper East Side represent stark disparities in income, racial composition and health outcomes. This pilot study examined one aspect of the disparities between these neighborhoods that may contribute to unequal health outcomes: health promoting and health damaging messages. In general, we found that East Harlem has more ads (of all kinds), more health harming ads, and fewer health-promoting ads than the Upper East Side. And, we also found that both neighborhoods have more health harming ads than health promoting. While the presence of health damaging ads cannot account for all the negative health outcomes in a particular urban neighborhood, the disproportionate display of the health damaging ads in East Harlem as compared to the Upper East Side, suggests that some New York City residents bear a greater burden of these messages. The disparity in the types of health ads that city residents in different neighborhoods are exposed to is a subject that demands further study. In addition, our pilot study demonstrates that young people can be engaged in studies to document the health characteristics of their communities, an activity that can be a first step in analysis of differences in health and action to reduce inequities in health.
Ewing, R. 2005. Building environment to promote health. J Epidemiol Community Health 59 (7):536-7.
Kipke, M.D., E. Iverson, D. Moore, C. Booker, V. Ruelas, A.L. Peters, and F. Kaufman. 2007. Food and park environments: neighborhood-level risks for childhood obesity in East Los Angeles. J Adolesc Health 40 (4):325-33.
Macdonald, L., S. Cummins, and S. Macintyre. 2007. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite 29 (1):251-4.
Pasch, K.E. , K.A. Komro, C.L. Perry, M.O. Hearst, and K. Farbakhsh. 2007. Outdoor alcohol advertising near schools: what does it advertise and how is it related to intentions and use of alcohol among young adolescents? . J Stud Alcohol Drugs68 (4):587-96.
Satterthwaite, D. 1993. The impact on health of urban environments. Environ Urban 5 (2):87-111.
Snyder, L. , F. Milici, M. Slater, H. Sun, and Y. Strizhakova. 2006. Effects of alcohol exposure on youth drinking. Archives of pediatrics and adolescent medicine 160 (1):18-24.
Stafford, M., and M. Marmot. 2003. Neighbourhood deprivation and health: does it affect us all equally? Int J Epidemiol 32 (3):357-66.
For more information on this study contact Jessie Daniels at email@example.com
With thousands of new books published each year, it’s hard to find titles of interest. To help readers sort through the piles, we present an idiosyncratic list of 10 books published in 2007 (or early 2008) that address the relationships among corporations, markets, government and health. These books may help Corporations and Health Watch readers to understand better the impact of corporate practices on health, to occupy cold winter nights, or to pick a gift for a deserving friend. We invite you to submit titles of other books you suggest, limiting titles to those published in 2007.
Ten Titles on Corporations and Health
Benjamin R. Barber. Consumed How Markets Corrupt Children, Infantilize adults, and Swallow Citizens Whole. W.W. Norton and Company, New York, 2007. Political theorist argues over-production of goods forces markets to infantilize consumers and undermine democracy.
Allan M. Brandt. The Cigarette Century The Rise, Fall and Deadly Persistence of the Product that Defined America. Basic Books, New York, 2007. Medical historian analyzes impact of tobacco industry on US and global health and politics.
Jillian Clare Cohen, Patricia Illingworth , & Udo Schuklenk, editors. The Power of Pills: Social, Ethical and Legal Issues in Drug Development, Marketing and Pricing. Pluto Press, London, England, 2007. Three academics edited this interdisciplinary collection of essays that analyze and critique the global pharmaceutical industry.
Philip J. Cook. Paying the Tab The Costs and Benefits of Alcohols Control. Princeton University Press, Princeton, NJ, 2007. Economist analyzes US alcohol policy and suggests increasing taxes to reduce harm.
Devra Davis. The Secret History of the War on Cancer. New York, Basic Books, 2007. Toxicologist describes how industry shapes US response to cancer at expense of prevention.
Richard Feldman. Ricochet Confessions of a Gun Lobbyist. Hoboken, N.J., John Wiley and Son, 2008. Former NRA lobbyist describes how group “betrays trust” of gun supporters.
David Harsanyi. Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists, and other Boneheaded Bureaucrats Are Turning America into a Nation of Children. Broadway, New York, 2007. Libertarian columnist for the Denver Post rants against government interference on health.
Tim McCarthy. Auto Mania Cars, Consumers and the Environment. Yale University Press, New Haven, CT, 2007. Historian describes how auto industry transformed United States in the twentieth century.
Michael Pollan. In Defense of Food: An Eater’s Manifesto. Penguin, New York, 2008. Food journalist suggests actions that individuals, communities and policy makers can take to reclaim food from industrial producers.
Robert B. Reich. Supercapitalism. The Transformation of Business, Democracy, and Everyday Life. Alfred A. Knopf, New York, 2007. Policy analyst and former Clinton Labor Secretary argues that new global competitive pressures force business to serve investors and consumers at expense of society and suggests public policies to restore democratic control of markets.