Corporate Practices as a Determinant of Health Disparities: An Interview with Stephen Thomas

Stephen Thomas, Ph.D. is the director of the Center for Minority Health (CMH) and the Philip Hallen Professor of Community Health and Social Justice in the University of Pittsburgh Graduate School of Public Health. He has written widely about racebased disparities and is founding cochair, with Thomas LaVeist from Johns Hopkins University, of the new Academy for Health Equity, an organization whose mission is to “utilize rigorous scientific research, policy development, and community advocacy to eliminate health disparities and create a social movement designed to ensure equal opportunity for health.” Recently Corporations and Health Watch director Nick Freudenberg interviewed Dr. Thomas about his views on corporate practices as a social determinant of health and as a creator of disparities in health, an interview excerpted here.

CHW: In your view, what role do the practices of food, alcohol, and tobacco industries play in explaining differences in black and white health status?

ST: I think this question about fast food, alcohol, and tobacco marketing is an underrecognized burden driving racial and ethnic health disparities simply because of the artificial tension between market forces and issues of personal judgment. I don’t think they’re all artificial but they are sometimes set up as if they are mutually exclusive. In a free society we assume that people have the right to choose and therefore if they choose to make bad choice it’s their fault, not the fault of the broader society or the environment in which they live and operate. And that gives a false choice that has resulted in many African American communities suffering disproportionately from very sophisticated targeted marketing in black neighborhoods when it comes to legal commercial products that are known risk factors associated with poor health outcomes. For a long time, the tobacco industry put a lot of money into cultivating publications and organizations serving African Americans including, but not limited to, Jet and Ebony magazines. Additionally, they’ve sponsored conferences with civil rights organizations like the Urban League and NAACP as well as demonstrate their commitment to “diversity” by hiring black executives to get them into the African American community and establish market share and brand loyalty. The industry’s successful use of “cultural tailoring” resulted in a positive dynamic with black leaders and those spheres of influence in which they operate. In this way tobacco and alcohol industry executives have more “bottom line credibility” than those of us in public health.

CHW: Do you see differences between tobacco and food and alcohol, other industries which play an important role in health, both in the way they’ve acted in black communities and in the way they’re perceived in the black community?

ST: Yes. First of all the alcohol and tobacco industries market products that are not required to sustain life, and yet the food industry does. And both the alcohol and tobacco industries have used sophisticated marketing techniques to penetrate the black community with products that are known to be associated with negative health outcomes. Tobacco is the most egregious because there’s no healthy way to use their products, but the alcohol industry has also been very sophisticated in their penetration. For the food industry, it was only recently that we had enough scientific evidence to show that these poor food choices, (empty calories, fat, supersizing), and the marketing of fast food in black neighborhoods is directly related to poor health outcomes.

Billboard for Uptown Cigarettes, a product developed by RJ Reynolds to market to African Americans but withdrawn after community protests.

CHW: Given these differences, how would you suggest that public health researchers and those concerned about health disparities address the food industry?

ST: I don’t think we’ll be able to fight that battle in the food industry the way we did with tobacco because you do have to eat to live, and so it requires a partnership. We cannot demonize fast food like we demonized tobacco. It’s not likely that we’ll have the equivalent of a tobacco settlement with fast food companies. We might consider following the path of the Robert Wood Johnson Foundation, which is partnering with the food industry as a way of trying to address the national problem of childhood obesity. So it is a Faustian bargain when McDonald’s starts distributing pedometers and positioning themselves to be the promoters of physical activity and good health.

CHW: As food companies look to partner, particularly with African American communities, what should communities do in order to ensure fair partnerships?

ST: I don’t think you can have a fair partnership on an unfair playing field. So I can think of no equal partner when you talk about the industry. I think therefore that vulnerable neighborhoods, be they Black, Hispanic, or poor of any color are always at a disadvantage. So they’d end up trading jobs and economic benefits that do not reduce the risk of the products that’s being marketed in the community. I don’t think it could be done fairly, in other words I think that there is a role for the federal government and for regulation in those kinds of interactions.

CHW: The federal government has said eliminating disparities in health is one of its goals. Do you think Federal, state and local government can make real differences in health disparities by targeting the disparity producing activities of the industries that we’re discussing?

ST: Well the goal to eliminate racial and ethnic health disparities outlined in Healthy People 2010 was really set in motion before the current administration was in place. But the current administration has actually supported decreased regulation and an increase in letting the market decide policy. Their focus has been on personal responsibility and as a result, poor food choices and exposure to alcohol and tobacco advertisements have been seen more as individual choices and moral failings rather than actual business practices, business policies, and federal policies that make urban city communities in particular vulnerable. It’s my hope that in Healthy People 2020 we do not lose the focus on eliminating racial and ethnic health disparities. The sevenpart Public Broadcasting documentary “Unnatural Causes” will hopefully raise awareness about the role that policy and poverty and social determinates of health play in population health. However, if you don’t watch public TV you may not even know that the documentary exists. It’s really up to us as a community to use the documentary to mobilize at the local level as a grassroots movement for health equity. I think grassroots movements can affect change at these broader levels where social determinants of health operate. But it cannot be done unless the community is educated.

CHW: As you’ve probably seen, there’s a lot of discussion in public health about how public health advocates frame issues in order to successfully mobilize communities. I wonder if you think there’s potential for using the disparities in health and the racial targeting frames as a way of approaching industry and personal responsibility for health.

ST: I think that the health disparity and health equity frame has created a space to move beyond the biomedical model, organ systems model and the diseasespecific model, so that we really can address these broader issues. The problem is that the language really doesn’t capture headlines. One need only look at the national news to see literally a story every day focused on a new medical breakthrough for some rare and odd disease and seldom do we have that kind of focus on racial and ethnic health disparities. So we need to do work in how to frame our issues also in a very aggressive media market. Currently, there is no national organization currently focused on health disparity. However, this summer will be the founding meeting of the Academy for Health Equity in Denver and I think that’s the nascent beginnings of a national organization to provide leadership in this area. But, like any new nonprofit organization, it is vulnerable to changes in funding cycles and other startup issues. And because they’ve staked out their moral and scientific ground in “health equity”, the organization may not be able to morally take money from pharmaceuticals and other [such] businesses because it would be a contradiction … inconsistent with their philosophical foundation.

CHW: As you know, advertisers, including alcohol, tobacco and food corporations, use cultural and racial ethnic images and themes to sell products that are health damaging. How do you think this targeting is viewed in the black community and does it raise ethical issues for you?

ST: I think the targeting is viewed positively, even if the product is negative, because the images are so compelling. In other words, the industry has trumped public health in understanding how to shape behavior. They have powerful imagery and we have no equivalent in terms of matching this level of sophistication. So when you see a McDonald’s or any fast food product ad that takes place in a black church or has the gospel theme music, automatically black people resonate with that even though the product may be a well known “killer” of black people. Someone inside the public relations firm has tapped into the cultural understanding of black people. And I have yet to see public health counter with our version of this understanding. And even if we did, we’d never get the market share or broadcast time. So here again we are on an unequal playing field: ethnic targeting works. Our aim should not be to criticize it because they’re being successful with promoting negative behaviors, but to somehow harness it to do just the opposite.

CHW: Do you think that there’s room within ethnic targeting to contest how the food, alcohol and tobacco corporations do that? For instance, the “Truth” Campaign around tobacco targeted youth around a specific set of values.

ST: I think that we can attack it but there are several things I’ve seen that diminish my enthusiasm for how effective it can be. For example, we have tobacco companies now doing primetime TV spots, very highly produced, supposedly promoting antismoking among teens. But if you talk to anyone in the professional health communication industry, they will very clearly tell you that the methods being used don’t work. So what you’re seeing is that the industry is using their market share to promote antismoking messages that they already know don’t work. In the environmental area, we have oil companies promoting environmental friendliness. We will soon see alcohol companies promoting “don’t drink”. I don’t think that we can count on them to actually do things that are not in their selfinterest. And so on the surface it looks like they’re promoting health messages and in reality they’re actually using techniques that have already proven to be unsuccessful in health behavior change. We have no equivalent counter point to this type of PR insurgency. . The Truth campaign was excellent, but fragile in the sense that it is vulnerable to funding cuts and it is vulnerable to only being able to be used on one area like tobacco. We need the equivalent of that across the full range of products being marketed that are known to cause disease.

CHW: Let’s say some grouping of public health professionals and advocates working in African American and Latino communities asks for your advice about how to create such a broadbased mobilization. What advice could you give them? What strategy could they take to counter multiple industries and multiple products to compete effectively with these industries in the middletolong term?

ST: I believe we have to think completely outside of the box. I’m going to be radical here for a moment and say that there should be a tax on companies with products that are known to be associated with premature illness and death. These funds would go into a national endowment to support the media campaign, a campaign that is not under industry control and that would use people like Chris Rock and other entertainers to produce the health education message as part of their public service contribution. I don’t think the reach of the entertainment industry can be underestimated in terms of getting the word out. But there has to be a sustainable funding base that’s not so vulnerable to a downturn in grants and those kinds of things.

CHW: What piece of that do you think can happen on the neighborhood level?

ST: I’ll give you an example around the issue of tobacco: in Philadelphia people literally went out and whitewashed billboards where there were tobacco ads. That was front page news; it was highly visible. It definitely mobilized people, but the problem is that it also destroyed property. And when it was all over, after the media cycle, was what next? The billboards were back up. I think that at the local level, we need to have a billboard audit and to have a policy where some percentage of billboards is controlled by the community to promote health and prevent disease.

CHW: Earlier you talked about the role of tobacco philanthropy in the black community. Do you have any suggestions or thoughts about how to raise that as an issue for dialogue and debate within African American or for that matter other communities?

ST: I think it has to be raised by black people. When white public health professionals raise the issue, they never come up with a way of replacing the revenue that’s lost. As a result, a black magazine or a black organization can’t have its national meeting because the revenue’s lost. So it looks like well wishing white liberals not understanding the dynamics of what it takes to sustain black publications or black organizations. It’s like a false choice, a trap. So there have to be credible African Americans leading this charge.

CHW: Perhaps the tax fund that you talked about could offer a real alternative for supporting arts and cultural and other organizations that would address race and class based health disparities.

ST: Absolutely. Unfortunately, black advocacy groups in Washington that could take on this issue have lost their credibility because they’ve taken money from the tobacco and alcohol industries in order to support their lobbying efforts on behalf of the black community. We shouldn’t underestimate the power of the marketplace. If we get African Americans and other minorities to change their habits then we don’t have to rely solely on the practices of advertisers. There is probably some history of how industries have changed simply because the consumer has changed and I think we need to look back and find examples, especially coming out of the civil rights movement, and see if we can replicate it. I also think that we need enforcement. Finally, I would say that we have to look in the mirror as public health officials and harness the new technology of YouTube, the web and Wikipedia to really break out beyond the traditional channels. Right now as you can see with what’s happened with digital music; the whole industry’s business model is upsidedown. That has opened up space for us in public health to use digital media as a way of creating a new space where the playing field is more equal to create innovative messaging that can promote health and prevent disease. I don’t think we’ve done enough in that arena. And we cannot simply complain; we also have to produce. Now is the time for less talk and more action!