In a decision that could help public health researchers and activists gain access to corporate information, the Supreme Court on Tuesday ruled unanimously that corporations have no personal privacy rights for purposes of the Freedom of Information Act. The decision overturned a United States Court of Appeals that had ruled for the company, saying that “corporations, like human beings, face public embarrassment, harassment and stigma”.
New Report on US Trade Policy and Food Security
The Institute for Agriculture and Trade Policy has released a new report analyzing how US trade policy can better respond to global climate and food crises and documenting the role of agribusiness in setting trade policies that benefit their bottom lines rather than global well-being.
Food Disparagement: A Threat to Freedom of Speech? Request for Assistance in Tracking
Agribusiness interests have pushed through laws designed to make the expression of critical ideas about food production seem too costly. These laws are working outside of actual courtrooms and out of public view. Corporations have gotten food disparagement laws passed in 13 states, essentially making it a litigation risk to say anything critical about food. Now that the laws have been passed, the same corporate interests use them as leverage to silence their critics, frequently sending letter to those who speak out or those who publish them, threatening to sue under these menacing laws.
Have you or someone you know received similar threats? Have you felt the effects of your voice getting silenced? We ask you to send in copies of any threats of litigation using food disparagement laws as their premise, any other evidence of corporate control of what we can say about how food is produced, or any other effects you have felt. We will keep your confidence (some of us are nearly lawyers and understand this stuff). Please email your anecdotes and pdf copies of any written threats topaulaznyc@gmail.com or ask for a mailing address to send photocopies. For more information and some examples of threats to sue under these laws in action, go to http://signalinterference.wordpress.com/.
Signal Interference’s primary researcher is Paula Z. Segal, a Haywood Burns Fellow in Civil and Human Rights at the City University of New York Law School at Queens College. Her work focuses on access to land, inclusive democratic processes and working towards a just, sustainable and sane food system. Ms. Segal does legal research for the Brooklyn Food Coalition and is on the editorial board of the New York City Law Review. She is also guest blogger at Our Rights, Our Future, the blog of the National Campaign to Restore Civil Rights.
More on Food Disparagement Laws:
- Bederman, David. Remarks Limitations on Commercial Speech: The Evolution of Agricultural Disparagement Statutes, 10 DePaul Bus. L. J. 169, 173 (1998).
- Bederman, David J. Food Libel: Litigating Scientific Uncertainty In A Constitutional Twilight Zone, 10 DePaul Bus. L. J. 191, 217 n. 149 (1998).
- Goetz, Thomas. Venerable Talk Show Host Gets First Taste of Food Disparagement Laws, Village Voice April 29, 1997, 39, available athttp://www.organicconsumers.org/disparg.html.
- Jones, Ellen Gay. Forbidden Fruit: Talking About Pesticides and Food Safety in the Era of Agricultural Product Disparagement Laws, 66 Brook. L. Rev. 823 (2001).
- Lynch, Colleen K.. Disregarding the Marketplace of Ideas: A Constitutional Analysis of Agricultural Disparagement Statutes, 18 J.L. & Com. 167, 178 (1998).
The Impact of Corporate Practices on Urban Health
With half the world’s population now living in cities, public health researchers have focused new attention on the health impact of urban living and the development of new approaches to creating healthier cities. Recent reports by UN-HABITAT, the World Health Organization (WHO), the Commission on Social Determinants of Health and others have highlighted the challenges of improving the health of urban populations.
While these reports acknowledge that government, civil society and business all shape the health of urban residents, it is the first two that receive the most attention. UN HABITAT, for example, has called attention to the importance of good local and national governance in improving urban health, and Healthy Cities convened by WHO Europe emphasizes the importance of convening stakeholders in order to improve urban health. In this commentary, I examine the role of business in urban health, with a particular focus on corporations.
How Business Shapes the Health of Cities
Why this special attention to business and why the singling out of their health impact on cities?
Increasingly, it is business decisions that create the urban environments that shape health and disease. The food we eat, the air we breathe, the houses we live in, the conditions at workplaces and communities, our opportunities to meet friends and partners, and our identities as consumers and citizens—all are powerfully influenced by businesses. The choices that businesses make about what to produce, how to market, where to sell and what to charge set the stage for health behaviors, lifestyles and urban social and physical environments.
While business decisions influence the health of all people everywhere, cities are especially important arenas of influence. Cities and corporations have an intimate historical relationship; both are products of the evolution of markets and both were transformed by industrialization. Cities first emerged as agriculture produced surpluses that enabled population concentrations not directly dependent on farming. As populations grew, labor became more differentiated creating ever more specialized markets. Technological developments enabled fewer people to produce sufficient food to sustain humanity, pushing populations out of the countryside and into cities where the availability of cheap labor attracted employers, further concentrating populations. As cities became centers of production and selling, they also became nodes of trade and commerce, amplifying their economic and political position.
From their earliest days, cities were also generators of inequality, enabling some to accumulate wealth and power while large portions of the urban population lived in squalor. Today, cities are the command and control centers of global business, the headquarters of the media empires that market business products, and the dense markets that create the greatest opportunities for profit. Increasingly, the business push for more consumption shapes the physical space of cities, making them a marketing tool for tourism, shopping, eating and romance. As a result, the decisions made in corporate boardrooms often have a greater impact on health than those made by health officials or elected officials.
Why hasn’t the impact of business on urban health attracted more attention? I suggest three reasons. First, many public health professionals believe that the ways in which companies make decisions and operate is not our business. Public health is a government responsibility, they say, and our efforts to improve health have to rely on the powers and capabilities of the public sector. Second, in part as a result of an aggressive public relations effort by business to make its powers seem inevitable, many people believe that business dominance is the only possible economic and political arrangement possible. The demise of most alternative systems with the collapse of state socialism in the 1990s further reinforced the belief that another world is not possible. Finally, most public health professionals lack the knowledge and skills to understand how businesses make decisions, the pathways by which their actions shape health or the strategies we could use to modify health-damaging business practices. Fortunately, we are in control of changing that.
Food, Guns and Tobacco: The Urban Story
The development of strategies to promote health-enhancing and reduce harmful consequences of business practices on cities requires detailed empirical analysis of specific companies, products and practices in specific urban contexts. While business practices can either promote or undermine health, public health officials and advocates often direct their attention to harmful practices given their mandate to protect population health. The following examples illustrate some of the ways that business decisions affect urban health.
- In 1994, after forceful advocacy by the global food industry, among others, Mexico and the United States signed the North American Free Trade Agreement, making it easier for US companies both to sell low-cost corn, processed food and other goods to Mexican citizens, and to invest US dollars in the Mexican food industry. Between 1988 and 1997, US foreign direct investment in the Mexican food processing industry increased 25-fold. Between 1988 and 1999, the total energy intake from fat in Mexico increased from 23.5% to 30.3 % with the largest increases in urban areas. Between 1992 and 2000, calories that Mexicans consumed from carbonated soft drinks increased by almost 40%. By 2002, the average Mexican was drinking more Coca Cola servings per year than US residents. In this same period, the national prevalence of overweight and obesity increased by 78%, and between 1993 and 1999, the prevalence of diabetes in Mexico increased by 30%. The increases were highest in the densely populated urban areas where targeted marketing and retail density made unhealthy food readily available. Thus, a trade agreement promoted by multinational companies led to changes in the practices of global companies, national supermarket chains and local retail outlets, which in turn contributed to epidemics of obesity and diabetes, concentrated in Mexico’s rapidly growing cities. 1
- In the 1990s, small arms manufacturers in the United States produced and widely distributed cheap handguns known as Saturday night specials. Handguns accounted for 80% of gun deaths in the US and widespread availability of inexpensive guns put these weapons within reach of gang members, would-be criminals, and worried homeowners. 2Fear of crime and youth violence made cities prime markets for gun makers and these guns played a major role in the increase in urban homicides and gun injuries during this period. Most Saturday night specials were produced by several gun companies in Southern California that were created in the early 1990s to realize a new market opportunity. 3 By the mid 1990s, these companies were producing more than a million guns a year. According to tracing data from the Bureau of Alcohol, Tobacco and Firearms, guns made by these companies were 3.4 times more likely to be involved in a crime than were handguns from other major manufacturers. With supporters from the National Rifle Association and other parts of the gun lobby, these manufacturers were able to resist local, state and national efforts to regulate the sales of these weapons more strictly.
- As developed countries establish stronger public health measures to control tobacco use, the tobacco industry has moved its marketing to developing nations, where billions of new potential customers can be found in the urban settlements that make efficient and targeted advertising possible. In South Africa, for example, tobacco companies have created marketing campaigns aimed at Black women, showing tobacco use as a new freedom connected to urban living and offering giveaways to encourage use. An important goal of tobacco marketing in developing world cities is to change norms so that tobacco use will be more socially acceptable and to create peer support for smoking, especially among women and adolescents.
Pathways from Business to Health
These three examples illustrate some of the ways that business decisions affect the health of urban populations. First, businesses operate at several levels of organizations and scales. On the global level, multinational companies and trade associations influence trade policies, regulatory regimes and prevailing ideology. For example, the pro-industry neoliberal agenda of deregulation, privatization and lowering of trade barriers has set the tone for global discussions on businesses and health for much of the last two decades. This ideology sets the framework in which national and local health officials propose policies to promote health. On the community level, food, alcohol and tobacco retailers decide which products to offer at what prices, influenced in part by global and national advertising that shape norms and desires and in part by the material living conditions of their customers. The power of business to shape health depends in part on its ability to operate at these multiple levels, creating synergies of impact due to horizontal and vertical integration of its operations.
Second, business has the capacity to operate in several domains, including the commercial, the political, the legal and the economic. It uses media to create and shape desires, lobbying and campaign contributions to influence politics and regulation, public relations and philanthropy to influence values and norms and campaign contributions to affect elections. Again, the ability to operate across sectors magnifies its influence.
Third, businesses have increasingly been able to construct cities to advance their goals. Whether it is the downtown development projects that attract tourists and encourage consumption, the dense markets that create niches for product diversification, the proliferating media that offer new ways to sell to more people or the extralegal and illegal markets emerging in informal urban settlements and slums, cities are places to buy and sell. While alternative urban spaces like peer networks, neighborhood associations, public meeting places and social movements still exist, everywhere they compete, often unsuccessfully, with market forces.
What can public health professionals do?
So what can public health researchers, professionals and advocates do to reduce the impact of harmful business practices on cities?
1. Develop the knowledge and skills to understand and change harmful business practices. To play a stronger role in protecting population health, health professionals will need to learn a new set of skills. Already some public health training programs have begun to take this task on, but more needs to be done. 4
2. Find allies that can magnify our influence. By itself, the public health community has limited influences on business practices. In partnership with advocacy organizations, researchers, and social movements such as the environmental justice, corporate responsibility, global justice and consumer protection movements, we have a greater potential to influence policy.
3. Partner with local government and health departments to make protecting the public against harmful business practices a public health priority. In New York City, for example, the city health department and the Mayor have strengthened public oversight of the tobacco industry, fast food companies and gun sellers. Their successes have created new opportunities for other local, state and national governments.
4. Study business practices as a modifiable social determinant of health. Growing global interest in studying and addressing social determinant of health creates an opportunity to consider business practices as such an influence and to conduct research on the most effective and economical strategies for modifying business practices in order to promote health and reduce disparities in health.
5. Join efforts to create a more level political playing field. As long as business interests can dominate political, electoral, legal, economic and regulatory processes, the public health community will have a limited voice in making policy decision that can modify harmful practices. To change this unfavorable climate, public health professionals can join campaigns to limit corporate influence on politics and create spaces for more equal participation by those most harmed by current practices.
6. Use the assets of cities to contest harmful corporate practices. While urban populations are often the targets of harmful corporate practices, cities also have assets that can counter these efforts. Cities are the cradles of social movements, provide ready access to local and national media, and offer options for more sustainable, democratic and healthier social arrangements. By using these urban resources, public health professionals and advocates can help to create alternatives to the status quo.
By Nicholas Freudenberg, Founder and Director of Corporations and Health Watch and Distinguished Professor of Public Health at Hunter College, City University of New York.
- Freudenberg N. Free trade, the food industry and obesity: How changes in US-Mexico food trade contributed to an epidemic. Corporations and Health Watch, July 2007.
- Nieto M, Dunstan R, Koehler G: Firearm-Related Violence in California: Incidence and Economic Costs. Sacramento, California Research Bureau, 1994.
- Wintemute, G. Ring of Fire: The Handgun Makers of Southern California, Violence Prevention Research Program, Sacramento, California, 1994.
- See Teaching about Corporations and Health: Bringing Corporate Practices into Public Health Classrooms.Corporations and Health Watch, December 2007 and Corporate Research: The Basics, June 2008.
Corporate Practices in the News
In this article, we briefly describe recent health-related news on corporate practices in the alcohol, pharmaceutical, and food industries.
Alcohol
Economic crisis depresses beer sales
As the economy stagnates, the beer industry worries about falling beer sales. “They’re the worst trends we’ve ever seen,” said Benj Steinman, President of Beer Marketer’s Insights, who spoke in October at the National Beer Wholesalers Association Convention in Chicago. Steinman blamed the drop on the high jobless rates among young adult male blue-collar workers—the industry’s traditional workhorse. “If we were down another 2% next year it wouldn’t surprise me,” Harry Schuhmacher, editor of Beer Business Daily, told wholesalers. Sales of craft beers, however, continue to increase, gaining 11% so far this year as compared to last year. These trends demonstrate the deep effects the recession has on sales of alcohol, food and other products, a topic explored in a previous Corporations and Health Watch post.
Pharmaceuticals
Drug industry finds that 15-second ads don’t make the sell
To save money in a tough economy, many Big Pharma companies have shortened their direct-to-consumer television ads from 30 seconds to 15 seconds. As shown below, data compiled by Ameritest , a copy-testing firm, and Competitrack, an advertising tracking firm indicates that 15-second over-the-counter drug ads constituted 25% of drug ads in 2007, 63% last year and 65% so far this year. In the same period, Big Pharma drug makers lost market share to private label manufacturers, suggesting that shorter ads were less persuasive in winning new customers. “The companies that live and die by their advertising are stretching their budgets with 15-second ads, and frankly there’s a lot for them to learn,” said Ameritest CEO Charles Young. “It’s an awfully short form for creatives to work with. If it devolves into simply reminder advertising, you’re not building brands. You need to bring emotion and news value to those brands.”
In 2005, the drug industry spent more than $4 billion on direct-to-consumer advertising. Advertising is a tax deductible business expense and also enjoys the constitutional protection that the Supreme Court has applied to commercial speech. The rationale for such protection is that advertising helps consumers to make informed decisions. Can a 15- or 30-second ad contribute to more informed health care consumers?
Pharma spending on online advertising to reach $1 billion this year
Like the food and alcohol industries, the pharmaceutical industry is expanding its online advertising. According to a report prepared by eMarketer, online ad spending by drug companies is expected to reach $1 billion this year and keep rising through 2014. One factor slowing growth is the lack of clear guidelines for this form of advertising from the US Food and Drug Administration. A year ago, the FDA held public hearings on the topic and solicited e-mail comments. “Pharma marketers are waiting around,” said eMarketer’s Victoria Petrock, author of the report entitled DTC Pharmaceutical Marketing Online: A Slow Shift to Digital. “They are trying to test the waters but realizing that the FDA isn’t going to come down with a template or a hard-and-fast ruling. Even when that happens, there’s still going to be a process of give-and-take and experimentation.”
Food
Michelle Obama on restaurant practices
The following excerpts are from a speech Michelle Obama made in Washington, D.C. to the National Restaurant Association in September 2010:
“Together, you represent 40 percent of the nearly one million restaurants in the United States, from the biggest chains to the smallest diners. You know what Americans like to eat and what they don’t. You’ve seen how the ingredients we put in our bodies affect the way we feel and the way we feel about ourselves. And you also understand the unique role that food, and restaurants especially, play in our own lives and in the life of our nation….. And the truth is that while restaurants are offering more options and families take advantage of them more often, they aren’t always the healthiest choices…
And as America’s restaurant owners, you’re responsible for one-third of the calories our kids get on a daily basis. The choices you make determine what’s listed on the menus, what’s advertised on billboards, and what’s served on our plates.
And your decisions about how a dish is prepared, what goes into it and where is it placed on the menu, that can have a real impact on the way people eat….Together we have to do more…And we need your help to lead this effort. And today I am asking you to use that creativity to rethink the food you offer, especially dishes aimed at young people, and to help us make the healthier choice the easier choice…First, it’s important to reduce the number of empty calories that our families are consuming, calories that have no nutritional benefit whatsoever. After all, we as humans, we are programmed to crave sugary, fatty, salty foods. And as people who work to meet those needs, I know it’s tempting to respond by creating products that are sweeter, richer and saltier than ever before. But here’s the catch. See, feeding those cravings does just respond to people’s natural desires, it actually helps shape them. The more of these foods people eat, the more they’re accustomed to that taste, and after a while, those unhealthy foods become a permanent part of their eating habits.
But here’s the good news: It can work the other way around just as easily. Just as we can shape our children’s preferences for high-calorie, low-nutrient foods, with a little persistence and creativity we can also turn them on to higher quality, healthier foods.”
Image Credits:
- Grant Hutchins via Flickr
- Competitrack and Ameritest
Big Pharma Getting Legal Heat for Marketing Tactics
The pharmaceutical industry has had a lot of success in recent years. Its profit margin is about 16%, seventh highest of the 215 industries tracked by Morningstar, an investment research company. In 2003, the drug industry succeeded in getting Congress to pass and President Bush to sign the Medicare Expansion Act that, by some estimates, increased drug industry profits by $139 billion. And last year the Pharmaceutical Researchers and Manufacturers Association (PhRMA) made a deal with President Obama to cut costs for some drugs in exchange for a commitment not to allow the health care reform bill to allow importation of drugs from other countries or to fix prices. As a result, the pharmaceutical industry will get assured reimbursement for drugs for millions of additional Americans.
With these successes, one would think that the pharmaceutical industry would be satisfied with using its clout to set the rules for its own benefits. Instead, however, a recent series of news reports shows that pharmaceutical companies are regularly attracting the attention of legal authorities in their aggressive marketing of drugs. Consider the following:
- Earlier this month, the Wall Street Journal reported that US authorities have subpoenaed records of GlaxoSmithKline in an investigation of their marketing of the diabetes drug Avandia.
- In late September, according to the New York Times, the Swiss drug company Novartis agreed to pay $422.5 million to settle criminal and civil investigations into the marketing of the antiseizure medicine Trileptal and five other drugs. Novartis was accused of paying illegal kickbacks to health care professionals through speaker programs, advisory boards, entertainment, travel and meals. Novartis pleaded guilty to one misdemeanor charge of mislabeling, but denied wrongdoing.
- In April 2010, AstraZeneca completed a deal to pay $520 million to settle federal investigations into marketing practices for its blockbuster schizophrenia drug, Seroquel.
- In 2009, Pfizer signed a corporate integrity agreement over illegal marketing of the painkiller Bextra and other drugs. That plea bargain included a $2.3 billion fine, the largest criminal fine in the nation’s history.
- In October, the investigative journalism group ProPublica launched a series of stories showing that many of the doctors hired by pharmaceutical companies to promote their products had been accused of professional misconduct, were disciplined by state boards or lacked credentials as researchers or specialists.
- ProPublica also discovered that former employees of drug companies have filed a series of lawsuits that allege that the money that drug companies said they paid to physicians to educate other health providers was in fact often used for illegal purposes to pay doctors for prescribing their brand-name medications.
Why do drug companies break the law?
First, according to legal and academic observers, they don’t appear to respect or fear the law. According to federal prosecutor Michael Loucks, then the head of the health-care fraud unit of the U.S. Attorney’s Office in Boston, when lawyers for Pfizer Inc., the world’s largest drug company, promised him in January 2004 that the company wouldn’t break the law again, they knew the company was involved in other illegal promotions. “At the very same time Pfizer was in our office negotiating and resolving the allegations of criminal conduct in 2004,” said Loucks, “Pfizer was itself in its other operations violating those very same laws. They’ve repeatedly marketed drugs for things they knew they couldn’t demonstrate efficacy for. That’s clearly criminal.” According to Jerry Avorn, a professor at Harvard Medical School in Boston and author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, “Marketing departments of many drug companies don’t respect any boundaries of professionalism or the law. The Pfizer and Lilly cases involved the illegal promotion of drugs that have been shown to cause substantial harm and death to patients.”
Another reason for widespread lawlessness is that the fines represent a small portion of drug industry profits. As large as the penalties are for drug companies caught breaking the off-label law, the fines are tiny compared with the firms’ annual revenues. According to Bloomberg News, the total of $2.75 billion in fines that Pfizer has paid in off-label penalties since 2004 is a little more than 1 percent of the company’s revenue of $245 billion from 2004 to 2008.
Finally, companies break the law because they think they can get away with it. The Food and Drug Administration has been chronically understaffed, dependent on the drug industry for the fees that support its operations and using experts in the pay of the very industries they are regulating. According to Dr. Marcia Angell, a former editor of the New England Journal of Medicine, “There is growing evidence that the Center for Drug Evaluation and Research, the part of the [Food and Drug] agency that regulates prescription drugs, has become the servant of the industry it regulates.” Whether the new tougher stance of the current FDA will be able to reverse these trends remains to be seen.
In sum, the drug industry resorts to lawless activities because they face relentless pressure to maximize profits and cut costs, because they often see the law as an obstacle to profits rather than a legitimate moral framework that should govern their behavior and because the regulatory agency charged with monitoring the drug industry has often lacked the resources and sometimes the will to provide aggressive oversight. Protecting public health against dangerous and illegal promotion of prescription drugs will require changing these three dynamics.
Photo Credits:
- epSos.de via Flickr
Crowdsourcing: A New Approach to Monitoring Harmful Corporate Practices?
What do the US Food and Drug Administration, the advocacy group Corporate Accountability International, and the investigative journalism outlet ProPublica have in common? All three have used crowdsourcing, a technique for gathering information from multiple sources using a variety of new media, to monitor health-related practices of corporations. In this article, CHW reviews these efforts, and explores the advantages and challenges of using crowdsourcing to gather information about corporate practices.
The Food and Drug Administration’s Bad Ad Program
In May 2010, the Food and Drug Administration (FDA) introduced its “Bad Ad Program” in which doctors are trained to identify misleading or untruthful pharmaceutical ads, and then report them by email or phone to the FDA. Until now, FDA’s enforcement effort relied on a few dozen staffers to review hundreds of pharmaceutical ads, brochures, and presentations voluntarily submitted by companies or reported to the agency by drug industry personnel. Upon discovery of misleading or untruthful information, the FDA sends warning letters to companies, but given the burden of review and the limited staff, letters have often not been sent until long after the ad has reached its market.
“The Bad Ad Program will help health care providers recognize misleading prescription drug promotion and provide them with an easy way to report this activity to the agency,” said Thomas Abrams, director of FDA’s drug advertising division. Pharmaceutical Research and Manufacturers of America (PhaRMA), the lobbying group that includes the many of the world’s largest drug manufacturers, including Pfizer, Merck & Co. and GlaxoSmithKline, said in a statement that it supported the effort as “another step to help educate—and receive feedback from—health care providers about prescription drug advertising and promotion.”
Drug makers spend about $20 billion per year to promote their products in medical journal ads, information booths at medical conferences and multimillion dollar TV ad campaigns. About $4 billion of industry spending is used for direct-to-consumer advertisements. These campaigns have been associated, in some cases, with heavy use of what were later found to be dangerous drugs, such as Vioxx, a pain reliever, and Avandia, a drug used to control diabetes.
Corporate Accountability International’s Retire Ronald Campaign
In its recent campaign to persuade McDonald’s Corporation to retire Ronald McDonald and its advertising specifically targeting children, Corporate Accountability International (CAI) used crowdsourcing to encourage members and advocates to report sighting of Ronald to help CAI analyze how and where the company was using Ronald and also to engage and motivate parents and advocacy groups to join their campaign. The responses showed that Ronald was appearing in schools, hospitals, and community centers around the country, often mixing philanthropy, public relations, and marketing, and gave CAI “a better sense of just where and how he was hooking kids on unhealthy food.”
ProPublica’s Distributed Reporting Project
After BP promised to create a $20 billion fund to reimburse individuals, businesses, and others damaged by its oil spill,ProPublica, the online investigative journalism outlet, decided to investigate whether BP was living up to the commitments it had made to reimburse claims quickly, fairly, and transparently. Those who had filed a claim with BP were asked to complete an online survey, widely distributed by a variety of print and online media. Later, when Ken Feinberg took over the administration of the reimbursement fund, ProPublica expanded its investigation to monitor his activities. In 2010, ProPublica received a Knight-Batten Award for Innovations in Journalism for its Distributed Reporting Project that had systemized “the process of crowdsourcing, conducting experiments, polishing their process and tasking citizens with serious assignments.” When the group created its Reporting Network in 2009, ProPublica writer Amanda Michel explained, “By collaborating directly with the public, we aim to deliver a greater range of information. E-mail, cell phones, instant messenger, ProPublica.org and social networking sites such as Facebook are our tools. Questions that hold public figures and those in power accountable are our guides.”
The Advantages and Challenges of Using Crowdsourcing
Crowdsourcing has its origins in corporate America. In 2006, Jeff Howe and Mark Robinson first wrote about crowdsourcing in Wired magazine. Howe defined it as “the act of a company or institution taking a function once performed by employees and outsourcing it to an undefined (and generally large) network of people in the form of an open call. This can take the form of peer-production (when the job is performed collaboratively), but is also often undertaken by sole individuals. The crucial prerequisite is the use of the open call format and the large network of potential laborers.” In recent years, companies have used crowdsourcing to design ad campaigns, choose winners in corporate contests, and conduct market research.
For health researchers, advocates, and regulators, crowdsourcing has some distinct advantages. For researchers, it can provide access to a wider range of sources and respondents than traditional survey or focus group research. It can also reduce participant burden by using familiar technologies and media such as the Internet, cell phones, or social media to elicit responses, and by allowing participants to respond when and how they choose. For advocates, as illustrated by the Retire Ronald campaign, crowdsourcing can help to describe a phenomenon and to mobilize people to take action. Those who reported sightings of Ronald were contacts for community action in subsequent phases of the campaign. For regulators, as the FDA’s Bad Ad Campaign shows, crowdsourcing can help to overcome limited staff and resources, and give an agency a wider sample of problem practices. Crowdsourcing allows all users to apply mapping and other techniques to analyze data. Moreover, reported data can be posted online, allowing corrections or amplifications, or triggering additional responses from those who have encountered similar problems, a digital snowball sample.
Crowdsourcing may be especially relevant to monitoring corporate practices because it can help level the playing field—adding new eyes and ears to organizations that seldom have the resources of their corporate targets. Imagine a system in which consumers who purchase faulty products, community witnesses to violations of pollution laws, or viewers of misleading or untruthful advertisements could send an email or text message, or make a phone call to a readily available site that could display all reports geographically and by topic in real time?
Like any method, crowdsourcing also poses challenges. The results can vary from a collection of anecdotes to systematic data; each has its purposes but collectors of crowdsourced information need to determine the valid uses based on the purpose and the response. In addition, some reports may come from disgruntled but not wronged customers or from businesses trying to gain an edge on their competitors by filing false charges. However, any reporting system has these perils and police and other agencies have developed strategies to assist in distinguishing between valid and bogus reports. Finally, crowdsourcing is a complement to, not a substitute for, other investigative strategies. Researchers still need to collect systematic data from a defined sample, organizers still need the face-to-face encounters that lead to political mobilization, and regulators still need full-time enforcement agents to ensure that reports of wrongdoing are investigated and prosecuted as needed. At best, crowdsourcing can become a new tool to expand and deepen other forms of investigation.
In the last few decades, multinational corporations have led the world in finding new applications for science, technology, and emerging media. Viral marketing, neurocognitive research to understand and influence consumer choices, and data mining of public databases to gain commercial insights are all examples. If public health researchers, officials, and advocates want to protect population health, they will need to master these technologies. Such mastery is a prerequisite both to regulate their use by corporations and to find new uses to advance public rather than private interests. By learning about crowdsourcing and applying it to monitor corporate practices, the public health community can fulfill its professional mandate of promoting the health of the public.
Nicholas Freudenberg is Founder and Director of Corporations and Health Watch and Distinguished Professor of Public Health at Hunter College, City University of New York.
Reducing Fast Food Outlets through Zoning
Over the last three decades, obesity rates in the United States have doubled in adults and tripled in children and adolescents, and reports now indicate that approximately one-third of children and adolescents and two-thirds of adults are either overweight or obese (1). Obesity has increased among all racial, ethnic, and income groups, but the highest rates occur among minorities and the poor (2, 3). This is particularly concerning given obesity’s link with numerous chronic health conditions, including diabetes, stroke, heart disease, high blood pressure, and some cancers (4).
While advocates correctly emphasize the importance of making healthy food more available to reduce obesity and other health problems, some researchers believe that such measures can only be effective if they are coupled with efforts to limit unhealthy foods as well (5). After all, eating a few more fruits and vegetables daily is unlikely to improve health if one is also consuming a Big Mac, fries and 32 ounces of soda a day. These researchers note that the policy rationale for reducing access to unhealthy foods is to make healthy choices the easier path.
In particular, fast food companies may play a key role in the obesity epidemic because of their large and inexpensive portion sizes, the high levels of calories, fat, and sodium contained in fast food, and the frequency with which those most affected by obesity (especially poor populations and children) consume fast food (6). Americans rely on fast food outlets for a substantial amount of their food, with almost half of food spending going to meals consumed outside the home (7). And not surprisingly, studies have found an association between eating fast food and higher fat consumption and weight (8, 9).
In considering how access to unhealthy foods might be reduced, municipal zoning codes may hold unique potential. Zoning laws determine how city land may be used and where these different uses may occur. As a police power, through which states are obligated to protect the public’s health, welfare, and safety, zoning laws may be a powerful tool for improving food environments (10). To help advocates better understand how zoning might be used to reduce access to unhealthy foods, this article provides information about how zoning has been used to influence fast food outlets, describes how various jurisdictions have approached the regulation of fast food, discusses potential arguments for and against the zoning of fast food, and describes some of the ways that the food industry has opposed efforts to zone fast food.
How has zoning been used to regulate fast food outlets?
City governments have developed a variety of ways of reducing fast food outlets through zoning. These typically fall into two categories: bans or restrictions (10). The most common types of zoning bans and restrictions to reduce fast food outlets are described briefly below (11). (For more detailed descriptions of these approaches, see Mair et al., 2005)
- Banning fast food outlets and/or drive-through service. Banning fast food outlets has been done via complete bans on new fast food outlets throughout a city or town, or less restrictively, as bans in which new fast food and/or drive-through service can only be allowed via conditional or special use permits.
- Banning “formula” restaurants. Formula businesses have been defined as those “that have standardized services, décor, methods of operation, and other features that make them virtually identical to businesses elsewhere.” Formula restaurants typically refer to large national chains, but in some cases have been interpreted to mean very small, local chains.
- Banning fast food in certain parts of a city. Often when fast food has been banned only from certain areas within a city, it is banned from areas that have a “unique character” that the city wants to preserve and fast food restaurants are banned for aesthetic reasons.
- Restricting the number of fast food outlets. This involves a cap on the number of fast food outlets that can exist in a given area or an entire city.
- Restricting the density of fast food outlets. Density of fast food outlets has been regulated per unit space (eg. one fast food outlet for every 400 feet of lot frontage along the street, as in the Westwood Village area of Los Angeles, California) and via space between fast food outlets.
- Regulating the distance between fast food outlets and other sites. These other sites have included schools, churches, hospitals, nursing homes, public recreation areas, and residentially zoned property.
Where has zoning been used to reduce fast food outlets?
South Los Angeles, California
In July 2008, the Los Angeles City Council approved a measure to place a one-year moratorium on the opening of new fast food establishments in several south Los Angeles neighborhoods with high fast food density and high obesity. The measure defined fast food as, “[a]ny establishment which dispenses food for consumption on or off the premises, and which has the following characteristics: a limited menu, items prepared in advance or prepared or heated quickly, no table orders, and food served in disposable wrapping or containers” (12). The new law only applied to stand-alone restaurants, not to those located inside malls or shopping centers (13). The rationale for implementing the measure as a moratorium was to give city planners time to assess the best use of minimal remaining land in these neighborhoods for the creation of a healthier food environment, and to attempt to draw grocery stores and sit-down restaurants to the area (13). The moratorium has now been extended to two years, and no evaluation data has yet been published regarding the measure’s effectiveness, though one analysis has suggested that the ban is not the best approach for addressing obesity in these areas (14).
Concord, Massachusetts
Concord, Massachusetts, a town of approximately 17,000 that is located within commuting distance of Boston, implemented a complete ban on drive-in and fast food restaurants in 1981 (11, 15). The rationale for the ordinance was two-fold: “to lessen congestion in the streets” and “to preserve and enhance the development of the natural, scenic and aesthetic qualities of the community” (11). City officials indicate that no one seems to miss the fast food outlets banned via the ordinance (15), however, to our knowledge, no health-related assessments of the ban’s effects have been conducted to date.
Detroit, Michigan
In Detroit, for close to two decades, the zoning code has prohibited most fast food restaurants from being built within 500 feet of all elementary, junior, and senior high schools (11, 15). The code’s language includes both “standard” restaurants and “carry-out or fast food” restaurants. As in Concord, no health-related evaluation data of this fast food restriction exists.
What kinds of arguments have been made for the zoning of fast food outlets?
Historically, the arguments used most commonly to reduce fast food outlets through zoning have been related to the increases fast food outlets can cause in traffic, pollution, and trash around the site (11), as well as the threat they may pose to pedestrian safety (16). Many have also successfully argued that fast food outlets be banned in specific areas in order to preserve a certain aesthetic to which fast food outlets do not conform (11).
A measure passed to ban new fast food outlets in South Los Angeles in 2008 (described above) marks the first time that health has been used as the explicit rationale for a change in the zoning of restaurants. The language of this ordinance reads that it was intended to “provide a strong and competitive commercial sector which best serves the needs of the community, attract uses which strengthen the economic base and expand market opportunities for existing and new businesses, enhance the appearance of commercial districts, and identify and address the over-concentration of uses which are detrimental to the health and welfare of the people of the community” (12).
What are the arguments against zoning fast food and potential responses to these arguments?
Argument 1: Reducing access to fast food in places considered “food deserts” could make residents vulnerable to not getting enough to eat.
Response: Fast food bans via zoning do not typically remove all fast food restaurants in a given area; they merely restrict the opening of new fast food outlets. The effect of such bans is to arrest the growth in fast food outlets and to make room for healthier food options. Stopping the growth of fast food outlets in areas considered “food deserts” may thus be an important first step in changing the overall food landscape in these neighborhoods, especially when banning fast food is implemented in conjunction with proactive efforts to increase healthy food options. Additionally, research indicates that hunger and obesity may be paradoxically intertwined. Insufficient income and food stamp benefits often force food choices based on economics rather than nutrition and health, and may encourage some people to overeat when they have money and go hungry when it runs out (5). If what people are overeating is fast food because that is what is most accessible, then the risks of obesity—even among populations that suffer from hunger—can be high.
Argument 2: Since zoning typically only affects new fast food outlets, it is not useful in reducing access to existing fast food restaurants.
Response: It’s true that eliminating or limiting the operation of existing fast food outlets through zoning is difficult and costly to implement. To address existing outlets, municipalities usually do one of three things: allow the business to continue, without changes or expansion; allow the business to continue operation for a specified period of time (amortization); or use eminent domain to provide the business owner with “just compensation” for the value of the business (17). This last route is the rarest of the three. Thus, in areas with a very high density of existing fast food outlets, the reduction that zoning could provide might be a legitimate concern. However, in most places, a prohibition or restriction of new fast food restaurants would likely substantially alter the food environment over time.
Argument 3: It’s wrong for government to tell people what kinds of food they can have access to.
Response: This “nanny state” argument falls short when we recognize the extraordinary influence the fast food industry has on what we eat, as compared with government. Through the location of their outlets, as well as their prices, portion sizes, and advertising, fast food restaurants have made themselves an integral part of American life, just as they play an integral role in the obesity epidemic. Advocates suggest that we ask ourselves, “Who do we trust more to tell us what kinds of foods to eat: corporate executives with a financial bottom line or public health officials?”
Argument 4: There are other, better targets than fast food if we want to reduce obesity.
Response: The reduction of fast food outlets is rarely if ever intended as the sole approach to improving food environments. Rather, policies to reduce fast food are intended play a single but nonetheless critical role in a larger array of efforts to improve food environments.
How do food and restaurant industries oppose zoning changes?
The food and restaurant industries have opposed the zoning of fast food primarily through strong media responses to efforts to zone fast food and through lobbying. Media responses typically use the “nanny state” claim (Argument 3 above), and come from organizations like the Center for Consumer Freedom (CCF), which is a food and restaurant industry front group. For instance, in response to a report released by Institute of Medicine in 2009 that recommended zoning of fast food in areas near schools to reduce childhood obesity, CCF’s director of research said, “The big picture is [activists] want to control what everybody is eating. The theory is that we’re too stupid to make our own eating choices, so let’s make sure the restaurants are far away from you.” The president and executive director of CCF is Rick Berman, a food and tobacco industry lobbyist who also runs Berman & Co., a restaurant and tobacco industry public affairs group that is estimated to earn $10 million annually.
The National Restaurant Association also opposes zoning changes that would limit fast food outlets, and has developed a well-oiled machine for lobbying state and local legislators. In a 2005 CorpWatch article, Michele Simon wrote, “The National Restaurant Association has 60,000 member companies representing more than 300,000 outlets. NRA works quite effectively in tandem with each state’s restaurant association, providing model legislation, talking points, and additional technical assistance.”
By Emma Tsui, Postdoctoral Fellow at the City University of New York School of Public Health at Hunter College and editor at Corporations and Health Watch.
References
- Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, and Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.
- Black J and Macinko J. Neighborhoods and obesity. Nutr Rev. 2008;66:2-20.
- Drewnowski A. Obesity, diets, and social inequalities. Nutr Rev. 2009;67(Suppl 1):S36-S39.
- Visscher TL, Seidell JC. The public health impact of obesity. Annual Review of Public Health 2001;22:355-75
- Dinour, L, Fuentes L, Freudenberg N. Reversing Obesity in New York City: An Action Plan for Reducing the Promotion and Accessibility of Unhealthy Food, CUNY Campaign Against Diabetes and Public Health Association of New York City, October 2008.
- Brownell KD. Fast food and obesity in children. Pediatrics 2004;113(1 Pt 1):132.
- Clauson A. Share of food spending for eating out reaches 47 percent. Food Rev. 1999;22:20–22.
- Bowman SA and Vinyard BT. Fast food consumption of U.S. adults: impact on energy and nutrient intakes and overweight status. J Am Coll Nutr. 2004 Apr;23(2):163-8.
- Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, and Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004 Jan;113(1 Pt 1):112-8.
- Hodge J. The Use of Zoning to Restrict Access to Fast Food Outlets: A Potential Strategy to Reduce Obesity. Presentation to the CDC Diabetes and Obesity Conference, May 2006.
- Mair JS, Pierce MW, and Teret SP. The use of zoning to restrict fast food outlets: A potential strategy to combat obesity. The Center for Law and the Public’s Health at Johns Hopkins & Georgetown Universities, October 2005.
- Los Angeles City Council. Los Angeles, California Ordinance 180103 (July 29, 2008).
- Hoag, C. “Los Angeles to vote on fast food ban.” The Huffington Post. July 29, 2008.
- Sturm R and Cohen DA. Zoning for health? The year-old ban on new fast-food restaurants in South LA. Health Aff (Millwood). 2009 Nov-Dec;28(6):w1088-97. Epub 2009 Oct 6.
- Fernandez, M. Pros and Cons of a Zoning Diet: Fighting Obesity by Limiting Fast-Food Restaurants. The New York Times, September 24, 2006.
- Spacht AC. The zoning diet: Using restrictive zoning to shrink American waistlines. Notre Dame Law Review. 2009 85(1): 391-418.
- National Policy and Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Model Healthy Food Zone Ordinance. October 2009.
Photo credits:
Beverage Industry Uses Old and New Strategies to Block Soda Taxes
The battle over soda taxation at the state level rages on, as more and more cash-strapped states seek to close budget shortfalls and avoid cuts to critical services such as public safety and transportation. Officials in at least 20 cities and states have proposed new excise taxes or to remove existing sales tax exemptions on non-alcoholic drinks. The beverage industry has responded by spending millions of dollars on lobbying and advertising against the proposed beverage “sin taxes” since 2009.
In a recent twist, the beverage industry has offered the city of Philadelphia what it calls a $10 million “good-will-gesture donation” to fund health initiatives in the city if the city agrees to abandon its proposed excise tax on soda. As noted by a food industry analyst, the move “demonstrates just how much the soda industry fears any attempt to tax its product.” Although the $10 million may seem like a generous offer, Philadelphia’s tax proposal, in contrast, would have raised $77 million in revenues, with $20 million going toward obesity prevention.
In this article, we review the strategies the beverage industry has used to try to block efforts to tax soda and sugar-sweetened beverages at the federal level, and in several key localities, including New York State, Washington State, Maine, Philadelphia, and Washington D.C. We also present evidence that clearly demonstrates how the proposed taxes and presumed increase in the price of soda would help Americans lower obesity rates by reducing our per capita soda consumption.
Beverage industry blocks proposals to tax soda at federal level
A federal excise tax on soda was first proposed in September 2009 as one means of offsetting the cost of healthcare reform and reducing the nation’s high rates of obesity. Although the proposals did not get very far, several high-level talks did take place, including a Senate Finance Committee hearing and closed-door talks with members of the House Ways and Means Committee (1). In response, the beverage industry immediately mobilized a broad-based lobbying effort to quash any such proposal. The coalition operated under the name Americans Against Food Taxes, and included soft drink manufacturers, suppliers, and mass-marketers such as McDonald’s.
In Washington D.C., corporations such as Coca-Cola Co., Pepsi Co., and numerous fast food companies spent $18 million in lobbying activities, and several million more in campaign donations to officials (2). Television commercials, such as this one, which appealed to concerns of everyday families about affording groceries, cost over $10 million to produce and air in key districts (2).
The American Beverage Association also went on the offensive in response to the increasing scientific evidence on the link between increased soda consumption and weight gain. The industry group attacked the findings of nutrition researchers, and funded studies of their own that were more favorable to the beverage industry’s interest in keeping soda consumption high. Kevin Keane, senior vice president of public affairs for the American Beverage Association, claimed that researchers “pick and choose the facts that support their view and attack anyone who disagrees. It’s scientific McCarthyism” (2). The industry’s well-funded efforts to silence any talk of a federal tax on soda were ultimately successful.
New York State fails to pass revised soda tax proposal
Corporations and Health Watch previously reported on the failed campaign to implement a “penny per ounce” excise tax as part of an effort to help close some of New York’s 2009-2010 budget shortfall. After Governor Patterson first announced the proposal in December 2008, the beverage industry poured massive amounts of funding (over $3 million) into lobbying and other efforts to oppose the measure, often working under the coalition called New Yorkers Against Unfair Taxes. The American Beverage Association spent nearly $900,000 lobbying in New York State in 2009, up from zero dollars in 2008. This influx of money appears to have worked, as original supporters of the tax like Senator Jeffrey Klein (D-Bronx/Westchester) became instrumental in getting the proposal off the table. Senator Klein accepted $36,000 in campaign contributions from the beverage industry and related groups since the tax was proposed in December 2008, actions that coincided with his decision to reverse his position on the soda tax.
Given New York State’s unrelenting fiscal troubles and multibillion-dollar shortfall, Governor Patterson tried to revive his soda tax proposal for the 2010-2011 budget, this time with a “carrot and stick” approach that would have allowed for an exemption for diet drinks and bottled water. At the present time, soda, diet soda, and bottled water are subject to a sales tax, but Governor Paterson wanted to add on an additional excise tax of “a penny per ounce” which would be levied on the beverage bottler for sugary sodas, with a “carrot” of sales tax exemptions for water and diet sodas. Governor Paterson maintained that the public would support the proposal as long as “we can justify where the taxes are going” (3). However, the revised proposal failed as well, owing in large part to the American Beverage Association’s ability to dominate discourse on the issue by spending $9.4 million in New York State in the first four months of 2010.
Philadelphia forced to raise property taxes and slash public safety programs rather than tax soda
Another locality where proposals to tax soda have recently failed is Philadelphia, where an estimated 70 percent of children in the city’s poorest neighborhoods are considered to be overweight or obese, according to city data. There, the City Council has recently refused to vote on the proposal to tax soda and other drinks with added sugar. Had the original proposal by Mayor Nutter been successful, Philadelphia would have levied a 2-cent per ounce excise tax on sugary drinks as part of an effort to balance the city’s 2010-2011 fiscal budget. The proposed tax was eventually reduced to a working number of between ½ to ¾ cents per ounce, which would have raised an estimated $9 million to $14 million in 2010-2011. The proposed tax wasintended to avoid cuts to libraries, recreation and public safety.
In Philadelphia, area retailers, teamsters and beverage corporations came together to oppose the tax, claiming that it would lead to the loss of nearly 1,000 of an estimated 13,000 food store jobs, as well as 2,000 jobs in distribution and bottling. The beverage industry has been criticized for the role that it played in the defeat of this soda tax. Harold Honickman, a “beverage mogul” who owns Canada Dry Delaware Valley Bottling Co., and whose net worth is estimated at up to $850 million, became the face of the anti-soda tax coalition, when he stepped up to offer $10 million on behalf of the beverage industry for city health and recreation programs just weeks before the scheduled vote. Mayor Nutter commented that, “It seemed a little strange in the middle of this fiscal and public health issue, that out of nowhere an offer of money was made, essentially to make this go away. I don’t operate like that, and our government does not operate like that.”
With City Council members deciding not to vote on the soda tax, the Mayor was forced to find other means of closing the budget gap. In order to close the budget shortfall, Philadelphia will be forced to shed 339 city positions, in addition to slashing police and fire companies’ budgets, reducing libraries to four-day weeks, cutting $500,000 from shelters and supportive housing programs, and raising property taxes 9.9 percent.
Washington D.C. fails to pass soda tax to fund Healthy Schools Act
In Washington D.C., penny per ounce soda taxes were considered as a means of funding healthy school foods programs earlier this year. The bill would have mandated more physical education and that low-calorie and low-fat meals be served to the area’s approximately 70,000 students. In a preliminary vote in April of this year, the 13-member D.C. Council unanimously voted to back the Healthy Schools Act, without a soda excise tax attached. However, once the soda tax was attached to the bill, several weeks of intensive lobbying followed by groups such as the Maryland-Delaware-D.C. Beverage Association, and support for the penny per ounce tax quickly dwindled. Instead, the city decided to apply its 6 percent sales tax to soda and other sweetened beverages to fund the $6 million cost of the program.
Industry works to repeal taxes in States that have passed excise taxes
It is noteworthy that a few states – Washington, Maine and Colorado – were recently successful in passing excise taxes on soda, but the beverage industry has now stepped up efforts to overturn these taxes. In April, the Washington state legislature passed a tax of 2 cents for every 12 ounces of soda and other sugary beverage, with a 2012 expiration date. According to theWashington Post, the American Beverage Association soon began funneling money to its Washington State branch. The beverage industry coalition, operating under the name Stop Grocery Taxes, had has collected over 395,000 signatures which will place Initiative I-1107 “to stop the tax hikes on food and beverages” on the state ballot in November. A similar approach has already been successful in Maine, where two years ago the legislature passed a soda tax of 42 cents per gallon. Last November, the beverage industry spent over $4 million on its Fed Up With Taxes Campaign, which was successful in putting the tax on the ballot and encouraging voters to reject the tax.
The case for a soda tax
While industry groups claim that soda taxes are nothing more than a money grab from taxpayers struggling to support families, there is substantial evidence that increases in price will in fact reduce soda consumption. In a recent report by the USDA, it was estimated that a ten percent price increase would decrease purchases by 12.6%. Cathy Nonas, head of nutrition programs for the New York City Department of Health, has noted, “If the consumer sees the price difference when they’re about ready to buy the product, we do see a reduction in consumption of an unhealthy food.”
With Americans currently consuming approximately 50 gallons of soda per year (4), and nearly two thirds of American adults who are overweight or obese, a reduction in consumption of sodas and other high calorie beverages will translate to better health.
Note: The proposals described above deal mainly with excise taxes, which would be levied on the beverage bottler. Sales taxes, on the other hand, are levied directly on the consumer at checkout. Sales taxes are generally a percentage of the total cost, whereas excise taxes tend to be levied per unit or quantity (e.g., per ounce, or per a given quantity of syrup used). In addition, sales taxes apply to a range of products, whereas excise taxes are usually associated with a particular product category, such as alcohol or tobacco.
Excise taxes are generally considered preferable by health advocates in terms of their likely effect on price and consumption patterns, although few states currently have excise taxes on soda (exceptions include Arkansas and West Virginia). Soda and other sugar-sweetened beverages, despite their low nutrient content, are exempt from sales tax in many localities because they are considered “grocery items.”
By Lauren Evans, writer for Corporations and Health Watch and student in the Doctor of Public Health program at the City University of New York.
References
- Hamburger T, Geiger K. Soda tax fizzles; Targeting lawmakers and nutritionists, beverage firms put a stopper in the plan. Los Angeles Times. February 7, 2010.
- Geiger K, Hamburger T. States poised to become new battleground in soda tax wars; Lawmakers in California and elsewhere seek levies on sweetened drinks. Los Angeles Times. February 21, 2010.
- Madore JT. Proposal could be pain in the wallet; Paterson unveils new taxes, big cuts in budget plan; says $7.4B hole calls for difficult, necessary moves. Newsday. January 10, 2010.
- Bittman M. A sin we sip instead of smoke? The New York Times. February 14, 2010.
Recommended reading on relationship between taxes and soda consumption:
- Brownell KD, Frieden TR. Ounces of prevention – the public policy case for taxes on sugared beverages. New England Journal of Medicine. Published at www.nejm.org April 8, 2009.
- Duffey K, Gordon-Larsen P, Shikany JM, Guilkey D, Jacobs DR Jr, Popkin BM. Food price and diet and health outcomes: 20 years of the CARDIA Study. Archives of Internal Medicine. 2010;170(5):420-426.
- Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition, Aug 2006; 84: 274 – 288. Available at
- USDA, Economic Research Service. Taxing Caloric Sweetened Beverages: Potential Effects on Beverage Consumption, Caloric Intake, and Obesity. Economic Research Report Number 100, July 2010.
Merging Medicine and Marketing: An Interview with Ray Moynihan, Author of Sex, Lies, and Pharmaceuticals
Ray Moynihan is an award-winning health journalist and researcher, and co-author of the bestselling book Selling Sickness: How the World’s Biggest Drug Companies Are Turning Us All Into Patients, which was published in 2006. His latest book, Sex, Lies, and Pharmaceuticals: How Drug Companies Plan to Profit From Female Sexual Dysfunction, written with Dr. Barbara Mintzes, will be released this October. The book builds on his past work and explores how pharmaceutical companies are helping to define and construct women’s sexual difficulties as symptoms of a new disorder. In August, medical anthropologist S.D. Gottlieb interviewed Ray Moynihan for Corporations and Health Watch about the role of the pharmaceutical industry in defining pathology and his new book. What follows is an edited version of that interview.
CHW: Can you explain to the readers of Corporations and Health Watch what it means for pharmaceutical companies to be creating diseases and disorder?
RM: I don’t normally say that companies create diseases. What the evidence suggests is that companies have helped to sponsor the creation of diseases, to create the scientific building blocks of disorders. This can happen in a range of ways. The boundaries that define conditions can slowly be widened. We’ve seen this happen with depression, with Attention Deficit Disorder, we’re seeing it now with female sexual dysfunction. Some of the ordinary ups and downs of life become blurred with the symptoms of medical conditions. This has become one of the elements of contemporary pharmaceutical company marketing because the more people who can be labeled as requiring a pill, the bigger the markets for the drugs. It’s often a subtle process. You’ve got to follow the money to look at the relationships between the companies and the medical profession. When you do that what we see is a merging of marketing and medical science. In the United States particularly, pharmaceutical marketing is off the leash. A key aspect of that marketing is telling as many people as possible that they need not just one drug but a range of drugs. The marketing is insidiously trying to make us feel as if the ups and downs of life are the symptoms of conditions that require drugs. Anyone living in the United States with a television will recognize these: overactive bladder, stomach problems, mild depression, or a bit of unusual busyness in children. Now we have adult ADD as well. This insidious process is largely unregulated because the regulators focus on drugs, not on the science that defines the conditions.
CHW: That’s a great point. Can you speak more about the problem of the difference between regulation and actual oversight of how pharmaceutical companies develop these notions of pathology?
RM: When you look at the specific panels of doctors who sit down and define illnesses, conditions, and the boundaries of high cholesterol, higher blood pressure, type 2 diabetes, or depression—the doctors actually sit down around a table and decide who is sick and who is healthy—you’ll find that many of those doctors are extremely close financially to the drug companies, and will clearly profit if those boundaries are set as widely as possible. Now this is a crude analysis because it comes out of investigative journalism, not a long history of academic research. Certainly there’s been wider debate about medicalization for a long time, but what I’m trying to do is throw the spotlight on the process by which conditions, diseases, dysfunctions, and disorders are being generated and promoted, The closer you look at that process, the more that it smells.
CHW: So to probe a little deeper, you have a book coming out about the idea of female sexual dysfunction. Can you tell us about this category—how is it constructed and what does it mean?
RM: Female sexual dysfunction does have a technical definition in the pages of the Diagnostic and Statistical Manual of Mental Disorders, but I won’t bore your readers with those details. But there are technical definitions. DSM-4 defines four sub-disorders: disorders of desire, arousal, pain and intercourse, and orgasm.
CHW: And do they all have to be present in order to diagnose FSD?
RM: No, they don’t. They are four separate sub-disorders. But that formal definition is constantly in play and is extremely controversial. For the last decade, there has been a cogent, well organized, and small but effective campaign to criticize those formal definitions and promote an alternative view. That’s an incredibly important part of this story. But back to the definitions themselves. For the last decade or so, there’s been an attempt to portray female sexual dysfunction as being a widespread and treatable medical condition that could affect up to 43% of women. That figure sounds absurd, but it is still widely used by people within the medical profession. It comes from a 1999 article in the Journal of the American Medical Association. It somehow has a degree of scientific credibility, despite the fact that many people have criticized the figure and now that figure has largely been discredited. So the simplistic narrative that has been promoted is that 43% of women have this condition, that it can be severe, under-diagnosed, and it can respond to treatment. And anyone who questions this narrative must be trying to disrespect or delegitimize the genuine suffering of women.
CHW: Isn’t that a slippery slope, to be critical of this diagnosis because it could suggest a lack of recognition of the plight of women?
RM: Absolutely. Almost everyone who is critical of the way in which this condition has been promoted acknowledges that sexual difficulties are widespread and that sometimes those difficulties are so debilitating that a medical angle and a medication may be the best strategy. I don’t think there’s any denying that. The controversy is about the extent of those treatable medical problems. And I think that estimates like 43% are clearly such vast exaggerations that they themselves have sparked a backlash of rationality. When you drill behind that 43% figure and look at the surveys from which it comes, you realize that it in no way represents the proportion of women with treatable medical problems. It represents the proportion of women who say yes to having experienced very common ups and downs in their sex lives. People who have had lack of interest in sex for a few months, people who have had problems with pain, people who have had problems with orgasm. Very common aspects of sexuality that have been categorized as the symptoms of a treatable medical condition.
CHW: Can you clarify why you think these experiences might not require medical intervention?
RM: Sure. In 2000, the New View Campaign was co-created by a New York psychologist called Dr. Leonore Tiefer. This is a global campaign that has a totally different way of framing sexual difficulties. They talk about sexual problems and why women might suffer sexual difficulties. In their view, a passing lack of interest in sex is not something that should be pathologized, not something that should be seen as a symptom of a disorder called Hypoactive Sexual Desire Disorder. It’s an aspect of ordinary life that sometimes is so serious and severe that professional help may be necessary and valuable, but in many cases is not.
CHW: To bring it back to the production of the disorder, a lot of readers probably know about the successful—and profitable—male sexual dysfunction drugs on the market, the most familiar version of which is Viagra. In your view, how has the development and marketing of female sexual dysfunction drugs differed from or paralleled the drug for erectile dysfunction?
RM: The biggest difference is that despite ten years or more of trying a whole range of different drug therapies, nothing has yet been successful in terms of female drugs, whereas my understanding is that the trials of Viagra showed fairly good evidence of effects. But when it’s come to trials of drugs for female sexual dysfunction, so far the FDA has approved nothing. To date, there have been three main waves of potential drugs to treat this condition. First, there was Viagra. The trials of that showed that for women it didn’t work any differently from a placebo. Secondly, there was testosterone, and that failed at the FDA because of fairly negligible benefits but serious risks of harm. And then thirdly we’ve just had this drug called flibanserin which affects the neurotransmitters in the brain, and that just recently failed as well. So I think in all these trials we have seen the power of the placebo.
What is similar is that as the drug companies approach the FDA approval for these drugs, they put a lot of energy into what’s called preparing the market, trying to cultivate the market so that as soon as their drug is approved, a lot of doctors are ready to prescribe. And we saw this most beautifully this year, 2010, when the German drug company Boehringer Inglheim were seeking approval for their drug flibanserin in June. For the last couple of years, behind the scenes, very quietly, Boehringer has been developing links with senior researchers within the world of sexual research. It’s been holding forums, it’s been starting to prepare the market, it’s been funding medical education, things like that. In May 2010, they sponsored a very aggressive media assault that rolled out across the United States and the world, trying to frame sexual difficulties in women as a problem in the brain. They claimed that their drug, which was about to go up for approval, could then be the white knight that rode in on a horse to fix the problem. Things didn’t go according to plan. The FDA rejected the drug. So in a sense there are very similar marketing strategies at play here, but one of the big differences is there’s been no drug approved yet in the United States.
CHW: My understanding of Viagra’s history is that it was more or less coincidence that its indication for erectile dysfunction was discovered. From what you’re saying, it sounds like the female sexual dysfunction pill has been much more directed in its intentions than the discovery of Viagra.
RM: You’re right. Viagra was being tested for something else and this was discovered as a serendipitous side effect and that then became the main indication. And I think that the discovery of Viagra’s sexual benefits for men in the 1990s immediately sparked enormous interest on the part of Pfizer and other companies in the possibility of a market among women. So a lot of energy is going into trying to find a drug that may get approval here. And of course testosterone is used in men and so it was a natural idea to try it in women. The German drug company that has brought us flibanserin also has a similar narrative to the Viagra narrative. Boehringer Inglheim says that flibanserin’s sexual benefits were only discovered accidentally, because the drug was originally tested as an antidepressant. And as it happened, it failed as an antidepressant and now it looks like it may have failed as a sexual dysfunction drug as well.
CHW: Let’s go back to the ideas of companies framing and structuring the marketplace, instead of creating markets. I’m wondering about the innovation-oriented conferences. I read one of your 2003 articles about female sexual dysfunction and you mention in that article the idea of innovation-oriented conferences where so-called “knowledge and opinion leaders” in the pharmaceutical world are coming together to educate other clinicians, to create a community of experts, and to use clinicians as emissaries to other clinicians.
RM: Yes, that’s exactly right. There really is a very frightening merging of marketing and medical science going on, often behind closed doors at these so-called scientific gatherings. The extent of involvement of drug companies in these so-called scientific gatherings has really gotten out of control. Particularly in the early 2000s when this disorder was being developed as a widespread epidemic, the extent of involvement of Pharma was extreme. So not only did companies fund, sponsor, place their booths, and have their marketing people interact with doctors and researchers at these events, the company representatives were actually inside the educational lecture halls taking part in all of the debates, and these debates were actually defining what is human pathology and what is normal life. So drug companies help to define their own markets. I was at a conference in Paris just last year and to my dismay, the senior drug company marketing staff were not just there flogging their drugs, they were in the mainstream so-called scientific discussions, going on about how to define and treat these conditions.
Let me briefly describe three of the building blocks where this merging of medicine and marketing is happening. One is the studies of prevalence. So when we hear studies that say one in ten women have Hypoactive Sexual Desire Disorder, sometimes these surveys are being designed and executed by drug companies. So if you look closely at the fine print of the journal articles that produce these prevalence estimates, these big surveys, companies are actually explicitly involved in them. The next thing is the measurement tools – the tools that are used to measure whether or not a woman suffers from this so-called condition, and whether or not a drug helps. Drug companies have actually created those measurement tools. They’re not being done independently outside the companies, they’re being specifically created by company staff. The third area, and this is perhaps the most shocking, is the diagnostic questionnaires that are used to determine whether or not someone has Hypoactive Sexual Desire Disorder are actually being created by the staff from the companies who are making the drugs for the same condition. In the book Sex, Lies, and Pharmaceuticals I present this evidence. It’s referenced and fact-checked within an inch of its life.
CHW: How would you say that pharmaceutical companies defend this practice when they’re called to task?
RM: I think that we’ve all slowly slipped into these processes. The closeness between the pharmaceutical industry and the medical profession is at least a century old. Recently, the relationship has gotten closer, and in the last decades of the 20th century, without knowing it, we’ve seen a frightening merging of the profession and the industry. In the first decade of the 21st century, the world is starting to wake up to this and we’re seeing widespread concern about this overly cozy relationship between doctors and drug companies. In America, there are now new laws that will force companies to reveal every single payment to every doctor that they put on the payroll. These are unprecedented levels of transparency, and ultimately they’ll produce a new independence in the relationship between industry and the profession.
What’s flown under the radar in all of this is the way in which this closeness has actually started to affect how we define illness. And direct-to-consumer advertising in America has been the vehicle by which the industry has helped to pathologize vast swaths of the healthy population. So far, industry has not really been called to account for this, because this analysis is still not widely understood. On the rare occasions that the industry does have to answer the criticism that it is widening the boundaries of illness, companies simply say that they are responding to legitimate areas of unmet need, legitimately funding science to help bring an end to suffering and improve the health of people and populations, and that its relationships with professionals are entirely appropriate and legitimate, and legal and acceptable. That is their standard approach.
They can’t really deny any of the evidence that we’re discussing, because all the evidence is there. In this new environment, it will be interesting to watch where there is a genuine push for more independence between health professionals and industry and what effect that will have on the way in which we define illness. If we bring a whole fresh bunch of people, good people, and ask them to put their minds to this problem of how to define an illness without that conversation being in the shadows of the pharmaceutical companies, I think we might come up with some very different sorts of answers. We may not find that diseases and definitions keep being broadened.
CHW: The United States FDA advisory panel recently issued a recommendation against the Boehringer Inglheim oral drug for sexual dysfunction that’s pending FDA approval. Many people don’t recognize that there’s an advisory panel that’s separate from the FDA regulatory panel. In 2000, the FDA issued preliminary guidelines to help companies plan human studies of drugs for female sexual dysfunction complaints. Can you talk about government involvement in promoting companies’ developments of new categories of illness?
RM: The FDA has its hands full trying to understand the risks and benefits of pharmaceuticals and other products. I would argue that it is not qualified to critique and evaluate the science behind the actual conditions. The regulators, like almost everyone else, take on good faith the disease definitions that are handed to them by groups of experts within the medical profession. But we can no longer take those definitions on good faith. We must look closely at them, who has defined them, who has funded them, and at the relationships between the people doing the defining and the drug companies. And really, I think, we need to start again.
Even this year, I don’t think the advisors to the FDA were well enough aware of the deep controversy surrounding this thing called HSDD, Hypoactive Sexual Desire Disorder. You have a bizarre situation occur where the FDA’s advisors and the FDA are assessing a drug for a condition called HSDD, while at the same time, a panel that is rewriting the DSM, the manual of diseases, has proposed abandoning HSDD as a disease entity. So, in fact, HSDD may no longer exist within a couple of years, and yet the FDA is happily and enthusiastically assessing a drug for this condition. This is just one example where I think the FDA regulators generally need to be a lot more rigorous in their analysis of claims about the nature of conditions. The other important thing to say is that the FDA has actually explicitly encouraged companies to design the instruments that measure the success of their drugs. I find that bizarre but I think it flows from something deeper. Increasingly, health care and medicine are not seen just as something that helps prevent disease and augments human health. Rather they are seen as industries, very large industries, and the FDA sees its role as facilitating that industry. Don’t forget that the FDA itself is funded in a very big way by industry.
CHW: And populated with people who have a lot of industry experience as well. It’s self-contained in some way.
RM: That’s right, and there are often debates within the FDA itself about the extent to which it is too close to industry. At least one bill has been proposed to end industry funding for the FDA. I suppose these are deeper and bigger debates for another day, but they’re certainly relevant to this debate about how conditions are constructed and promoted.
CHW: As our final question, I wanted to ask about one of the things that prompted my interest in this most recently, which is the Boehringer Inglheim website called sexbrainbody.com. It’s one of many drug company educational content websites that precede FDA approval. What do you think are the benefits or challenges that websites might provide for patients?
RM: The pharmaceutical industry and their allies are asking us to believe that their promotion and marketing is actually information and education. This is a deep assault on our sense of reason and I really don’t understand how the assertion can even be made. That’s the big picture answer to your question. The smaller answer is that consumers need to be extremely skeptical of any sources of information that are sponsored by the drug companies or other industries with vested interests in the outcome of that information. I think that the sexbrainbody website was a crude attempt by Boehringer to help build the market for its drug. These promotional exercises, even though there may be independent people involved in running them, need to be heavily labeled. There should be laws that mandate that the sponsorship should be front and center on the front page of such websites. The sad thing is that there are not easily, readily accessible websites that offer truly independent information and education. The few sources that are around don’t have the firepower behind them that a drug company hungry for a new market can bring.
This question of who educates consumers about drugs is raging in Europe at the moment, as the drug companies are attempting to introduce direct-to- consumer advertising into Europe under the guise of providing information to people. And we’re living through a very strange epoch where the belief that knowledge can be generated independently of corporate interests is under threat. Somehow we have come to believe that corporate involvement in the generation of information of knowledge or education is acceptable, actually something to encourage. It’s a blurring of categories.
CHW: Thank you so much.
Ray Moynihan was interviewed by S.D. Gottlieb, MHS, PhD, anthropologist and author of the recent dissertation entitled, “Manufactured Uncertainty: the Human Papillomavirus and the Object Multiple.”
For other related CHW posts, see:
- Vaccine Promotion in the Hands of a Corporation: The Missed Opportunity of Merck’s Marketing of Gardasil
- Assessing the Health Implications of the Supreme Court Decision on Corporate Campaign Contributions
Image credits:
Corporations and Health Watch 