Corporate Targeting and the Impact of Corporate Practices on Socioeconomic, Racial/ethnic, Gender and Age Inequities in Health

Selected Peer-reviewed Articles

A small but growing number of studies examine how corporate practices influence health inequities. Studies have described and analyzed how corporations target selected populations for marketing of unhealthy products, assessed the impact of these practices on differences in health behavior and health, and explored other ways that corporate decisions maintain or exacerbate health disparities.

Here Corporations and Health Watch summarizes a few of these recent reports and invites readers to submit additions to the list for subsequent posting.

 

Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis.2006; 3(3):A76.

Analyzes the results of an audit of community supermarkets and fast food restaurants to assess the location and availability of food choices that enable individuals to meet the dietary guidelines established by the U.S. Department of Agriculture. The researchers used supermarket and fast food restaurant audit tools to assess the availability of healthy food choices in the urban area of St. Louis, Missouri. The researchers found that two factors (race and income) are associated with the location of food outlets and the selection of foods available. Individuals living in mixed or white high-poverty areas and in primarily African American areas are less likely to have access to foods that would enable them to make healthy food choices. The researchers recommend collaborations with the business community and political structures to make it economically viable to provide equal access to healthy food choices.

 

Brody H, Hunt LM. BiDil: assessing a race-based pharmaceutical. Ann Fam Med. 2006; 4(6): 556-60.

Analyzes scientific evidence on BiDil, the first drug approved by the Food and Drug Administration to be marketed to a single racial-ethnic group, African Americans, for the treatment of congestive heart failure. The authors discuss the problems that can arise when race is viewed as a biological-medical construct, leading to an overly simplistic assumption of a racial and hence presumed genetic difference while obscuring the “economic, social, cultural, and ethical issues lurking in the background.” The authors predict that the manufacturer will launch a publicity campaign targeting African Americans, and that family medicine doctors will be asked by their patients for the new “for blacks only” medication.

 

Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008; 19(1):26-40.

Reviews data on disparities in cancer morbidity and mortality in the United States, and reviews evidence on corporate practices contribute to cancer risk behavior, incidence, and cancer disparities. The authors propose that the practices of the tobacco, alcohol and food industries be considered as modifiable social determinants of health. The authors conclude with recommendations for research, practice, and policy that would lead to what they term “less carcinogenic” corporate practices.

 

Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place 2008;14:32-44.

Analyzes pathways by which racial segregation contributes to higher density of fast food outlets in Black neighborhoods in US. The author proposes that population characteristics, economic characteristics, physical infrastructure and social processes of Black neighborhoods each contribute to creation of “localized geographic areas for targeting by fast food corporations and operators.”

 

Kwate NO, Lee TH. Ghettoizing outdoor advertising: disadvantage and ad panel density in black neighborhoods. J Urban Health. 2007;84(1):21-31.

 

Investigates correlates of density of outdoor advertising in predominantly African American neighborhoods in New York City. Authors found that that black neighborhoods have more outdoor advertising space than white neighborhoods, and these spaces disproportionately market alcohol and tobacco advertisements. By linking census data with property data at the census block group level, investigators found that two neighborhood-level determinants of ad density were income level and physical decay.

 

Macdonald L, Cummins S, Macintyre S. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite. 2007l;49(1):251-4.

Investigates associations between area deprivation and the location of the four largest fast-food chains in Scotland and England. The authors report statistically significant increases in density of outlets from more affluent to more deprived areas for each individual fast-food chain and all chains combined. They conclude that these findings support a “concentration” effect whereby environmental risk factors for obesity appear to be ‘concentrated’ in more deprived areas.

 

Monsivais P, Drewnowski A. The rising cost of low-energy-density foods. J Am Diet Assoc. 2007; 107(12): 2071-6.

Discusses the results of a study on the energy density and retail prices of 372 foods and beverages in major supermarket chains in the Seattle, WA metropolitan area in 2004 and 2006 (energy density and prices were calculated in terms of $/100g and $/1,000 kcal). The researchers discuss the role of lower energy-density foods as a strategy for managing overweight and obesity. The two-year price change for the least energy-dense foods was +19.5% whereas the price change for the most energy-dense foods was -1.8%. The researchers suggest that the lower price of energy-dense foods and the resistance of energy-dense foods to price inflation may help explain why the highest rates of obesity in the United States are observed among those with limited economic means.

 

Morrison MA, Krugman DM, Pumsoon P. Under the radar: smokeless tobacco advertising in magazines with substantial youth readership. Am J Public Health. 2008; 98(3): 543-48.

Reviews the level of advertising of smokeless tobacco products before and after the Smokeless Tobacco Master Settlement Agreement (STMSA). The researchers determined that the STMSA appears to have had a limited effect on adolescents’ exposure to the advertising of smokeless tobacco in magazines with high youth readership. The researchers determined that adolescent boys (aged 12-17) are at greatest risk for exposure to smokeless tobacco advertisements.

 

Primack BA, Bost JE, Land SR, Fine MJ. Volume of tobacco advertising in African American markets: systematic review and meta-analyses. Public Health Rep. 2007; 122(5): 607-15.

Reviews the peer-reviewed literature on the density of pro-tobacco media messages. Of the studies identified for inclusion, 11 met the eligibility criteria for the current review. The researchers pooled the results of these studies in a meta-analysis and conclude that African Americans are exposed to a higher volume of pro-tobacco advertising. The researchers also cite evidence demonstrating that African Americans bear the greatest morbidity and mortality burdens due to smoking, and that exposure to pro-tobacco media messages predicts cigarette smoking.

 

Schor JB, Ford M. From Tastes Great to Cool: Children’s Food Marketing and the Rise of the Symbolic. Journal of Law, Medicine & Ethics. 2007; Spring issue on Childhood Obesity: 10-21.

Discusses the increasing participation of children in the consumer markets, their heavy media use and exposure to high levels of advertising. The researchers discuss deteriorating diets and rising obesity, as well as the shift in children’s food advertisements from product attributes to symbolic messages. The researchers cite studies that demonstrate that exposure to junk food marketing is much higher for low-income children as well as racial and ethnic minority children, groups that also have higher rates of obesity.

 

Thompson DA, Flores G, Ebel BE, Christakis DA. Comida en venta: after-school advertising on Spanish-language television in the United States. J Pediatr. 2008; 152(4): 576-81.

Analyzes the content of food and drink commercials aired during after-school hours (3 to 9 p.m.) on two Spanish-language television stations in the United States. The researchers found that children viewing Spanish-language television in the United States after school are exposed to food and drink commercials, mostly advertising unhealthy foods, including fast foods and sugared drinks. The researchers propose that food and beverage advertising to children via Spanish-language television may contribute to the high rates of obesity among Latino children.

 

Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007; 18(4 Suppl): 10-38

Reviews more than 400 internal documents from the tobacco industry to explore the ways in which the tobacco industry targeted inner cities populated predominately by low-income African American residents in the 1970s-1990s. The authors cite studies demonstrating that smoking rates remain higher among the poor, the less educated and other underserved populations, despite significant reductions in the overall smoking rate in the United States. This archival analysis demonstrates how the tobacco industry’s promotion activities and the “menthol wars” fought by tobacco companies in America’s inner-cities have contributed to the tobacco-related health disparities that we observe today.

Corporations and Campus Research: How private industry dollars influence scientific discovery and threaten public health

On March 26, 2008, the New York Times published a front page story revealing that the Liggett Group, a major tobacco company, had supported research at Weill Cornell Medical College showing the benefits of early screening for lung cancer. The article, published by the New England Journal of Medicine in 2006 did not disclose the source of funding. The Journal’s editor, Dr. Jeffrey M. Drazen, told the Times“In the seven years that I’ve been here, we have never knowingly published anything supported by a cigarette maker.” The authors of the report and officials at Weill Medical College denied any effort to cover up the source of the funding. However, former New England Journal editor Dr. Jerome Kassirer, author of a book about medical conflicts of interest, expressed skepticism about this denial. He told the Times that he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. You have to ask yourself the question, ‘Why did the tobacco company want to support her research?’ They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous.

Last November, the University of California at Berkeley and BP, the global energy company formerly known as British Petroleum, signed a $500 million, 10-year deal to create the Energy Biosciences Institute to conduct research on energy and environmental issues. BP will appoint four of the Institute’s eight directors and, according to the Daily Cal, the Berkeley student newspaper, at least 50 BP scientists will be able to conduct proprietaryresearch at UC Berkeley and the University of Illinois. These researchers work under the sole control and discretion of BP, and their work can remain secret and thus free from scrutiny. Critics expressed concerns about the academic integrity of the Institute and also questioned a partnership with a company that has been indicted in numerous environmental violations and illegal business practices. Only a few months prior to signing the contract with Berkeley, BP and its subsidiaries paid $373 million to settle dozens of legal cases, including one that involved the leaking of crude oil from pipelines in Alaska.

To prove that UC doesn’t limit sponsorship to industries under attack by public health and environmental advocates, University of California at Davis recently accepted an endowed chair in chocolate science from the Mars Corporation in order to study the antioxidant properties of cacao.In fiscal year 2006-7, UC received more than $16.6 million from Philip Morris for tobacco research, and in September 2007, the Board of Regents voted 14 to 4 to continue accepting tobacco money for faculty research. According to the San Francisco Chronicle, nearly all the regents expressed disdain for the tobacco industry’s criminal behavior and distortion of research, but several of those who voted to continue to accept funding said they were deferring to faculty concerns about academic freedom. Intended to shield researchers from tobacco industry influences, the resolution adds new administrative procedures. Under this new measure, research proposals seeking tobacco industry funding are now required to pass through a scholarly review and receive approval from the campus chancellor. In addition, the UC president must present annual reports to the Regents on the number of proposals submitted, approved and funded, along with a description of each.

Moving east, the University of Virginia’s School of Medicine decided in 2006 to accept $25 million from Philip Morris to fund research on youth and tobacco. When challenged on the decision, Dean Arthur Garson insisted the answer was simple, a company has offered us $20 million to develop better ways so kids don’t smoke. Period.

These and many similar accounts highlight a growing trend in academia to accept industry money to pay for research, new laboratories, and high-powered professors. In 2005, industry provided universities with $2.3 billion for research and development. While the dollar amount has been growing, according to Daniel Greenberg, author of Science for Sale The Perils, Rewards and Delusions of Campus Capitalism,1 industry actually contributes only a tiny fraction of the overall university research budget—far more comes form government sources such as the National Institutes of Health (NIH) and the National Science Foundation (NSF). In New York State, for example, total university spending on research and development in 2004 was $3.4 billion, of which only $146 million—just over 4%—came from industry.

Why the new push for corporate funding for university research?

If industry pays for only a small part of academic research, why are universities now so eager to pull in industry dollars? Why are they willing to cede control of their own research, a prerogative often jealously guarded in the past? And what are the consequences of this growing source of support for academic institutions and for public health research? In this reportCorporations and Health Watch examines industry influence on academic research; assesses its impact on universities, science and public health; and describes critics’ efforts to counter this trend and pose other policy options.

As in any intimate relationship, changes reflect the concerns of both partners. For universities, the most obvious starting point is dollars. Between 1970 and 2003, federal funding for research increased dramatically, making it easy for many universities and researchers to steadily increase their research revenues. Just between 1999 and 2003, the NIH budget more than doubled from $13 billion to $27 billion.2 But since then, the Bush Administration has cut funding for scientific research at both NIH and NSF, forcing universities to turn elsewhere to support their habit.

On the business side, the quest for a stronger and more direct presence in university research reflects the downturn in federal funding but also a recognition that direct funding offers some advantages. These include the right to conduct research that benefits companies directly; to withhold information that could jeopardize profits; and to send university scientists to appear in public forums to advance the company’s agenda, perhaps with greater credibility than their own staff. In the longer run, these trends can help business to privatize university research, allowing market forces and the search for profits—rather than academic traditions—to dictate the rules of research. As Robert Reich notes in his new book Supercapitalism,3 increased competition among global companies forces them to seek every competitive edge they can find. Increasingly, bought scientists are one such edge.Rather than discontinue research projects altogether, universities and health institutions are taking up partnerships with corporations, exchanging rights to intellectual property for financial support. While this practice is not uncommon to university engineering and technology programs, its increasing presence in the biomedical and other health sectors is of particular concern to the health of the public.

The BP deal with Berkeley illustrates these benefits of direct funding, allowing dozens of scientists to pursue a research agenda shaped by the company on university property, where scientists benefit from the publicly supported (through California tax support and prior NIH funding) research infrastructure but escape the usual obligation to share their findings with the public and the wider scientific community.

The tobacco industry has long hired scientists to ‘debunk,’ or increase doubt about accepted scientific findings that show that tobacco causes cancer and other health conditions. Research studies show that several industries often withhold research findings that could cause a problem for their products or choose to require scientists to pose their research questions in a way that minimizes the possibility for finding harm.

In 2005, the British newspaper The Observer reported that a respected osteoporosis researcher at Sheffield University had questioned American pharmaceutical giant Procter and Gamble’s (P&G), decision to publish drug research in his name even though he had not been given full access to the data that the paper reported, and that the report was written by a ‘ghost writer’ paid for by P&G before being given to him.When researchers change findings at the behest of the sponsoring company to or fail to disclose industry sponsorship of their work, companies exploit the credibility of apparently independent scientists. In the case of Vioxx, the painkiller withdrawn from the market by Merck after it was linked to serious cardiovascular side effects, it appears that university scientists changed their findings at the behest of the company. The editor of the New England Journal of Medicine, which originally published the study, charged that an internal company memo showed that the researchers knowingly suppressed data on three additional heart attacks among Vioxx users that was available months before the paper was published.4 Had that data been included, Vioxx would have looked much riskier.

If universities and companies benefit from new partnerships, what’s the problem?

While growing corporate academic research partnerships may bring benefits to both universities and companies, they raise serious problems for academic integrity, scientific credibility and public health.

First, the imperative to produce findings that benefit the bottom line encourages biased, even dangerous science. For example, on his blog (BrodyHooked) and in his new book Hooked: How Medicine’s Dependence on the Pharmaceutical Industry Undermines Professional Ethics,5 Howard Brody, Director of the Institute for the Medical Humanities University of Texas Medical Branch notes that commercially sponsored studies paid for by the pharmaceutical industry are roughly four times more likely than neutral studies to favor the company’s drug. So commercial bias has been shown to be real and substantial.Similarly, researchers found that studies sponsored by the food industry to evaluate the health benefits of their product were 7.6 times more likely to find such benefits than were studies wholly funded by independent sources.6

Closer corporate ties may also jeopardize traditional academic values of freedom of inquiry, an obligation to share and disseminate research findings freely, and to criticize other researchers’ work without fear of reprisal. In exchange for their dollars, companies often ask universities to sign agreements that restrict publication rights, assign patents or other intellectual property to the company rather than the scientist or the public, and compromise protections for human volunteers.This biased evidence base can skew public policy deliberations—if negative findings have been suppressed, policy makers may falsely assume a product has been demonstrated to be safe. Moreover, increased media focus on industry manipulation of scientific research to benefit its bottom line, whether by suppressing negative findings, ghost writing articles, or preventing authors from sharing proprietary discoveries that could benefit the sponsoring company, can tarnish all scientists. This increased distrust of scientists can make it harder for researchers to participate in public debate as independent voices. For example, when it turned out that much of the research evidence—and advocacy—on behalf of the Human Papilloma Virus vaccine was sponsored by Merck & Co., the maker of the vaccine Gardasil, many citizen groups opposed mandatory vaccinations, even though most public health officials believe the vaccine is a public health advance.7

Since companies support research that they believe will bring in new revenues, they are more likely to fund projects that yield intellectual property that can be patented and sold, such as alternative fuel sources, new processed foods, or medical drugs and devices. Some of these products may promote population health but others do not. Significantly, research that benefits the public but does not generate profits is avoided, thus skewing the research enterprise. As corporate funding increases and government funding declines, this trend may accelerate.

Companies often attach many strings to their gifts, ensuring they can maintain control of the research. For example, in the partnership between BP and UC Berkeley, BP requires that it appoint company representatives for 4 out of 8 board of director seats. Corporate ties to university leaders are especially prevalent in medical schools. In a national survey of department chairs at 140 medical schools and teaching hospitals, Eric Campbell, Senior Scientist at the Institute for Health Policy at Massachusetts General Hospital, found that 60% of department chairs and 67% of departments as administrative units had relationships with industry—as a consultant, member of an advisory board, paid speaker, officer, founder, or member of the board of directors.8 When such ties are normative, resisting undue corporate influence may be especially difficult.

Developing guidelines for reducing corporate influence on university research

In summary, closer ties with corporations may represent a threat to universities because they can undermine academic freedom, divert university resources from other more pressing scientific questions and social needs, and make universities accessories to corporate interests rather than free-standing critical institutions.

In recent years, several research organizations and researchers have proposed guidelines to reduce corporate influences on university research. Many professional organizations, university administrators and researchers are resisting the corporate takeover and seeking to establish professional guidelines and standards that limit corporate influence on the university.

Public Citizen’s Health Research Group, for example, lays out a framework in which one can begin to think about solutions to or prevention of potential conflicts. In a 2007 report to the Institute of Medicine’s Committee on Conflict of Interest in Medical Research, Education, and Practice, the Health Research Group described three basic approaches that can be taken up by institutions—legal restrictions, policy restrictions, and disclosure.9

As an example of a policy decision, the University of Texas’ McCombs School of Business recently turned down an offer of money from Altria Group, the former parent company to Philip Morris. For UT McCombs, the decision was an ethical one. Dean George stated the leadership of the school felt that in some sense it was tainted money, that it is money gotten from a product that is significantly harming people. Associate Dean Paula Murray called the decision to turn down Altria’s money a no-brainer. 10

Professional associations like the International Epidemiology Association, the Institute on Medicine as a Profession, and the Union of Concerned Scientists, as well as advocacy campaigns such as the Restoring Scientific Integrity Network, the Prescription Project, theCenter for Tobacco Control Research and Education, and the Center for Science in the Public Interest work to educate researchers about corporate influences on university research and advocate for the adoption of policies that will remove industry interests from academic research endeavors.

Both the Center for Science in the Public Interest (CSPI) and the Union of Concerned Scientists offer explicit policy options for universities and individual researchers.

 

How to get corporate interests out of academic research

1. Universities can adopt corporate funding policies to protect their autonomy and preserve researchers’ academic freedoms.

2. Universities can prohibit representatives of corporate donors from sitting on research programs’ governing boards.

3. Universities can prohibit industry donors from controlling the content and direction of research programs.

4. Universities can eliminate ‘first rights’ intellectual property clauses from donor agreements.

5. Universities can ensure that company representatives cannot make substantive editorial changes in manuscripts or delay their publication.

Source: The Center for Science in the Public Interest. Strings Tied to Industry-Academic Collaborations at ‘Big Oil U.’ Press Release. Jan 22, 2008.

And the Union of Concerned Scientists called on the scientific community to hold Congress accountable to upholding the pursuit of scientific integrity with the following suggestions:

Scientists employed by government institutions commit themselves to serve the public good free from undisclosed conflicts of interest and to carry out science that is reliable and useful, while respecting statutory limitations such as national security laws. Therefore, government scientists should, without fear of reprisal or retaliation, have the freedom to:

  • Conduct their work without political or private-sector interference;
  • Communicate candidly their findings to Congress, the public, and their scientific peers;
  • Publish their work and to participate fully in the scientific community;
  • Disclose misrepresentation, censorship, and other abuses of science; and
  • Have their technical work evaluated by scientific peers.

A third set of guidelines, shown below, has been proposed by the Royal Netherlands Academy of Sciences.11 These provide detailed suggestions for how to negotiate university industry agreements that do not compromise academic integrity or bias results. By using these various guidelines, academic institutions and university researchers can begin to reassert their rights and responsibilities to set the terms for their scientific inquiries.

Declaration of scientific independence*

1. The structure of the research shall not be geared towards producing the desired outcome for the client.

2. The assignment and its objective shall preferably be formulated jointly by the client and the researcher.

3. Remuneration and other tokens of appreciation shall never depend on the outcomes or interpretation of the research.

4. The results of the scientific research shall be published irrespective of whether they are favourable to the client.

5. The scientist shall always be free to publish the findings of the research within a specified reasonable period of time. In this context two months can be regarded as a reasonable period, with six months generally the maximum (this period being calculated from the moment that the final results are submitted to the client). An exception should be made where there are issues of intellectual property in which case a period of no longer than 12 month would be acceptable.

6. The methods of publication shall be stipulated in the contract. Publication in a scientific journal shall take place in consultation with the client, but the researcher shall have the final say on the contents, the authors, the form of publication and where the research will be published.

7. External financiers of research assignments and/or other sponsors shall be mentioned by name in publications and other forms of disclosure.

8. Relevant interests and/or advisory relations of the researcher(s) shall be cited in publications and other forms of disclosure.

9. The text of the contract shall be available for inspection in confidence by the National Council on Research Integrity (LOWI).

 

*This Declaration forms the heart of the code of conduct proposed by the Royal Netherlands Academy of Sciences.

Source: Van der Meer J et al, 2007.11

References

1. Greenberg DS. Science for Sale The Perils, Rewards and Delusions of Campus Capitalism.ChicagoILUniversity of Chicago Press; 2007.
2. Mervis J. NIH Shrinks, NSF Crawls as Congress Finishes Spending Bills. Science. 2006:311(5757):28–9. 
3. Reich RB. Supercapitalism: The Transformation of Business, Democracy, and Everyday Life. New York: Kopf; 2007. 
4. Curfman GD, Morrissey S, Drazen JM. Expression of concern: Bombardier et al., Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med. 2000;343:1520-8. 
5. Brody H. Hooked: How Medicine’s Dependence on the Pharmaceutical Industry Undermines Professional Ethics. Rowman & Littlefield Publishers, Inc.: Lanham, MD; 2008.
6. Lesser LI, Ebbeling CB, Goozner M, Wypij D, Ludwig DS. Relationship between funding source and conclusion among nutrition-related scientific articles. PLoS Med. 2007 Jan;4(1):e5. 
7. Allen TJ. Merck’s Murky Dealings: HPV Vaccine Lobby Backfires. Special to CorpWatch, March 7th, 2007. Available at:http://www.corpwatch.org/article.php?id=14401. Accessed March 24, 2008. 
8. Campbell EG. Institutional academic industry relationships. JAMA. 2007;298(15):1779-86.
9. Lurie P. Presentation before the Institute of Medicine’s Committee on Conflict of Interest in Medical Research, Education, and Practice (HRG publication #1830). November 5, 2007. Washington, DC. Available at:http://www.citizen.org/publications/release.cfm?ID=7553
&secID=1656&catID=126
. Accessed on March 24, 2008. 
10. Finder A. Some Campuses Decide Tobacco Company Money Is ‘Tainted.’ The New York Times. Feb 4, 2008. Available at:http://www.nytimes.com/2008/02/04/education/04tobacco.html. Accessed on March 24, 2008. 
11. van der Meer JW, de Gier AM, van Swaaij WP, Katan MB. Independent medical research. Neth J Med. 2007;65(4):124-6.

Do pharmaceutical marketing and pricing practices reduce compliance with cardiovascular medications?

Cardiovascular disease (CVD) is the most prevalent condition treated in primary care practice and contributes to the socioeconomic and racial/ethnic inequities in health that characterize the U.S. Treating hypertension and hyperlipidemia, CVD’s major risk factors, can significantly reduce the risk of severe cardiovascular outcomes. Although safe and effective medications are available for this purpose, maintaining healthy blood pressure and cholesterol is difficult, particularly for people from disadvantaged populations. Conventional wisdom says that providing free pharmaceutical samples should help patients to take their medicine but a recent study in Medical Care found that “individuals receiving samples have higher prescription expenditures than their counterparts.” The authors concluded that “these findings suggest that sample recipients remain disproportionately burdened by prescription costs even after sample receipt.”1 While there are many factors that contribute to this problem, here we examine the role of prescription medication marketing practices and costs on patient adherence to prescribed medications.

Adherence to prescribed medications for the control of chronic conditions may be particularly difficult for many disadvantaged populations for multiple reasons, including sociocultural influences that inhibit productive patient-physician communication, low health literacy, and difficulty adjustinglifestyle and health behaviors, among others. These factors have been described in the medical literature and are often the target of patient-level interventions. However another significant but less-studied influence on adherence is the inability of patients to consistently fill prescriptions because of cost of medications. Numerous studies have shown that lower income and/or uninsured patients frequently forgo needed medical care because of cost2,3,4,5,6 delay filling and refilling prescriptions because of cost,7 or share prescriptions with friends and family members because of cost.8 Given these data, we wonder why cost has been given so little attention, and propose that pharmaceutical industry marketing practices might be a factor in compliance.

The pharmaceutical industry continues to develop and market new classes of medications to treat hypertension and hyperlipidemia, even though effective medications to treat these conditions have been available for many years. While the new medications are typically considerably more expensive, they are heavily advertised for any improvement in effectiveness, specificity in their action, and reduced side effects than the earlier drugs. However, there are convincing data showing that in many cases established therapies can be about as effective as the newer medications for many patients.9,10 For example, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial showed that thiazide-type diuretics are as effective as newer antihypertensive medications, such as an angiotensin converting enzyme (ACE) inhibitor, in reducing blood pressure and cardiovascular complications.9 We acknowledge that contradictory evidence also exists.11 Appropriate decisions about which of the available medication therapies should be prescribed to individual patients include clinical considerations, tolerance of side effects, and other patient-level factors. To date, cost seems to have been of less immediate concern for many prescribing physicians.

To understand why cost might not be routinely considered as a primary factor in clinical decision making, we must take a look at the way medications are marketed. The largest domain of pharmaceutical marketing is the direct promotion of medications to physicians by pharmaceutical representatives, termed “detailing.” Such interactions with pharmaceutical representatives are frequent, occur in multiple clinical settings, and begin as early as medical school. Pharmaceutical representatives have a well-established role in the clinical setting that may extend beyond educating physicians about new medications. Data indicate that this marketing behavior is likely to have had an impact on CVD treatment patterns in particular as the medications to treat its major risk factors are among the most marketed medications, and marketed medications tend to overwhelm the market share of all medications for a particular condition. For example, those medications that are marketed for hyperlipidemia account for about two-thirds of the market share of medications to treat this condition.12

A recent anthropological assessment argues that pharmaceutical representatives create a”culture of gift exchanges” in hospitals and clinics.13 Gifts can include early data on “cutting edge” treatments, supplies for both home and office, opportunities to attend professional conferences, staff lunches, and so on. Some analysts argue that this gift culture creates a conflict of interest for physicians, influencing them to make inappropriate clinical decisions. In this view, pharmaceutical representatives may negatively influence clinical practice not by encouraging physicians to ignore good clinical practice when prescribing medications (that is, accounting for clinical considerations, tolerance of side effects, and other patient-level factors). Rather, sales people may lead physicians to make questionable medication choices when factors other than these clinical benefits are the primary factors at stake. Specifically, interactions with pharmaceutical representatives may lead physicians to prescribe the newest and/or most costly medications to some patients for whom less expensive, cost-effective treatment alternatives are also available. (See Peay and Peay,14 for a discussion of this issue.) This practice would not only increase medical costs, but could also lead to poor medication access and adherence, and ultimately lead to poorer patient outcomes – particularly for the most disadvantaged patients.

So exactly how might pharmaceutical marketing practices mask real cost considerations? One way is the distribution of free product samples. Free samples of medication (“sampling”) are given to physicians to pass along to their patients, a key part of the gift culture previously described. The stated intent of sampling is to allow patients to have access to a free short-term trial of a new medication to determine drug tolerance, side effects, and clinical response, before making a commitment to purchase a longer term supply of the medication. However, physicians frequently report that they give samples in order to provide free or low-cost medications to their uninsured/underinsured patients.15,16

Studies suggest that most physicians recognize that medication cost may be a substantial barrier to patients’ ability to adhere to prescribed medication regimens, and believe that cost should be a consideration when making treatment choices for patients. (See Alexander et al.17,18,19 for discussions of this issue.) However few physicians actually take the necessary steps to adequately monitor either cost or cost-related adherence, by, for example, initiating conversations about medication-taking behaviors, the out-of-pocket costs of medications, and the potential for cost to be a barrier to filling or refilling prescriptions and medication adherence.17,20,21 For physicians who are made aware of cost concerns, the sample closet is frequently thought to be their only resource. Surprisingly few physicians are aware of strategies other than pharmaceutical sponsored medication samples to help patients reduce their financial burdens due to the cost of multiple medications.17,22 Alternatives can include suggesting behavior modification, prescribing generic medications, using pharmaceutical sponsored Medication Assistance Programs, and referring patients to 340B Drug Pricing Programs (federal programs that entitle health centers to purchase/distribute medications at Medicaid prices or lower). Thus, despite the concern about the problems associated with pharmaceutical marketing in general, many physicians strongly support “sampling.”

What is the harm of “sampling?” While potential harms have not yet been described fully, the availability of samples may influence medication choices when there are many medication options available to the physician. For example, while it is possible that use of samples encourages adherence to prescribed medications, it is also possible that the use of samples reduces adherence because patients who are used to receiving free samples only take these expensive medications when samples are available. Additionally, because the large number of uninsured/underinsured patients, the ongoing availability of samples cannot be assured. Thus, reliance on samples alone for uninsured/underinsured patients is an inadequate long-term strategy to provide access to pharmaceuticals. Additionally, the distribution of samples presents a great potential for medical errors due to inadequate labeling and record keeping, in addition to the previously discussed concerns about inappropriate treatment choices. Beginning in 2004, the Joint Commission on Accreditation of Healthcare Organizations requires that accredited health care organizations follow specific guidelines for managing medications that includes processes for ordering and prescribing, preparing and dispensing, administering, monitoring, selecting and procuring, and storing medications, including samples. Because the nature of relationships with pharmaceutical representatives was intentionally informal (as part of a “gift culture” described above), shifting the system of documenting the receipt/distribution of samples received from pharmaceutical representatives from an informal to a formal system has been difficult for many safety net settings.

We believe rigorously designed observational and experimental studies are warranted to determine whether the potential cost saving benefit of having samples available equals the potential harm that this practice might cause for the treatment of cardiovascular disease and its major risk factors in primary care settings. Such studies will also help to address the larger question about whether pharmaceutical marketing practices in general make it more or less difficult for physicians to address medication cost concerns of their patients, and, ultimately to improve adherence to necessary treatments for the major risk factors for cardiovascular disease and reduce health disparities.

Nancy Sohler, Ph.D., MPH, is an assistant medical professor of health policy at the Sophie Davis Medical School of the City University of New York.

Jonathan N. Tobin, Ph.D., is the President/CEO of Clinical Directors Network, a primary care practice-based research network and clinician training organization that works with medically underserved communities. He is also Professor and Director of Education and Training at the Institute for Public Health Sciences of Yeshiva University.

Andrea Cassells, MPH, is the Director of Clinical Affairs at Clinical Directors Network in New York City.

For More Information

Organizations working to change health harming practices of the pharmaceutical industry:

The Prescription Project 
Prescription Access Litigation 
Consumers Union Prescription for Change 
Marketing Overdose (Consumers International) 
Pushing Prescriptions (Center for Public Integrity) 
Center for Medical Consumers

 

References

1. Jackson JE, Doescher MP, Saver BG, Fishman P. Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions. Med Care. 2004;42(11):1056-65.
2. Wilson IB, Rogers WH, Chang H, Safran DG. Cost-related Skipping of Medications and Other Treatments Among Medicare Beneficiaries Between 1998 and 2000: Results of a National Study. J Gen Intern Med. 2005;20:715-20. 
3. Heisler M, Wagner TH, Piette JD. Patient Strategies to Cope with High Prescription Medication Costs: Who is Cutting Back on Necessities, Increasing Debt, or Underusing Medications? J Behav Med. 2005;28(1):43-51.
4. Klein D, Turvey C; Wallace R. Elders Who Delay Medication Because of Cost: Health Insurance, Demographic, Health and Financial Correlates. Gerontologist. 2004;44(6):779-87.
5. Kennedy J, Coyne J, Sclar D. Drug affordability and prescription noncompliance in the United States: 1997-2002. Clin Ther. 2004;26(4):607-14.
6. Piette JD, Heisler M, Krein S, Kerr EA. The Role of Patient-Physician Trust in Moderating Medication Nonadherence Due to Cost Pressures. Arch Intern Med. 2005;165(15):1749-55.
7. Jackson JE, Doescher MP, Saver BG, Fishman P. Prescription drug coverage, health, and medication acquisition among seniors with one or more chronic conditions. Med Care. 2004; 42(11):1056-65.
8. Bonuck KA, Memmott MM, Arno PS. Cost-Related Prescription Drug Misuse Among Older Persons. Health Aff.2001;20(5):241-51.
9. Davis BR, Piller LB, Cutler JA, Furberg C, Dunn K, Franklin S, Goff D, Leenen F, Mohiuddin S, Papademetriou V, Proschan M, Ellsworth A, Golden J, Colon P, Crow R, for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Collaborative Research Group. Role of Diuretics in the Prevention of Heart Failure: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation. 2006;113:2201-10.
10. Cheetham TC, Chan J, Benson V, Richmond C, Levin E, Campen D. Successful conversion of patients with hypercholesterolemia from a brand name to a generic cholesterol-lowering drug. Am J Manag Care. 2005;11(9):546-52.
11. Litchenberg FR. Are the benefits of newer drugs worth their cost? Evidence from the 1996 MEPS. Health Aff.2001;20(5):241-251.
12. National Institute for Health Care Management Foundation, Prescription Drugs and Mass Media advertising 2000(November 2001). 
13. Oldani MJ. Thick Prescriptions: Toward an interpretation of pharmaceutical sales practices. Med Anthropol Q.2004;18(3):325-56.
14. Peay MY, Peay ER. The role of commercial sources in the adoption of a new drug. Soc Sci Med. 1988;26:1183-99.
15. Spiller LD, Wymer WW. Physicians’ perceptions and uses of commercial drug information sources: an examination of pharmaceutical marketing to physicians. Health Mark Q. 2001;19:91-106.
16. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A Physician Survey of the Effect of Drug Sample Availability on Physicians’ Behavior. J Gen Intern Med. 2000;15(7):478-83.
17. Alexander GC, Casalino LP, Meltzer DO. Physician strategies to reduce patients’ out-of-pocket prescription costs. Arch Intern Med. 2005;165(6):633-36.
18. Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient-physician communication about out-of-pocket costs. J Gen Intern Med. 2004;19(8):856-60.
19. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA,2003;290:953-58.
20. Shrank WH, Fox SA, Kirk A, Ettner SL, Cantrell CH, Glassman P, Asch SM. The effect of pharmacy benefit design on patient-physician communication about costs. J Gen Intern Med. 2006;21(4):334-39.
21. Bokhour BG, Berlowitz DR, Long JA, Kressin NR. How do providers assess antihypertensive medication adherence in medical encounters? J Gen Intern Med. 2006;21:577-83.
22. Shrank WH, Hoang T, Ettner SL, Glassman PA, Nair K, DeLapp D, Dirstine J, Avorn J, Asch SM. The implications of choice: prescribing generic or preferred pharmaceuticals improves medication adherence for chronic conditions. Arch Intern Med. 2006;166(3):332-37.

Photo Credits:

1. betsythedevine
2. fortinbras

Corporations, Health and the 2008 Presidential Race, Part Three: Clinton, McCain, Obama and the Food Industry

As public concern about obesity and nutrition has increased, the food and beverage industry has worked tirelessly to avoid any additional regulation of its practices. Most recently, legislation to restore the Federal Trade Commission’s power to restrict junk food marketing, update school food standards, and mandate nutrition information on chain restaurant menus have all been introduced but none have been successful. Among others, the American Beverage Association, National Restaurant Association, Grocery Manufacturers Association, the Snack Food Association and the National Automatic Merchandising Association work to hold on to their ability to have their members rather than the government monitor their business practices. The industry and its trade associations use their political muscle to shift the decision-making process away from Congress and the President and into their own hands.

To help achieve this outcome, during the 2006 Congressional election cycle, the food and beverage industry contributed more than $3.5m to Democrats and nearly $7.5m to Republican federal candidates (from both PACs and individuals). In 2008, according to the Center for Responsive Politics, the food and beverage industry has already contributed more than $2m to Democrats and more than $3m to Republicans.

The top twenty food and beverage industry
political donors 2008
  1. The National Restaurant Association ($426,500)
  2. Osi Restaurant Partners ($340,500)
  3. McDonald’s Corp ($134,420)
  4. Coca-Cola Co ($97,750)
  5. Ilitch Holdings ($96,100)
  6. Starbucks Coffee ($84,979)
  7. Wendy’s ($82,850)
  8. Mjkl Enterprises ($65,100)
  9. Brinker International ($63,650)
  10. Coca-Cola Enterprises ($60,250)
  1. Yum! Brands ($55,950)
  2. Triarc Companies ($51,150)
  3. Coca-Cola ($47,575)
  4. Aramark Corp ($45,160)
  5. Darden Restaurants ($42,050)
  6. American Beverage Assn ($41,350)
  7. Pizza Hut Franchisees Assn ($39,750)
  8. Waffle House ($36,800)
  9. Trident Seafoods ($34,700)
  10. Davco Restaurants ($34,200)

 

Presidential Candidates and the Food Industry

In the 2008 primary campaign, Senator Clinton has been the top recipient of money from the food and beverage industry ($689,378); Senator Obama ranks fourth ($216,273), and Senator McCain, sixth ($114,600), as of February 11, 2008.

As obesity rates continue to climb and as we near the presidential election, it’s critical to examine how the three remaining Presidential candidates have responded to the food industry’s political agenda to avoid government oversight.

mcdonalds The “Cheeseburger Bill,” known officially as the Personal Responsibility in Food Consumption Acti in the House and the Common Sense Consumption Act in the Senate, would protect food companies from being sued by individuals for weight gain. It passed in the House in 2004 and 2005, failed to pass in the Senate but has garnered more co-sponsorship support than perhaps any other federal food-related bill. Republicans have been the main backers of the Cheeseburger Bill. Neither Senator Clinton, Senator McCain nor Senator Obama has supported any version of this bill.

The majority of the bills to further regulate the food and beverage industry go through the Senate’s Agriculture, Nutrition and Forestry Committee. None of the three candidates sit on this committee. Other health-related bills fall under the jurisdiction of the Health, Education, Labor and Pensions (HeLP) committee. Both Senators Clinton and Obama are members of this committee. An examination of their committee work and the bills they have co-sponsored can provide a window into these candidates’ perspectives on multiple health-related issues.

Perhaps the bill with the most momentum this year (although it ultimately died) was Senator Harkin’s bill (S.771) to revise the definition of “foods of minimal nutritional value” which would further regulate competitive foods sold in schools, at any time of day. Senator Clinton supported this bill along with 27 of her Senate colleagues. Senator McCain and Senator Obama did not cosponsor this bill.

Below is a table showing how the three main candidates chose to sponsor or cosponsor additional selected obesity-related bills in 110th Congress. Some of these bills would work to further regulate the food and beverage industry. For example, one element of Senator Harkin’s Healthy Lifestyles and Prevention America Act (S.1342) requires some restaurants and vending machines to provide nutritional information about each food available for purchase.

2008 Presidential Candidates sponsorship and cosponsorship of obesity-related bills in the 110th Congress

 

Bill # Bill Title Clinton McCain Obama
School Foods
S.2066** A bill to establish nutrition and physical education standards for schools(aswell as other food issues) N N Y (sponsor)
S.1432 A bill to amend the Food Stamp Act of 1977 and the Richard B. Russell National School Lunch Act to improve access to healthy foods, and for other purposes. Y N N
Physical Activity
S.2173 A bill to amend the Elementary and Secondary Education Act of 1965 to improve standards for physical education. N N N
S.651 A bill to help promote the national recommendation of physical activity to kids, families, and communities across the United States. Y N
S.2066** See above N N Y (sponsor)
Funding and Research
S.1068 A bill to promote healthy communities. Y N Y (sponsor)
S.866 A bill to provide for increased planning and funding for health promotion programs of the Department of Health and Human Services. Y N N
S.1067 A bill to require Federal agencies to support health impact assessments and take other actions to improve health and the environmental quality of communities, and for other purposes. Y N Y (sponsor)
S.1172 A bill to reduce hunger in the United States. Y N Y
Employee Wellness
S.1753 A bill to amend the Internal Revenue Code of 1986 to provide a tax credit to employers for the costs of implementing wellness programs, and for other purposes. N N N
Broad-Based
S.1342 A bill to improve the health of Americans and reduce health care costs by reorienting the Nation’s health care system toward prevention, wellness, and self care. N N N

Source: THOMAS, Library of Congress.

**Although Senator Obama did not support Senator Harkin’s bill to update school food standards, he did sponsor S.2066. This bill would also update standards for competitive foods sold in schools. Standards would be consistent with recommendations made by the Institute of Medicine’s Report Nutrition Standards for Food in Schools. It is stalled in the Ag, Nutrition and Forestry Committee and has no cosponsors.

In a previous Congressional session, Senator Clinton spoke about her concern for media’s effect on children. On March 8, 2006, she explained her support for Children and Media Research Advancement Act (S.1902):

The bill I introduced with Senators Lieberman, Brownback, Santorum, Bayh, and Durbin included pilot projects to look at the effect of media on young children, and to look at food marketing and obesity. Although those projects were not included in this manager’s package, I continue to be very pleased with the bill. It’s a step forward for children. And I look forward to working with my colleagues in other venues to ensure that the pilot projects get done.

None of the candidates have cosponsored Senator Harkin’s Menu Education and Labeling (MEAL) Act, requiring, among other practices, nutrition information on chain restaurant menus.

Junk Food Marketing

Commonsense Media posed the following questions on junk food marketing to the presidential candidates.

Childhood obesity has reached epidemic proportions in this country. The latest research suggests that junk food ads are a major contributing factor. Would you support legislation to regulate the type of foods that could be advertised during children’s programming (similar to laws considered in Australia and the United Kingdom)?

Senator Clinton’s response:

According to a Kaiser Family Foundation report released this year, “Food for Thought: Television Food Advertising to Children in the United States,” a committee convened by Institute of Medicine found that “television advertising influences the food preferences, purchase requests, and diets, of children under age 12 years and is associated with increased rates of obesity among children and youth.” That’s why, according to the report, policymakers in Great Britain have banned ads for foods high in fat, salt, or sugar in programming aimed at children under 16 years of age and have prohibited the use of premiums or children’s characters in food ads to young people.

In the United States, we are going in the right direction: In December 2006, 10 of the top food companies in the country announced a new Children’s Food and Beverage Advertising Initiative that includes a commitment to devote at least 50 percent of all advertising to healthier foods or to messages that encourage fitness or nutrition. I believe there is more work to be done. I would like to see the entire food industry come together to develop voluntary guidelines that take their responsibility to children seriously. I think that there are a lot of steps that the private sector and the public sector, working together, can take to curb marketing and availability of unhealthy products to our children. In the Senate, I co-sponsored the Improved Nutrition and Physical Activity Act — which passed in the Senate — to address obesity and eating disorders in children, and I introduced the School Food Fresh Program that links schools with local farmers to bring healthy locally grown snacks to schoolchildren. When I am president, I will continue to explore these options and support measures to put our children on a path to healthy living.

As I mentioned earlier, I championed the Children and Media Research Advancement Act to study the impact of electronic media on child development. This bill provides targeted funding to research the links between advertising and childhood obesity. Since 1980, the proportion of overweight children has doubled, and the rate for adolescents has tripled. We have to understand the relationship between advertising and obesity if we are to build the public will to take action.

And Senator Obama responded:

We’re never going to be able to shield our children from all the potentially bad influences out there. And it would be counterproductive to just build walls that shield them entirely. Our best hope is to educate our children and give them the information and the tools they need to make wise choices. Our children are bombarded by all sorts of messages all the time. If it’s not from television commercials, it’s from somewhere else. We need to teach them how to sort out these messages. I question whether legislating to control certain types of advertising is going to help our children in the long run. I think there are other, helpful steps we can take to reduce childhood obesity. A generation ago, nearly half of all school-aged children walked or biked to school. Today, nearly 9 out of 10 children are driven to school. And once there, children are not very physically active — only 8 percent of elementary schools require daily physical education. Childhood obesity is nearly epidemic, particularly among minority populations, and school systems can play an important role in tackling this issue. For example, only about a quarter of schools adhere to nutritional standards for fat content in school lunches. I will work with schools to create more healthful environments for children, including assistance with contract policy development for local vendors, grant support for school-based health screening programs and clinical services, increased financial support for physical education, and educational programs for students.

Senator McCain has yet to issue a response to these questions. On his campaign website he explains his belief in personal responsibility:

  • We must do more to take care of ourselves to prevent chronic diseases when possible, and do more to adhere to treatment after we are diagnosed with an illness.
  • Childhood obesity, diabetes and high blood pressure are all on the rise. We must again teach our children about health, nutrition and exercise – vital life information.
  • Public health initiatives must be undertaken with all our citizens to stem the growing epidemic of obesity and diabetes, and to deter smoking.

In their focus on education, Senators Obama and McCain reinforce a more conservative framework that emphasizes teaching children as the key to healthier lifestyles, rather than restricting, regulating or more closely monitoring the food industry. Senator Clinton’s language does address junk food advertising directly, but she advocates voluntary self-regulation and increased funding to study the links between advertising and childhood obesity.

The Candidates on Family Farms

Both Senator Clinton and Senator Obama preach support for family farms. In a questionnaire from the Congressional Hunger Center and Drake University Law School, the presidential candidates were asked:

In both rural and urban areas, many Americans lack convenient access to food. As President, how would you increase individuals’ and communities’ access to food?

Senator Clinton’s response:

I will work to increase access to locally grown and distributed food. As Senator, I was proud to start the Farm-to-Fork initiative, to provide consumers with better access to fresh, high quality, locally grown products through farmers’ markets, retailers, restaurants and schools. Given Farm-to-Fork’s success, I would consider working to replicate it around the country.

And Senator Obama’s response:

I support improved access to food through local and regional food systems. As president, I will emphasize the need for Americans to Buy Fresh and Buy Local, implement USDA policies and promote local and regional food systems, support funding for farm-to-school projects, and allow schools to give priority to local sources when ordering food (and grow vibrant and rural economies).

Senator McCain did not respond by the deadline.

Both Clinton and Obama voted for an amendment which would limit farm subsidies in the 2007 Farm Bill. McCain did not cast a vote but was a cosponsor of this amendment, initially introduced by Senator Dorgan (D-ND). This amendment has since been rejected.

All three candidates failed to vote either for or against the 2007 Farm Bill. This Bill, passed in the Senate this past December, is largely viewed as more of the same – subsidies to the largest agribusinesses — and would have been an opportunity for these candidates to take a stand against Big Food. The Senate and the House have passed distinct versions of the bill which now must be negotiated in Congress.

Can food be a political issue in the 2008 election?

At the end of the day, none of the candidates have been outspoken critics of the powers that rest in the hands of the food and beverage industry, nor have any called on the federal government to take a more direct approach in restricting this industry’s influence on society. As the Presidential campaign plays out in the coming months, nutrition,food advocates and journalists have the opportunity to ask the candidates – and voters – to consider what role the next President should play in addressing our nation’s food problems and confronting the growing epidemics of obesity and diabetes.

Alexandra Lewin is a doctoral studuent in nutrition at Cornell University and is completing her dissertation on federal obesity policy.

 

View CHW’s coverage on Corporations, Health and the 2008 Presidential Race:

Part 1: Following the Money
Part 2: Clinton, Obama and McCain on the Role of Corporations

New Alliances: Food Safety and Animal Welfare Organizations Join Forces to Demand Change

This past February, the nation saw the largest recall of meat in American history. More than140 million pounds of frozen ground beef slaughtered by the Hallmark Meat Packing Corporation in the last two years and supplied to Westland Meat Company was recalled after an undercover Humane Society of the United States (HSUS) video revealed evidence of widespread mistreatment of “downed” cattle. Hallmark employees were seen attempting to force downed cattle to slaughter by kicking them, applying electrical shocks, battering them with the blades of forklifts, and jabbing them in the eyes. In addition to outrage over inhumane treatment, the video raised the alarm of food safety organizations, as downed cattle are more likely to be infected with foodborne pathogens. Such concerns were heightened by the disclosure that Westland Meat Company was a supplier to the National School Lunch Program and commercial outlets.

In this case, researchers, advocates and policy makers concerned about public health, food safety and animal rights worked together to expose and seek to correct a situation that they believed violated food safety rules, animal rights and basic public health principles.On February 20, 2008, one day after the the United States Department of Agriculture announced the recall of Hallmark/Westland beef, seven food safety and animal rights organizations wrote a joint letter to USDA Secretary Ed Schafer urging the department to list the retail recipients of the Hallmark/Westland meat to better inform consumers about the recall. These organizations, Center for Foodborne Illness Research & Prevention; Center for Science in the Public Interest; Consumer Federation of America; Consumers Union; Food & Water Watch; Government Accountability Project and Safe Tables Our Priority [S.T.O.P.], further urged Schafer to enforce a rule proposed in March 2006 that would allow the agency to list retail consignees on USDA press releases. Though the rule had widespread consumer support it has not been approved.

The seven organizations argued that the public had a right to know to which retail outlets Westland had distributed the meat. Consumers Union issued a press release on February 28, 2008 stating that thanks to a 2007 law that Consumers Union (CU) helped to pass, the State of California had published the names of retailers that had carried the recalled Hallmark/Westland meat. However, because USDA had not taken action to approve changes to its internal policies regarding recall disclosure, consumers outside of the California received no such information. “Recalled meat was shipped beyond California’s borders, and because of USDA’s continuing secrecy about the names of the retailers, consumers in other states have no way of knowing if they purchased any of the recalled beef,” CU argued. The organization located the recent recall in a series of food safety failures that CU including bacterial contamination of chicken and the rise of beef contaminated with E Coli and suggested the incidents cumulatively suggested a “gaping hole in the food safety net.”

CSPI, an organization with a long history of fighting for the release such information from the USDA, argued that the USDA’s obscuring the names of retail establishments that received recalled beef “creates confusion by suggesting that recalled products do not reach consumers. In fact, the bulk

Protecting Industry at the Expense of Public Health and Safety

When the USDA published January 2004 regulations on   Bovine Spongiform Encephalopathy (BSE) following the first U.S. case in December of 2003, the agency claimed that all meat from downed cattle would be prohibited from entering the food supply. However, following publication of the regulations, the agency issued Notice 5-04 which instructed inspecting veterinarians to allow those downed cattle which appeared healthy and whose nonambulatory status was the result of an injury rather than illness. Food safety organizations, researchers and other experts on BSE immediately took issue with the loophole arguing that because illness may predispose livestock to injury, and because the exact cause of an animal’s nonambulatory state is difficult to ascertain, all downed animals should be prohibited from slaughter for food. In written comments to the USDA, former USDA senior staff veterinarian Linda Detwiler stated, “I urge the USDA to not alter this definition and to continue to prohibit for food any bovine which cannot walk to the ‘knock box’ [area of slaughter] regardless of reason.”

Following a period of public comment, an analysis by the Humane Society illustrated that although trade associations publicly supported the regulations following the 2003 BSE case, behind the scenes these organizations worked to weaken the ban to allow for slaughter those cattle which cannot walk from injury rather than illness.

Strategic Alliances, Flexible Coalitions

Beyond working together to publicize the HSUS findings and demand that consumers have access to a full list of Hallmark/Westland retail distributions, humane treatment and food safety organizations made other alliances in the Hallmark/Westland case.

Following the HSUS investigation, Food & Water Watch published information on their website about the longstanding problems with understaffing and unfilled meat inspector vacancies at the USDA. Food & Water Watch learned from the USDA’s Food Safety and Inspection Service (FSIS) that the vacancy rate for FDA inspectors at the Alameda district in California, where Hallmark is located, was 11.33% at the end of FY 2007 and that inspectors at the Hallmark site were instructed that they should not enter the pens because a FSIS veterinarian would conduct all of the human handling checks. In a letter to USDA Secretary Schafer of the USDA, Food and Water Executive Director Wenonah Hauter and Stan Painter, President of the National Joint Council of Food Inspection Locals argued: “In slaughter plants with inspector shortages or vacancies” plant employees know there is no chance that a government official will be able to visit the pens to do any checks, until the slaughter line is stopped. This would give company employees plenty of notice to halt behaviors that violate regulations, before any government official reaches the pens.”

Weeks after the video release, HSUS posted a series of comments and letters from religious leaders around the country responding to the Hallmark/Westland case. Comments posted by HSUS illustrate that religious leaders were concerned both by the inhumane treatment of downed cows and food safety. Religious leaders emphasized the interconnectedness of life and the inconsistency between cruelty to animals and core Judeo-Christian values. Some also pointed to the importance of eating a vegetarian diet and highlighted environmental concerns associated with factory farming. Others argued for greater corporate and regulatory accountability. Brother David Andrews, Coordinator for Justice and Peace Congregation of Holy Cross stated that food companies needed to “take notice, to review their practices and to ensure that the animals in their care are treated humanely. Citizens need to be demanding that the entire food and dairy system be reviewed with an examination of the guarantees that need to be in place to protect animals from treatment evidenced by this shocking example, more than lip service or verbal assurances are needed.”

These alliances between food safety, animal welfare, labor and religious leaders, facilitated in large part by the internet and “net roots” organizing, demonstrate the potential for broad-based coalitions that can challenge inhumane and health harming corporate practices and demand a stronger regulatory system.

Each of the participating organizations has framed issue in slightly different terms. HSUS and Food and Water Watch primarily focus on the inhumane treatment suffered by downed cows but also emphasize the food safety issues associated with processing such cattle for slaughter. Food and Water watch has worked to expose the food safety, animal welfare, environmental and economic effects of factory farming which leads to conditions such as downed cattle. CSPI and Consumers Union/Consumer Reports, while touching upon humane treatment issues, focus largely upon the rights of consumers to healthful food and a stronger food safety system. What these differing emphases share is a moral stance that contrasts with the meat industry’s position that the industry itself is best suited to regulate its own behavior, a perspective challenged by the video images.

By working collectively to demand a common bottom line such coalitions – even when temporary – can mobilize broader constituencies for change. At the same time, by framing the issue in slightly different terms, the organizations maintain an independent focus on different areas of expertise. Moreover, the groups have different tactical and strategic repertoires, such as HSUS’ undercover operations or CSPI’s use of lawsuits, enabling the coalition to operate on a variety of fronts.

Moving Forward

In addition to raising concerns about the failing of the nation’s food safety inspection system, a situation that puts the health of American public and especially children and other vulnerable groups at risk, the Hallmark/Westland case also revealed the productive capacity of coalition work between humane treatment/animal rights and food safety organizations to change health harming corporate practices. One reason why these alliances seem to work is that while the animal welfare organizations highlight their opposition to cruelty to animals, including the fate suffered by factory farmed animals, and discuss a vegetarian lifestyle, they take a more moderate position than animal rights organizations such as People for the Ethical Treatment of Animals (PETA).

While alliances may be difficult where there are differences along ideological lines, the Hallmark/Westland case illustrates the potential for broader coalitions that might have broader application for other issues. For example Food and Water Watch’s work touches upon environmental and labor issues pertaining to factory farming and that group’s letter to USDA Secretary Ed Schafer was coauthored by the President of the National Joint Council of Food Inspection Locals. Working closely with environmental and labor organizations could strengthen the demand for greater food safety regulations, reduce the environmental impact of farming, and improve working conditions and humane treatment of animals.

Following the Hallmark/Westland expose, two Hallmark employees were charged in California courts for the actions captured by HSUS. While such charges may deter some future violations, these two employees were likely operating under the direction of Hallmark, which seemingly had a vested interest in getting downed cattle to slaughter. Improving conditions for farm animals would require a reconfiguration of the factory farming system. For instance, the HSUS reports that improved bedding and surface area could cut the number of downed cattle by up to 90%. However, the best footing for cows (sand) is also much harder to move and to clean than concrete floors, which are currently used. Unfortunately industry seems unlikely to make changes that would be considered cost prohibitive but would result in healthier cattle and ultimately increased food safety. Under the current administration, the USDA seems unwilling to pass rules and regulations which would favor public health and safety when they conflict with industry positions. By including labor rights, food safety and animal welfare organizations in these emerging coalitions, advocates can help to refocus attention back on industry and away from the actions of a few employees who will be held up as exceptions to the rule. When such coalitions can successfully pose an alternative approach to assuring food safety and animal protection, they can begin to mobilize the political support needed to implement these alternatives.

Interview with Lena Pons

Lena Pons is a Policy Analyst for the Auto Safety Group, a division of the national, nonprofit organization Public Citizen, that seeks to protect health, safety and democracy. The Auto Safety Group focuses on issues of auto safety, government and corporate accountability, human health and environmental sustainability as related to auto emissions. Its recent work has focused on improving fuel economy through both legislative and legal routes. The Auto Safety Group also works with other organizations on issues related to the Clean Air Act, fuel economy and automobile emissions. In January 2008, Corporations and Health Watch’s Zoë MeleoErwin interviewed Lena Pons. We present excerpts here.

CHW: Recently the Environmental Protection Agency ruled that California and the sixteen other states couldn’t set their own, more strict, emission standards. What role did the auto industry play in this defeat?

LP: Congressman Henry Waxman of the House Oversight Committee identified that there was some interference from Vice President Dick Cheney and Chrysler. Following a meeting that EPA administrator Stephen Johnson had with Cheney and Chrysler, they devised this legal argument for why the California waiver should be denied. And the California waiver was denied in a highly unusual way. They presented no technical justification the only documentation on the waiver denial that was given is a three or four page letter from EPA administrator Johnson to California Governor Arnold Schwarzenegger. It outlines that as a result of the energy bill being signed into law, California standards no longer meet the rubric under the Clean Air Act to say that they’re more protective. The claim by EPA is dubious because the California standards would go into effect sooner and their target emissions reduction is more stringent than that of the new national standards. What the waiver denial is based on is the assumption that the most recently passed energy bill will produce a comparable amount of public health. But there’s absolutely no data to support that; they’ve presented absolutely no estimate of what the public health benefit of the standards that were passed by this latest energy law would be. The states that have full regulations written on adopting these standards plus a handful of environmental groups have all sued EPA on the grounds that their waiver denial has not been properly supported.

CHW: One of the things the auto industry said in response to California waiver was that it would be a confusing and inefficient patchwork quilt of fuel economy programs. How legitimate is that argument?

LP: The seventeen states that have either passed the regulations or have stated intent by executive order to pass the regulations would cover slightly more than half of the entire population of the country. And a big part of that is that there are huge states involved; California and New York alone include over 15% of the total US population. California set separate standards, several states had adopted them and the functional outcome of that is that all of the vehicles sold in the United States meet these low emission vehicle requirements for the most part. The auto industry is saying that you would lose a lot of consumer choice in these states that have passed these regulations because they just wouldn’t be able to sell certain vehicles in the states. But in terms of the patchwork effect, when you’re talking about 50% of the country plus now Canada has standards that will be roughly the same as California, it’s just not going to be cost effective for them to produce two sets of vehicles. They’re never going to comply with a patchwork of regulations; they’re just going to comply to the most stringent set. So the reality of that argument is that they don’t want to meet the more stringent California standards.

CHW: What were the issues involved in the 2006 lighttruck fuel economy rule and what was Public Citizen Auto Group’s involvement in the case?

LP: The biggest issue in that case was that the National Highway Traffic Safety Administration (NHTSA) had valued the reduced carbon dioxide emissions from having improved fuel economy as having zero public benefit. We filed a suit in the 9 th Circuit Court of Appeals on the 2006 lighttruck fuel economy rule in collaboration with several other environmental groups and were represented by an independent law firm. We ultimately won in that the court found that the rule was arbitrary and capricious. It’s been vacated; the agency will have to go back and rewrite it to reflect some of the problems that they identified. The court also found that NHTSA had changed the fundamental way that the fuel economy standards were calculated and that without promoting a backstop, some kind of minimum value for fuel economy, that it was overvaluing consumer choice over the need of the United States to save energy—a specific criterion that was laid out in the Energy Policy and Conservation Act in 1975 which established the fuel economy standards. And so they found that the way that fuel economy standards could be calculated could stand as long as there was a minimum fuel economy value. This is a mixed victory because the new calculation scheme doesn’t actually force the auto makers to promote the best available technologies. But with a backstop it at least prevents a degradation below this minimum value, which is positive.

CHW: In your campaigns on auto safety, public health and environmental sustainability, what strategies does the Auto Safety Group employ? And specifically, how important is litigation as a tactic?

LP: Ideally we try to influence any rule making through the notice and comment period. And if the agency is nonresponsive to our comments then our next recourse is to litigate. So litigation has certainly been a part of our strategy used to a significant public benefit because, as a result of multiple litigation campaigns, we’ve been able to secure much stronger regulations than what the agency initially applied. Some of the time the regulations that the agency has presented us with are not actually in compliance with the law that Congress set forth and then we feel that we have a responsibility to make sure that the agency is upholding the law. So we like to influence the legislative process to get Congress to put forth the best possible law and then through the regulatory process we have an opportunity to influence rulemaking. But when we find that our concerns are ignored by the agency then we have no other recourse than to litigate.

CHW: Recently European Union officials announced that auto makers would have to greatly reduce carbon dioxide tailpipe emissions or face fines. How have automakers responded and do you have any thoughts on how this will influence the United States?

LP: There’s been a lot of skepticism as to whether those regulations will be durable. Probably the best indicator of what auto makers are going to do is the fact that at this year’s auto show they’ve really brought out a lot of highly fuel efficient concept vehicles that we haven’t seen before. For instance, Ford put a concept Focus out on the floor this year that’s supposed to get 20% improved fuel economy, which is an indication that they probably have more technology than they’re willing to admit openly in terms of improving vehicle fuel economy and by extension emissions. There were also stronger Japanese regulations in 2007, I believe Canada has recently strengthened their regulations, and China introduced their first fuel economy standards last year, so I think that auto makers are really starting to think pretty hard about it. With respect to bringing European vehicles to the United States, General Motors produces “Opel” brand vehicles that are much more fuel efficient than a comparable vehicle that would be sold under the Saturn brand in the United States. Now they’re bringing several of those Opel vehicles to the United States and will sell them as Saturn Vehicles. So they clearly do have the technology because they’re building more fuel efficient vehicles in other markets. But not all the auto makers have the flexibility that General Motors has; an auto maker like Chrysler is clearly going to have a more difficult time because they don’t really have a foreign manufacturing brand that is making improved fuel economy vehicles.

CHW: How does consumer demand influence changing fuel economy and emissions standards?

LP: Consumer demand with respect to fuel economy is a really strange relationship. I’ve read a variety of studies about how people use fuel economy as a determining factor in their automobile purchase decisions. And most state that people aren’t particularly longsighted in terms of how they make their vehicle purchase decisions. If you think back to the oil price shocks in the 1970s, one lasted for 14 months and the other one lasted for 19 months and so people haven’t really adjusted to the idea that oil prices are always going to be high.

Even if you look at the last five years, there was a really strong spike in oil prices following Hurricane Katrina and then they dropped back down about 70 cents per gallon. That kind of price volatility really suggests that people will make their decision about fuel economy based on whatever the price of gas is the day that they go to the dealership. And that’s why you see sales figures for a vehicle like the Prius are going to track pretty much with the price of oil and so in a month when gas prices are very high consumers are going to be more likely to purchase a vehicle like the Prius and months where oil prices are lower then consumers are more likely to choose a vehicle that might not get the same kind of fuel economy. But I think that people are really starting to become quite a bit more environmentally conscious and the durability of a problem like global warming, as opposed to something that might be more volatile like the geopolitical effects of Middle East oil consumption, might be starting to shift people’s perspectives about how they factor in fuel economy.

CHW: What strategies does the auto industry use to influence consumer decision making in terms of choosing less fuel efficient vehicles?

LP: The auto industry has consistently taken the position that people make their decision about a vehicle based on a variety of factors and one of the factors is “peak performance,”—the maximum possible zerotosixty acceleration or the towing capacity of a truck. It is fairly well supported that people are often swayed by peak performance but in reality people don’t really actualize that peak performance. For example, over 60% of truck owners never realize the peak performance even one time in their entire ownership of that vehicle. For twenty years or more, the auto industry has really been pushing this idea that you’re getting a better value because you’re going to get this truck that could tow a huge boat but you don’t own a boat and you have no need for this kind of towing capacity. And the auto industry has really consistently pushed this idea that people won’t be willing to trade for a smaller vehicle. But Porsche made this announcement just this week that they’re going to start offering hybrid versions of their vehicles. Now this is highly unusual because these are performance vehicles. Porsche has consistently paid fines for noncompliance with fuel economy standards and so I think that the argument by the auto industry that they can’t provide the same kinds of performance characteristics just doesn’t really hold water in light of these developments that have come as a result of new regulations.

CHW: Is this particular to the US?

LP: There is some perception that in the United States we want these huge SUVs and pickup trucks. But what’s interesting is that there have been several recent studies in Europe that have supported the idea that even though fuel economy standards, or greenhouse gas emission standards which are sort of interchangeable, have gotten more stringent in Europe, the popularity of larger vehicles has increased. In affluent western European countries you’re seeing an increasing number of people purchasing SUVs. I think that probably the bigger determining factor in terms of saying that this is a uniquely American problem, which I don’t really believe that it is, is just that people in the United States for the most part live more spreadout than they do in most places in the world. The average size of vehicles in densely populated urban areas in the United States is pretty much the same as what you would see in Europe.

CHW: One of the arguments the auto industry makes against improving fuel economy and reducing emissions is that the cost would be prohibitive and that this cost would then be passed down to consumers. How legitimate is this argument?

LP: Well it depends on what changes you’re demanding. If you’re demanding that auto makers convert every vehicle into a hybrid, then you might have a pretty good argument that it would be cost prohibitive. And a big part of that is the cost you’re paying for a battery that’s still relatively expensive to manufacture. But as batteries technologies continue to get better and as lithium ion batteries become more viable, that’s going to reduce weight, improve efficiency and reduce costs. The auto industry has been given a tremendous amount of lead time, but they have not been making incremental changes since the 1985 standard were actualized. And not every vehicle has to get 40% better fuel economy next year; over the next ten years the fleet of vehicles has to achieve 40% better fuel economy on the whole. Adding some of these technologies to vehicles would be fairly cost prohibitive, but the vehicles that need the most help are typically the most expensive to begin with. In order to make this incremental improvement in something like a Ford Focus you might add some initial cost to that car but you’re going to have a lifetime savings in terms of fuel cost which is going to get better and better. As the price of oil continues to rise the benefit of burning less fuel is going to get better and better. So I don’t think that the cost argument is necessarily as weighty as the auto industry has made it.

CHW: What is the auto industry’s current stance on the relationship between tailpipe emissions and global warming?

LP: Often when you talk to somebody from the auto industry they’ll talk about how criteria pollutants emissions of the newest vehicles are incredibly low. But when you talk about carbon dioxide, the only way to reduce carbon dioxide emissions from vehicles, at least from the tailpipe, is to burn less fuel or burn a fuel that is lower in carbon. They generally try to downplay the relationship between tailpipe emissions and global warming, but I don’t think that anybody in the industry is saying that carbon dioxide doesn’t cause global warming and that global warming isn’t happening. And a lot of times they also focus on “well look at this concept vehicle that’s ten or fifteen years down the line.”

CHW: Does the auto industry take any particular position on the relationship between tailpipe emissions and public health?

LP: Well once again, they’re going to discuss the issue of tailpipe emissions in terms of criteria pollutants which have certainly decreased a great deal. You’re seeing lower levels of nitrogenoxides and sulfuroxides and then by extension lower levels of ground level ozone, and ground level ozone is typically the biggest contributor to asthma and other kinds of auto emissions related health problems. But I don’t think that they like to talk about emissions at all. So they won’t say something like “there’s no link between auto emissions and health problems” but they will focus on the fact that through improved aftertreatment and exhaust systems you’re starting to see criteria pollutant emissions that are really pretty low, almost zero. An ultralow emission vehicle is really going to have nearzero criteria pollutant emissions, which doesn’t really affect carbon dioxide. But then carbon dioxide is, at least at current concentrations, not really a public health threat, at least in terms of asthma and inhalation effects. There are certainly health effects related to the problems of global warming.

CHW: What alliances do you see for public health researchers and auto safety and emission standards activists?

LP: There’s a lot of potential for interdisciplinary action related to these huge problems of energy policy and global warming and the places where energy policy intersects with public health. I think that every new solution obviously brings with it new problems. There are concerns about the toxicity of batteries they might use for hybrids. You’ve got a benefit in reduced vehicle emissions, but when you dispose of the batteries they’re generally made of stuff that isn’t necessarily super clean. There will need to be a really aggressive battery recycling program. I think that these are not insurmountable obstacles but certainly there’s always potential for people who come from different viewpoints to work together on these issues.

CHW: Finally, I’d like to ask you about the presidential elections. Do any of the Presidential candidates favor tougher national emission standards and are any of them focusing on that issue?

LP: All of the candidates on the Democratic side have recommended fuel economy standards that are stronger than what was passed in this latest energy bill. As far as I know, no candidate on either side, Democrat or Republican, has taken a position specifically targeting emissions from vehicles. There are a variety of strategies that have been talked about, one of which would be a carbon tax which would then make the price of gasoline more expensive. That might convince consumers to consider improved fuel efficiency. And another proposal to reduce vehicle emissions is a low carbon fuel standard, which is a performance standard for fuels in terms of carbon dioxide emissions.

CHW: Thanks very much for your time.

Corporations, Health and the 2008 Presidential Race, Part 2: Clinton, Obama and McCain on the Role of Corporations

The next President of the US faces some important decisions on the role that corporations will play in politics, the economy and health. He—or she—will need to decide whether to continue or end the Bush Administration’s dismantling of the federal regulatory apparatus, whether and how to restore the FDA’s capacity to protect our food and drugs, what role global corporations will play in setting trade rules, whether to limit or expand the role of money and special interests in politics, and whether or how to counter the health influences of the food, tobacco, alcohol, pharmaceutical, gun, automobile and other industries. As Americans elect their next Decider-in-Chief, what do we know about the positions of the main contenders on these critical issues? In the first of two reports, Corporations and Health Watch reviews the evidence on the positions of Senators Hilary Clinton, John McCain and Barack Obama on these questions.

Predicting how a candidate will act once elected is always difficult. As we have seen, he who campaigns as a compassionate conservative can morph into Scrooge. With three sitting Senators running for office, it is possible to compare their votes on critical issues. In addition, by tracking which industries contribute to whom, we can at least see how industry leaders use their checkbooks to rate the candidates. Finally, public statements, campaign websites and prior involvement with corporations provide additional sources of evidence, as do Presidential ratings by advocacy and political groups of various political perspectives.

Role of federal government in corporate oversight

In the last few years, the US Senate has voted on several issues related to government oversight of corporations, providing some insights into the candidates’ views. For example, Senator Clinton voted for restricting rules on personal bankruptcy (2001) (the business position) and for repealing the tax subsidy for companies that move jobs offshore (2005) (against the business position). She has said there is a culture of corruption and cronyism in Washington and that we need to stop outsourcing critical government functions to private companies, close the revolving door between government and the lobbying shop, and end no-bid contracts.1 Recently, her office has issued a report describing her economic blueprint for the 21st century that includes more populist language on corporations than in earlier campaign documents. She calls for leveling the playing field by reducing special breaks for big corporations, and goes on to note:

Over the past seven years, big corporations and special interests have been given a free pass to profit, often at the expense of the American worker. As President, Hillary will make it a priority to scale back special benefits and subsidies to these corporations and put those resources to work for our economy again. She will again take on the special interests and restore the voices of working families. Hillary’s plan to reign in the special interests will take back at least $55 billion per year from drug companies, oil companies, and firms that ship jobs overseas and invest those resources to improve the lives of working families.2

Senator Obama voted against reforming bankruptcy to include means testing and restrictions (2005) and for repealing the tax subsidy for companies that move jobs offshore (2005), both votes against the business position. Obama has said that corporations should be responsible for work conditions and pensions and that there should be tax incentives for corporate responsibility. He has criticized the excess influence of agribusiness lobbying and said he would work to reduce this if he were president. He states that the US should close tax loopholes for companies that relocate abroad and end tax breaks for companies that outsource jobs.1

In these votes, McCain voted for restricting rules on personal bankruptcy (2001), for reforming bankruptcy to include means testing and restrictions (2005), and against repealing the tax subsidy for companies that move jobs offshore (2005)1 all votes in favor of the business positions on these issues. In January 208, McCain advocated making the Bush tax cuts for corporations permanent, noting, I would make sure that not only the tax cuts are made permanent, but we cut corporate income taxes. That would keep businesses here, and it would keep jobs here and create jobs here.

In 2006, based on 12 key Senate votes, the US Chamber of Commerce noted that John McCain endorsed their positions on 100% of the votes, Senator Clinton on 67%, and Senator Obama on 55%. Seventeen other senators, all Republicans, shared McCain’s perfect business rating. Twenty eight senators, all Democrats and one independent, had lower scores than Obama, i.e., were rated less business friendly according to the US Chamber of Commerce criteria. These ratings suggest that both Obama and Clinton vote with business more often than their Democratic colleagues while Senator McCain represents the most-business friendly sector of Republican Senators. More recently, the Chamber of Commerce lowered its rating of Senator McCain to 80%.

Despite this voting record, compared to the other Republican Presidential candidates, Senator McCain has been perceived to be less friendly to business interests. The ISI Group, a New York brokerage firm, noted, If there was a bill negative for HMOs or pharmaceutical companies during the past eight years, chances were good that John McCain was the Republican sponsor.4

On tobacco, in 1998, McCain proposed anti-smoking legislation that would raise taxes on cigarettes, restrict the industry’s ability to advertise, and grant the Food & Drug Administration broad new authority over tobacco companies. The proposal would also have limited liability suits against the Big Tobacco. McCain estimated that his package would cost the industry more than half a billion dollars over 25 years. In an aggressive lobbying campaign, the tobacco industry defeated the measure in the Senate.

In the 2008 primary campaigns, McCain received less money from the tobacco industry than other Republican candidates and less than Clinton and Obama.5 A Republican operative observed that Senator McCain is not well-beloved by the lobbying world, to say the least, and he’s used that to his advantage with voters.3 The recent New York Times story that Senator McCain had a close and what the Times called an inappropriate relationship with a telecommunications lobbyist.

In the 2007 checkbook primary, lobbyists cast their dollar-votes for Senator Clinton, contributing $823,087 to her, compared to $416,321 to Senator McCain and $86,283 to Senator Obama.7

Energy and the Automobile Industry

The next President will need to decide whether to make incremental or substantive changes in US energy policy. What do their voting records say about the current top contenders?

Senator Clinton voted against terminating CAFE standards within 15 months (2002), for targeting 100,000 hydrogen-powered vehicles by 2010 (2003), against the Bush administration’s energy policy (2003), for banning drilling in the Arctic National Wildlife Refuge (ANWR) (2005), for factoring global warming into federal project planning (2007), for making oil-producing and -exporting cartels illegal (2007), and for removing oil and gas exploration subsidies (2007).1

Senator Obama voted for banning drilling in ANWR (2005), for reducing oil usage by 40% by 2025 (2005), for factoring global warming into federal project planning (2007), for making oil-producing and -exporting cartels illegal (2007), and for removing oil and gas exploration subsidies (2007).1

Senator McCain voted for oil drilling in ANWR in 2000 and against oil drilling in ANWR in 2002, promising new images of flip-flops in coming days. He voted against terminating CAFE standards within 15 months (2002), for targeting 100,000 hydrogen-powered vehicles by 2010 (2003), against the Bush administration’s energy policy (2003), for banning drilling in ANWR (2005), and against reducing oil usage by 40% by 2025 (2005). His positions on energy policy are more pro-environmental than President Bush but less than his Democratic opponents.1

On emission standards, the US Chamber of Commerce observes that Clinton has said as President, she would increase fleetwide fuel economy standards to 55 miles a gallon by 2030 with funds to help automakers modernize; Obama would double fleetwide fuel economy standards within 18 years with tax credits and loan guarantees to help automakers modernize and McCain supports raising fuel economy standards but has not specified by how much.2

The Campaign for America’s Future, a strategy center for the progressive movement that advocates more sustainable energy policies, has given Senators Obama and Clinton a rating of 100% and Senator McCain a rating of 17%.

Regulating the drug industry

Another key decision facing the next president is how to shape the nation’s approach to regulation of the drug industry. In the past eight years, the FDA’s reputation and credibility have declined sharply, both because of under-funding and close ties to the industries it regulates.

Senator Clinton has advocated that the FDA should provide more oversight over pharmaceutical companies’ financial relationships with providers. There is no mention of direct-to-consumer advertising or data marketing practices, but seems to focus solely on the relationship with prescribers. Senator Obama has said that some drug manufacturers are explicitly paying generic drug makers not to enter the market so they can preserve their monopolies and keep charging Americans exorbitant prices for brand name products. He has said his health care plan will work to ensure that market power does not lead to higher prices for consumers. In the Iowa primary, McCain said that if there are ways to bring greater competition to our drug markets by safe re-importation of drugs, by faster introduction of generic drugs, or by any other means we should do so….8

A pro-drug industry website that monitors the FDA noted that Clinton, McCain and Obama all favor drug importation. That means that it is inevitable that a president who favors importation will be in the White House with a Democratic House and Senate that will be more receptive to the concept than at any time prior.8

Money in politics

It is likely that the influence of money on politics will be a topic for discussion in the 2008 general election, yet the heavy reliance of all candidates on corporate money (see Corporations, Health and the 2008 Presidential Elections, Part 1, Following the Money) makes it difficult to imagine any pf the candidates supporting substantial reforms.

While McCain has been a strong supporter of limiting the influence of money in politics—he once said his support for McCain-Feingold bill was an issue of transcendent importance to him—he will have a hard time reconciling this commitment with his promise to appoint Supreme Court justices like Scalia and Thomas—consistent supporters of Big Business and opponents of campaign finance reform. A recent story in Business Week asked, Is John McCain Good for Business?, observing that McCain has crusaded against the influence of corporate lobbyists, yet has more K Street fixers raising money for his campaign than any other Presidential candidate.9 The recent New York Times and Washington Post stories on his relationship with a lobbyist emphasize his vulnerability on this issue. In the 2007 primary cycle, 78% of McCain’s contributions campaign from corporate funds. Meanwhile, Hillary Clinton appeared on the cover of Fortune magazine as Big Business’s candidate; and last Spring Obama was the top recipient of Wall Street contributions, suggesting that no matter who wins, business will have ready access to the next President.

In future articles in this series, Corporations and Health Watch will examine the candidates’ positions on free trade, the food industry and on FDA reform.

References

1. Campaign Issues 2008.
2. Hilary Clinton. Solutions for America. Economic Blueprint. Hillary Clinton’s Economic Blueprint for the 21st Century
3. US hamber of Commerce. Senate Vote Scorecard, 2006.
4. Quoted in Calmes J, Frangos A. “McCain’s Breaks with GOP left scars but could increase his “electability”.” Wall Street Journal. February 7, 2008, p A1 and A16.
5. Corporations and Health Watch. Corporations, Health and the 2008 Presidential Elections Following the Money.
6. Rutenberg R, Thompson MW, Kirkpatrick D, Laboton S. “For McCain, Self-Confidence on Ethics Poses Its Own Risk.” New York Times. February 21, 2008, p. A1.
7. Open Secrets.
8. Eye on the FDA. Where the Candidates Stand Parts 1-8.
9. Javers E. Is John McCain good for business? Business week. February 6, 2008.

 

View CHW’s coverage on Corporations, Health and the 2008 Presidential Race:

Part 1: Following the Money
Part 2: Clinton, Obama and McCain on the Role of Corporations Part 3: Clinton, McCain, Obama and the Food Industry

Tracking the Effects of Corporate Practices on Health