With half the world’s population now living in cities, public health researchers have focused new attention on the health impact of urban living and the development of new approaches to creating healthier cities. Recent reports by UN-HABITAT, the World Health Organization (WHO), the Commission on Social Determinants of Health and others have highlighted the challenges of improving the health of urban populations.
While these reports acknowledge that government, civil society and business all shape the health of urban residents, it is the first two that receive the most attention. UN HABITAT, for example, has called attention to the importance of good local and national governance in improving urban health, and Healthy Cities convened by WHO Europe emphasizes the importance of convening stakeholders in order to improve urban health. In this commentary, I examine the role of business in urban health, with a particular focus on corporations.
How Business Shapes the Health of Cities
Why this special attention to business and why the singling out of their health impact on cities?
Increasingly, it is business decisions that create the urban environments that shape health and disease. The food we eat, the air we breathe, the houses we live in, the conditions at workplaces and communities, our opportunities to meet friends and partners, and our identities as consumers and citizens—all are powerfully influenced by businesses. The choices that businesses make about what to produce, how to market, where to sell and what to charge set the stage for health behaviors, lifestyles and urban social and physical environments.
While business decisions influence the health of all people everywhere, cities are especially important arenas of influence. Cities and corporations have an intimate historical relationship; both are products of the evolution of markets and both were transformed by industrialization. Cities first emerged as agriculture produced surpluses that enabled population concentrations not directly dependent on farming. As populations grew, labor became more differentiated creating ever more specialized markets. Technological developments enabled fewer people to produce sufficient food to sustain humanity, pushing populations out of the countryside and into cities where the availability of cheap labor attracted employers, further concentrating populations. As cities became centers of production and selling, they also became nodes of trade and commerce, amplifying their economic and political position.
From their earliest days, cities were also generators of inequality, enabling some to accumulate wealth and power while large portions of the urban population lived in squalor. Today, cities are the command and control centers of global business, the headquarters of the media empires that market business products, and the dense markets that create the greatest opportunities for profit. Increasingly, the business push for more consumption shapes the physical space of cities, making them a marketing tool for tourism, shopping, eating and romance. As a result, the decisions made in corporate boardrooms often have a greater impact on health than those made by health officials or elected officials.
Why hasn’t the impact of business on urban health attracted more attention? I suggest three reasons. First, many public health professionals believe that the ways in which companies make decisions and operate is not our business. Public health is a government responsibility, they say, and our efforts to improve health have to rely on the powers and capabilities of the public sector. Second, in part as a result of an aggressive public relations effort by business to make its powers seem inevitable, many people believe that business dominance is the only possible economic and political arrangement possible. The demise of most alternative systems with the collapse of state socialism in the 1990s further reinforced the belief that another world is not possible. Finally, most public health professionals lack the knowledge and skills to understand how businesses make decisions, the pathways by which their actions shape health or the strategies we could use to modify health-damaging business practices. Fortunately, we are in control of changing that.
Food, Guns and Tobacco: The Urban Story
The development of strategies to promote health-enhancing and reduce harmful consequences of business practices on cities requires detailed empirical analysis of specific companies, products and practices in specific urban contexts. While business practices can either promote or undermine health, public health officials and advocates often direct their attention to harmful practices given their mandate to protect population health. The following examples illustrate some of the ways that business decisions affect urban health.
- In 1994, after forceful advocacy by the global food industry, among others, Mexico and the United States signed the North American Free Trade Agreement, making it easier for US companies both to sell low-cost corn, processed food and other goods to Mexican citizens, and to invest US dollars in the Mexican food industry. Between 1988 and 1997, US foreign direct investment in the Mexican food processing industry increased 25-fold. Between 1988 and 1999, the total energy intake from fat in Mexico increased from 23.5% to 30.3 % with the largest increases in urban areas. Between 1992 and 2000, calories that Mexicans consumed from carbonated soft drinks increased by almost 40%. By 2002, the average Mexican was drinking more Coca Cola servings per year than US residents. In this same period, the national prevalence of overweight and obesity increased by 78%, and between 1993 and 1999, the prevalence of diabetes in Mexico increased by 30%. The increases were highest in the densely populated urban areas where targeted marketing and retail density made unhealthy food readily available. Thus, a trade agreement promoted by multinational companies led to changes in the practices of global companies, national supermarket chains and local retail outlets, which in turn contributed to epidemics of obesity and diabetes, concentrated in Mexico’s rapidly growing cities. 1
- In the 1990s, small arms manufacturers in the United States produced and widely distributed cheap handguns known as Saturday night specials. Handguns accounted for 80% of gun deaths in the US and widespread availability of inexpensive guns put these weapons within reach of gang members, would-be criminals, and worried homeowners. 2Fear of crime and youth violence made cities prime markets for gun makers and these guns played a major role in the increase in urban homicides and gun injuries during this period. Most Saturday night specials were produced by several gun companies in Southern California that were created in the early 1990s to realize a new market opportunity. 3 By the mid 1990s, these companies were producing more than a million guns a year. According to tracing data from the Bureau of Alcohol, Tobacco and Firearms, guns made by these companies were 3.4 times more likely to be involved in a crime than were handguns from other major manufacturers. With supporters from the National Rifle Association and other parts of the gun lobby, these manufacturers were able to resist local, state and national efforts to regulate the sales of these weapons more strictly.
- As developed countries establish stronger public health measures to control tobacco use, the tobacco industry has moved its marketing to developing nations, where billions of new potential customers can be found in the urban settlements that make efficient and targeted advertising possible. In South Africa, for example, tobacco companies have created marketing campaigns aimed at Black women, showing tobacco use as a new freedom connected to urban living and offering giveaways to encourage use. An important goal of tobacco marketing in developing world cities is to change norms so that tobacco use will be more socially acceptable and to create peer support for smoking, especially among women and adolescents.
Pathways from Business to Health
These three examples illustrate some of the ways that business decisions affect the health of urban populations. First, businesses operate at several levels of organizations and scales. On the global level, multinational companies and trade associations influence trade policies, regulatory regimes and prevailing ideology. For example, the pro-industry neoliberal agenda of deregulation, privatization and lowering of trade barriers has set the tone for global discussions on businesses and health for much of the last two decades. This ideology sets the framework in which national and local health officials propose policies to promote health. On the community level, food, alcohol and tobacco retailers decide which products to offer at what prices, influenced in part by global and national advertising that shape norms and desires and in part by the material living conditions of their customers. The power of business to shape health depends in part on its ability to operate at these multiple levels, creating synergies of impact due to horizontal and vertical integration of its operations.
Second, business has the capacity to operate in several domains, including the commercial, the political, the legal and the economic. It uses media to create and shape desires, lobbying and campaign contributions to influence politics and regulation, public relations and philanthropy to influence values and norms and campaign contributions to affect elections. Again, the ability to operate across sectors magnifies its influence.
Third, businesses have increasingly been able to construct cities to advance their goals. Whether it is the downtown development projects that attract tourists and encourage consumption, the dense markets that create niches for product diversification, the proliferating media that offer new ways to sell to more people or the extralegal and illegal markets emerging in informal urban settlements and slums, cities are places to buy and sell. While alternative urban spaces like peer networks, neighborhood associations, public meeting places and social movements still exist, everywhere they compete, often unsuccessfully, with market forces.
What can public health professionals do?
So what can public health researchers, professionals and advocates do to reduce the impact of harmful business practices on cities?
1. Develop the knowledge and skills to understand and change harmful business practices. To play a stronger role in protecting population health, health professionals will need to learn a new set of skills. Already some public health training programs have begun to take this task on, but more needs to be done. 4
2. Find allies that can magnify our influence. By itself, the public health community has limited influences on business practices. In partnership with advocacy organizations, researchers, and social movements such as the environmental justice, corporate responsibility, global justice and consumer protection movements, we have a greater potential to influence policy.
3. Partner with local government and health departments to make protecting the public against harmful business practices a public health priority. In New York City, for example, the city health department and the Mayor have strengthened public oversight of the tobacco industry, fast food companies and gun sellers. Their successes have created new opportunities for other local, state and national governments.
4. Study business practices as a modifiable social determinant of health. Growing global interest in studying and addressing social determinant of health creates an opportunity to consider business practices as such an influence and to conduct research on the most effective and economical strategies for modifying business practices in order to promote health and reduce disparities in health.
5. Join efforts to create a more level political playing field. As long as business interests can dominate political, electoral, legal, economic and regulatory processes, the public health community will have a limited voice in making policy decision that can modify harmful practices. To change this unfavorable climate, public health professionals can join campaigns to limit corporate influence on politics and create spaces for more equal participation by those most harmed by current practices.
6. Use the assets of cities to contest harmful corporate practices. While urban populations are often the targets of harmful corporate practices, cities also have assets that can counter these efforts. Cities are the cradles of social movements, provide ready access to local and national media, and offer options for more sustainable, democratic and healthier social arrangements. By using these urban resources, public health professionals and advocates can help to create alternatives to the status quo.
By Nicholas Freudenberg, Founder and Director of Corporations and Health Watch and Distinguished Professor of Public Health at Hunter College, City University of New York.
- Freudenberg N. Free trade, the food industry and obesity: How changes in US-Mexico food trade contributed to an epidemic. Corporations and Health Watch, July 2007.
- Nieto M, Dunstan R, Koehler G: Firearm-Related Violence in California: Incidence and Economic Costs. Sacramento, California Research Bureau, 1994.
- Wintemute, G. Ring of Fire: The Handgun Makers of Southern California, Violence Prevention Research Program, Sacramento, California, 1994.
- See Teaching about Corporations and Health: Bringing Corporate Practices into Public Health Classrooms.Corporations and Health Watch, December 2007 and Corporate Research: The Basics, June 2008.