Campaign Profile: The Public Health Advocacy Institute

Are the lessons learned in the legal and advocacy fights against Big Tobacco relevant to changing the practices of the food industry that contribute to obesity? What are the benefits and limitations of litigation against producers of unhealthy foods? On what legal grounds is the food industry most vulnerable to challenge? These are the questions that staff of the Public Health Advocacy Institute (PHAI), a legal “think-and-do” tank, seek to answer.

Forged in the legal battles against Big Tobacco, PHAI was originally founded in 1979 as a Massachusetts-based public health organization which became the Tobacco Control Resource Center (TCRC) and its legal research arm the Tobacco Products Liability Project (TPLP). In 2006, the TCRC and TPLP joined forces with the Boston-based Tufts/Northeastern University Obesity and Law Project, a public health law and research organization, to form PHAI.

In its current work, PHAI seeks to use legal strategies to achieve specific public health goals. Northeastern University’s School of Law serves as a home and resource for PHAI as it seeks to nurture a new generation of professionals. Lawyers, public health advocates, policy analysts and physicians are invited to take on the food industry’s role in obesity, collaborate at annual conferences, and stay updated with the tools necessary to continue the global fight for tobacco control.

First, the group seeks to expand the repertoire of legal arguments that public health lawyers can use to challenge corporate behavior that harms health. For example, PHAI lawyers are considering ways to use laws against deceptive advertising as grounds for legal action in much the same way product liability was used in tobacco litigation cases. In the case of tobacco, large punitive damages awards were intended to deter tobacco companies from further actions that harmed health.

Second, PHAI takes the campaign to reduce obesity into new settings such as public schools and after-school settings. Research produced by their School Food Project served as a catalyst for advocating to remove high sugar sodas from public schools.

Third, PHAI attorneys remain deeply committed to global tobacco control and work to expose the illegal activities of Big Tobacco by researching internal industry documents and producing scholarly publications and amicus briefs. The group’s newest work is expanding to the global arena as members engage the World Health Organization Framework Convention on Tobacco Control (WHOFCTC) to work to connect tobacco control and human rights with health policy decision-making processes.

New Tactics and the Next Generation of Public Health Law

Each year, PHAI hosts an international conference, Legal Approaches to the Obesity Epidemic, where an interdisciplinary gathering of advocates consider new strategies to change food and beverage industry’s influence on the health of the public. Each conference chooses a theme to highlight emerging issues. For example, during the 2005 conference, speakers emphasized the need for public health efforts to target advertising campaigns that contribute to childhood obesity and related illnesses.

Marking a shift away from personal injury litigation strategies used during the ‘tobacco wars’ [1], the shift to targeting advertising incited harsh reactions from industry groups. Groups like Consumer Freedom, a food and restaurant industry lobbying group, criticized the PHAI conferences, calling them a “cabal of activists” who “use junk-science in an attempt to erode consumer freedom and turn food companies into their newest cash cow” [2]. Despite these attacks, PHAI continues to support groups such as the Physician Committee for Responsible Medicine, which have successfully used lawsuits to change Kraft’s false advertising practices [3].

While PHAI sees tobacco litigation as one strategy for making corporations more responsible, the group’s recent work emphasizes broader, population and environment-based interventions to reduce obesity—namely, policy, regulation and legislation. In a 2002 article in the Journal of the American Medical Association, PHAI President Richard Daynard acknowledged litigation as a tool to control obesity and points to the key differences between tobacco and food. “In the absence of proof that particular food industry practices cause obesity, suits seeking compensation for obesity-related injury are unlikely to succeed, while suits seeking to protect consumers from unfair or deceptive food marketing techniques are more likely to succeed” [4]. In a 2004 interview with Medscape, Daynard argued that consumer responsibility and personal responsibility “would be much more credible if the consumer was actually being told how fattening the food was and [had] a chance to say, no, I think I won’t take that order; I’ll order something else” [5]. Legal work to combat unhealthy food consumption seeks to increase product labeling and hold companies responsible for quality regulations and monitoring the actual caloric content of food marketed as “low in fat” or “high in fiber.”

Negotiating with the Food Industry

In an effort to better understand how food industry practices contribute to childhood obesity, PHAI spearheads new research design and policy recommendations. Their work has contributed to large-scale changes, such as the 2006 negotiation arranged by former President Bill Clinton, Governor Mike Huckabee, and the American Heart Association that promises to remove many sweetened beverages including Coke and Pepsi products from schools by 2009 [6]. PHAI member and Tufts Professor of Public Health and Family Medicine Aviva Must says she “would prefer these machines carry just water and low-fat dairy products, but I think this is a good start.”

To inform these campaigns, in 2006 PHAI released a report, Raw Deal: A Report on School Beverage Contracts. In a collaborative project with the Center for Science in the Public Interest (CSPI), the group conducted a national survey of school beverage contracts evaluating whether the alleged financial benefits were realized by schools. The exclusive contracts between beverage companies and schools place soft drink vending machines in accessible locations throughout elementary, middle and high school settings, and provide schools with income in exchange for exclusive “pouring rights.” However, the study found that the majority of the revenue from the contracts, was going not to the schools, but to the beverage companies. “The study highlights the need for legal tools to assist school districts in negotiating relationships that put the health and welfare of children first” [7] says Jason Smith, Associate Executive Director and head of PHAI’s Healthy Eating Law and Policy Project.

PHAI’s Healthy Eating Law and Policy Research Project also investigated how the law affects the foods available in public schools. Research from this project led to a policy guide to assist schools to develop healthier food policies. The report, Mapping School Food, highlights the need for policy makers to create school food programs informed by public health prevention strategies, and presents practical suggestions on how to quickly achieve change. Funded by a grant from the Robert Wood Johnson Foundation, the Healthy Eating Law and Policy Research Project is also expanding its research to consider food availability in after-school activity programs [8].

Acting Locally and Globally on Tobacco

To continue its effort on tobacco, PHAI’s team of lawyers and public health advocates are arming tobacco control professionals with data from newly available internal industry documents released under the provisions of the 1998 Master Settlement Agreement.

In their analyses of the formerly secret tobacco documents, PHAI Senior Staff Attorney, Sara Guardino and President Richard Daynard uncovered some of the ways that tobacco lawyers used the law to keep information about the harm of smoking from reaching the public. In their recent publication, Tobacco industry lawyers as “disease vectors,” they present evidence showing industry lawyers had “taken steps to manufacture attorney-client privilege” including assisting in the concealment of documents and the use of aggressive litigation techniques. PHAI lawyers and researchers have helped to expose illegal techniques employed by industry lawyers, including ‘scorched earth’ strategies—wherein plaintiffs’ efforts to bring tobacco companies to trial are thwarted by superfluous litigation.

PHAI’s discoveries from internal tobacco document inquiries and its history with tobacco litigation inform tobacco control policy recommendations both nationally and globally. The Tobacco Control Resource Center at PHAI provides legal and policy information to local, state and national decision-makers, files amicus briefs, and helps to build global information networks among tobacco control advocates around the world.

PHAI recently joined efforts to advance the Framework Convention for Tobacco Control, the first international public health treaty for the control of tobacco products. In Viet Nam, for example, a nation that has signed the FCTC, PHAI is helping to link tobacco control advocates with human rights organizations. In their Fall 2007 newsletter, PHAI says this approach is critical to creating change; “Linking the broader range of women’s, children, and social, economic and cultural rights with the WHO FCTC helps to highlight the ways in which these rights are inextricably interlinked, interrelated and indivisible” [9].

The Institute is now also working with health departments, NGOs, and tobacco control organizations in several nations to develop long-term strategies to reduce the influence of tobacco companies on the health of the public. By carving out legal grounds on which to challenge tobacco and food industry’s health damaging practices, PHAI helps set the stage for a unified effort toward public health solutions. Whether countering Big Tobacco’s tactics of obfuscation, assisting public school food policy development, or facilitating global tobacco control dialogue, PHAI is creating an organized public health legal approach to counter corporate influences on well-being and setting precedents for a global movement for health.

 

References

1. Daynard RA, Hash LE, Robbins A. Food Litigation: Lessons from the tobacco wars. JAMA. 2002;288(17):2179.

2. Cabal Of Activists And Lawyers Plot To Sue Food Companies. Consumer Freedom. June 19, 2003. Available at: http://www.consumerfreedom.com/print.cfml?id=1975&page=headline.

3. Thorn B. Conference: obesity lawsuits should focus on ads, children. Nation’s Restaurant News. Oct 17, 2005.

4. Daynard RA, Hash LE, Robbins A. Food Litigation: Lessons from the tobacco wars. JAMA. 2002;288(17):2179.

5. Barclay L. Legal Approaches to Obesity: A newsmaker interview with Richard Daynard, JD, PhD.

6. Mohl B. After Soda Ban, Nutritionists Say More Can Be Done. The Boston Globe. May 4, 2006;A1.

7. School Beverage Contracts Leaving Districts With a Bad Aftertaste: The Public Health Advocacy Institute Releases First National Study of School Beverage Contracts. Press Release. Public Health Advocacy Institute. Dec. 6, 2006.

8. PHAI Fall 2007 Newsletter.

9. PHAI newsletter fall 2007 p. 7

 

Photo Credits:

1. Vending Machine by warpr
2. Urban Convenience Store by coyenator

New York State Assemblyman Felix Ortiz, The Marin Institute and Corporations and Health Watch Hold Press Conference on Alcohol Advertising in the New York City Public Transit System

On November 8, 2007 New York State Assemblyman Felix Ortiz, Marin Institute and Corporations and Health Watch held a joint press conference at the New York City Hall steps to draw attention to recent research on alcohol advertising in the New York City transit system.

At this event, a representative of Assemblyman Ortiz’s office highlighted two new New York bills, A9506 and A9507, which seek to ban alcohol advertising in the subway system and which would impose fines for violations.

Bruce Lee Livingston, Executive Director, and Michele Simon, Research and Policy Director, of the Marin Institute reviewed findings from their recent study “The End of the Line for Alcohol Ads on Public Transit,” in which they found that the New York Metropolitan Transportation Authority has one of the most permissive policies on alcohol advertising in public transit in the country.

Finally, Dr. Nicholas Freudenberg, distinguished professor of public health at Hunter College, City University of New York, discussed findings from a July 2007 Corporations and Health Watch study demonstrating that of the total advertisements observed in New York City subway stations during June and July 2007, nearly 30% were for alcoholic beverages.

The three organizations highlighted the negative health and social impact of alcohol advertising on New Yorkers and particularly on underage children who are exposed to such advertisements daily in their travels through the MTA system.

Public health vs. free trade: Sweden and European Union clash over alcohol policy

Last June, the European Court of Justice ruled that a Swedish ban on individuals importing alcohol inhibited the free movement of goods within the European Union, a key pillar of the EU’s single market goal. The Court found that the measure “is inappropriate for attaining the objective of limiting alcohol consumption generally and is not proportionate for attaining the objective of protecting young persons from the harmful effects of alcohol.”

 In Sweden, a state-run monopoly known as Systembolaget handles all retail sales of alcoholic beverages. A Swedish citizen, Klas Rosengren, had imported Spanish wine outside this system and Sweden had confiscated the wine and instituted criminal proceedings against him, an action halted by the court ruling. While Rosengren and the alcohol industry hailed the ruling, Bjoern Rydberg, the communications director at Systembolaget, minimized its importance, “This decision is not very important as previous rulings have already stated that the products have to be taxed” [1]. Since most individuals import alcohol privately in order to avoid paying Sweden’s high alcohol tax, the incentive for private importation is not high if taxes are due anyway.

Whatever the short term impact of this ruling, the dispute centers on two contradictory principles– a nation’s right to protect public health against harm from, in this case, alcohol, and the right of companies to free movements of goods within the growing boundaries of the European Union. How these conflicts are settled in Europe and elsewhere will influence whether globalization and free trade undermine public health protection or lead to new ways to balance trade promotion and health promotion.

In the late 19th century, in response to high levels of alcohol consumption and health-related alcohol problems, Sweden began a series of initiatives to reduce alcohol use. These included a rationing system introduced in the 1920s, high taxes on alcohol, the establishment of the state monopoly on retailing in order to minimize the profit motive, a state monopoly on importation of alcohol, and reduced availability of alcohol by, for example, closing the retail stores on Saturdays. Social movements also took on alcohol; a popular slogan of the labor and temperance movements was, “You cannot stagger to freedom.” Over time, these policy measures were relatively successful. By the 1980s, Sweden had one of the lowest rates of per capita consumption of alcohol and alcohol-related health problems in western Europe [2].

In 1995, Sweden joined the European Union and many of its previous alcohol policies were changed. For example, only the retail monopoly was retained and alcohol taxes were lowered. By 1997, beer prices decreased by about 20% and between 1996 and 2004 legal imports trebled and illegal imports quadrupled, as estimated from survey data. In addition, the number of authorized alcohol outlets was increased and Saturday business hours were restored. These changes were associated with a steep increase in per capita annual alcohol consumption, from 8 liters in 1996 to 10.4 liters in 2004.2 Data also suggest an increase in the frequency of heavy drinking, a pattern associated with alcohol-related injuries and violence. Compared to other countries, Swedes have developed a distinctive pattern of drinking with relatively few drinking occasions but a high frequency of heavy drinking among both adults and young people. Some studies have shown that compared to other western European countries, Sweden has a higher rate of alcohol-related mortality associated with increased consumption [3].

In 2005, concerned that the EU was going to further preempt its alcohol control policies, Sweden’s Systembolaget launched a preemptive European-wide print and internet ad campaign. In messages addressed to the European Union President, Jorge Manual Barroso, the Swedish ad read, “Dear Mr Barroso, here’s why you should seriously consider cutting down on drinking”. It then cited World Health Organization data showing that Europe had the highest alcohol consumption of the six global regions and that 600,000 Europeans died of alcohol-related causes in 2002, accounting for 6.3% of all premature deaths and 10.8% of the disease burden [4].

In the coming years, Sweden and the EU will continue the battle to resolve conflicts between public health protection and liberalization of trade rules. At stake is the right of nations to determine their own policies to protect health and the right of industries and global markets to eliminate obstacles to their ability to sell what they want where they want. As shown in Table 1, alcohol consumption patterns in Europe vary widely, in part in response to local cultures but also due to differences in alcohol control policies on tax, pricing and retail distribution. In the business friendly Czech Republic, annual consumption rates are almost 2.5 times higher than in Sweden and the incidence of chronic liver disease and cirrhosis is more than three times higher. How the European Union sets alcohol policy will influence whether Sweden becomes more like the Czech Republic or vice versa.

Alcohol in Three European Countries

 

 

Sweden

France

Czech Republic

 

  

 

Average annual consumption 
(in liters of pure alcohol)

 

5.62

 

9.5

 

13.67

Incidence of chronic liver disease/cirrhosis
(per 100,000 people)

5.26

13.33

16.66

Price of .5 liters of beer
Price of .7 liters of spirits (in Euros)

1.29
21.54

.66
11

.23
3.19

Tax on beer 
Tax on spirits 
(as % of retail price)

26%
67%

9%
33%

7%
26.1%

Restrictions on alcohol sales

State monopoly

Sales license required

License required for production but not sales of alcohol

 

     

 

By Nicholas Freudenberg, Hunter College, City University of New York.

 

Sources: WHO Europe, Eurocare (European Alochol Policy Alliance and the Institute of Alcohol Studies)

1. Court rules against Swedish alcohol import controls. Agence France Press, June 5, 2007. Accessed at http://www.eubuisness.com/EUlaw/1181037607.17/ 
2. Norstrom T, Ramstedt M. Sweden – is alcohol becoming a regular commodity? Addiction 2006; 101(11): 1543-1545. 
3. Norstrom T., ed. Alcohol in postwar Europe: consumption, drinking patterns, consequences and policy responses in 15 European countries. Almqvist and Wiksell, Stockhom, 2002, pp. 157-76. 
4. Bevanger L. Swedish ads urge EU alcohol curbs, BBC News, Oslo, November 22, 2005. Accessed at http://news.bbc.co.uk/2/hi/europe/4458622.stm

Photo credits:

1. Systembolaget 
2. Tom Rovers

 
 

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 

Senators and Activists Agree: No Soda in Schools

Soft drink companies agreed to voluntary guidelines to remove sugar dense sodas from public schools in a deal brokered by the William J. Clinton Foundation and the American Heart Association in 2006, but advocates for healthy food choices are calling for tighter restrictions. The global campaign, Dump Soft Drinks, and new legislation being drafted in the Senate are calling for nutrition-based limitations in the food and beverages available in easy-to-reach school vending machines.

Proposed Amendment Seeks to Reduce Soda and Junk Food in Schools

After years of advocating for improved nutritional standards in schools, Senators Lisa Murkowski (R., AK) and Tom Harkin (D., IA) say they will offer an amendment to the Senate farm bill that will “improve the diets and nutrition of America’s school children by setting reasonable, common-sense standards for the foods and beverages that are sold in school vending machines and similar outlets” [1].

The nutritional standards for food sales haven’t changed since the late 1970’s, “when microwaves were considered cutting-edge, newfangled technology,” Harkin told The Wall Street Journal [2]. The proposed legislation would eliminate soft drinks and other high sugar beverages from elementary and middle school, but would allow low-fat flavored milk products, diet sodas, and sports drinks in high schools. It would also place limits on salty, high calorie and fatty snack foods.

 

Global Dump Soft Drinks Campaign

Setting nutrition standards for school vending machines is just one of Dump Soft Drinks‘ recommendations. The campaign is lead by two advocacy groups well versed in both national and global public health fights for healthy diets and food. With theDump Soft Drinks campaign, the Center for 

Science in the Public Interest (CSPI) and their global counterpart, theInternational Association of Consumer Food Organizations (IACFO), work to inform consumers about how soft drinks contribute to diet-related diseases like obesity and diabetes.

The campaign emphasizes global health effects beyond schools. In the US and Europe, rates of obesity and diabetes are increasing due to unhealthy diets and lack of physical activity, a trend now reaching global dimensions. In their report “Soft Drinks and Obesity—Global Threats to Diet and Health” [3], Dump Soft Drinks shows specific examples of the correlation between increasing soda consumption and rising diabetes rates in countries like Mexico and China. The report also points to the role played by transnational corporations that market nutritionally empty products in developing countries—many of which, paradoxically, continue to be burdened by under-nutrition.

The campaign calls for marketing restrictions on companies like Coca-Cola Co. and PepsiCo Inc. that spend billions on target marketing each year. Following the United Kingdom’s new legislation that limits marketing to younger audiences, Dump Soft Drinks wants to see the end of US soft drink marketing to children and teenagers under 16. They also advocate for labeling regulations and propose a value-added tax to soft drinks that would go toward boosting government health and nutrition education programs.

Dump Soft Drinks: Recommendations to limit soft drink companies’ contribution to diet-related disease

1. Increase the promotion of new lower-sugar products, sell existing high sugar products in smaller portions, and support independently funded research on the use of safe substitute sweeteners.

2. Cease all marketing of sugar-laden beverages to children under 16, including print and broadcast advertising, product placement, the Internet, mobile phones, athletic event sponsorship, signage, merchandising, and other means.

3. Prominently display the calorie content, per serving, of all beverages on the fronts of containers and the outer labels of multi-container packages, along with the number of servings per bottle or can as part of a comprehensive labeling system utilizing simple and uniform symbols to convey nutritional value. Sugary beverages should also include rotating consumer alerts such as “High sugar – drink only occasionally” or “For occasional consumption. Drink water to quench thirst.”

4. Stop promoting and selling sweetened beverages, including sports drinks and fruit flavored beverages and teas, in all public and private elementary, middle, and high schools; sell fruit juice in container sizes of 250 ml or less.

5. Pay a modest Value Added Tax on soft drinks – with governments using the proceeds for nutrition education and physical activity programs and to subsidize the costs of fruits and vegetables.

6. Ensure that sponsorships involving the promotion of physical activity and health be made in a transparent fashion only to independent health charities or government agencies which, in turn, use such funds for programs not associated with the company’s logo, brands, or other proprietary information. Physical activity and nutrition education programs sponsored by beverage companies should not convey the impression that all products produced by the company are healthful and nutritious.

Opponents cite declining US and European soft drink sales and ask “Why not let parents and children make their own food and beverage decisions?” In an interview with Fox News, CSPI spokesperson, Bruce Silverglade, addressed this concern. “Coca-cola and Pepsi spend almost $5 billion dollars a year advertising their products worldwide. That is a sum that is exponentially higher than the amount spent on nutrition education… Marketing undermines … parental authority and counteracts the efforts by parents to teach their children to live more healthily” [4].

Working to fight the childhood obesity epidemic, both The Global Dump Soft Drinks Campaign and the Senate farm bill amendment agree that as a learning environment, schools are obligated to model healthy food choices as nutrition education by limiting the sales of soft drinks and junk food.

CSPI worked with Senators Harkin and Murkowski to develop legislation that would receive broad support. Health advocates and food and beverage industry allies are now standing behind the proposed federal nutrition-based standards. Though battles to push the legislation through Congress remain to be fought, it is currently endorsed by the American Dietetic Association, the American Public Health Association and the National PTA, Coca-Cola, PepsiCo, Cadbury Schweppes and the American Beverage Association.

 

References

1. Harkin-Murkowski amendment will update decade-old nutrition standards in schools nationwide. Senator Lisa Murkowski, United States Senate Press Release. Dec 4, 2007. Available athttp://murkowski.senate.gov/pressapp/record.cfm?id=288191.

2.McKay B. Soda Makers Support Tougher Curbs. The Wall Street Journal. Nov 9, 2007:B2. Available athttp://online.wsj.com/article/SB119458164755287687.html.

3.Soft Drinks and Obesity—Global Threats to Diet and Health. The Global Dump Soft Drinks Campaign.http://www.dumpsoda.org.

4. Should Government Limit Marketing of Soft Drinks to Children? Fox TV News Debate. Washington, D.C. Nov 16, 2007. Available at http://www.dumpsoda.org/media.html.

 

Photo Credit:
United States Federal Government, Public Domain.

Campaign Profile: The Prescription Project

The problem of conflicts of interest between the pharmaceutical industry and prescribing physicians

The Prescription Project seeks to ensure that “industry-physician relationships are free of conflicts of interest and that physicians base their prescribing decisions on accurate and unbiased information.” Recent events such as Merck’s withdrawal of Vioxx after aggressively promoting its use to physicians and consumers and an FDA warning on GlaxoKlineSmith’s heavily promoted diabetes drug Avandia have focused public attention on the ways that the drug industry promotes its products.

The Prescription Project was founded in 2007 to encourage new approaches to ending conflicts of interest. In combination with a team of academic researchers, two of the project’s directors published an article on the problem of conflicts of interests between industry and physicians in the Journal of American Medical Association [1]. Community Catalyst, a national non-profit health care advocacy organization, founded the Prescription Project in partnership with the Institute on Medicine as a Profession, a research center at Columbia University with funding from the Pew Charitable Trust. Jim O’Hara, the managing director of policy initiatives at Pew, explained the rationale for the Project,  “If you’ve been in the waiting room when these Chinese lunches are taken into the back office, it may raise the question whether the decisions are based on the best scientific evidence about medication or whether or not those Sichuan shrimp have something to do with the prescribing patterns” [2]. The pharmaceutical industry spends $7 billion dollars per year marketing to doctors and another $18 billion on samples for physicians and patients [3].

Research and Policy Guidance for Academic Medical Centers and Government

By conducting research on the influence of pharmaceutical marketing on physician prescribing behavior, The Prescription Project provides evidence to guide policy recommendations for medical institutions. The group also conducts case study investigations of Academic Medical Centers (AMCs), seeking to understand the impact of its suggested guidelines. For example, if such studies show that the pharmaceutical industries continue to support drug research in institutions that impose guidelines, other institutions may overcome their resistance to change. Already several medical centers, including those at Yale, the University of Pennsylvania, Stanford and the University of Michigan have implemented or announced restrictions on drug industry marketing to their physicians.

The Project also seeks to influence national policy on conflict of interest rules such as the Physician Payments Sunshine Act recently introduced to the Senate [4]. Charles Grassley (R-IA), co-author of the Sunshine Act, recently told the New York Times ”Right now, the public has no way to know whether a doctor’s been given money that might affect prescribing habits” [5]. Media coverage of these proposals offers the Prescription Project an opportunity to influence the national debate [6].

The Prescription Project also advocates at the state level, urging legislatures to follow the precedent set by states like Maine, Vermont and New Hampshire that have passed prescription confidentiality legislation [7]. Though the law has been overturned and is now being fought in appeals court, New Hampshire’s 2006 Prescription Confidentiality Act was the first of its kind [8].

Prescription Project Critics

The Project has attracted criticism both from the pharmaceutical industry and physicians. Critics within medical institutions argue the Prescription Project’s guidelines to reduce conflicts of interest are unnecessary because physicians do not make decisions based on “pizza and pens,” as Harvard Medical School hematologist Thomas Stossel is quoted saying in a recent Lancet article [9]. Stossel is concerned that restrictions on interactions between the drug industry and physicians could obstruct the biomedical advances that have come out of collaborative research partnerships [9].

The drug industry insists that the guidelines the Prescription Project proposes are unnecessary. Ken Johnson, senior vice president at the Pharmaceutical Research and Manufacturers of America, said, “A new law is not necessary when pharmaceutical marketing is already heavily regulated by the Food and Drug Administration [5].” In addition, the American Medical Association, which received more than  $46 million for its 2005 sale of data on physician prescribing practices [7], has yet to take a position on the federal proposal [10]. (See box below).

Despite those who feel that guidelines on industry-physician relationships are not needed, studies show that free samples and meals, gifts, funding for travel and lodging, continuing medical education, research funding, and honoraria funded by pharmaceutical companies do influence physician prescribing and professional behavior [11]. Social and psychological studies indicate gift-giving can bias decisions about patient care and create an unspoken reciprocity agreement wherein physicians are obligated to prescribe the products most heavily marketed to them [12, 13]. This situation not only creates real or perceived conflicts-of-interest, but may also increase overall drug spending [14].

Beyond voluntary guidelines

Based on this evidence [15] and its own research [13] on the psychological dynamics of industry marketing, the Prescription Project believes that voluntary guidelines will not prevent conflict-of-interest [13]. They recommend instead the prohibition of industry-physician interactions [13]. The Prescription Project’s Executive Director, Robert Restuccia, commends AMCs, such as Boston Medical Center and Boston University School of Medicine, which have taken up the groups recommendations because they “recognize the harmful impact of pharmaceutical marketing—it undermines better patient care, increases our nation’s health care costs and ultimately decreases confidence in physician independence” [16]. For The Prescription Project, AMCs serve as model institutions for strict mandates because of their ability to adopt change quickly and instill medical ethics in coming generations of medical providers.

Data Mining

For more than 65 years, the American Medical Association has been selling pharmaceutical companies the Physician Masterfile, a database that contains information on the prescribing practices and other characteristics of 900,000 practitioners, most of whom are not AMA members [17]. Most physicians are unaware of this practice. The drug companies then use data mining techniques to understand the profiles of prescribers of their products and provide pharmaceutical sales representatives, “drug detailers”, with the guidance needed on how best to approach individual doctors.  The Prescription Project has collaborated with the National Physicians Alliance and American Medical Student Association to demand an end to the sale of this information to pharmaceutical companies and better protection of physician privacy.

Data mining is a big business for data collection companies such as IMS Health Inc., Plymouth Meeting, Verispan L.L.C., Wolters Kluwer Health. These businesses combine physician data with pharmaceutical prescribing data from pharmacy chains and other prescription sources to form complex physician profiles. The data mining groups then sell the hybrid information to drug companies, which in turn, create specialized marketing efforts directed at individual providers. The AMA insists the sale of the Masterfile is strictly for “licensure,” the legitimate process of verifying credentials and maintaining continuing medical education efforts [17], but the hefty profit its sale turns each year and the failure of the society to inform practitioners of the practice, has led many to call for policy change.

At the annual AMA meeting in Chicago this past summer, physicians engaged in the conflict-of-interest problem spoke out against the AMA’s relationship with Pharma interest groups. A member of the National Physicians Alliance, Dr. Ben Schaefer said he understands the necessity of physician prescribing data for research and continuing education, but states, “As a physician, I want my prescription information to be protected from commercial exploitation” [18]. Three states have passed legislation that either prohibits data mining or allows physicians to make their own privacy decisions, but in each case, data mining companies have sued.

Drug companies argue the data mining restrictions violate commercial free speech and threaten public health research. Chief Executive Director of Wolters Kluwer Health, Jeff McCaulley, admits “It’s true that the pharmaceutical sales reps were using these lists to target high-prescribing doctors,” but he says the pharmaceutical industry has changed its practices and is now more “responsible” with physician data [19]. Despite these claims, pharma interests have vowed to take legal action against any similar measures.

The Prescription Project has taken on a role as watchdog on the data mining issue. Legal council, Sean Flynn, noted that “the incorporation of prescribers into the commission structure of pharmaceutical sales incentives debases the medical profession, and, the more the practice becomes public, (the more it) breaks the chain of trust between doctor and client” [18].

McDonald’s and Children’s Health: The Production of New Customers

In a recent study published in the Archives of Pediatrics and Adolescent Medicine, 1 researchers found that low income 3 to 5 year old children preferred the taste of hamburgers, chicken, French fries, carrots or low fat milk if they thought the products were from McDonald’s, whether or not they actually were. Thus, in their first years of life, children had come to associate McDonald’s branding with desirable foods, creating a lifetime potential for obesity and over consumption of the high fat, low nutrient products that McDonald’s features. To understand its success in imprinting even the youngest children, Corporations and Health Watch investigated the range of McDonald’s activities geared towards children. By focusing on the specific ways that one company goes about reaching children, we hope to gain insights that can guide public health strategies to reduce childhood obesity.

According to its 2006 Annual Report, McDonald’s is the leading global foodservice retailer with more than 30,000 local restaurants serving 52 million people in more than 100 countries each day. Its 2006 revenues were $ 21.6 billion, up 16% from 2004.

 

McDonald’s leads in food advertising to children

Marketing directly to children began in the 1960s. McDonald’s founder Ray Kroc, along with Walt Disney, has been credited with recognizing that children constitute a valuable and distinct market segment. Kroc observed that, “A child who loves our TV commercials and brings her grandparents to a McDonald’s gives us two more customers.” 2(p. 41) Developing brand loyalty in children influences both later purchases and the buying patterns of parents. At the forefront of marketing to children, McDonald’s spends more on advertising in general than any other brand. 2(p. 4) In 2006, McDonald’s spent almost $2.5 million a day on traditional advertising in the United States. About 40% of McDonald’s total advertising budget is directed at children. 3(p.102)

The use of cartoon characters and icons

Ronald McDonald, the face of McDonald’s, is a symbol of the corporation’s dedication to reaching young customers. The only fictional character with a higher degree of name recognition by children is Santa Claus. 2(p.4) A study of 9-10 year old Australian youth demonstrated that more than half believed that Ronald McDonald knew what was best for them to eat. 3(p.100) To reinforce the association of fun and entertainment with its fast food, McDonald’s offers a line of videos featuring Ronald McDonald and the McDonaldland characters. McDonald’s use of cartoons to market to children extends to the Internet as well. An earlier version of the McDonald’s children’s website told young visitors Ronald was the “ultimate authority on everything” and they were encouraged to send Ronald an email telling him their favorite food items, their favorite sports team, favorite book and their name. 2(p. 45) Directly soliciting children for personal information is now prohibited without parental approval thanks to the Children’s Online Privacy Protection Act of 2000. One of the McDonald’s current websites aimed at children, Ronald.com, tells children they can “learn, play and create while having fun.” On the site, children interact with “adver-games” which are designed to engage children with both the game and an advertisement. The site’s games all feature Ronald McDonald somewhere in the game. Happymeal.com, a site designed to encourage children toward physical activity, also prominently features the “Happy Meals” logo each time a new game is opened.

Restaurant design

The atmosphere of McDonald’s itself is designed to be “family friendly.” McDonald’s operates more than 8.000 playgrounds around the United States, more than any other private American corporation and far more than any municipality. Originally modeled on Disney World, the playgrounds provide an environment that is designed to appeal to children through bright colors, toys and clowns, and also to parents by providing a safe place for children to play. For children who live in low-income neighborhoods without safe or adequately maintained public parks and playgrounds, McDonald’s may offer one of the few opportunities for such forms of play and sociality. Birthday and other parties can be held at many McDonald’s which provides, on a cost per child basis, the food, invitations, paper and plastic wear, party entertainers, party favors and clean-up afterward. These design elements contribute to associating McDonald’s with fun and socialibility.

Toys and entertainment

In 1979, McDonald’s launched its first “Happy Meal,” which included numerous toys such as a “McDoodler stencil,” a puzzle book, and McDonaldland character eraser in a cardboard box with a circus theme. By 2003, 20% of McDonald’s meals sold were Happy Meals and they accounted for $3.5 billion in revenues. The fast food giant stands as one the United State’s largest distributors of toys. 2(p. 4) In addition to toys, McDonald’s appeals directly to children through cartoon characters, catchy jingles, and food shaped and colored to appeal to children. In addition, McDonald’s develops strategic partnerships, sponsorships, character licensing agreements and endorsements with celebrities and corporations such as NBA stars, Disney, the Fox Kids Network, DreamWorks and the Olympics. 2 Among the celebrities who have done product endorsements for McDonald’s are Venus and Serena Williams, Cedric the Entertainer, Kobe Bryant and Michael Jordan. Through such alliances, McDonald’s aims to have children associate the good feelings they have about celebrities, characters and companies with McDonald’s itself. That fit and celebrated athletes promote its products further associates McDonald’s with health and fitness.

In addition to television commercials featuring celebrities and promoting cartoon character toy give-a-ways, McDonald’s targets children through product placement and sponsorship. The fast food company has paid to have its food products featured in such children’s films as “George of the Jungle,” “The Flintstones,” and “Richie Rich.” 3(p.113) McDonald’s also sponsored the children’s show “The Teletubbies” and distributed toys representing the four characters. As with the Teletubbies, the company produces multiple versions of toys associated with movies and television. 4(p. 181) Children are encouraged to collect them all to obtain the full set, thus encouraging return visits—and more Happy Meals. In 1999 alone, McDonald’s released eighty different versions of Furby. 2(p.47)

McDonald’s marketing to children extends beyond television commercials, kid-friendly websites, toys and playgrounds. In 1987 McDonald’s launched their “McKids” line of clothing that was initially sold at Sears, Roebuck & Co. It was later picked up by Wal-Mart which dropped the line in 2003. Now McKids is offering a line of branded toys such as bikes, skateboards and scooters designed to encourage children to be more active between their visits to the Golden Arches.

McEducation

In their 2005 study of the clustering of fast food restaurants around public schools, Bryn et al reported that “Fast-food restaurants are concentrated within a short walking distance from schools, exposing children to poor-quality food environments in their school neighborhoods.” In the early years of McDonald’s, founder Ray Kroc actually flew in a Cessna scouting for new sites near schools. 2(p. 66) Like other fast food companies, McDonald’s does more than just place itself close to schools; in recent years it has opened outlets within high school cafeterias. According to a recent CDC survey, in 2006, 24% of the nation’s high schools and 19% of its middle schools offered on-site brand name fast foods.

McDonald’s also sponsors Channel One programming, provides educational curricula that feature information about working at McDonald’s and offers incentive programs, like “McSpellit Club,” whereby students can earn meals at the restaurant for spelling, reading and good attendance. 4,5 In addition, McDonald’s is a client of Cover Concepts, a company which provides branded textbook covers free to students and schools. 5 Finally, in 2005, with 31,000 elementary schools around the country, McDonald’s launched its “Passport to Play” program, aimed at encouraging physical fitness for third through fifth graders. Each time children play a game from around the country, they receive a golden arches stamp on a pretend passport. The website states, “Passport to Play is a fun way to keep kids’ minds engaged and bodies active. Teach your students how kids from around the world play, snack and grow [emphasis added].” Bryn Austin, assistant professor of pediatrics at the Boston Children’s Hospital suggested the program might be a “Trojan Horse” created to keep McDonald’s name in schools.

But McDonald’s doesn’t just take money from students; it raises money for them. In New Haven, CT, a group of teachers and staff from the New Haven Middle School participated in a McDonald’s educational program working a 4 hour shift at the counters and the drive-up window. By doing so, their school received 20% of the profits during the time they staffed the establishment. While the teachers worked, students decorated the walls of the restaurant with pictures of the golden arches. 3(p. 130) On October 13 of this year, 450 McDonald’s establishments in Tennessee participated in a similar “McTeachers Night” program. In addition, the corporation sponsors young people’s sports teams such as the McDonald’s All American High School Basketball Team.

Strategic Locations and Charity 

To keep its name in front of young people, McDonald’s develops partnerships with institutions where children are likely to be found. In August 2001, the fast food corporation began a 10 year, $16 million contract with the Smithsonian Institution’s Air and Space Museum. The museum features McDonald’s food as well as food from two other companies owned by McDonald’s, Boston Market and Donatos Pizzeria.3(p. 300) The Philadelphia Children’s Hospital and other children’s hospitals around the country feature a McDonald’s in their facilities. Finally, The Ronald McDonald House Charities has provided housing and meals to families with more than two million seriously ill children, further reinforcing the idea that Ronald McDonald and the McDonald’s corporation care about children’s health.

Influencing parents to reach children

Children are believed to influence approximately $500 billion of spending each year. 3(p. 101) Thus, while McDonald’s focuses much of its marketing on children, the fast food giant also seeks to influence parents’ purchasing decisions. Corporate memos discuss the company’s desire for adults to feel like “good parents” by taking their children to McDonald’s in order to make them happy. 2(p. 50). To counter criticism that fast and junk foods contribute to obesity and other health problems, McDonald’s recently launched a contest to recruit mothers for three day paid field trips where they will be given access to the farms “where our fresh ingredients are grown, to our world-class suppliers and to our restaurants.”

McWorld

As McDonald’s saturates US markets and succeeds in attracting young Americans as lifetime customers, growth increasingly depends on expanding its consumer base through overseas marketing. McDonald’s opens about four new restaurants every day overseas. 2(p.229) The table below shows the growth in McDonald’s outlets in various parts of the world between 1991 and 2001. 3(p.58)

Growth in McDonald’s Outlets by World Region, 1991-2001

In preparation for the 2008 Beijing Olympics, McDonald’s is promoting aninternational contest for 300 children, 100 from China, to win trips to the games.

The increased visibility and availability of McDonald’s around the world has succeeded in reaching greater numbers of children. At one primary school in Beijing, all of the children recognized and liked Ronald McDonald, and believed that “Uncle McDonald was funny, gentle, kind and…understood children’s hearts.” 2(p. 231) In Japan, 98% of children recognized Ronald McDonald; In England the figure was 93%. 3(p. 99) Ronald McDonald speaks to children in twenty-five languages including Russian, Portuguese, Tagalog, Hindi, Cantonese and Papiamento. 3(p. 13) A 1996 survey of children’s television programming in Australia, Austria, Belgium, Denmark, Finland, France, Germany, Greece, Netherlands, Norway, Sweden, UK and the United States found that McDonald’s was the most prolific advertiser overall.

But does it work?

Commenting on the results of the previously mentioned study of children’s preference for food with a McDonald’s packaging, company spokesman Walt Riker stated that McDonald’s had been “actively addressing” the issue of children and nutrition and that McDonald’s was “providing solutions.” However, Dr. Victor Stasbuger, an author of American Academy of Pediatrics policy calling for limits on marketing to children argued that the study illustrated the success of fast food marketing to children: “Advertisers have tried to do exactly what this study is talking about–to brand younger and younger children, to instill in them an almost obsessional desire for a particular brand-name product.”

Impact on health

In 1998, 89% of children in the United States eight years of age or younger had visited a McDonald’s at least once a month. In response to this information, R.J. Milano, a McDonald’s Vice President stated that their goal for the following year was to reach 100%. He boasted “I’m going to own every kid transaction out there.” 3(p. 291). The health impact for both youth and adults of increased intake of salt, fat and sugar associated with the consumption of fast and junk foods has become clear as rates childhood obesity and type 2 diabetes have escalated. At least 30% of calories in the average child’s diet are currently derived from fast food, salty snacks, sweets and soft drinks. In response to increased media attention and legal action, fast food companies such as McDonald’s claim to be offering healthier alternatives. In addition, McDonald’s was one of 11 major food companies that recently agreed to limit voluntarily its food advertising to children . Recently McDonald’s began offering Happy Meals with slices of apples and milk. However, while the new Happy Meals did reduce overall fat and calorie content, the “Apple Dippers” included in the meal increased the sugar content. Additionally, while McDonald’s has done away with its “supersize” option for adults, in 2001 it introduced “Mighty Kids Meals” which offer more food for only slightly more money.

Regulations around the world

More than 50 other countries currently regulate marketing directed at children. Twenty-five European states prohibit advertising during children’s programming of a duration of 30 minutes or less. In 1992, Sweden banned all television marketing directed at children twelve and under. Similarly, advertising in children’s programming have been banned in Ireland, Norway, Belgium and Holland.1 Since 2001 Broadcasting Commission of Ireland has prohibited the use of celebrities and cartoon characters to advertise food. Regulations disallowing advertising to children 13 years or younger have been in effect since 1980 in the Canadian province of Quebec. In the United States, the Federal Trade Commission lacks the authority to restrict television advertising. Given the previous failure of voluntary guidelines to reduce growing rates of obesity, numerous advocacy and public health groups have called for government regulations.

Recommendations

Many public health organizations in the United States and elsewhere have made specific recommendations. In December 2005, the Institute of Medicine (IOM) released a comprehensive report on the impact of food marketing to children in the United States. The report found that American children are not achieving basic nutritional goals both in terms of underconsumption of important nutrients and overconsumption of fat, salt and sugar. While the dietary patterns of children are a complex in origin and include cultural values, economic status, social environments and media environments, the IOM concluded that food and beverage marketing “influences the preferences and purchase requests of children, influences consumption at least in the short term, is a likely contributor to less healthy diets, and may contribute to negative diet-related health outcomes and risks among children and youth.”

Strategic Alliance, a coalition of nutrition and physical activity advocates in California, recommends that all marketing and advertising of junk and fast foods be eliminated for children and youth. Amongst other measures, International Association of Consumer Food Organizations (IACFO)—an international association of non-governmental organizations representing consumer interests in the areas of nutrition, food safety, and food policy—urges governments to restrict or ban all food advertisements to children and prohibit the marketing of soda, junk and fast foods in schools. The IACFO also points to the importance of global action on this issue, noting that restrictions in the developed world often send multinational corporations overseas to the global south where they market unhealthy products with greater ease. Given escalating global rates of diet related chronic disease, public health and advocacy calls for more stringent and federally and globally enforceable standards seem warranted. In the words of Gro Harlem Brundtland , former Director General of the World Health Organization: “Marketing approaches matter for public health. They influence our own–and in particular our children’s–patterns of behavior. Given that they are designed to succeed, they have serious consequences for those at whom they are targeted.”

Zoe Meleo-Erwin, MA is graduate student in sociology at The Graduate Center, City University of New York.

 

References

1. Robinson, TN; Borzekowski, DLG; Matheson, DM & Kraemer, HC. Effects of Fast Food Branding on Young Children’s Taste Preferences. Archives of Pediatrics and Adolescent Medicine. 2007. 161(8):792-797.
2. Schlosser, E. Fast Food Nation: The Dark Side of the All-American Meal. 2001. Boston: Houghton Mifflin.
3. Brownell, K. & Horgen, KB. Food Fight: The Inside Story of the Food Industry, America’s Obesity Crisis & What We Can Do About It. 2004. New York: McGraw Hill.
4. Nestle, M. Food Politics: How the Food Industry Influences Nutrition and Health. 2002. Berkeley: University of California Press.
5. Story, M. & French, S. Food Advertising and Marketing Directed at Children and Adolescents in the US. International Journal of Behavioral Nutrition and Physical Activity. 2004;1:3. Available at: http://www.ijbnpa.org/content/1/1/3. Accessed October 21, 2007.

Photo credits:

1. La Fotodama 
2. Sama Sama – Massa
3. Petite-Tomo

Tracking the Effects of Corporate Practices on Health