Commentary: Shifting priorities in public health: from changing lifestyles to changing political, economic, and social circumstances

Public health researchers seeking to focus greater attention on the role of corporate practices in health and disease often encounter the argument that the only significant modifiable determinant of health is lifestyle.  In this commentary, social epidemiologist Sandro Galea, MD, DrPH, Associate Professor at the University of Michigan School of Public Health makes the case for a broader perspective.

The typical public health observational study goes something like this.  We identify a disease of interest.  We then try to figure out if an exposure is indeed associated with this disease. We conduct a study and collect data from participants.  We then use a variety of increasingly sophisticated analytic tools to isolate the relationship between the exposure of interest and the disease.  Once we have identified such an association with some confidence, we recommend a behavior change that will limit exposure to that particular factor.  For example, here is the conclusion from a recent, well done study aimed at understanding several factors that may cause cardiovascular disease: “strategies should focus on reducing obesity, in particular through physical activity, elimination of cigarette smoking, and moderation of alcohol intake” (1).

In other words, to reduce heart disease, we need a lifestyle change, to eat less, exercise more, and smoke less, in order to become healthier.  These types of conclusions come from peer-reviewed academic papers published in reputable public health journals. In many ways, these recommendations arise naturally and logically from the dominant public health paradigm.  We understand the factors that make us sick and now all we have to do is to change the way we live so that we are no longer exposed to those factors.

Although it is seldom stated in this manner, the public health literature veritably shrugs in disbelief when contemplating these issues, suggesting “how could they possibly keep smoking (or drinking too much etc) when we tell them over and over how bad that is for their health?” Or, “how could they possibly continue having such an unhealthy lifestyle?”

Tobacco as a Lifestyle Problem

Let’s look back at one of the great triumphs of modern public health science to provide us with hints about our lifestyle and whether we truly can do something about it.  All students of public health well know the details of what the Centers for Disease Control and Prevention (CDC) rightly identified as modern pubic health’s greatest triumph—the identification of tobacco smoking as a risk for disease(2).  In the middle of the twentieth century a few physicians-turned-epidemiologists used follow-up cohort studies to show that cigarette smoking was associated with lung cancer and heart disease.   These studies led to other comparable studies confirming these findings.  There was opposition to this observation at first, primarily from cigarette companies, but, with the production of the surgeon general’s report on smoking in 1964, the fact that smoking causes poor health in many forms became accepted within public health circles.  What followed of course was a dramatic burgeoning public health effort to help eliminate smoking.  A large industry grew around health education programs to teach all of us about the adverse consequences of smoking and countless education programs aimed to help smokers quit.

Smoking prevalence dropped throughout North America from 42% in 1965 to 25.5% in 1990 to a current prevalence of approximately 20.8% percent (3).

Clearly, public health research and practice “saved the day”.   Through careful empiric research, we were able to identify a health menace and we have, ever since, been devoting energy to help eradicate this menace. One cannot walk through any major US urban area without seeing a plethora of health education messages touting the evils of smoking, offering Quit-Lines and other aides to quite smoking and, increasingly, rather horrifying pictures of the pathologic consequences of smoking aimed at scaring us into not smoking.

But we, or at least 1 in every 5 of us, keep smoking. In fact, we keep participating in many of these factors that we surely must by now know cause poor health, including 1 in 5 of us drink too much on a regular basis, 1 in 3 of us are overweight, and 1 in 3 of us own firearms (4).  All of these factors are well recognized to be among the leading causes of death in this country (5).

Why do people choose unhealthy lifestyles? 

Which then brings us to the issue at hand. Why is it that so many patently harmful factors in our lifestyle continue despite public health’s valiant effort?   The existing literature suggests three common answers.  First, some posit that there are psychological reasons, including pleasure in risk taking and defying conventional wisdom, in continuing to embrace unhealthy lifestyles.   Second, some argue that public health professionals are not as good as we need to be at conveying what unhealthy lifestyles should be avoided. A third explanation asserts that ultimately people do not care much about being healthy and would rather do as they please without regard for health.  All these can be summarized to say that fundamentally, people choose the lifestyle they want, irrespective of what public health might say.

While these (and other)  explanations all have some validity,  they should matter little to us as public health professionals because a focus on lifestyle is simply not the most efficient or effective approach for public health to take.  Why?

Perhaps another example, one that contrasts with the previous smoking one, illustrates the point. Another of the CDC’s great recent achievements in public health is the reduction in motor vehicle injuries and deaths (2). As the automobile took the US by storm by the middle of the twentieth century, the rates of motor vehicle accidents and deaths were soaring. There were 93,803 unintentional motor vehicle related deaths in 1960, for example (5).  Clearly, our lifestyle choice to drive was also killing us. One approach would have been for the public health establishment to urge every American to drive less, to walk instead or take mass transit – to change their transportation life style.  But that is not what happened.

Instead, a consumer movement emerged that demanded the automobile industry to make safer cars  and Congress passed laws to make that happen, usually over the objection of the automobile industry and with significant compromises.   For example, Ralph Nader’s Unsafe at any speed (1965) resulted in changes that substantially changed the contribution of motor vehicle accidents to our burden of disease morbidity and mortality.  However, in stark contrast to the tobacco example, the focus of the changes aimed at reducing car-related disease was not on the “users” of the car but rather on the circumstances of the driving.  Certainly driver education improved, but it is widely recognized that the greatest contributor to the change in car-related morbidity and mortality were safer cars, safer roads and better enforcement of traffic regulations aimed at making those collisions that were inevitable less injurious. As a result, although there are now more than 200 million drivers on the roads on a regular basis, compared to under 90 million in 1960, the rates of motor vehicle accidents in the US is less than 1.5 per 100 million vehicle miles traveled compared to approximately 5 per 100 million vehicle miles traveled in 1960 (6, 7).  In other words, we did not really change our lifestyle (driving) at all (in fact, we are driving much more than ever), but still improved our health. We can argue about whether a different approach might have led to more sustainable and better environmental outcomes, but in this case changing corporate practices rather than lifestyle led to dramatic improvements in public health.

In contrast, until the last decade or so, tobacco control focused primarily on changing individual behavior.  As new policies were passed to ban smoking in public places and increase tobacco sales taxes, the declines in tobacco smoking accelerated, showing the value of integrating strategies to change individual lifestyle and policy.

Both these examples in fact reinforce the observation that changing lifestyles is immeasurably difficult, requiring not only efforts to change deeply held beliefs and practices one person at a time but also to continue to “treat”  the new recruits into tobacco use, or eating or drinking too much.  Thus, perhaps changing lifestyles should not be the point of what we do in public health but rather changing circumstances should be. Perhaps it is time to recognize that changing lifestyles is in fact very difficult and that a more efficient and effective approach would be to change the political, economic, and social circumstances within which  people live their life as they please, to the fullest. This strategy also acknowledges that people do not choose lifestyles in a vacuum but are influenced by corporate practices such as advertising and product design, by public policies, and by the “opportunity structures” of our market economy.

Objections to a critique of lifestyle

This argument can lead to complaints along three grounds.  First, some would object to leaving individuals to their own lifestyle choices within a healthier environment as insufficient given that some lifestyles are inherently injurious to self or others.  Second, some critics might assert that if public health were to take responsibility for the circumstances within which we live, it would contribute to a “nanny state”, highly unpopular in a country where individual autonomy is prized almost above all other virtues.  Third, some public health experts believe that it is outside our professional domain to seek to change economic, political, and social circumstances. In my view, each of these criticisms is in fact wrong. Let us tackle each one.

We cannot avoid dealing with lifestyles; some lifestyles are always harmful. It may seem that some lifestyles are simply harmful in an absolute sense, but is this really the case?  Let’s return to the cigarette example.  We now know that tobacco companies worked hard to make cigarettes more addictive to increase consumption and therefore profit. From the point of view of addictiveness and carcinogenicity, they are harmful by design.  To take another example, people choose high fat, high calorie food in part because that is what has been most advertised and made most available.  In these two cases, the health consequences of lifestyle “choices” are the direct result of efforts to make a profit.  With different food or tobacco policies, the default choices could be very different.  So what do public health professionals work to change—the environments and policies that make some lifestyle choices unhealthy or the behaviors themselves?

Public health cannot tackle political, economic, or social circumstances because that threatens individual autonomy. Would a public health focus on changing the circumstances within which we live mean that public health would reduce individual autonomy?  Of course it could but the critical point is that doing so would not be any different than what is already done to our individual autonomy by forces other than public health.  We do not choose the cigarettes we smoke—we smoke cigarettes that are made for us by corporations acting under a set of their own incentives (primarily to maximize profits) that are often not aligned with the goal of improving our health.  We often have little choice about the food we eat.  Recent research shows that those living in poor neighborhoods have more access to unhealthy foods and less to healthy ones. Not surprisingly, they then eat those available foods.  Similarly, for the most part drivers do not choose to drive in safer cars, on safer roads than we used to drive on 50 years ago. These choices are made for us by political, economic, and social forces that are larger than ourselves. It has always been so and it will always be so. Urging public health to tackle reshaping our circumstances would introduce a player among these forces that shape our circumstances whose interest is in the promotion of health rather than in the promotion of profit (as in the case of corporations) or electoral success (as in the case of political parties).  The choice is not whether parents should have sole rights to make health decisions about their children – our world is too complicated for that.  Rather, the question is who do Americans want looking out for their children’s health—public health professionals or McDonalds?  Public health professionals should welcome an opportunity to argue they will better protect autonomy than Ronald McDonald.

Public health simply is not equipped to tackle changing contexts. This third objection is a plaintive one—but what can public health do?  Public health arises from medicine, which is concerned with the health of individuals. The forces of public health are much weaker than are political, economic, or social forces.  How could we possibly compete?  It is self-evident that unless we try to compete we cannot succeed. It is also true that challenging contextual forces that shape health as a central focus would require substantial retooling of the public health profession.  It would require re-thinking how we teach our students, the goals and methods of professional practice, and the value of being well-regarded by all sectors of society.  But other professions have been able to conduct similar retooling. Why then not public health?  For example, many US State Attorneys General were, in the 1970s and 1980s focused on the eradication of organized crime.  This scarcely remains the focus on AG efforts nationwide today. In fact, AG efforts have been, in the past decade, much more focused on curtailing illegal financial sector activity than on what the AG offices used to work on a decade ago. Surely such focus shifting could not have been easy. But it happened, and arguably the law-abiding citizenry is better for it.

Another approach to public health is possible

Similarly, public health can decide that the old target, lifestyle, is no longer, or perhaps never was, such a fruitful target for our efforts, and move toward another target, the circumstances within which we live, the political, economic, and corporate practices that shape our environment, with the goals of effecting change here in order to promote the health of the public.   The objections to such an approach rest primarily on a lack of imagination on our part that we can indeed achieve a change in focus in the profession.  I argue that such a change is not optional, as much as necessary, for public health achievement in the twenty-first century.

Sandro Galea is the editor of Macrosocial Determinants of Health (Springer 2007) and can be reached at sgalea@umich.edu.

 

References

1.  Costanza MK, Cayanis E, Ross BM, Flaherty MS, Alvin GB, Das K, Morabia A. Relative contributions of genes, environments, and interactions to blood lipid concentrations in adult populations. American Journal of Epidemiology2005;161(8):714-724.

2. CDC. Ten great public health achievements–United States, 1900-1999. MMWR 1999;48:241-3.

3CDC. Surveillance for Selected Tobacco-Use Behaviors — United States, 1900-1994. MMWR 1994; 43: 5-6.

4.  Mokdad AH,  et al. Actual causes of death in the United States, 2000.  JAMA. 2004;291(10):1238-45.

5.  Okoro et al. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics. 2005;166(3):e370-e376

6.  CDC.  Achievements in Public Health, 1900-1999 Motor-Vehicle Safety: A 20th Century Public Health Achievement. MMWR 1999; 48(18);369-374.

7.  Fatality Analysis Reporting System.  Encyclopedia.  Available at http://www-fars.nhtsa.dot.gov/Main/index.aspx

 
 

Youth-Involved Street Survey of Health Enhancing and Health Damaging Messages in Disparate Urban Neighborhoods Using Digital Technology

Neighborhood environments can both promote health (Ewing 2005) and encourage disease (Satterthwaite 1993). Differences in presence of health enhancing and health damaging messages and environments may account for some differences in health among neighborhoods with different socioeconomic and racial/ethnic characteristics (Kipke et al. 2007; Macdonald, Cummins, and Macintyre 2007; Pasch et al. 2007; Snyder et al. 2006; Stafford and Marmot 2003). In this pilot study, our hypothesis is that health-enhancing messages are more prevalent in wealthier neighborhoods and health damaging ones more prevalent in economically impoverished neighborhoods.   For the purposes of this pilot study, we define “health enhancing” messages as messages which promote the consumption of whole grains, fresh fruit and vegetables, low fat dairy and meats or public health service advertisements (e.g., a smoking cessation ad) and “health damaging” as advertisements for alcohol, tobacco and high fat, low nutrient foods.  In preparation for a larger scale study, our goal here was to test a methodology for comparing such messages across communities with differing sociodemographic and environmental characteristics


Disparate Urban Neighborhoods: Upper East Side, East Harlem

To carry out this study, we involved youth researchers in measuring the health enhancing and health damaging messages in two, disparate urban neighborhoods: the affluent and predominantly white Upper East Side of Manhattan, and the neighboring but economically impoverished and predominantly Black and Latino East Harlem. Lexington Avenue, a major thoroughfare, runs through both neighborhoods.    The youth researchers worked in two phases measuring health enhancing and health damaging messages along Lexington Avenue in the two neighborhoods.  The first phase included a class of thirty-three Hunter College undergraduate students; the second phase, a smaller group of three high-school-aged students recruited from Global Kids, a community-based youth organization.   In each phase, the youth surveyed ten block segments of Lexington Avenue in the two neighborhoods.

Using Digital Technology to Measure Health Enhancing and Health Damaging Messages

Researchers at Hunter College partnered with the Fund for the City of New York (FCNY), a nonprofit research and policy group, to modify their ComNET software to measure health enhancing or damaging messages.  FCNY developed the ComNET software to document problems in the urban environment and engage community members in notifying the responsible municipal agencies to address those problems in the urban environment.  ComNET is designed for use on handheld digital devices, equipped with digital cameras.  The use of ComNET and digital technology made this project possible and offered a number of advantages.

First, the handheld devices serve as an important incentive for the engaging the youth.  Young people, most of whom have grown up immersed in digital technologies, quickly learn how to manipulate the devices and yet still see them as fun, innovative “toys.”    It would be much more difficult to engage youth in this research without the use of digital technology.   Second, the ability to quickly upload the data and have it almost immediately available for data cleaning and analysis is an invaluable asset of working with the ComNET software.   The decade-long development of the technology by FCNY and the infrastructure that they have in place to ensure the smooth functioning of the devices, upload, cleaning and analysis of the data, provided a strong foundation for the methodology used here and obviated the research group from investing time and money in developing such a technology.

Findings

The hypothesis that health enhancing messages are more prevalent in better off neighborhoods and health damaging ones more prevalent in poorer neighborhoods appears to be supported by the data from our pilot study. Table and Figure 1 shows that in the 10-block segment our project surveyed, the percentage of health harming ads in East Harlem is 29% greater than in the Upper East Side.  East Harlem also contains nearly 10% fewer health promoting ads than does the Upper East Side.  Both neighborhoods have a higher concentration of health harming than health promoting advertisements.  Tables 2 and 3 illustrate that tobacco and alcohol advertisements are more prevalent in East Harlem than in the Upper East Side where health-harming ads tend to be food-related.

For access to charts/graphs, please access pdf here

Limitations 

The findings here are necessarily limited because this was a pilot study.  First, the sample size (ten block segments measured by two groups) was too small to confidently generalize to all urban areas, all New York City, or even the two neighborhoods studied here.   Further limitations include some challenges with digital technology.  The ComNET software is very effective at measuring some types of problems in the urban environment, but needs further modification to accurately and efficiently measure health enhancing and health damaging messages. Specifically, the addition of a feature that would allow for multiple features for one entry would speed up the process considerably. The limitations of this admittedly small and suggestive pilot study can be addressed in a larger and more systematic follow-up study.

Conclusion

New York City neighborhoods of East Harlem and the Upper East Side represent stark disparities in income, racial composition and health outcomes.  This pilot study examined one aspect of the disparities between these neighborhoods that may contribute to unequal health outcomes: health promoting and health damaging messages.   In general, we found that East Harlem has more ads (of all kinds), more health harming ads, and fewer health-promoting ads than the Upper East Side.     And, we also found that both neighborhoods have more health harming ads than health promoting.   While the presence of health damaging ads cannot account for all the negative health outcomes in a particular urban neighborhood, the disproportionate display of the health damaging ads in East Harlem as compared to the Upper East Side, suggests that some New York City residents bear a greater burden of these messages.  The disparity in the types of health ads that city residents in different neighborhoods are exposed to is a subject that demands further study.  In addition, our pilot study demonstrates that young people can be engaged in studies to document the health characteristics of their communities, an activity that can be a first step in analysis of differences in health and action to reduce inequities in health.

References

Ewing, R. 2005. Building environment to promote health. J Epidemiol Community Health 59 (7):536-7.

Kipke, M.D., E. Iverson, D. Moore, C. Booker, V. Ruelas, A.L. Peters, and F. Kaufman. 2007. Food and park environments: neighborhood-level risks for childhood obesity in East Los Angeles. J Adolesc Health 40 (4):325-33.

Macdonald, L., S. Cummins, and S. Macintyre. 2007. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite 29 (1):251-4.

Pasch, K.E. , K.A.  Komro, C.L. Perry, M.O.  Hearst, and K. Farbakhsh. 2007. Outdoor alcohol advertising near schools: what does it advertise and how is it related to intentions and use of alcohol among young adolescents? . J Stud Alcohol Drugs68 (4):587-96.

Satterthwaite, D. 1993. The impact on health of urban environments. Environ Urban 5 (2):87-111.

Snyder, L. , F.  Milici, M.  Slater, H.  Sun, and Y. Strizhakova. 2006. Effects of alcohol exposure on youth drinking. Archives of pediatrics and adolescent medicine 160 (1):18-24.

Stafford, M., and M. Marmot. 2003. Neighbourhood deprivation and health: does it affect us all equally? Int J Epidemiol 32 (3):357-66.

 

For more information on this study contact Jessie Daniels at jdaniels@hunter.cuny.edu

Books on Corporations and Health, 2007

With thousands of new books published each year, it’s hard to find titles of interest. To help readers sort through the piles, we present an idiosyncratic list of 10 books published in 2007 (or early 2008) that address the relationships among corporations, markets, government and health. These books may help Corporations and Health Watch readers to understand better the impact of corporate practices on health, to occupy cold winter nights, or to pick a gift for a deserving friend. We invite you to submit titles of other books you suggest, limiting titles to those published in 2007.


Ten Titles on Corporations and Health

Benjamin R. Barber. Consumed How Markets Corrupt Children, Infantilize adults, and Swallow Citizens Whole. W.W. Norton and Company, New York, 2007. Political theorist argues over-production of goods forces markets to infantilize consumers and undermine democracy.

Allan M. Brandt. The Cigarette Century The Rise, Fall and Deadly Persistence of the Product that Defined America. Basic Books, New York, 2007. Medical historian analyzes impact of tobacco industry on US and global health and politics.

Jillian Clare Cohen, Patricia Illingworth , & Udo Schuklenk, editors. The Power of Pills: Social, Ethical and Legal Issues in Drug Development, Marketing and Pricing. Pluto Press, London, England, 2007. Three academics edited this interdisciplinary collection of essays that analyze and critique the global pharmaceutical industry.

Philip J. Cook. Paying the Tab The Costs and Benefits of Alcohols Control. Princeton University Press, Princeton, NJ, 2007. Economist analyzes US alcohol policy and suggests increasing taxes to reduce harm.

Devra Davis. The Secret History of the War on Cancer. New York, Basic Books, 2007. Toxicologist describes how industry shapes US response to cancer at expense of prevention.

Richard Feldman. Ricochet Confessions of a Gun Lobbyist. Hoboken, N.J., John Wiley and Son, 2008. Former NRA lobbyist describes how group “betrays trust” of gun supporters.

David Harsanyi. Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists, and other Boneheaded Bureaucrats Are Turning America into a Nation of Children. Broadway, New York, 2007. Libertarian columnist for the Denver Post rants against government interference on health.

Tim McCarthy. Auto Mania Cars, Consumers and the Environment. Yale University Press, New Haven, CT, 2007. Historian describes how auto industry transformed United States in the twentieth century.

Michael Pollan. In Defense of Food: An Eater’s Manifesto. Penguin, New York, 2008. Food journalist suggests actions that individuals, communities and policy makers can take to reclaim food from industrial producers.

Robert B. Reich. Supercapitalism. The Transformation of Business, Democracy, and Everyday Life. Alfred A. Knopf, New York, 2007. Policy analyst and former Clinton Labor Secretary argues that new global competitive pressures force business to serve investors and consumers at expense of society and suggests public policies to restore democratic control of markets.

Campaign Profile: The Public Health Advocacy Institute

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

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

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

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

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

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

New Tactics and the Next Generation of Public Health Law

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

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

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

Negotiating with the Food Industry

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

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

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

Acting Locally and Globally on Tobacco

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

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

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

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

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

 

References

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

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

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

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

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

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

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

8. PHAI Fall 2007 Newsletter.

9. PHAI newsletter fall 2007 p. 7

 

Photo Credits:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alcohol in Three European Countries

 

 

Sweden

France

Czech Republic

 

  

 

Average annual consumption 
(in liters of pure alcohol)

 

5.62

 

9.5

 

13.67

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

5.26

13.33

16.66

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

1.29
21.54

.66
11

.23
3.19

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

26%
67%

9%
33%

7%
26.1%

Restrictions on alcohol sales

State monopoly

Sales license required

License required for production but not sales of alcohol

 

     

 

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

 

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

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

Photo credits:

1. Systembolaget 
2. Tom Rovers

 
 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What to teach about corporations and health?

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

Box 1

Ten Key Concepts about
Corporations and Health

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

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

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

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

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

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

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

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

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

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


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

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

Box 2

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

Core Course

Selected Concepts

Biostatistics

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

Epidemiology

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

Health Policy and Management

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

Environmental Health Sciences

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

Health and social behavior

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

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

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

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

Box 3

Getting Started

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

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

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

Organize sessions on corporations and health at professional meetings

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

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

 

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

 

References

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

Photo Credit:

1. Mountainbread 

Tracking the Effects of Corporate Practices on Health