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Books on Corporations and Health, 2007

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.

Commentary: Teaching about Corporations and Health: Bringing Corporate Practices into Public Health Classrooms

Increasingly the decisions made in corporate boardrooms, executive offices and in advertising, law, public relations and lobbying firms shape population health in both developed and developing nations. The investment, product design, marketing, pricing and retail practices of the tobacco, food, alcohol, firearms, automobile, pharmaceutical, energy and other industries have contributed to the growing global burden of chronic diseases, injuries and pollution-associated illnesses and deaths. While a growing body of evidence examines the influences of corporate practices on health [1], for the most part the public health curriculum does not address this issue and most public health students do not learn about how corporations influence health and what public health professionals can do protect the public against harmful corporate practices or to encourage healthy ones.

In those places where the subject is considered, e.g., in occupational or environmental health courses or in the study of tobacco and health, usually faculty and students examine one exposure, industry or health outcome at a time, limiting the ability to identify generalizable intervention strategies. As a result, public health agencies often lack the capacity or tools to take on one of the most powerful – and remediable – social determinants of health.

In this commentary, I explore how academic public health programs can introduce concepts, competencies and skills that will help students to identify and analyze corporate influences on health and take action to encourage healthy and discourage unhealthy policies and practices.

Why teach about corporations and health in schools of public health?

In order to bring the subject of corporate induced disease into the curriculum of schools and programs in public health, proponents will first need to convince faculty, students, administrators and accrediting bodies that this subject is important. What arguments might persuade our colleagues to take on this topic?

First, as noted, evidence suggests that corporate induced diseases impose a substantial and growing burden of disease. (Here the term “corporate induced disease” is used to describe the burden of illness whose agents are industrial products or processes that are harmful to consumers who buy them, workers who work with them at their job, and community residents who are exposed to them in the ambient environment.[2] ) In the twentieth century, 100 million people died of tobacco-related causes and in the 21st century one billion people are expected to die as a result of tobacco use. Obesity, caused in part by the food industry’s relentless efforts to persuade people to eat more, is a growing cause of illness and death, especially of rising rates of diabetes. Other diseases are related to heavily promoted high fat, high salt, high sugar and low nutrient processed foods. The automobile industry contributes to injuries and deaths associated with accidents, air pollution and physical inactivity and the firearms industry produces and distributes products that contribute to homicide, suicide and gun injuries. The pharmaceutical industry over-promotes some dangerous products, like Vioxx, and prices some beneficial drugs others out of reach of patients who could benefit. In pursuing these lethal but usually legal activities, corporations are simply meeting their mandate to maximize profits for shareholders.

In other circumstances, corporations make positive contributions to population health by, for example, making healthy products both more available and affordable, providing workers with sufficient income to purchase food, housing and the other necessities of life, or by making philanthropic contributions. Only by empirical investigation can public health researchers identify those corporate practices associated with harm or benefit and suggest strategies to reduce the former or increase the latter. By preparing public health students to carry out such investigations, academic programs fulfill their basic mission of educating professionals who can assure population health.

A second argument for adding a focus on corporate-induced disease to the public health curriculum is that it opens new doors for intervention. Controlling special interests that threaten the health of the public has always been a public health priority. In a 1999 publication listing the ten great public health accomplishments of the twentieth century, the US Centers for Disease Control and Prevention identified five that required changing corporate practices: reducing the harm from tobacco, improving food safety, reducing automobile accidents, improving worker safety, and reducing deaths from coronary heart disease [3]. How can organized public health extend these accomplishments into this century? What are realistic goals for reducing the burden of corporate-induced chronic diseases, injuries, and pollution in the 21st century? Only by putting these questions at the center of our curriculum will public health programs graduate the professionals who can answer them.

More broadly, the study of corporate induced diseases can provide insights into pathways and mechanisms by which social factors influence health. In its 2003 report Who Will Keep the Public Healthy? [4], the Institute of Medicine called for the public health curriculum to put added emphasis on several concepts including systems thinking, ecological approaches to health, public health policy and law, public health ethics, public health biology and global health. Studying how governments and markets interact to shape patterns of disease, the biological and social pathways by which corporate practices become embodied into states of health, and the legal, political and other strategies that can be used to change corporate practices and policies that harm health provide opportunities for applying these new concepts and methods.

Finally, deeper study of corporate-induced diseases also offers the public health curriculum another opportunity to integrate the many disciplines that inform public health (e.g., law, engineering, economics, political science, medicine, sociology, anthropology and others), thus preparing students for the complexity of interdisciplinary study and intervention.

Convincing colleagues to bring the subject of corporate induced diseases into the public health curriculum will also require addressing their resistance to such a move. Some argue that consideration of corporate induced disease is too political, a diversion from our commitment to objective science. Moreover, assert these critics, critiquing social arrangements is not the role of public health professionals. But public health has always debated the influence of social and economic factors on health. By its definition, public health must consider the impact of political factors on health. Objecting to such investigations is like insisting that researchers on ocean tides cannot consider the influence of the moon.

And even if investigators bring their biases into their research, the methods they use have the potential to provide clear cut answers. Whether the vector for a particular disease is a mosquito or a tobacco company, the same methodologies can be used to study the pathways and distribution of the resulting illnesses and to plan and evaluate control strategies. As Brandt has recently described in his history of cigarettes [5], the objections to controlling tobacco resulted not from any lack of credible scientific evidence but from the political opposition of the tobacco industry. Scientists can apply their methods rigorously or sloppily but the role of corporate decisions in health and disease is no more nor less political than any other causal factor.

Another objection is that some analysts may bring an ideological bias to research on corporations and health – that their research seeks not to uncover the truth but to advance an anticorporate political agenda. But the scientific community has created a variety of mechanism to detect and reveal bias: replication of results, peer review, the requirement for plausible mechanisms of action, an accumulated weight of evidence, etc. These standard methods should be applied to research on corporations and health, whether it is sponsored and carried out by political activists, independent scientists or industry staff.

Another criticism of a focus on corporate-induced disease is that it insufficiently addresses the role of individual behavior. In this line of reasoning, to smoke tobacco, eat too much, drive carelessly, or consume unneeded or harmful medications is always at the most proximal level an individual choice. Focusing on upstream factors like advertising or pricing may play some distal role in disease causation but unless we can persuade individuals to act differently, our health problems will continue. This line of reasoning is particularly resonant in American culture and is also vociferously championed by business.

Some public health professionals agree that industry plays a significant role in shaping patterns of health and disease but believe that it is futile for public health workers to attempt to change as basic a feature of our social arrangement as free market dominance of the economic sphere. In this view, studying and seeking to change corporate practices is tilting at windmills and public health professionals and students should better spend their time engaged in more productive activities.

Finally, some public health faculty believe that our curriculum is already too crowded and perhaps fragmented. Adding one more topic to a 15 session course will simply push out other important concepts, they say. In this view, whatever the current clamor for new teaching on emergency preparedness, public health biology, informatics or corporate induced diseases, principled faculty should resist these topics du jour.

In summary, to succeed in introducing the subject of the corporate impact on health into the public health curriculum will require developing and articulating the epidemiological and other arguments that support this move and understanding and addressing our colleagues concerns about such a move.

What to teach about corporations and health?

Once faculty have made a decision to include the role of corporations in health as a topic within the public health curriculum, the question arises as to what specifically to teach. In Box 1, I suggest 10 key concepts to introduce. These suggestions are intended to spark discussion and debate – to elicit additional recommendations for priority concepts.

Box 1

Ten Key Concepts about
Corporations and Health

1. Corporations and their practices can be considered as vectors of 
disease. (e.g., the tobacco, alcohol, and food industries 
distribute and promote pathogenic products) and as 
social determinants of health.

2. Decisions made in corporate boardrooms and executive offices 
have a profound influence on health.

3. Corporate practices account for a significant proportion of the 
attributable risk for many major causes 
of mortality and morbidity.

4. Differential exposure to unhealthy corporate practices 
contributes to socioeconomic, racial/ethnic 
and other health inequities.

5. Corporate marketing is a major determinant of 
lifestyle and thus health.

6. In order to increase profits, corporations often promote disease.

7. Public health researchers have a responsibility 
to study major determinants of health and to 
report findings to public, even if such findings challenge the status 
quo.

8. Reducing harmful corporate practices and 
encouraging health-promoting ones is an 
appropriate task for public health professionals and 
has led to prior public health successes.

9. Strategies to reduce harmful corporate practices 
must consider local, national and global responses, 
otherwise the burden is merely shifted to another population.

10. Changing corporate practices will require changing 
the relationship between government and business.


How to bring the subject of corporations and health into the public health curriculum

Faculty can use a variety of pedagogical strategies to bring this topic into the public health curriculum. First, concepts and examples related to corporations and health can be integrated into the five required public health core courses. This strategy ensures that all public health MPH students will be introduced to this topic. Box 2 shows various concepts that can be included in each of the core courses. A variety of pedagogical methods can be used: case studies, literature reviews, mini-research studies, term reports, etc.

Box 2

Integrating Concepts on Corporations and Health into the Core Public Health Curriculum

Core Course

Selected Concepts

Biostatistics

Methods to assess roles of industry in causation; history of industry efforts to challenge statistical methods and assumptions

Epidemiology

Attributable risk, corporate practices as social determinants, industry challenges to various epidemiological methods, contested science, multilevel methods to assess impact of corporate practices on behaviors

Health Policy and Management

Roles of insurance and pharmaceutical industries in health and health policy, prevention vs. treatment, roles of special interests in shaping policy, advocacy strategies to change policies

Environmental Health Sciences

Roles of industry in setting standards and regulatory practices, pathways by which products influence health and environment, sustainability, links between occupational and consumer exposures to dangerous products

Health and social behavior

Corporate disease promotion vs health promotion, corporate influences on lifestyle and health behavior, strategies to modify corporate practices, community organizing and coalitions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A second strategy is to develop specific courses in corporations and health. Such courses provide interested students an opportunity to explore selected topics in more depth. Some subjects that have or can be considered as a public health elective course include: Globalization and health; Role of the tobacco, alcohol and food industries in population health; Interdisciplinary perspectives on roles of corporations and government in health; Public health strategies to modify corporate practices, and History of corporations and public health. Some of these courses may fit within a specific public health department while others lend themselves to interdisciplinary approaches, a perspective encouraged by the Institute of Medicine report on education for public health.

Third, students and faculty can develop research projects on the subject of corporations and health. These projects can be part of field placements, Master’s projects or course assignments. For example, students at the public health program at Hunter College have conducted a survey of alcohol advertising in the New York City subway system and have compared the street-level presence of the tobacco, alcohol and food industries in two New York City neighborhoods with differing socioeconomic characteristics.

Similarly, students can complete field placements or internships in research or advocacy organizations engaged in work on the tobacco, food, pharmaceutical, automobile or other industries. Such placements provide practical experience in documenting the impact of corporate practices on health, participating in research studies or advocacy campaigns to modify corporate practices or conducting policy analyses to identify appropriate control strategies. In some cases, such projects include collaborative work among local health departments, researchers, community or youth organizations and advocacy groups.

Finally, some public health program may develop tracks, interdisciplinary concentration areas, or centers on corporations and health. Such institutional arrangements can provide protected spaces outside traditional academic structures such as departments; provide opportunities for faculty and students across schools and disciplines to engage in dialogue and inquiry; and create ongoing links with other researchers, advocacy organizations, think tanks, public officials and others. For the most, part such units have to date focused on a specific industry or product. For example, the Center for Alcohol Marketing and Youth at Georgetown Universityor the Center for Tobacco Control Research and Education at University of California-Berkeley serve as critical academic resources for the efforts to reduce the harm from alcohol and tobacco use.

First steps in changing how public health schools approach corporations and health

Transforming the curriculum of public health academic programs is not something that will happen overnight. Rather, as faculty, students, researchers, advocates and public health officials find new ways to bring the subject of the impact of corporate practices on health into the classroom, curriculum and research practice of their programs, this approach will gain support. Eventually, future generations of students will ask what we were thinking in excluding this topic from our scrutiny. Box 3 lists some of the activities that faculty or students groups have used or are considering to get started on this path. Corporations and Health Watch visitors are encouraged to send their suggestions and experiences for future posting.

Box 3

Getting Started

Organize a faculty seminar on corporations and health and invite interested researchers from throughout your university

Create a websites or list serve on corporations and health for your school or university

Share course syllabi and discuss how to integrate the topic into core and other courses

Organize sessions on corporations and health at professional meetings

Encourage the Council on Education for Public Health, the American Public Health Association, those planning the public health certifying exam and other organizations to consider this topic

Create model academic and research programs where critical mass of faculty and resources exist.

 

By Nicholas Freudenberg, Founder and Director, Corporations and Health Watch.

 

References

1. See for example the selected bibliographies on the alcohol industry and the food industry as well as other references in theResources section of this website. 
2. Jaliel R. Presentation at Meeting of Industrial Diseases Study group of Ecole des Hautes Etudes Superieure, Washington, D.C. November 7, 2007. 
3. CDC. Ten great public health achievements–United States, 1900-1999. MMWR 1999;48:241-3.
4. Board on Health Promotion and Disease Prevention. Institute of Medicine. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, D.C.: National Acadmey Press, 2003.
5. Brandt A. The Cigarette Century. New York: Basic Books, 2007.

Photo Credit:

1. Mountainbread 

Interview with Kathryn Montgomery

Kathryn Montgomery is a professor in the Public Communication division of the School of Communication at American University where she heads the University’s Center for Social Media’s “Youth, Media and Democracy” project. She also works with the Center for Digital Democracy and the Berkeley Media Studies Group. In 1991, Montgomery founded the media advocacy group the Center for Media Education where she served as President for twelve years before the Center was closed. She is the author of two books, Target: Prime Time. Advocacy Groups and the Struggle over Entertainment Television (Oxford University Press, 1989) and Generation Digital: Politics, Commerce, and Childhood in the Age of the Internet (MIT Press, 2007), as well as other numerous publications including the 2007 report Interactive Food & Beverage Marketing: Targeting Children and Youth in the Digital Age which she coauthored with Jeff Chester. Montgomery has been a strong advocate in the areas of youth, health, education, and the democratic use of media.

Her research and advocacy work helped lead to the passage of a Federal Communications Commission ruling which required a minimum of three hours per week of educational/informational television programming for children; a television content based ratings system, and the first federal legislation designed to protect children’s privacy on the internet.

Corporations and Health Watch spoke with Kathryn Montgomery about the new digital media environment, how corporations target children and young people as consumers in increasingly sophisticated ways, and what efforts might be taken to curtail such corporate practices.


CHW
: Tell me about your early work on youth, digital media and marketing with the Center for Media Education.

KM: Early on we began looking closely at digital media. Here was a powerful new medium coming into place and not very many people were really looking at how it was going to affect children. The debates were mainly about pornography and safety online. We were given funding in the mid 90s by the Carnegie Corporation of New York to examine the marketing targeted to children on the Web. We also got a research grant from the Robert Wood Johnson Foundation to look at Alcohol and Tobacco marketing on the web. Even though there were a lot of people concerned about advertising in traditional media, not enough people were looking at the digital media. And this is where all marketing and advertising are going. If you’re going to do any interventions, you have to understand where it’s all headed. We also wanted to educate not only our fellow advocates and the professionals and academics in the field, but the regulators themselves. So we provided the kind of details that could help them in their investigations. Our efforts to document the marketing practices targeted at children resulted in the first law to protect children’s privacy on the internet.

CHW: Can you give me an overview of the current scope of marketing to youth?

KM: Well you know it’s kind of hard to put a figure on it. I know that at the present time all marketing online figures are something like 80 billion. It’s growing very rapidly, and children and teenagers are a very big market online. It is important to understand that in this new media environment the distinctions between online and offline are being completely blurred and, in some cases, obliterated, so we’re really just talking about an overall shift in the way marketing is done this notion of the “360 degree” approach which we wrote about in our report. The marketing encompasses a lot of different platforms; it is designed to be ubiquitous in children’s lives, following them wherever they go, online and off.

CHW: Although there’s a lot of integration, how is internet marketing to children different than what you would find in television or other forms of media like magazines?

KM: We’re talking about a complete integration of advertising and content. In many cases we’re talking about websites and other digital content areas that are engaged not just in marketing to children, but enlisting their involvement in market research. So it’s a very different, more all encompassing kind of medium and the marketing may be more subtle because it isn’t just that you’re seeing a lot of commercials but it’s a website; it might be an adver-game a gaming site that’s really for a product.

CHW: What can you tell me about adver-games? Unlike product placement, this seems like a very active engagement of youth with corporate marketing.

KM: Right. Some of the advertising in interactive games that we documented in our food marketing report is pretty similar to product placement but it’s interactive: you’ve got players who can interact with the ad. The ads are programmed and the software is programmed to track people’s behavior; they do profiling so that they know who you are. The whole thing is engagement; they want you engaged with these products.

CHW: Have you seen any data that would suggest that this sort of interactive marketing is more effective than just passively seeing a commercial?

KM: Except for those who are working for industry, I haven’t seen anything that really tries to address these things. A lot of market research is proprietary. To my knowledge there has been very little, if any, research within the academic community. I’ve been trying to get other academics to do this kind of research for a long time. I think partly because it’s changing so quickly, it’s kind of hard to get a handle on. And it’s not easy to develop research designs that will work. But if you look at the literature, and we cite a huge amount of it in our report, there’s documentation from the industry that these things are successful. Now obviously they’re experimenting with some of them, some things work better than others, but they are spending huge amounts of money in market research. This digital generation is the most researched generation in history.

CHW: Can you explain how “cradle to grave marketing” works?

KM: Marketers have been saying for at least twenty years, that with young people, in addition to the fact that they have money to spend, you want to instill brand loyalty. So you want to be able to get those young people to want your product at a young age. And now, interactive marketing and this incredible capability for profiling adds new meaning to “cradle to grave” because they can not only get you to feel loyal to the product they can actually follow you from cradle to grave, across platforms.

CHW: What about the tobacco or alcohol corporations that are specifically prohibited from marketing to children, how do they go about this?

KM: Of course they [the tobacco industry] say they’re not doing it, but then their efforts have been curtailed obviously. The settlement with the attorneys general forbade certain practices but we also know that they try their best to use other venues. The work that we did predated that decision because our report came out in 1997, but we did not find a lot of overt marketing online of these tobacco products to young people. Now it’s a lot harder to track. We know that in other media they’ve used the kinds of strategies that are designed to circumvent any rules and regulations and we still have major problems with teen smoking. So whether it’s some sort of peer-to-peer effort, there are all kinds of strategies that these companies may be using. We know that for all product categories targeting youth if you can link your product up with pop culture that’s very successful.

The alcohol companies don’t want any regulation on their marketing and they would argue that they’re not marketing to young people. But what we’ve found, and I’m not sure this has really changed, is that online they make a lot of their websites and their marketing efforts very appealing to young people of course they’re saying that you have to be 21, but there are many ways to get around that.

CHW: Can you describe how the food industry, which is not prohibited from marketing to youth, uses digital media and integrative media strategies?

KM: There are a million different ways they do it and they have really developed a panoply of interactive techniques that are designed to engage young people with their brand. They’re very complicated. Anything from putting their ads on mobile technology, offering coupons, having young people spread the word through email to their friends or working through social networks like MySpace and FaceBook to encourage people to use the brand icon, to putting what are known as viral videos on YouTube. Also there’s user generated video, this idea that you get young people to actually create the ads themselves for the products. Pizza Hut did this: “We can make you the vice president of pizza if you’ll make an ad.” They get hundreds and hundreds of young people, probably many more than that, creating their own ads, posting them, and then it spreads like wildfire. And we also know that food marketers and beverage marketers and others are researching who the most effective influencers are, and are recruiting them to promote brands among their peers.

CHW: How do they go about recruiting these influential young people?

KM: Oh there are all kinds of ways they do it. Market researchers can study social networking sites to find the young people with the largest networks of friends, for example. They have found ways to identify online who the “brand sirens” are, the people who like to talk about brands among their friends. There’s a company called Tremor that recruits young people to be part of this elite group of “tremorites.” It’s run by Proctor and Gamble and they work for other clients as well, including some of the beverage companies. Teens are invited to become a part of a privileged group and then given new products and programs in advance and encouraged to tell their friends about them.

The other thing to understand about marketing, particularly to adolescents in the new digital media, is that a lot of these efforts are designed to tap into the fundamental developmental needs of young people. Young people are experimenting with their identities: “how do I show who I am?” Of course marketers have done this for a long time. But now they have techniques that are even more powerful. So if you’re creating your profile on MySpace, in addition to your friends, you can include the brands that you like and that express who you are. Peer-to-peer involvement and being able to use the new digital media to convey your own ideas and to express what you think and feel lends itself beautifully to viral marketing.

CHW: One of the ways in which corporations go about getting their message out there broadly is through market segmentation: breaking up potential groups into discreet groups that can be reached with unique messages. Can you talk about some of the ways that food, alcohol, tobacco, and other industries go about trying to reach a broad range of young people?

KM: This is a rapidly changing digital media marketplace, so as we speak new techniques are being developed. But what I think we are seeing generally with market segmentation in the digital era is further, more refined and more microtargeted marketing that breaks people down not just by their preferences, demographic groups, spending and zip codes, but by their behavioral qualities that can be tracked online through behavioral profiling and database marketing. The important thing is that with these new, sophisticated technologies and the interactive media, people are marketed to as individuals not as segmented groups. Marketers are able to find out what you personally will respond to and they can adjust their advertising accordingly. And particularly looking at the social networking platforms where they can use the information you post about yourself, it’s incredible what these marketers are able to know about you. I think that most consumers don’t have a clue; I don’t think parents have a clue.

CHW: What’s your opinion about the recent announcement by eleven major food and drink companies to voluntarily limit television advertisements to US children under the age of 12?

KM: Well I’ve been monitoring this pretty closely and I was a speaker at the Federal Trade Commission workshop when the most recent announcement was made. There are some very important limitations to what these industries have agreed to do. First of all, the fast food restaurants were not well represented; we’ve got Burger King, before we had McDonald’s, but that whole industry is still not on board. Secondly, the changes that they have vowed to make are only going to apply to marketing that’s targeted at children under the age of 12. That’s totally leaving out adolescents and I would say its even leaving out “tweens” because they watch the stuff that’s targeted at older kids. Adolescents are very much at risk for obesity and they also make more of their own decisions about what they eat.

They’re not at the store saying, “buy me that;” they’re out in those fast food restaurants with their friends. So they need some interventions and the industry hasn’t come forward with anything. Finally, most of the voluntary advertising guidelines are focused on television, with very few changes to the emerging practices in the digital media.

CHW: Would you say that this announcement was something of a preemptive strategy by the industry to avoid further criticism?

This is a pattern: the industry will try to get by with as little as it can and hope the problem goes away. It will not bring up anything else unless we say “aha, but you’re doing this” and there’s a huge outcry about it and the government cares. So they are way ahead of the regulators and way ahead of the public on this stuff. I’m not suggesting that the industry is doing nothing; yes they are doing something, but they don’t want to be regulated. So they’re doing something to keep from being regulated. We need ongoing pressure on the industry and ongoing monitoring of what the practices are and the government has to play a leadership role. And I think the FTC is, but we’ll see what happens next. This is a longterm problem that’s going to take longterm strategies and none of the advocates and health professionals and other stakeholders can afford to let up the pressure. We have to continue; we’re in here for the long haul and its very important.

CHW: What do you think are the best policy solutions to curtail the influence of corporate marketing on youth and youth spaces?

KM: Well it’s a tough area to regulate directly. I don’t think it’s politically viable to call for a ban on advertising. These bans have not worked in the past. You cannot reverse these trends. But I think you can call for some rules of the game, which could include identifying certain practices that marketers should not use. When you deal with products like junk food, soft drinks, fast food restaurants, alcohol and tobacco, there you can have more restrictions. We haven’t had a very courageous government in the past that has wanted to tackle these marketing practices, and unfortunately the advocacy community has not had the knowledge and sophistication about the nature and extent of digital marketing to push an agenda. But we’re working to try to educate people to really see that there are some areas where interventions should be made and there is a proper role for government in developing them.

CHW: And do you see policy efforts as something that should happen at the national or international levels or is there potential for change at the state and municipal levels as well?

KM: Most of these are global corporations, so I think there is a need for some global initiatives, for groups across the world to work together and for regulatory agencies to work together. But at the same time I think there could be some statebased interventions or local interventions, certainly in terms of public accountability and education. In the tobacco control and alcohol control movement there have been some very successful efforts at the local and the state level.

CHW: What does digital marketing to youth look like outside of the United States? Is it a worldwide phenomenon, or is it more based in developed countries?

KM: We know this is a global phenomenon. In many ways, digital marketing is leapfrogging over national boundaries and directly into developing countries. Marketers are moving in very swiftly and very aggressively in many of these countries and sometimes I think too quickly to do anything about it. At the same time, we need to recognize that there are other critical international policy issues in addition to addressing the role of marketing. For example, we need to ensure equitable access to digital technologies. Because these technologies are a good thing for young people and we still have a digital divide in many places throughout the world. We will also need policies to ensure that the digital media are harnessed to improve the lives of young people.

CHW: In terms of advocacy efforts to change corporate practices, what tactics do you see as being effective?

KM: I think we need a multiple set of strategies coming from all kinds of different directions, at the national level, at the international level, at the state level, at the local level. And we need many more groups and individuals involved. And I think that the press is very important. If the pressure does not involve public exposure and what the health advocates have called “public shaming” then its not going to have much of an impact. You have to put heavyduty pressure on the industry, which will, in turn succeed in educating the public and letting policy makers know this is a problem. Strategic use of the media is a critical part of it.

CHW: Do you think that there’s any potential for digital media to serve as a counterforce against marketing to youth?

KM: I do think there’s a potential. The study we did in 2004 on the Internet and youth civic engagement showcased hundreds of nonprofit websites for and by young people. But we also found that many of these ventures were seriously underfunded. It was really not easy to compete in the powerful marketplace. Nor was it easy to recruit young people to be involved when you have the glitz of a MySpace or the popularity of a FaceBook. So I think they’ve got a lot of challenges facing them. But I believe there’s a huge amount of potential there. There’s a lot of great stuff going on that’s sort of spontaneously built by young people. It’s a wonderful thing that kids can get involved. And a number of young people are launching political campaigns within social networking platforms.

CHW: What do you believe are the implications of digital viral marketing on health and wellbeing of young people?

KM: What people need to understand about the digital media environment is that it is completely different from what we’ve seen before with our conventional media. This new digital media culture is everywhere, all the time, in the lives of young people and not only connecting you to other people, but also connecting you through this interactive umbilical cord to corporations. We are looking at a compelling culture that ties one’s sense of identity closely to corporate imperatives. It is designed to engage us and socializes us at an early age into being consumers. There is positive potential to promote health, so I think it’s not all one way or the other but you need to be very careful that the consumer culture part of it doesn’t smother and overwhelm the other parts. We need a broad public debate about how this new media culture can be a positive force in children’s lives.

Corporate Accountability International: Global Action Challenging Unhealthy Corporate Practices

For thirty years, Corporate Accountability International has fought and won campaigns against corporate abuse in the Food, Energy, Tobacco, Water, Oil, and Agribusiness industries. Many of those victories have set precedents in the fight for corporate accountability.

Early history as focused on Nestlé and infant formula

Corporate Accountability International began in 1977, under the name Infant Formula Action Coalition (INFACT). Its first target was the multinational food company Nestlé. At that time, Nestlé was the world’s largest producer of infant formula. Its aggressive global advertising and marketing campaigns promoted infant formula at the expense of breastmilk, despite overwhelming evidence that breast milk was the healthier choice.

Public health advocates were especially critical of Nestlé’s marketing in impoverished regions where money to purchase the formula, access to clean water, and proper sanitation of bottles was scarce or absent all together. As a result, the product was widely misused as people watered down the formula in an attempt to save money. The resulting health problems for mothers, children and families as well as population health were a direct result of Nestlé’s marketing practices.INFACT led a campaign and boycott of Nestlé which centered on bringing the company’s health and human rights abuses into public view and holding the corporation accountable. After nearly 10 years of fighting to restrict Nestlé’s behavior, INFACT saw victory as the World Health Organization (WHO) established global infant formula marketing standards. Nestlé then altered its marketing practices in “economically poor” regions that had been specifically hard hit by their practices, although battles between global infant formula companies and public health activists continue. According to Corporate Accountability International, the Nestle Boycott was an unprecedented victory for grassroots consumer campaigns—the first time a major corporation came to the table with ordinary consumers and agreed to make changes in its behavior worldwide.

Transformation to more broadly focused organization

Since the success of their Nestlé boycott, Corporate Accountability International has expanded, launching several successful campaigns related indirectly or directly to public health. For example, from 1984-1993, Corporate Accountability International (still INFACT at the time) took on General Electric, then the largest producer and promoter of nuclear weapons, for their role contributing to Cold War nuclear arms race. The organization began an international boycott of GE’s commercial goods that highlighted GE’s role in nuclear arms manufacturing. According to Corporate Accountability International, the boycott contributed to GE’s decision to drop its nuclear weapons business.

Beginning in the early 1990’s, Corporate Accountability International launched their Challenge Big Tobacco campaign and by 2003 achieved what its activists view as their biggest accomplishment: the WHO’s enactment of a global tobacco treaty, known as the Framework Convention on Tobacco Control (FCTC). The global tobacco treaty is the world’s first public health and corporate accountability treaty. It has the potential to save millions of lives and change the way tobacco corporations operate around the world. The treaty sets powerful precedents for regulating other industries like the pharmaceutical, water, food and agribusiness and oil industries. In 2004, INFACT changed its name to Corporate Accountability International to more accurately reflect the organization’s expanded mission.

Current Campaigns

Corporate Accountability International currently runs campaigns focusing on the Water, Tobacco, Oil, Food and Agribusiness, and Big Box Retail Industries. Its campaigns target some of the world’s largest corporations with the most direct impact on health, the environment and human rights.

“Think Outside the Bottle”

Corporate Accountability International’s current Challenge Corporate Control of Water campaign fights the privatization of water and the corporations that are attempting global control of this vital resource. The organization has seen national success with the ‘Think Outside the Bottle’ campaign that targets corporations like Pepsi, Coke and Nestlé for their practice of bottling tap water and selling it back to the public. Initial achievements include working to convince mayors to cancel bottled water contracts and to pass a resolution at the June 2007 U.S. Conference of Mayors that supported municipal water and called for a study of the impact of bottled water on cities.

Another water victory came as a direct result of a Corporate Accountability International campaign. Yielding to pressure from that group and other activists, Pepsi announced in July that it will make changes to the Aquafina bottled water drink label naming the waters actual source: the tap. In a press release, Corporate Accountability International called Pepsi’s concession an important first step. In a recent interview on Democracy Now!, Gigi Kellett, the group’s associate campaigns director, explained, she found that:

People on the street… don’t know where the water is coming from. And the bottled water corporations have spent tens of millions of dollars on ads that make people think that bottled water is somehow better, cleaner, safer than our public water systems. And in reality, we know that that’s not true. And so, we want to make sure that we’re increasing our people’s confidence in their public water systems once again and knowing that we need to be investing in our public systems.

Corporate Accountability International defines the success of its campaigns by their ability to persuade corporations to change policies or practices. In exchange for such corporate concessions, the organization ends the boycotts it has organized such as those against Nestlé, General Electric, and Philip Morris/Altria-owned Kraft. This approach relies on grassroots participation, both national and international, to expose unhealthy corporate behaviors and the political ties that keep corporations unchecked by the public sector. The campaigns seek to create public visibility and open debate of key global public health issues.

Tobacco Campaigns

In its Tobacco Industry Campaign, which began in 1993, Corporate Accountability International worked closely with the World Health Organization to target the tobacco industry.

In the early 1990s the organization began campaigns against Philip Morris (now Altria) and RJR Nabisco (now Reynolds American Tobacco). The campaign called for a boycott of then Philip Morris/Altria-owned Kraft, during which Corporate Accountability International exposed Big Tobacco’s attempts to hide behind Kraft’s family friendly image and to disguise its political influence. This campaign may have contributed to the recent company spin-off of Kraft. For the past 14 years, Corporate Accountability International members have attended Philip Morris’ annual shareholders meetings to raise health, human rights and other issues.

At the 2007 Philip Morris/Altria shareholder meeting, for example, Corporate Accountability International Executive Director Kathryn Mulvey called on PM/Altria CEO Louis Camilleri to honor a commitment the company had made to halt sponsorship of Formula One auto racing. Your corporation continues to sponsor these races. You are violating an agreement you signed six years ago—and the global tobacco treaty, which bans tobacco advertising, promotion and sponsorship in ratifying countries. In this effort, the group used the success of the Framework Convention for Tobacco Control (FCTC), to regulate the promotion of tobacco, as a tool to put pressure on individual companies.

As a result of the FCTC, the tobacco industry has faced new scrutiny in its marketing practices and new pressure to adhere to global standards. Corporate Accountability International, as one of many NGOs around the world with official relations with the WHO, played a key role in securing a strong FCTC and in strengthening enforcement action. Together, these hundreds of small and large NGOs have the potential to create a united front against Big Tobacco.

Last month, the President’s Cancer Panel, in which the U.S. Department of Health and Human Services, the National Institutes of Health and the National Cancer Institute were represented, released a report urging the President to ratify the FCTC and to more vigorously regulate food companies that promoted high fat, high calorie, low nutrient carcinogenic diets. The report, “Promoting Healthy Lifestyles,” reminds us; Even absent ratification, by signing the FCTC, the U.S. is obligated not to undermine the goals of the treaty. Thus, the Cancer Panel’s recommendations echoed the call of Corporate Accountability International Senior Organizer Megan Rising, who said, The time has come for the President to heed the call of his top health advisors and the U.S. public and submit the global tobacco treaty to the Senate for ratification. With even a presidential panel accepting its recommendations, it’s clear that Corporate Accountability International has contributed to putting corporate accountability on the nation’s public health agenda.

Photo Credit: All photos courtesy of Corporate Accountability International

The Corporate Quest for Preemption of State Laws: Impact on Public Health

For the most part, big corporations and their conservative supporters oppose federal involvement in their business. They see “big government” as the problem, not the solution and prefer free market to regulatory solutions to almost every problem. If government does need to be involved, big business would usually rather interact with state governments, which are sometimes seen as more malleable or subject to competition with other states. For example, licensing of corporations is a state function and in order to attract business, states compete to set the most attractive rules.

Recently, however, tobacco, gun, automobile, pharmaceutical and other companies have sought to move legal cases against them from state to federal court or to overturn state laws that hold them to a higher standard than do federal laws. Philip Morris, for example, tried unsuccessfully to move a tobacco lawsuit filed in Arkansas state court to federal court and the gun industry has long fought to move its battles to federal rather than state courts and legislatures.

 

Federal preemption is a constitutional principle by which federal law supersedes state law when the two conflict or, more rarely, when a federal law is so comprehensive that there’s no room for the state to act.(1) Proponents of preemption argue that when a federal agency regulates a product, only federal courts can hear liability claims against the manufacturer, even if the product has harmed citizens of a specific state.

Why corporations prefer federal courts

Why do corporations now prefer federal to state courts or regulation? One compelling argument is that in theory federal review is more rational, setting a single national standard that can be reviewed using the same body of (federal) law. If, for example, each state set different standards for automobile safety, car manufacturers might need to produce different models for each state and face contradictory mandates from state courts. In fact, several states, including California and New York, have set higher pollution control standards than the federal rules, leading to a federal court challenge by the auto industry and a National Highway Safety Administration proposal that would preclude states from adopting stricter fuel emissions standards for SUVs.(2) But efficiency is only one argument in favor of federal preemption. More practically, corporations prefer federal courts because they expect more favorable decisions. Federal courts generally award lower damages than state courts and corporate lawyers find it easier to master a single code of law rather than 50 separate ones. And with an increasingly conservative federal judiciary, corporate lawyers are more likely to find federal than state judges who share their free market values. Conversely, according to Edward Sveda, senior attorney for the Tobacco Products Liability Project at Northeastern University, plaintiffs in state cases forced to go to federal court are at a disadvantage because federal judges are less familiar with state statutes and starting in federal court reduces avenues for later appeal.(3)

Arguments against preemption

Critics of preemption of state tort law argue that such preemption is bad law and bad public policy. “Immunizing the makers of products that cause injury simply because, for instance, these products have been approved for marketing by a federal agency harms both the injured people and society generally”, claims Brian Wolfman, the Director of the Public Citizen Litigation Group in Washington, D.C..(1) Wolfman distinguishes between preemption of state “positive law,” direct state regulatory action in an arena also covered by federal regulations, and preemption of state “common law,” the laws set by previous state legal decisions. The latter, he argues, should not be preempted because it provides consumers with an important additional tool for deterring harmful corporate behavior. Another reason to oppose preemption of state action is the somewhat frequent failure of federal regulatory agencies to fulfill their mandate. For example, a 2006 survey of FDA employees by the Union of Concerned Scientists found that 61 percent of the respondents knew of cases where “Department of Health and Human Services or FDA political appointees have inappropriately injected themselves into FDA determinations or actions.”(4) Reports that the FDA approved Vioxx, the pain killer made by Merck, and Avandia, a diabetes medication made by GlaxoSmithKline, despite evidence of dangerous side effects illustrate the shortcomings of federal oversight. State tort liability may serve as a more effective deterrent against corporate promotion of dangerous products.

Under the Bush Administration, preemption has also found support within federal agencies. In 2006, the Food and Drug Administration approved new rules on drug labeling that pre-empted state laws, making it easier for drug companies to defeat consumer lawsuits. The National Highway Traffic Safety Administration proposed rules that would preempt state laws on safety standards for car roofs. In addition, last year, at the White House’s behest, the House approved food safety standards that would preempt states from setting higher standards than those set by the FDA.(5) Professor Thomas O. McGarity, a tort law expert at the University of Texas School of Law told the New York Times, “It’s very troubling. There is a certain hubris on the part of regulatory agencies to make the assumption they are doing their job perfectly and should not be second-guessed, especially in light of repeated histories of agencies being misled by industries.”

Supreme Court Rejects Philip Morris Plea for Federal preemption

On June 11, 2007, opponents of federal preemption won an important victory in the US Supreme Court. In a unanimous opinion, the Supremes rejected Philip Morris’s contention that since it was following federal FTC regulations in its cigarette testing and marketing program, it was acting as an agent of the federal government and was therefore exempt from Arkansas law. The Supreme Court disagreed, sending the case back to state court for resolution. As Matthew Myers, President of the Campaign for Tobacco-Free Kids, noted, “only a tobacco company would have the gall to argue that its deceptive practices are government-sanctioned acts.”(6) The plaintiffs, two young smokers, claimed that the company was violating Arkansas’s Deceptive Trade Practices Act in its promotion of Marlboro Light cigarettes. Sweda of the Northeastern Tobacco Project called the decision “a major setback for the industry.” (7) Smokers have filed similar suits in 20 states.

Industry uses diverse strategies to limit liability

While the recent Supreme Court decision slows the preemption bandwagon and may open new opportunities for public health advocates to make their cases in state courts, corporate interests do not depend on a single strategy to achieve their broader goals. In their efforts to shield themselves from liability or more vigorous regulation, corporations have used several different approaches, including legal challenges to state laws that impose stricter controls than the federal government, attempts to transfer court cases from state to federal judges, and blanket federal legislation that bans most liability laws against an entire industry. Two examples of the last approach are the Protection of Lawful Commerce in Arms Act, signed by President Bush in 2005, providing the gun industry with protection from both federal and state civil suits including retroactive dismissal of pending state and federal cases and the so-called Cheeseburger Bill, passed by the US House in 2004 and 2005 but not acted on by the Senate. The Cheeseburger Bill, supported by the Food Products Association, the National Council of Chain Restaurants, the National Restaurant Association and the U.S. Chamber of Commerce would have protected the food industry against obesity-related lawsuits brought by both individual plaintiffs and also federal agencies such as the Federal Trade Commission or the FDA.(8)

Each of these approaches entails some legal and political risks for the industry and as we have seen, industry wins some and loses some of its fights to avoid regulation and preempt state laws. What can public health advocates learn from a review of these experiences and how can those working in tobacco, food, pharmaceuticals and guns learn from each other’ successes and failures?

Lessons for Public Health Advocates

One obvious lesson is that advocates are best served by developing the capacity to contest industry in several different arenas: state and federal courts; local, state and federal legislatures and, of course, in the media. If corporate leaders and their allies know that they can usually win in a specific setting (e.g., the federal courts), they will always seek to engage their opponents on that front and to modify the rules to increase their chances of gaining the home court advantage. Tobacco control groups, the most experienced of the public health advocates seeking to change corporate behavior, have demonstrated their ability to work in multiple settings and liability lawyers engaged in challenging the drug industry are also gaining the experiences and resources needed to win in a variety of legal settings.

A second lesson may be the importance of integrating legal, legislative and electoral strategies. The 2008 election offers public health advocates an opportunity to encourage their constituents to select a Senate, House and President that will be more willing to protect public health and less willing to safeguard corporate interests. That election will also have a major influence on the shape of the federal judiciary in coming decades.

A third lesson is the value of opening new fronts that may increase the pressure for corporations to make healthier decisions. For example, in recent years, foreign governments including Brazil, Nigeria and the European Union have brought legal action in US and foreign courts against US tobacco companies to recover medical costs attributed to their products.(9,10,11) Whether such actions will prevail or lead to change in the global behavior of the tobacco industry remains to be seen However, too often legal or regulatory victories in the United States have led tobacco, drug, food or other companies to increase marketing of unhealthy products in other nations, especially developing nations with weaker public health laws. These practices exacerbate existing global inequalities in health. If corporate leaders know that unhealthy products and practices can be successfully challenged around the world, they may be more willing to adopt international standards that would can their liability and protect their reputations not only in the developed world but globally.

 

References

1. Wolfman B. Why preemption proponents are wrong. Trial.2007; 43:3. 
2. National Environmental Trust. California auto standards and state efforts to curb global warming pollution from cars and light trucks. No date. Accessed on July 27, 2007 at http://www.net.org/warming/docs/pavley/net_pavley_fact_sheetfinal.pdf 
3. Lynch J. U.S. justices return cigarette suit to state court. Arkansas Democrat-Gazette(Little Rock), June 12, 2007, p.1. 
4. Union of Concerned Scientists. FDA Scientists Pressured to Exclude, Alter Findings; Scientists Fear Retaliation for Voicing Safety Concerns. July 2006. Accessed on July 27, 2007 at http://www.ucsusa.org/news/press_release/fda-scientists-pressured.html
5. Labaton S. “Silent tort reform is overriding states” powers. New York Times, March 10, 2006, p.C5. 
6. Myers, M. Supreme Court Ruling is Victory for Consumers Deceived by Tobacco Company Light Cigarettes. Campaign for Tobacco-Free Kids, June 11, 2007. 
7. Stohr. G. Philip Morris Loses US High Court Case on Suit Site. Bloomberg News, June 11, 2007. Accessed July 27, 2007 at www.bloomberg.com/apps/news?pid=newsarchive&sid=arvBsOuQ.nN8 
8. Burnett D. Fast-Food Lawsuits and the Cheeseburger Bill: Critiquing Congress’s Response to the Obesity Epidemic Virginia Journal of Social Policy and the Law 2007; 14(3): 357-414. 
9. No author. Foreign governments are not entitled to recover tobacco-related medical expenses. Health Law Week, March 23, 2007. 
10. Haruna G. Tobacco control battle shifts to courts. Accra Mail, May 8, 2007. 
11. No author. European Court of Justice rules that decision of EC Commission to file civil actions against US tobacco companies in US federal court did not alter legal rights of companies European Union, 13(1), January 2007.

Public Health Advocacy to Change Corporate Practices: Implications for Health Education Practice and Research

Corporate practices, such as advertising, public relations, lobbying, litigation, and sponsoring scientific research, have a significant impact on the health of the people in the United States. Recently, health professionals and advocates have created a newscope of practice that aims to modify corporate practices that harm health. This article describes how corporate policies influence health and reviews recent health campaigns aimed at changing corporate behavior in six industries selected for their central role in the U.S. economy and their influence on major causes of mortality and morbidity. These are the alcohol, automobile, food, gun, pharmaceutical, and tobacco industries. The article defines corporate disease promotion and illustrates the range of public health activities that have emerged to counter such corporate behaviors. It analyzes the role of health professionals, government, and advocacy groups in these campaigns and assesses the implications of this domain for health education practice and research.

Public Health Advocacy to Change Corporate Practices: Implications for Health Education Practice and Research [pdf] 

In recent years, citizens, consumer and health activists, state and local government officials, and health professionals have created a new arena of public health advocacy designed to change corporate policies that damage health. Tobacco control activists have been at the forefront, winning new legislation to restrict advertising, limit public smoking, and raise excise taxes and forcing the tobacco industry to contribute billions of dollars to pay for tobacco-related illnesses and support efforts to reduce smoking (Glantz & Balbach, 2002; Kluger, 1997; Schroeder, 2004). More recently, however, consumer and environmental activists have also targeted the automobile industry for its production and advertising of unsafe and polluting sports utility vehicles (SUVs; Bradsher, 2002; Gladwell, 2004). Health, food, and nutrition groups have challenged the food industry for its contributions to obesity and diabetes (Nestle, 2002, 2003), and antiviolence, public safety, and health organizations have opposed the marketing and production practices of the gun industry (P. H. Brown & Abel, 2003; Diaz, 1999). Mothers Against Drunk Driving and its allies have criticized the alcohol industry for its youth-oriented advertising (Hamilton, 2000); health professionals, senior citizens, and health care reformers have taken on the pharmaceutical industry for making windfall profits based on publicly funded research, covering up harmful side effects of their products, and disease mongering, creating, or exaggerating new diagnoses to promote sales of their products (Angell, 2004; Moyniham, Heath, & Henry, 2002; Topol, 2004).

This special section of Health Education & Behavior examines this new public health advocacy to change health-damaging corporate behavior and analyzes its implication for health education practice and research. In this article, I define the concept of disease promotion, review the scientific and political rationale for efforts to change corporate behavior, and provide an overviewof the scope of this emerging arena of health advocacy. I also explore its implications for health education practice and research.

In the next article, Dorfman,Wallack, andWoodruff (2005) use the concept of framing to assess commonalities among recent public health campaigns to control, for example, the tobacco, food, and gun industries, and to analyze the underlying philosophical and moral frameworks for these debates. They suggest that health educators can use new insights on framing from research in communications, political science, sociology, and media studies to win broader public support for health objectives. In the third article, Nathanson (2005) compares the achievements of tobacco control movements in the United States, Canada, France, and Great Britain. She argues that political systems, historical traditions, and government structures in each nation create unique opportunities
and constraints for tobacco control and suggests that this cross-national perspective can help health educators and other health professionals plan more effective strategies. Finally, Kreuter (2005) examines the relevance of this new public health practice and locates it within the context of health promotion both in the United States and around the world.

THE SCIENCE AND POLITICS OF DISEASE PROMOTION

Disease promotion describes organizational practices or policies that encourage unhealthy behaviors, lifestyles, or environments. The concept is based on the social determinants of health literature, which identifies social, political, and structural factors and processes that contribute to patterns of health and disease. Recently, researchers have called for greater attention to these determinants and have advocated increased scientific and professional efforts to develop interventions that address this level of causation (Marmot, 2002; Tarlov & St. Peter, 2000; Wilkinson, 1996). In addition, disease promotion borrows from the concept of health promotion and its emphasis on agency—the ability to act to improve health—but reverses the focus to spotlight actors and actions that harm health.

No level of social organization has a monopoly on disease promotion: cells, organs, individuals, groups, organizations, government, and ecosystems can each act to advance disease. Our focus here, however, is on population health and therefore on organizational agents of disease promotion. The goal of studying the process of disease promotion is to identify opportunities for prevention.

Corporations have long been an essential component of American society. In the late 19th century, they emerged as central agents of the American economy, and today, most observers agree that they dominate the global economy (Bakan, 2004; Berle & Means, 1968; Friedman, 1982; Galbraith, 1952). Their actions shape every aspect of our health and lives, from the food we eat and the air we breathe to our concepts of democracy, sexuality, intimacy, and self-worth. Obviously, corporations play a vital role in our economy: They provide millions of jobs, produce many of the goods and services that distinguish the American lifestyle, pay taxes, and contribute to charity.

But it is equally evident that corporate practices play a central role inAmerica’s health problems. According to a recent Centers for Disease Control and Prevention (CDC) report (Mokdad, Marks, Stroup, & Gerberding, 2004, 2005), in 2000, products of the tobacco industry were estimated to kill 435,000 Americans a year; diet and physical inactivity, in part because of food industry advertising and the easy availability of high-fat, high-calorie foods, were implicated in at least 365,000 deaths; alcohol was associated with 85,000 deaths, including homicides, automobile accidents, and alcohol-related diseases, such as cirrhosis and liver cancer; 43,000 Americans died in automobile accidents, and several thousand additional deaths were associated with automobile pollution; and 29,000 Americans died in gun-related homicides, suicides, or accidents, and many more were injured. Finally, by pricing its drugs out of reach of people who need them, opposing policies that would lower prices, covering up life-threatening side effects, and focusing on the most profitable drugs rather than those that best protect public health, the drug industry contributes to many excess deaths (Angell, 2004; Topol, 2004). In addition to the lost lives, the products of these industries cost consumers, taxpayers, and the larger society billions of dollars of costs in health care and lost productivity (CDC, 2002; Finkelstein, Fiebelkorn, & Wang, 2003). Sturm (2002) has estimated that the annual U.S.
health care costs associated with obesity are $395 per person, with current or former tobacco use $230 per year and with problem drinking $150 per year, costs that can be seen in part as industry taxes on society and individuals.

Obviously, not every death or illness related to a particular product can be blamed on corporate practices. No complex health problem has a single cause, and undoubtedly, biological, behavioral, cultural, and environmental factors contribute to morbidity and mortality from tobacco, food, automobile, guns, alcohol, and pharmaceuticals. Here, the epidemiological concept of attributable risk is helpful. Attributable risk indicates the absolute incidence of a condition that can be attributed to a causal factor; it is a function of both relative risk (the ratio of incidence in those exposed versus those not exposed) and the prevalence of the causal factor (Susser, 1973). Precisely because corporate practices, such as advertising and political interference with regulation, are so ubiquitous, their influence is significant. To give a hypothetical example, even if exposure to fast food advertising contributed much less to obesity than an obesity gene at the individual level, the fact that so many more people are exposed to advertising than carry the obesity gene would mean that advertising caused more cases of obesity than genetic factors.

Clearly, the number of tobacco and gun deaths would decline precipitously if these industries did not produce, promote, and distribute their products; their efforts to resist public control have contributed substantially to mortality. On the other hand, the food, automobile, and pharmaceutical industries produce goods that can both enhance and damage health. However, the fact that an industry may contribute to health problems should not discourage investigation of policies aimed at limiting its harmful consequences.

Future research is needed to quantify the attributable risk related to specific industry practices. But the pervasive exposure to disease-promoting practices and the very substantial health burden the products of these industries impose require public health professionals to examine whether changing the behavior of corporations is a promising strategy for improving public health and achieving national health goals, such as those articulated in Healthy People 2010 (U.S. Department of Health and Human Services, 1999).

Some evidence supports the value of policy change to modify corporate behavior. In 1998, the Congressional Prevention Coalition, a bipartisan group of more than 60 lawmakers dedicated to prevention, asked the Partnership for Prevention (2000), a nonprofit nonpartisan group, to assess opportunities for prevention. Based on interviews with more than 80 public health researchers, the group identified several policies with the greatest potential for reducing mortality and morbidity. Six strategies with potential for saving almost 250,000 lives a year require changing corporate practices or overcoming corporate opposition. Table 1 shows these six policies and the expert panel’s estimate of the number of lives each change would save annually.

[Table 1: Priorities for Policy Change – see PDF]

In this article, I have chosen to focus on six industries (tobacco, food, automobile, gun, alcohol, and pharmaceutical) because of their central role in health and disease, their importance to the U.S. and global economies, and their economic and political influence and because public health advocates have already acted to modify their practices (Advocates for Highway and Auto Safety, 2001; Angell, 2004; Center on Alcohol Marketing and Youth, 2002; Diaz, 1999; Glantz & Balbach, 2002; Nestle, 2002).

A FRAMEWORK FOR THE STUDY OF HEALTH ADVOCACY TO CHANGE CORPORATE PRACTICES

A systematic study of health advocacy to change corporate practices would benefit from a framework that focuses on variables of interest and allows comparisons across industries, cases, and levels of social organization (e.g., local, state, or national). Figure 1 shows such a conceptual model for the study of campaigns to change corporate behaviors that harm health. I propose it as a heuristic to guide future research, subject to modification based on empirical findings. These campaigns are shaped by the broader social and political context (Box 1 in Figure 1), which includes political structures (Nathanson, 2005), economic conditions, cultural beliefs, and historical influences
(Cohen, 2003; Hertz, 2001). The second row shows each of the three principal actors: corporations and their allies (Box 2); the government, including the federal, state, and local levels and the executive, legislative, and judicial branches (Box 3); and public health and advocacy organizations (Box 4), which includes health departments (which thus may appear in both Boxes 3 and 4; see Wolfson, 2001, for a discussion), health care providers, professional organizations, advocacy groups, and others. Each of these actors has organizational structures, histories, cultures, and connections with various networks and faces external pressures that influence their behaviors. In the third row, the focus is on this behavior itself, the actions that corporations (Box 5) and health professionals and
advocates (Box 6) take in their efforts to change or defend corporate practices and policies
deemed to harm health. As shown in the fourth row, these interactions shape health outcomes (Box 7), which are also influenced by other biological, environmental, behavioral, social, and political factors. The vertical and horizontal arrows in Figure 1 show the dynamic character of these public health campaigns and also the multiple opportunities for intervention.

[Figure 1 – Conceptual model for the study of campaigns to change corporate practices that harm
health – see PDF]

For public health advocates, the central question is the following: What actions can best ensure that their activities lead to improved health outcomes? For health researchers, the key questions are the following: What is the relative efficacy of these interventions compared to others, what factors influence the process and outcome of these interactions, and to what extent can findings derived from one campaign or one industry be generalized to another? In the next section, I examine some of the actors and actions engaged in campaigns to change corporate practices.

CORPORATE ACTORS AND ACTIONS

Corporate practices and policies that damage health are carried out by a variety of actors. Although corporations, such as Philip Morris (Kessler, 2001), Colt Industries (P. H. Brown & Abel, 2003), and Merck (Hawthorne, 2003), have played central roles in defending their own practices against public health critics, other players are also important. Advertisers, for example, design and carry out campaigns to increase sales of harmful products. Trade associations, such as the Pharmaceutical Research and Manufacturers Association (Angell, 2004) and the National Shooting Sports Foundation (P. H. Brown & Abel, 2003), often serve as the public voice of industries. Lobbying and lawfirms, such as Hill and Knowlton (Kluger, 1997) and Verner, Liipfert, Bernard, McPherson, and Hand (Pertschuk, 2001), often act to advance the legislative and legal agendas of several of the industries reviewed here. Retail associations also contribute to lobbying and legislation at the state and local levels. Citizen organizations also act to defend corporations. The National Rifle Association (NRA), for example, is one of the most influential organizations inWashington, D.C., and often acts to defend the gun industry (P.H. Brown & Abel, 2003).

A few analysts have assessed the respective roles of these actors in specific circumstances (Bradsher, 2002; P. H. Brown & Abel, 2003; Nestle, 2002; Pertschuk, 2001), but more research is needed to identify the particular and generalizable contributions of each and the implications for advocacy campaigns.

Corporate Behaviors That Promote Diseases

Corporations and their allies engage in a variety of actions to advance their agendas.

Advertising. Advertising seeks to create new customers and encourage existing ones to purchase more. When the product being advertised is lethal (as in the case of tobacco or guns) or can easily be used in ways that harm health (e.g., alcohol, SUVs, and some pharmaceuticals), advertising falls squarely within the rubric of disease promotion. The six target industries spend vast amounts on advertising, as shown in Table 2. In 2003, the domestic advertising spending for these six industries alone ($38.7 billion) was 7 times greater than the combined total budgets of the U.S. CDC and Prevention ($3.84 billion), the Food and Drug Administration (FDA; $1.45 billion), the Federal Trade Commission ($176.5 million), and the Consumer Safety Product Commission ($57 million; U.S. Department of Health and Human Services, 2003).

As manufacturers saturate their potential customers in one population, advertising seeks new markets, thus creating the potential to spread risks to health. For example, the tobacco industry targets African Americans and smokers in the developing world (Balbach, Gasior, & Barbeau, 2003), the gun industry persuadeswomen to buy handguns to feel safer (Brady, n.d.), and the alcohol industry markets sweet wine coolers to young drinkers (Garfield, Chung, & Rathouz, 2003). In recent years, drug companies have advertised prescription drugs directly to consumers. “Feeling sad? Anxious? Tired?” asks a Pfizer ad for the antidepressant drug Zoloft (Ives, 2003). Although drug and media companies claim that these ads empower consumers to make informed choices and communicate better with their doctors, consumer advocates claim they downplay side effects
or adverse reactions and may lead some patients to pressure doctors to prescribe medicines they do not need (Ives, 2003).

[Table 2 – Annual Spending on Advertising, Political Contributions, and Number of Lobbyists by
Industry – see PDF]

Public Relations. Public relations fosters a positive public image for corporate America and blocks proposals that harm its perceived interests (Marchand, 1998). When critics challenge the safety of a product, corporations and their trade associations often respond forcefully, seeking to influence the debate in such a way as to preclude action to limit profits, restrict advertising, or regulate manufacturing or distribution. For example, when the FDA proposed new regulations for vitamins, industry groups sponsored television ads showing soldiers storming suburban homes to seize vitamin C bottles (Kessler, 2001, p. 335).

To make their public messages more credible, industries may create front groups to act as their public voice. Philip Morris formed the National Smokers Alliance to contest tobacco regulation (Kessler, 2001, p. 170); the tobacco, food, and restaurant industries funded the Center for Consumer Freedom to oppose smoking bans in public places and lower legal limits on blood alcohol levels (Brownell, 2003, p. 269); and the auto industry hired aWashington lobbying firm to create Nevadans for Fair Fuel Economy Standards, a paper organization that opposed higher mileage standards that would reduce pollution (Bradsher, 2002, p. 64). To improve its public image, the food industry has supported the American Dietetic Association (Nestle, 2002), and the tobacco industry has contributed to arts, sports, and African American groups (Kluger, 1997).

As Dorfman et al. (2005) explain, public relations seeks to frame the public dialogue on issues relevant to the industry. Across the six industries reviewed here, corporations articulate strikingly similar messages: Market mechanisms provide the best remedies for dangers to consumers, it is wrong to restrict advertising of legal products, individuals are responsible for their own behavior, and having choices is the American way (Brownell, 2003 pp. 258-268; Diaz, 1999; Menashe & Siegel, 1998). In many cases, corporate publicrelations expenses are tax deductible, creating a public subsidy for messages intended to thwart policy changes to protect health.

Industries also use more subtle forms of public relations to quell unfavorable portrayals. In a stark display of the power of the tobacco industry, in the 1980s, nowomen’s magazine that accepted tobacco advertising published a single article, editorial, or column on the harmful effects of tobacco, despite the fact that it was then that lung cancer surpassed breast cancer as the leading cause of cancer deaths among women (Anderson, 1995; Hertz, 2001, p. 137). As U.S. and global media ownership becomes more concentrated among a handful of large multinational corporations (Bagdikian, 2004), often with links to the six industries described here, the willingness of major media outlets to investigate corporate malfeasance or disease promotion may further diminish.

Lobbying and Other Legislative Activities. Lobbying and other legislative activities are a central tool for advancing corporate objectives. In 2000, the Center for Responsive Politics (n.d.) estimated that there were more than 20,000 registered lobbyists in Washington, D.C. About 1,000 lobbyists work in the nation’s capital for the food industry (Nestle, 2002, p. 99) and 675 for the pharmaceutical industry (S. Brown & Doyle, 2004; see Table 2). More lobbyists work in state capitals. In the mid-1990s, for example, the tobacco industry had 25 lobbyists in Minnesota alone (Wolfson, 2001, p. 153) working to defeat or water down that state’s tobacco regulations.

Lobbyists work both to pass legislation that benefits their employers and to defeat laws deemed to be harmful. In 2003, the pharmaceutical industry poured millions of dollars into a concerted, and successful, lobbying effort to convince Congress to pass legislation that would increase coverage of senior citizens for some prescription drugs and defeat provisions that would have allowed the federal government to negotiate lower prices on behalf of Medicare patients or import lower cost medicines from Europe or Canada. Analysts estimated the law would increase drug company profits by $13 billion a year. Pharmaceutical companies acted despite overwhelming public support for the restrictions they opposed and expert opinion that the measure would leave major gaps in coverage
and fail to contain costs (Connolly, 2003). In 1994, lobbyists for the dietary supplement industry succeeded in persuading Congress and the president to agree to label dietary supplements as foods rather than drugs, thus escaping FDA requirements for safety and effectiveness. A few years later, after aggressive advertising of the benefits of these products, deaths from supplements, such as ephedra, illustrated the public health costs of this deregulation and led to calls for renewed public oversight (Fontarosa, Drummond, & DeAngelis, 2003).

Corporate success at lobbying is increased by the revolving door between industry and the government. For example, presidential adviser Karl Rove had been chief political strategist for Philip Morris before working for Bush, and the president’s chief of staff, Andrew Card, had been General Motors’ top lobbyist in Washington, D.C. (Bradsher, 2002). Dan Glickman, secretary of agriculture in the Clinton administration, left office to join a law firm that lobbies for agriculture and food companies (Nestle, 2002, p. 100). In 1994, when Philip Morris needed someone to testify against FDA regulation of tobacco before Congress, it hired former FDA Commissioner Charles Edwards, paying him $120,000 for the consultancy (Kessler, 2001, p. 315). In 1998, 128 former members of Congress were listed as lobbyists, 12% of all senators and representatives who had left office since 1970 (Abramson, 1998; Nestle, 2002, p. 100). Compared to the handful of lobbyists who advocate for public health, these personal and professional associations between elected and appointed officials and corporate lobbyists provide industry with a competitive advantage in influencing legislation and regulation.

Campaign Contributions and Electoral Activities. Campaign contributions and electoral activities help cement this advantage by increasing the chances that the legislators or executive branch officials that lobbyists meet will be grateful or indebted to them. The six industries reviewed here each make substantial campaign contributions, as shown in Table 2. Many industry political action committees contribute to both parties, ensuring influence no matter what the outcome of an election. In 2002, for example, the drug industry contributed about $22 million to the Republicans and almost $8 million to Democrats (S. Brown & Doyle, 2004). The NRA and its gun industry allies offer not only financial support to sympathetic candidates but also assistance in voter mobilization and campaigning (Diaz, 1999), helping to explain why the gun industry and the NRA consistently win legislative victories even though public opinion polls show high levels of public support for restrictions on assault rifles and opposition to exempting gun manufacturers from liability suits.

Litigation. Litigation allows industry to delay, weaken, or overturn laws and regulations they dislike. The six industries have gone to court to seek action against individuals, organizations, and government agencies that they perceived as threats to their business goals. For example, in 1996, the Texas Cattle Ranchers Association filed a $10 million suit against OprahWinfrey for violating that state’s food disparagement lawby saying the threat of mad cow disease made her stop eating hamburgers. Although Winfrey ultimately won, she spent more than $1 million defending herself, a cost that might deter less wealthy critics (Nestle, 2002, pp. 162-165). In 1994, Philip Morris filed a $10 billion libel lawsuit against ABC television for reporting that cigarettes were “artificially spiked”
with nicotine (Kessler, 2001, p. 156). A tobacco industry executive later commented that “with one legal action—the filing of the ABC suit—the word ‘spiking’ has been dropped from the lexicon of the anti-tobacco crowd. Frankly, if that is all the suit ever does, it will have beenworth it” (Kessler, 2001, p. 169). In 2000, seven gun makers filed a suit against Housing and Urban Development Secretary Andrew Cuomo, New York State Attorney General (AG) Elliott Spitzer, and other state and local officials, claiming they were violating the gun makers’right to sell legal firearms by seeking to force them to accept a code of conduct on the sale and design of handguns. The manufacturers did not seek monetary damages but instead asked the court to bar the officials from seeking to convince local
police departments to buy weapons only from companies that had signed the agreement (P. H. Brown & Abel, 2003).

Scientific Research. Scientific research often influences the public debates about whether specific products harm health. Many industries seek to influence this debate by funding scientific research that will support their case and by hiring scientists to contest damaging information. Until the Tobacco Master Settlement Agreement eliminated it, the Tobacco Institute funded scientists to refute links between smoking and health and to bring this so-called evidence to the public. The food industry supports nutrition researchers who emphasize exercise rather than diet as the cause of obesity, and the New York State AG recently brought the drug maker GlaxoSmithKline to court for failing to publish or disclose studies that showed no benefit from its popular antidepressant Paxil (Harris,
2004). Krimsky (2003), who has studied corporate behavior related to scientific research, uses the term manufactured doubt to describe the practice of sowing confusion to avoid or delay regulatory action.

Illegal Activities. Illegal activities are another strategy some corporations have used to advance their objectives. In the early 1970s, Ford Motor Company fabricated auto safety test data, leading to a $7 million fine (Yates, 1983, p. 261). In 1994, tobacco industry executives lied under oath to Congress about their prior knowledge on nicotine’s addictiveness (Kessler, 2001), and in 1999, the U.S. Justice Department reached a $255 million settlement with the vitamin industry for price fixing, a practice that made its products more expensive for consumers (Nestle, 2002, p. 168). Given spotty enforcement of regulations on corporate behavior, data are not available to ascertain whether illegal activities constitute the renegade actions of a few bad apples or a common business practice.

In summary, a variety of corporate behaviors, including advertising, public relations, lobbying, litigation, campaign contributions, and sponsored research, advance industry objectives of increasing profits and defeating stricter regulations. Although in most cases their activities comply with current laws, these actions nevertheless contribute to preventable illnesses and deaths. In most cases, there is no evidence that corporate managers who engage in these behaviors intend to harm health; although, the evidence of the harmful impact is usually widely known. Many of these corporate behaviors also appear to contradict free-market principles. Free markets depend on equal access to information and on competition. When corporate interests suppress information, obfuscate public debate, or stifle competition, they interfere with the market forces that proponents of free markets cite as the best protection for consumers.

Has the adverse impact of corporate influence on health worsened in recent years? Although data are not available to answer this question definitively, several trends provide cause for concern. First, advertising has increased significantly in the past 2 decades, and corporate influence now penetrates every sphere of public and private life, from the classrooms and malls to movies and music (Cohen, 2003). Second, corporate involvement in political life has grown significantly, with increases in the number of lobbyists, the amount of campaign contributions, and the influence of big business interests in Washington, D.C., and state capitals (Drew, 2000). Third, since 1980, many U.S. industries have been deregulated or allowed to monitor themselves, and the remaining regulatory agencies are often underfunded, understaffed, and frequently criticized by corporate and political leaders, making them less able and willing to carry out their missions (Hilts, 2003; Kessler, 2001). Finally, for a variety of reasons, a number of potentially countervailing powers, such as an informed and mobilized electorate, active consumer and environmental movements, forceful local and state officials, and a crusading media, have declined, leaving fewer voices to challenge corporate influence (Bagdikian, 2004; Cohen, 2003; Patterson, 2003). Whether the new public health activism described here can become such a counterweight remains to be seen.

HEALTH AND ADVOCACY RESPONSES TO
CORPORATE DISEASE PROMOTION

A variety of constituencies have mobilized to take action to protect public health against these corporate practices. A review of campaigns against the six target industries reveals common actors, strategies, and outcomes.

The Actors

Who are the individuals and organizations involved in advocating for changes in corporate
practices? Several key stakeholder groups have played roles in many campaigns to modify corporate practices.

National Organizations. National organizations serve as conveners, clearinghouses, catalysts, and advocates in government arenas. Larger organizations often have full-time staffs of scientists, lawyers, educators, lobbyists, and organizers. Examples of such groups include the Center for Science in the Public Interest, Union of Concerned Scientists, Public Citizen, Brady Campaign to Prevent Gun Violence, Sierra Club, American Legacy Foundation (which also funds advocacy groups), American Lung Association, and Mothers Against Drunk Driving. These organizations often have a detailed understanding of the policy process and the resources to compete with industry groups in legislative
and legal bodies. In some cases, the national groups can provide grassroots groups with credibility and clout; although, they may also seek to compromise grassroots militancy to achieve political compromises (Wolfson, 2001).

Coalitions. Coalitions bring together like-minded organizations to amplify their political power, share resources, or coordinate strategies. Coalitions organize political strategies, mobilize their constituencies, and educate the public. Most coalitions confine their attention to a single industry (e.g., tobacco, guns, or food), but some work across local, state, and national levels. Examples include the Coalition for a Healthy California, which led the effort to support tobacco control propositions (Glantz & Balbach, 2002, p. 382); the Coalition on Smoking or Health, which included several large national voluntary health organizations (Wolfson, 2001, p. 84); the Louisiana Alliance to Prevent Underage Drinking; and The Infant Feeding Action Coalition, which coordinated the boycott of
Nestle (2002, p. 149). Although coalitions play integral roles in campaigns to modify corporate
behavior, maintaining the coalition and keeping it focused on external goals can often be demanding (Pertschuk, 2001; Wolfson, 2001).

Health Professionals and Researchers. Health professionals and researchers provide scientific and technical expertise to efforts to modify health-damaging policies. They conduct original research, summarize available evidence, testify at public hearings or in court cases, and educate advocates and organizers. Organizations, such as the Center on Alcohol Marketing and Youth at Georgetown University in Washington, D.C., and the Center for Gun Policy and Research at Johns Hopkins University, and individuals, such as Marion Nestle, a nutritionist at New York University; Stanton Glantz, a tobacco researcher at the University of California San Francisco; and GarenWintimute, director of the Violence Prevention Research Program at the University of California Davis, have
provided epidemiological and policy evidence that advocates have taken to the political arena. Some researchers are advocates themselves, whereas others prefer to let theirwork speak for itself. Of course, other scientists also work for the corporations that are the targets of advocacy campaigns; contesting industry-supported research is often a key task for the researchers allied with advocacy efforts.

Public Health Agencies. Public health agencies, such as local and state health departments, have often become key players in campaigns against tobacco, alcohol, guns, and other harmful products. Local health departments are often active members of tobacco control coalitions, often funding community organizations to carry out education and advocacy (Wolfson, 2001). In Marin County, California, the county Department of Health and Human Services joined a coalition that successfully supplanted Miller Brewing Company as a sponsor for the county fair, using its booth at the fair to educate about alcohol rather than give out beer (Marin Institute, 2004). Some local health departments have also supported efforts to end the sales of high sugar soda in schools (Fried & Nestle, 2002).At the federal level, a fewadministrators have taken stands against health-damaging industries. As head of the FDA, for example, Kessler (2001) led the fight against the tobacco industry, and Dr. Jeffrey Runge, of the National Highway Traffic Safety Administration, has been an outspoken critic of the automobile industry’s failure to make safer cars (Skrzycki, 2003).

Legal Groups. Legal groups are at the front line of the litigation against the tobacco, automobile, food, and gun industries. Using class action lawsuits, they have sought damages, injunctions, and changes in advertising or manufacturing. Players include lawyers at universities and nonprofit groups, such as John Banzaf at GeorgeWashington University, the Northeastern University School of Law’s Tobacco Products Liability Project, and the Legal Action Project of the Brady Campaign to Prevent Gun Violence, and at law firms, such the Castano Group in New Orleans, a network of lawyers active in tobacco and gun litigation (P. H. Brown & Abel, pp. 301-303).

In the public sector, state AGs have played increasingly prominent roles in using litigation to protect consumers against corporate excesses. The best known example is the Master Tobacco Settlement negotiated by state AGs to end some forms of advertising and to fund antitobacco activities (Schroeder, 2004). New York AG Elliot Spitzer has also challenged the drug company GlaxoSmithKline for its failure to disclose negative information about a popular antidepressant, Paxil (Harris, 2004).

Local Organizations. Local organizations bring debates about corporate practices directly to their communities and often provoke a dialogue that sparks media coverage, popular mobilization, and a response from the government or industry. In many communities, for example, anti-SUV activists ticketed SUVs, charging them with pollution and defective safety designs (Earth on Empty, n.d.). In Philadelphia, a coalition of church and community groups forced Philip Morris to abandon its plan to introduce a new cigarette, Uptown, targeted at urban African Americans (Sutton, 1993).

Other Participants. Other participants in campaigns to change corporate practices include reporters and other media representatives, elected officials, and other business groups; for example, the insurance industry has often joined advocacy efforts to improve car safety. Often, these parties have helped mobilize public opinion, represent a group’s interest in the political arena, or add political heft to a campaign.

The Actions

The actors involved in campaigns to change corporate practices have used a variety of strategies to realize their objectives. Creating a typology of actions can help provide a framework for comparative assessment of the process and outcome of these strategies.

Getting Information. Getting information is often the first step in acting to change health-damaging corporate behavior. Advocates for tobacco and gun control have used the discovery process in court cases to uncover damaging information and industry efforts to hide such data (P. H. Brown & Abel, 2003; Kessler, 2001). National advocacy groups, such as Public Citizen and Center for Science in the Public Interest, have used the Freedom of Information Act to extract information about business activities from reluctant regulators (Hilts, 2003, p. 197). In some cases, industry insiders with troubled consciences have turned to the mass media to tell their stories, alleging, for example, that the tobacco industry covered up harmful data and that the gun industry knew its products were going to illegal dealers (Butterfield, 2003; Kessler, 2001).

Legislative Action. Legislative action provides public health advocates with the opportunity to suggest laws and regulations they believe will better protect public health. Health organizations and their allies haveworked to persuade lawmakers to raise taxes or end tax breaks on tobacco, alcohol, junk food, and fuel-inefficient cars to discourage their use (Hakim, 2004; Nicholl, 1998; Stivers, 1994); to set standards for production and advertising of health-damaging products (P. H. Brown & Abel, 2003); to modify zoning or land use laws to reduce access to tobacco, alcohol, or fast food (Ashe, Jernigan, Kline, & Galaz, 2003); to restrict use of tobacco, guns, or alcohol by certain populations or in certain places (Hemenway, 2004; Rabin & Sugarman, 2001); to mandate disclosure of product dangers (Kessler, 2001); and to fund health education to alert the public to hazards (Glantz & Balbach, 2002). To achieve these legislative objectives, advocacy groups have educated citizens and policy makers, lobbied, used the media, organized demonstrations and rallies, and formed coalitions.

Electoral Activities. Electoral activities take the action to the voting booth. In several recent local, state, and national elections, supporters and opponents of tobacco and gun control endorsed candidates, contributed money, and campaigned for politicians who supported their cause (DeMarco & Schneider, 2000; Zakocs, Earp, & Runyan, 2001). In some states, ballot initiatives and referenda provide another opportunity to take health issues to the voters. In California, for example, statewide or local tobacco control advocates used ballot initiatives or propositions to bring tobacco policy to the voters throughout the 1980s and 1990s (Glantz & Balbach, 2002).

Litigation. Litigation enables advocates to bring to court corporations alleged to have harmed health. Judges can order an end to dangerous practices, award compensatory or punitive damages, and set a precedent that will apply in other jurisdictions. In recent years, activists have taken each of the six industries reviewed here to court based on the health consequences of their actions. Several recent review articles have summarized the accomplishments and limitations of litigation as a public health strategy (Jacobson & Soliman, 2002; Parmet & Daynard, 2000; Pearson, 1997).

Actions Aimed at Corporations. Actions aimed at corporations provide advocates the opportunity to bring their messages directly to corporate directors or shareholders. In their campaigns to change howthe multinational Nestle Corporation marketed infant formula in developing nations, activists organized aworldwide boycott that has been periodically reinstated during the past 3 decades (Nestle, 2002, pp. 145-158). In the state of Washington, some activists have proposed revoking the corporate charters issued by the state for companies that repeatedly violate the law (Parrish, 1999). Investors have also become more active. By 2000, more than a trillion dollars was invested in U.S.-managed portfolios that used some social investment strategy, a thirtyfold increase from 1984 (Hertz, 2001, p. 122). Shareholder activism has, for example, forced 3M,America’s third largest billboard company, to end tobacco advertising on its billboards, and Kimberly Clark to sell its holdings in tobacco companies (Hertz, 2001, p. 124).

Education, Information, and Mobilization Campaigns. Education, information, and mobilization campaigns often constitute the foundation for other strategies and also serve to put an issue on the public agenda. Health advocates seeking to change corporate behavior have used counteradvertising campaigns against SUVs, tobacco, and alcohol (Agostinelli & Grube, 2002; Glantz & Balbach, 2002; Hakim, 2003); media advocacy to influence public opinion on alcohol, guns, and food advertising aimed at children (Holder &Treno, 1997;Wallack, Dorfman, Jernigan,&Themba, 1993); and community organizing to mobilize constituencies to support access to lower priced pharmaceutical products in other countries (American Association of Retired Persons, 2004). As Dorfman et al.
(2005) note, these strategies play an important role in framing conflicts between public health advocates and corporations and thus influence the outcome of these interactions.

In the past few decades, health professionals, advocates, and their supporters have accumulated an impressive body of experience using these strategies to influence corporate practices and policies. Each strategy has elicited counteractions by the corporate targets, and thus, strategies and tactics on both sides of these conflicts have changed continually. Systematic research is needed to identify the relative benefits and costs of these strategies and the circumstances that contribute to successful efforts to reduce the promotion of diseases.

The Outcomes

Although a comprehensive assessment of the efficacy of these strategies is beyond the scope of this report and perhaps premature, available evidence suggests that public health advocacy to change corporate practices has the potential to contribute to improved health. A few examples illustrate the range of achievements.

In some cases, environmental regulations can be remarkably effective in reducing threats to health. Between 1968 and 1983, for example, primarily as a result of new clean air standards advocated by the environmental movement, American automobile air pollution, which contributes to lung and heart disease, was reduced by 90% (Yates, 1983). Similarly, federal mandates for automobile seatbelts and air bags, long opposed by the auto industry (Doyle, 2000), are now credited with saving thousands of lives because consumer advocates persuaded Congress to require these devices (Martin, Crandall, & Pilkey, 2000).

In California, an aggressive tobacco control program that targeted both industry practices and individuals is estimated to have reduced tobacco consumption by 75% in 10 years, a much larger reduction than in states without such programs (Glantz & Balbach, 2002, p. 5). A recent study found that following a local law banning smoking in public places and in the workplace in Helena, Montana, the number of monthly admissions for acute myocardial infarction from the city but not from areas where the ban was not in effect dropped significantly (Sargent, Shepard,&Glantz, 2004), suggesting that changes in the law may be able to produce even short-term benefits.

In Washington, D.C., a lawbanning the purchase, sale, transfer, or possession of handguns by civilians was associated with a prompt decline in homicides and suicides in the city but not in adjoining areas without such bans (Loftin, McDowall, Wiersema, & Cottey, 1991). More recently, the threat of ongoing litigation led Colt Industries to decide to abandon much of its retail gun business and focus instead on producing for the military and police (P. H. Brown & Abel, 2003, p. 141), a clear example of pressure leading to changes in corporate practices.

IMPLICATIONS FOR HEALTH EDUCATION RESEARCH AND PRACTICE

To evaluate the overall health impact of campaigns to change corporate behavior and to develop guidelines for effective practice will require a more systematic approach to this phenomena and a more standardized body of literature. Some of the research questions that emerged from this review include the following:

1. What is the impact of corporate characteristics, such as the position of a company within its industry, the unique corporate culture, current profit levels, competitiveness within the industry, and its influence within the political arena, on a corporation’s policies and practices related to health? Under what circumstances do market forces lead to reductions in health-damaging practices?

2. What are the potentials and limitations of health advocacy campaigns at different levels and within different branches of the government? What shapes a particular government agency’s responsiveness to corporate versus health advocacy demands? Under what political and economic conditions are governments likely to support or oppose public health campaigns to change corporate behavior? What are the unique opportunities and constraints for change in different phases of economic, budget, and electoral cycles?

3. What frames best enable public health advocates to win public support for their goals? What are the relative advantages, disadvantages, and efficacy of the various strategies for changing corporate behavior? What is the relative efficacy of different types of advocacy coalitions or networks in changing corporate practices?

4. What are the specific social and behavioral processes by which corporate practices and policies damage health? What are the specific social and behavioral processes by which public health advocacy campaigns can mitigate or reverse these adverse health outcomes?

5. To what extent does corporate disease promotion contribute to or exacerbate disparities in health among different socioeconomic, racial, and ethnic groups? Do campaigns to change corporate behavior offer a way to reduce these inequities?

Designing studies to answer these questions constitutes a research agenda on disease promotion
and advocacy to change corporate practices that can guide future intervention.

A focus on corporate practices also challenges health educators to reconsider the theoretical paradigms that have guided our work. For many years, the dominant paradigm in health education has been that individual behavior and lifestyle are the primary determinants of population health in the United States (Fuchs, 1998; Knowles, 1977; McGinnis &Foege, 1993). Critics have long challenged this perspective (Freudenberg, 1978; Israel et al., 1995; Minkler, 1989), and a more recent synthesis is that policy also has an important influence on health and that public health interventions should seek to change individuals, organizations, and policies (Caraher & Coveney, 2004; Committee on Assuring the Health of the Public in the 21st Century, 2003; Green & Kreuter, 2005; Melkote, Muppidi, & Goswami, 2000). Despite this emerging scientific consensus, the vast majority of public health interventions still target only individual behavior, and few organized interventions have made meaningful and sustained efforts to change policy at a level that could influence population health (Bowen&Beresford, 2002; Freudenberg et al., 2000).

This focus on public health advocacy to change corporate practices also offers an opportunity to revise the dominant paradigm. If etiologic research confirms that corporate policies have a substantial impact on morbidity and mortality here in the United States and globally, modifying these behaviors takes on a new imperative. If evaluation research demonstrates that the intervention strategies described here successfully modify corporate behavior enough to reduce adverse health consequences, then public health professionals need to master the competencies needed to develop and sustain such interventions.

What does all this have to with health education? In 1986, the Ottawa Charter for Health Promotion (First International Conference on Health Promotion, 1986) defined health promotion as “the process of enabling people to increase control over, and to improve their health” (p. 1). More than any other single profession, health educators have as their central task educating and mobilizing individuals, organizations, and communities to promote health. Public health advocacy to change health-damaging corporate practices has emerged as a promising strategy for health promotion.Areviewof accounts of these advocacy campaigns shows that many of the core tasks in these efforts closely
parallel professional descriptions of health education competencies: framing public health issues, mobilizing community and institutional resources, educating the public, identifying political opportunities for action, building coalitions, and evaluating success. Similarly, the implicit or explicit rationales for these campaigns often rely on the same theoretical literatures that health educators use: theories on social movements, organizational and behavioral change, communications, ecological models, and empowerment (Glanz, Rimer, & Lewis, 2003; Green & Kreuter, 2005). These parallels between health education and health advocacy suggest that health educators already have some of the competencies needed to play leadership and supporting roles in these campaigns.

At the same time, advocacy to change corporate practices will require new competencies and perspectives. First, transferring the focus from changing the behavior of individuals to one that includes modifying corporate or government action will necessitate ideological as well as skills transformation. A starting point is to examine to what extent existing theories, such as the health belief model or social learning theories (Glanz et al., 2003), can also help predict and then change institutional behavior. Second, current health education practice relies heavily on cooperative and consensus-building strategies, based on the liberal assumption that people of goodwill can come together and agree on compromises. Recent advocacy campaigns to change corporate practices, however, have often used adversarial strategies, borrowing more from social movements and contentious politics (Tarrow et al., 1998) than from small group or social marketing theories. As Kreuter (2005) notes, power is the language that corporations speak and understand best. To prepare health educators with the skills to analyze power dynamics and the stomach and backbone for political conflict that advocacy campaigns against multinational corporations may require, training programs will need to modify their curricula.

Some health educators will raise understandable objections to an expansion of our practice to include advocacy to change corporate behavior. Some will contest the epidemiological evidence, asserting that the proximate role of individual behavior in current patterns of morbidity and mortality makes it the logical focus of health education efforts, not the more distant corporate policies. Others may agree that corporate practices play an important role but argue that changing such behaviors is too difficult or too risky, jeopardizing funding from government or corporate sources. Another point of view is that health educators should remain neutral rather than participate in social conflicts (e.g., debates on the appropriate roles for the government and markets in our society), maintaining
an objective, fair, and balanced stance. These concerns get to the heart of our definition of the role of health educators. Any expansion of health education practice to encompass health advocacy to change corporate behavior will require open and honest dialogue on these and related scientific, ethical, and professional questions.

Supporters of an expanded role for health education practice offer philosophical and pragmatic responses to their colleagues’concerns. First, they argue that public health and health education have always taken on special interests that harm health. Founders of modern U.S. public health, such as Alice Hamilton, C. E. Winslow, Margaret Sanger, Jane Adams, Mayhew Derryberry, and others (Rosen, 1993), tackled the employers, producers, landlords, and medical institutions that sometimes acted against the well-being of the public. Recently, the CDC (1999) identified the 10 greatest accomplishments of U.S. public health in the 20th century. Four of these—improving motor vehicle safety, making workplaces safer, producing safer and healthier foods, and recognizing tobacco as a
health hazard—involved modifying corporate practices that damaged health. Thus, say the supporters, advocacy to change corporate practice is not a new strategy but a return to our public health roots.

Second, borrowing from critics of the concept of scientific objectivity (Parsons, 2003), advocates argue that neutrality is a chimera and often serves to support the status quo by refusing to challenge those with the most power. Expecting health professionals to view the claims of the tobacco industry, for example, with equal credibility as those of public health researchers or advocates of tobacco control defies common sense and a 50-year historical record of deception (Glantz & Balbach, 2002; Kluger, 1997).

Supporters of advocacy campaigns to change corporate practices also reject the claim that the public opposes such action. They point to public opinion polls that show strong support for gun control, restricting tobacco advertising, strong public oversight of the drug industry, regulating pollution, and holding the food industry accountable for its role in the obesity epidemic (Batra, Patkar, Weibel, Pincock, & Leone, 2002; Nestle, 2003; Vernick, Teret, Howard, Teret, & Wintemute, 1993).

Finally, supporters of confronting disease promoters raise a moral imperative. If the mission of health educators is to promote health and the evidence shows that specific actions by corporations damage health, then there is a professional and moral obligation to act to reduce the harm. Failing to pursue promising strategies, they argue, violates ethical standards.

Recent events suggest that both the corporate quest for greater profits and less regulations and advocacy group efforts to modify corporate practices to better protect public health will continue. Public health professionals, including health educators, will need to decide how best to relate to these conflicts. By focusing attention on this emerging domain and by systematically assessing the potential for advocacy to change corporate practices to promote health, we can make informed choices about our future roles.

References [see PDF]

Corporate Practices and Health

In the last 20 years, in order to reduce prevalence of smoking, the public health community has become actively involved in combating the tobacco industry and its efforts to promote its products, avoid regulation, and mislead the public. Now others are applying these lessons to the food, automobile, firearms and pharmaceutical industries. What can we learn from a closer examination of these experiences?