Corporations and Health Watch

Pharma Goes Online; Feds Fail to Follow

Posted on July 9, 2009 by Corporations and Health Watch

While the fiercest opposition to direct-to-consumer (DTC) advertisements has been to television advertisements, pharmaceutical companies have increasingly turned their attention to online marketing and social media, such as Facebook and YouTube with very little opposition or regulation by the Food and Drug Administration. In this report, CHW explores the reasons for this increased use of online marketing and social media, profiles a few recent examples where online DTC advertisements have raised concerns, and suggest possible future directions for consumer advocates.

Since the Food and Drug Administration (FDA) first relaxed guidelines governing direct-to-consumer (DTC) pharmaceutical advertising in 1997, DTC advertising has increased dramatically, from approximately $1 billion per year in 1997¹ to $5.4 billion in 2006.² As a result, physician and advocacy groups and some elected officials have begun to raise questions about the ethics of DTC advertising.³ While the fiercest opposition to DTC advertisements has been to television advertisements, with less opposition, pharmaceutical companies have increasingly turned their attention to online marketing and social media, such as Facebook, YouTube, Sermo (for physicians), and iVillage (for women’s health).⁴ A recent article in Advertising Age notes that “what might be considered a yawn-worthy move into new and social media is nothing short of a revolution” for the pharmaceutical industry.⁵ In this report, Corporations and Health Watch explores the reasons for this increased use of online marketing and social media, profiles a few recent examples where online DTC advertisements have raised concerns, and suggest possible future directions for consumer advocates.

Online advertisements and social media challenge our conceptions of DTC advertisements

Some of the largest pharmaceutical companies have challenged common conceptions of DTC communication through the launch of popular blogs, YouTube channels and other forms of online media. For example, Johnson & Johnson’s McNeil Pediatrics unit sponsors an attention-deficit hyperactivity disorder group called “ADHD Moms” on the social media site Facebook,⁶ where the number of participants has grown to more than 8,200 without any expenditure by the company.¹ Johnson & Johnson also hosts a popular blog called “JNJ BTW” where the company seeks to create a space for a “three-dimensional view” of the company and a “conversation” with consumers. Novartis, Boehringer Ingelheim and AstraZeneca all use Twitter to deliver news about their companies, and several firms have launched controversial channels on YouTube to promote their drugs. Pharmaceutical companies also bid for key words such as “cholesterol” in Google and other search engines so that advertisements for their drugs will appear in the sponsored search results, for which the search engine company collects a fee each time someone clicks on the advertisement.⁷ In addition, contextual advertising on websites offers pharmaceutical companies the opportunity to place banners on websites targeted to visitors to certain websites or to visitors in certain geographic locations.⁷

Reasons for industry’s increased use of social media and online advertisements

At a time when print advertisements for pharmaceuticals are down 18% and television advertisements are down 4% to $4.4 billion in 2008 (compared to the $4.8 billion spent in 2007),¹ online marketing efforts have soared.^{1, 5} One reason drug makers have turned to online advertising is because it is a relatively inexpensive way to reach targeted audiences. But in addition to being cost-effective, online media communications are less likely to mobilize patient advocates who are critical of DTC advertising.^{4, 7}

Some observers have suggested that the “lower profile” yet highly effective online DTC advertisements might be “simply smart politics” on the part of pharmaceutical companies wishing to avoid attention by members of congress who wish to regulate DTC advertisements.² Pharmaceutical marketers have taken advantage of the fact that greater numbers of Americans are now seeking health information and support online instead of consulting their physicians.^{4, 5, 8} Patients are now seeking more interactive communications, and, in an interview with Advertising Age, a relationship-marketing agency CEO said that social media offers the pharmaceutical industry an opportunity to rebuild trust between the consumer and an industry that is often unpopular.⁵

Recent DTC “success stories”

Several pharmaceutical companies have launched highly successful online marketing communications, and in some ways these companies serve as industry forerunners.⁵ Here are some examples:

MULTIPLE SCLEROSIS: Patients with chronic conditions often turn to the internet for the support of others with similar concerns and for help in managing chronic conditions.⁴ Acorda Therapeutics, working with a division of global advertising agency Saatchi & Saatchi launched a community website called iwalkbecause.org in advance of the release of its drug for multiple sclerosis which will not be available until next year.⁵ According to a Saatchi executive, the community of people with multiple sclerosis is a group that searches for online information “ferociously.” ⁵

AMBIEN CR: Saatchi also worked on an integrated TV-web campaign for Sanofi-Aventis’ sleep drug Ambien CR.⁵ The 15-second commercial directed viewers to go to a “microsite” called silenceyourrooster.com with games, videos, and other social-media elements.⁵ In the first three days, the site received 1 million “hits” and a 2% “clickthrough rate” to the branded site www.ambiencr.com.⁵

ASTHMA: AstraZeneca launched a YouTube channel called “My Asthma Story” for its asthma drug Symbicort where they invite patients to submit videos about their positive experiences with Symbicort to their website, where consumers “essentially create their own advertisements for the drug.”⁵

RESTLESS LEGS: In late 2006, GlaxoSmithKline introduced an unbranded and very creative video on YouTube that received over 200,000 views, which led the company to establish its own YouTube channel, GSK Vision.⁵

Future Issues for advocates and regulators to consider

Overall, the FDA has, until recently, been weak in its response to pharmaceutical companies’ online DTC advertisements. In fact, there are no published guidelines for online pharmaceutical advertising by the FDA Division of Drug Marketing, Advertising, and Communications Research, the organization typically responsible for providing such oversight.⁵ As noted by a senior VP at the public relations and marketing communications firm Fleishman Hillard, “People are still figuring out how we employ new media, whish is such a completely new paradigm. What [pharmaceutical companies] are doing now is experimenting.” ⁵ Similarly, Symbicort brand manager for AstraZeneca notes, “The social-media space is still very much a gray area.” ⁵ Without oversight, controversy has begun to erupt as it did this past January, when a banner ad went online for the emergency contraceptive Plan B. Plan B is marketed by Duramed, a subsidiary of Barr Pharmaceuticals, which was recently acquired by Teva Pharmaceuticals USA.⁹ The company advertised on the MTV website which is very popular among girls 17 and younger, directing viewers to go to the Plan B website with the tagline “Because the unexpected happens.” ⁹

Last April, the FDA began to take action with regard to DTC advertising in new media by sending major pharmaceutical companies untitled letters in April asking them to not place misleading ads on search engines such as Google and Yahoo,⁵ as well as taking action regarding several YouTube videos with misleading pharmaceutical advertising content. For example, the FDA requested that UK drugmaker Shire Pharmaceuticals remove its YouTube video for Adderall XR, which the agency argued was overstating the hyperactivity drug’s effectiveness while omitting relevant information about risks.¹⁰ The FDA also began requiring pharmaceutical companies to embed safety and risk information in the videos themselves, rather than providing a link alongside the video advertisements they post.¹⁰

As pharmaceutical companies increasingly turn to online media and social marketing to reach consumers, regulatory guidance from the FDA on this “gray area” will be increasingly necessary, as will increased vigilance on the part of consumer advocates and Congressional leaders.

References

1 US DTC Rx advertising falls 8% to $4.4 billion. Pharma Marketletter. April 21, 2009.

2 US Pharma DTC “recession” started in 2006. Pharma Marketletter. December 5, 2008.

3 Douglas J. Wood Reed Smith LLP. Legal issues to watch in 2009. Advertising Age. December 15, 2009.

4 US drugmakers switch marketing approach. Pharma Marketletter. April 25, 2008.

5 Miley M, Thomaselli R. Big Pharma finally taking steps to reach patients with digital media: highly regulated industry slowly mobilizes with blogs, Twitter, YouTube. Advertising Age. May 11, 2009.

6 McNeil Pediatrics, ADHD Moms A Place for Moms of Children with ADHD. Press Release dated July 9, 2008. Available at: http://www.mcneilpediatrics.net/mcneilpediatrics/assets/
60CON08453A_ADHD_Moms_Press_Release_FINAL_FOR_DIST.pdf

7 US drug DTC cuts in 1st half 2008: TV ad effectiveness low, regulatory risk high? Pharma Marketletter. October 17, 2008.

8 California HealthCare Foundation. Social Media’s Challenge to Traditional Health Care Patients, Providers, Researchers, and Advocates Forge Online Connections. April 22, 2008. Accessed June 7, 2009 at: http://www.chcf.org/press/view.cfm?itemID=133633.

9 Thomaselli R. “Morning-After Pill” catches flak for MTV.com ad: site’s under-18 visitors will see banner for emergency contraceptive Plan B. Advertising Age. January 8, 2009.

10 US FDA swoops on YouTube “DTC Abuse.” Pharma Marketletter. December 4, 2008.

Image Credit:

1. tomsaint

Reader Response: “New York State’s Tax on Sugar Sweetened Beverages Goes Down the Drain: Lessons from Nutrition Advocates”

Posted on July 8, 2009 by Corporations and Health Watch

Last month Corporations and Health Watch posted a story “New York State’s Tax on Sugar Sweetened Beverages Goes Down the Drain: Lessons from Nutrition Advocates.” The following letter was written in response to this posting.

To Corporations and Health Watch:

I am writing to respectfully respond to the “New York State’s Tax on Sugar Sweetened Beverages Goes Down the Drain: Lessons from Nutrition Advocates” article by Ms. Dinour (posted in May 2009). Contrary to what the article implies, Citizens’ Committee for Children (CCC) has at no point wavered in its support and preference for the establishment of an excise tax on sugar-sweetened beverages. To educate elected officials, health care colleagues and the media on the advantages and strengths of an excise tax, we commissioned a public opinion poll on the proposal and provided poll results and detailed analysis of consumption and revenue to the Governor, the entire New York State Legislature, local and regional media outlets, as well as health care colleagues and advocates. In addition, we mobilized over 4,000 New Yorkers to connect to their state representatives electronically in support of the excise tax facilitating hundreds of e-letters. We traveled to Albany with volunteers and met repeatedly with elected officials to advance the excise tax proposal. We were in constant contact with the Governor’s Office, the Senate and Assembly, providing fiscal impact assessments, projections on consumption and revenue, and encouraging alterations to the sales tax proposal. We held press conferences, background sessions with journalists and media, and testified at hearings on the State Budget and tax options. In every instance we advanced the concept of an excise tax on sugar-sweetened beverages, not simply an innovative way to raise revenue, but as an effective way to improve public health and save lives by reducing consumption of unhealthy beverages. We remained focused on the targeted use of excise tax revenue as well and believed that resources needed to be dedicated to obesity prevention – something the proposal to increase sales taxes on beverages did not do.

The article also suggests that child advocates and health advocates had not gone far enough in their advocacy methods; stating by comparison that the “New Yorkers Against Unfair Taxes created a website, blog, cell phone texting service…” What is missing in this comparison is the open acknowledgement that New Yorkers Against Unfair Taxes is a coalition supported by local and regional business interests, industry organizations and corporations in food retail, bottling, beverage, and distribution. Also absent from the discussion is the fact that the resources, contributions and influence at the coalition’s disposal, were not only disportionate but that several corporations actually threatened to move thousands of jobs out of New York, should the sugar-sweetened beverage tax proposal pass. Conversely, the excise tax was supported by small non-profit advocacy organizations and health care providers focused on the health of the State’s citizens but without the vast resources and without the financial leverage and overwhelming monetary stake in the outcome.

CCC agrees with the article’s conclusion: that a key lesson for advocacy is the need for a “strong policy introduction and legislative champion and effective messaging throughout a campaign.” In fact, our poll clearly documented an increase in public support for the excise tax on sugar-sweetened beverages when participants are told of the public health, rather than gap closing, benefits. Health and child advocates did not waiver in their advocacy or messaging on that point. Unfortunately the media coined and hung on to the “fat tax” terminology, which not only demonized overweight people but also deflected attention from public health benefits of taxing unhealthy products. The catchy phrase helped to dumb down the public discussion and allowed for the lumping of this proposal in with regressive fees, fines and taxes. Faced with multiple and enormous tax policy and budgetary battles, the sugar sweetened beverage tax proposal eventually lost its greatest political champion: the Governor.

On this point, although the article states that advocates should understand “the historical, social and political environments in order to identify windows of opportunity,” it completely fails to acknowledge the historical, social and political environments that advocates faced when the Governor proposed a sales tax on sugar sweetened beverage tax. The debate, on the best method of taxing unhealthy beverages, took place at a time when New York State faced the most profound recession in decades and needed to close a $16 billion dollar budget gap. A time when there was profound concern about protecting hundreds of millions of dollars in investments in basic supports for children and families. In tandem with our efforts to advance a sugar sweetened beverage excise tax proposal, CCC and others were also leveraging significant political and organizational capacity to achieve a progressive increase in personal income tax to raise nearly $6 billion in revenue and ensure that the budget would not be balanced on the backs of the poorest constituents. Thankfully, we achieved both even though the political and social climate seemed against us from the outset, thereby proving the theory that you can lose the battle and still win the war.

We remain committed to advocating for the excise tax on sugar sweetened beverages because we believe that children will ultimately benefit. In fact, the United State’s Senate Finance Committee is now contemplating instituting such a tax as a means to raise revenue to support health care reform and combat obesity on a national scale. It is clear that the rigorous debate in New York has informed this national proposal. CCC continues to educate lawmakers, now on the federal level, and is hopeful that Congress can pass the tax and in doing so place the needs and interests of children and families ahead of those of the bottling and beverage industry.

Jennifer March-Joly, Ph.D.
Executive Director
Citizens’ Committee for Children of New York

Book Reviews: Global Politics & Pharmaceutical Industry Practices

Posted on July 8, 2009 by Corporations and Health Watch

Two books on the ethics, politics and practices of the global pharmaceutical trade. Reviewed are: The Global Politics of Pharmaceutical Monopoly, Power, Drug Patents, Access, Innovation and the application of the WTO Doha Declaration on TRIPS and Public Health by Ellen F.M. ‘t Hoen (AMB Diemen, 2009) and Global Pharmaceuticals: Ethics, Markets, Practices, edited by Adriana Petryna, Andrew Lakoff, & Arthur Kleinman (Duke University Press, 2006).

The Global Politics of Pharmaceutical Monopoly, Power, Drug Patents, Access, Innovation and the application of the WTO Doha Declaration on TRIPS and Public Health by Ellen F.M. ‘t Hoen (AMB Diemen, 2009. ISBN 97890-79700-06-6)

In her new book, The Global Politics of Pharmaceutical Monopoly, Power, Drug Patents, Access, Innovation and the application of the WTO Doha Declaration on TRIPS and Public Health, Ellen ‘t Hoen, former Director of Policy Advocacy for the Medecins Sans Frontieres (Doctors Without Borders) Access Campaign, outlines progress made in increasing access to medication and medical innovation. She also identifies critical unresolved issues in development and distribution of new medical technologies for the treatment and prevention of disease in the developing world. Specifically, this book describes how access to medication in the developing world is affected by the current global rules for pharmaceutical patents. The book highlights recent alternative mechanisms to encourage medical research and development in a way that also ensures access to the product—by separating the cost of research and development from the price of diagnostics, medicines, and vaccines.

Link to reviews of this book:

Knowledge Ecology Studies
European AIDS Treatment Group

Link to this book:

AMB Press (where you will find link to an on-line version of this book)

Global Pharmaceuticals: Ethics, Markets, Practices by Adriana Petryna, Andrew Lakoff, & Arthur Kleinman (eds.) (Duke University Press, 2006. 312pp. ISBN 082233741X)

This edited volume, a collection of ethnographies, tackles a timely topic- the inequalities produced by the current global pharmaceutical system that of the anthropologist. This collection provides insights into the burgeoning international pharmaceutical trade and the global inequalities reinforced by market-driven medicine. From an examination of how popular and professional understandings of psychiatric illness in the Western world to the experience of African families faced with the financial burden of AIDS treatment for its members, this book brings together experiences of individuals and communities and the roles they play along with organizations, corporations, and governments in the market-driven game of global pharma. This work is an important step in bringing the moral and ethical issues inherent in every phase of pharmaceutical production to the forefront of the social science research agenda.

Link to review of this book:

British Journal of Psychiatry

Link to this book:

Amazon.com

Commentary: Driving change: the global health impact of the restructured auto industry

Posted on July 8, 2009 by Corporations and Health Watch

In the last several months, the global auto industry has undergone a transformation as profound as any in its history. Despite a $50 billion taxpayer bailout, two of the three biggest US automakers, General Motors and Chrysler, have filed for bankruptcy. As the auto industry plans for its new smaller future, public health advocates need to consider how this restructuring will affect health. In this Commentary, CHW briefly describes some of the recent changes in the global auto industry, examines the possible health impact of these changes, and suggests possible directions for public health research and policy advocacy.

In the last several months, the global auto industry has undergone a transformation as profound as any in its history. Despite a $50 billion taxpayer bailout, two of the three biggest US automakers, General Motors (GM) and Chrysler, have filed for bankruptcy. Almost 300,000 auto workers have been laid off and more than 2,000 auto showrooms closed. While every sector of the industry has been hurt by the economic crisis, foreign car makers like Honda, Toyota and Hyundai continue to gain market share and Fiat, an Italian car maker, is expected to soon complete its purchase of Chrysler. After decades of government stalling, in May, President Obama announced tougher new federal fuel emission and mileage standards for US autos, creating new pressure for change.¹ As the auto industry plans for its new smaller future, public health advocates need to consider how this restructuring will affect health. In this Commentary, Corporations and Health Watch briefly describes some of the recent changes in the global auto industry, examines the possible health impact of these changes, and suggests possible directions for public health research and policy advocacy. Our goal in this preliminary report is to raise questions for more systematic analysis in the months and years ahead.

Downsizing Detroit

In the last 18 months, 289,000 workers in the US auto industry lost their jobs, about half were auto assemblers and the other half worked in the auto supply networks.² Between September 2008 and March 2009, these two sectors of the auto industry accounted for nearly 20% of the decline in the nation’s gross domestic product. In Spring 2009, US car makers were producing 423,000 vehicles a month, down from 600,000 late last year.² Some industry analysts predict that by the end of 2009, a total of 3,800 auto dealerships will be closed, almost double the number closed to date. The auto industry’s troubles predate the economic crisis –rising oil prices, a collapsing market for SUVs, and intense competition from European and Asian car makers all contributed to the industry’s meltdown.

Globally, the auto industry is also running off the road. The London-based HIS Global Insight Automotive Group estimates that total 2009 passenger car and light truck production will fall to 59.8 million units in 2009, a 16% drop from 2007.³ In the last year, car sales have declined in Japan, Europe and elsewhere. In 2008, auto sales in China hit a ten year low, although the Chinese stimulus plan, which provides subsidies for car purchases, has helped to lift sales more recently. As Michel Freyssnet observed in Le Monde, what is striking about the current crisis in the automobile industry is that “there is not any major market nor any manufacturer that is not in decline.” ⁴

In January 2009, people in China bought 748,000 cars, a 4.6% reduction from the year before while in the U.S., people bought 657,000 cars in January, a 37.1% reduction.⁴ This statistic highlights the changing face of the global auto industry. In the coming decade, most analysts agree that European, Japanese, and Chinese car makers will outpace the US industry, with Brazil, South Korea and India not far behind.

In China, for example, the high cost of gasoline is pushing even tougher fuel emission mandates than those announced by President Obama. In a plan released in May, China will require car makers to improve fuel economy an additional 18% by 2015, creating new pressures for more fuel efficient and smaller cars.⁵ Already China imposes a sales tax of 1% on fuel-efficient cars and 40% on gas-guzzling SUVs and sports cars. Since most multinational auto companies are vigorously competing for a share of the Chinese auto market, China has the potential to play a leading role in setting global environmental and production standards. As Dieter Zetsche, the chairman of Daimler, said at the opening day of the Shanghai auto show in April, “The center of gravity is moving eastward. This has, if anything, only accelerated through the crisis.”⁶

Auto industry analysts, from the World Watch Institute⁷ to KPMG⁸ to the US Department of Commerce⁹, seem to agree that if the auto industry is to survive, it must make fewer, smaller and better cars, with an emphasis on more environmentally friendly and fuel efficient vehicles. It also seems likely that carmakers in other countries, especially China, will continue to grow in influence. While the emerging auto markets in the global South are likely to demand smaller and more fuel-efficient cars, if their goal is to achieve developed nation levels of car ownership the overall adverse impact of cars on health and the environment may continue to grow. In the coming decade, this tension between equity in ownership levels and sustainable patterns of automobile production will dominate the debates among the global automobile industry, policy makers and environmentalists. On the one hand, the developed nations have no right to tell Asians, Africans and Latin Americans that they can’t have cars. On the other hand, a continued rise in automobile use will inevitably choke our cities, pollute our air, injure and maim growing numbers of people, and exacerbate human-induced climate change, all trends that will hurt the global south more. Only by reframing the issues can we escape this dilemma.

In the coming decade, this tension between equity in ownership levels and sustainable patterns of automobile production will dominate the debates among the global automobile industry, policy makers and environmentalists.

One important influence on how much Americans will drive and what kinds of cars they will buy is the price of gasoline. In the United States, oil demand has dropped without interruption for more than 15 months. Globally, the International Energy Agency estimated that daily average oil consumption would decline by 3% in 2009. ¹⁰ A rapid economic recovery, new oil production and consumer optimism could lead to more driving and fewer incentives to buy small cars. Conversely, a long recession, high gas prices, or continued political conflict in Nigeria, Iraq, Russia, Venezuela or other major oil-producing countries could accelerate the trends to less driving and smaller, more fuel-efficient vehicles.

How does the auto industry influence health?

For the last century, the auto industry has been a major influence on health. It has changed the air we breathe, the form of our cities and suburbs, and contributed to rising rates of obesity by encouraging sedentary behavior. An extensive literature documents the profound social and environmental impact of the automobile.^11, ^12, ¹³ At the individual level, automobile ownership has been associated with various health benefits. As Macintyre et al. note, car ownership can increase access to employment, shops selling healthy affordable food, leisure facilities, social support networks, health services and open space and help owners to avoid crime.¹⁴

At the population health level, more attention has been focused on the adverse impact of the density of automobile ownership. Here we consider its impact in four separate domains: air pollution, climate change, automobile accidents and injuries, and physical inactivity. Also of vital importance but considered only briefly below is the industry’s impact on the well-being of its workers and the communities in which its factories are located.

Air pollution Outdoor air pollution causes an estimated 800,000 deaths around the world each year and motor vehicles are a major source of such pollutants as nitrogen oxides (NOx) and volatile organic compounds (VOCs)—which interact to form ground level ozone—and of microscopic particulate matter (PM10). It is estimated that 1.4 billion people are exposed to urban air pollution above World Health Organization (WHO) limits. Deaths from air pollution are only the tip of the iceberg. For example, for every death caused by PM10 there will be 34 emergency admissions, 407 asthma days, 6,085 reduced activity days, and 18,864 acute respiratory symptom days.¹⁵

Climate change In April 2009, the US EPA issued a proposed finding that carbon dioxide (CO2) poses a danger to health and welfare, opening the door to federal regulation of CO2 from all sources.¹⁶ According to Environmental Defense, the United States has 5% of the world’s population and 30% of the world’s automobiles, but it contributes 45% of the world’s automotive CO2 emissions.¹⁷ Thus, reducing car use and increasing fuel efficiency of cars are essential steps in reversing human-induced climate change. According to Dan Becker, the Director of the Safe Climate Campaign, the improvements in fuel efficiency standards that President Obama announced last month are, “the biggest single step to curbing global warming. It’s a major step forward in cutting auto emissions.” ¹⁸

Accidents In the last century or so, cars have killed at least 30 million people, perhaps many more—each year cars kill 1.2 million and injure 50 million.¹⁹ According to the World Health Organization, traffic deaths and injuries are rising worldwide, likely to double by 2020 and automobile accidents are the leading cause of death for 10 to 24 years old.¹⁹ Children in less developed countries (LDCs), especially those in densely populated cities, experience the highest burden of automobile injuries, dying at six times the rate of children in higher income countries and accounting for 96% of all children killed in traffic collisions.¹³ The US automobile industry has a long record of opposing public health measures to improve car safety including seat belts, air bags and auto-locking brakes. Over the 20th century, as consumer and government pressure forced the US auto industry to add safety devices, auto deaths and injuries fell dramatically. Still, in the 1990s, automaker decisions to promote SUVs at the expense of sedans contributed to thousands of preventable deaths in the US from rollovers, crashes and collisions with pedestrians.²⁰

Obesity/physical inactivity More recently, automobiles and the cities and suburbs designed to accommodate them have been implicated as one factor contributing to rising rates of obesity. As cars have become more central in many transport systems, people are less likely to walk to shops or work and fewer children walk to school. One study found that each additional hour spent in the car was associated with a 6% increase in the likelihood of obesity.²¹

How will the restructuring of the auto industry influence its impact on these and other health outcomes?

Box 1 lists possible implications of some of the previously described trends. Future research will need to test these possible associations across time and place, seeking to gain insights into the pathways by which changes in auto industry practices lead to changes in health and health behavior. In addition, changes in the automobile industry are likely to be associated with other changes in the global economy, trends which may interact to produce positive or negative health consequences.

Box 1. Possible Health Consequences of Changes in the Auto Industry

Trend	Possible Health Effects
Fewer automobiles produced	Less driving, less air pollution including C02 emissions, fewer accidents and injuries, more walking and less obesity
Higher proportion of smaller more fuel efficient cars	Less air pollution including less carbon dioxide emissions and less global warming
Fewer miles driven	Less air pollution, fewer accidents and injuries, more walking and less obesity
Higher rates of automobile ownership in Asia, Africa and Latin America	More air pollution, more accidents and injuries, and less physical activity, exacerbating North-South health inequities

Finally, any review of the health consequences of the auto industry restructuring must acknowledge the profound adverse impact on workers in the automobile industry and on the communities where the auto industry has been centered. Hundreds of thousands of auto workers have and will lose their jobs and often their health insurance, putting them at risk of prolonged unemployment, home foreclosure, and high levels of stress. In addition, these catastrophic losses are concentrated in a few cities and regions, most notably Detroit and its suburbs, in the US, where they further jeopardize the well-being of populations already suffering from more than two decades of deindustrialization.

Future policy and research for a healthier auto industry

In the US, as in the rest of the world, the goal is not simply to restore the auto industry to a health that has often sickened the world by producing unsafe, polluting and environmentally damaging cars. To avoid this future, auto makers, government policy makers, public health and environmental professionals, labor unions, and advocates will need to engage in an ongoing dialogue. Here, Corporations and Health Watch suggests some proposals that may help to spark this dialogue.

1. Move from state to federal regulation for automobile safety and environmental standards.

In the past many years, public health and environmental activists have often emphasized state rather than federal regulation because of the business friendly environment in Washington. The recent economic crisis and the 2008 election may provide a window of opportunity to move the action back to Washington where decisions can benefit the population as a whole and pressure industry to meet consistent standards. Industry may now be willing to support such a move, at least in those cases where federal regulation doesn’t threaten profits. As the Alliance of Auto Manufacturers noted in May, a national program for regulating CO2 “avoids conflicting standards from different regulatory agencies, and it gives automakers much needed certainty for long-term product planning.”²²

2. Reinvigorate the National Highway Safety and Transport Administration and the Environmental Protection Agency.

For the federal government to play a positive role in reducing the health and environmental consequences of the automobile industry, it will need a vigorous and science-based regulatory infrastructure, much of which was decimated under the Bush Administration. Rebuilding these agencies will provide the means to implement new policies.

3. Consider the quid that tax payers can expect for the quo of the auto industry bailout.

Bailouts are not, by themselves, a solution to the auto industry’s problem. As Joseph Romm, a former US Energy Department staffer, wrote recently in Salon, “when you bail someone out of jail, there is no guarantee that he won’t jump bail, and even less of a guaranteed that he won’t ultimately end up in jail anyway.”²³ So continued government support has to be contingent on auto makers acting in the public interest. Among the auto industry practices US tax payers ought not to subsidize are: deceptive advertising that implies big cars are safe, design of cars that are environmentally damaging, or lobbying to thwart public health protections.

Film maker Michael Moore, who 20 years ago showed the seamy side of GM in his film “Roger and Me,” recently suggested that President Obama²⁴ follow the example President Roosevelt set after the attack on Pearl Harbor. Then, FDR ordered GM to halt car production and begin to produce planes, tanks and machine guns. Now, Moore urged Obama to convert our auto factories into ones capable of building mass transit vehicles and alternative energy devices.

4. Construct clear, compelling narratives and frames to present the issues facing the American auto industry to the American public.

For decades the US auto industry has opposed reforms that will reduce the public health and environmental harms its products cause, and, for decades, the American public has had difficulty contesting the industry’s self-serving arguments. Now the American public is much less likely to trust auto industry executives to decide what’s best for America. To realize this opportunity, public health and environmental advocates will need to find new language and narratives to help Americans consider their options. Recently, the psychologist Drew Westen and the pollster Celina Lake suggested some frameworks for discussions about auto industry reform, illustrated in the diagram below, in which the words in blue suggest future directions and those in red the policies we want to escape.²⁵

In the coming years, the auto industry will continue to change. Whether public health and environmental advocates will be able to influence those changes for the better depends on our success in engaging a wide variety of constituencies in policy debates about the future of the car. By understanding the health and environmental consequences of these changes and communicating them clearly, we have an opportunity to join the discussion.

By Nicholas Freudenberg, Distinguished Professor and Founder and Director of Corporations and Health Watch.

References

1 Broder JM. Obama to Toughen Rules on Emissions and Mileage. New York Times, May 18,2009. Available at:http://www.nytimes.com/2009/05/19/business/19emissions.html?_r=2

2 Uchitelle L. Once a key to recovery, Detroit adds to the pain. New York Times, June 1, 2009, p. B1, 3.

3 Cited in Rennert M. Global auto industry in crisis. Worldwatch Institute, May 18,2009. Available at:http://www.worldwatch.org/node/6113.

4 Freyssenet.A Major Battle Is Joined Over the Transition to the Clean Car. Tuesday 03 March 2009. Truthout. Originally Published in Le Monde Available at http://www.truthout.org/030509G

5 Bradsher K. Miles to go in China. Thursday, May 28, 2009, p. B1.

6 Bradsher K. China influence grows with car sales. New York Times, April 20, 2009.

7 Rennert M. Global auto industry in crisis. Worldwatch Institute, May 18,2009. Available at: http://www.worldwatch.org/node/6113

8 KPMG International. Momentum: KPMG’s Global Auto Executive Survey 2009. Available at:http://www.kpmg.com/SiteCollectionDocuments/Momentum-KPMG-Auto-Executive-Survey-2009.pdf

9 International Trade Administration. The Road Ahead for the U.S. Auto Market. U.S. Department of Commerce, Washington, D.C., 2008.

10 Mouawad J. Gas is up; drivers may not cut back. New York Times, May 21, 2009.

11 Ladd B. Autophobia Love and hate in the Automotive Age. Chicago: University of Chicago Press, 2008.

12 Woodcock J, Aldred R. Cars, corporations, and commodities: Consequences for the social determinants of health. Emerg Themes Epidemiol. 2008 ;21;5:4.

13 Dauvernge, P. 2008. The Shadows of Consumption Consequences for the Global Environment. Cambridge, MA: MIT Press, 2008.

14 Macintyre S, Ellaway A, Der G, Ford G, Hunt K. Do housing tenure and car access predict health because they are simply markers of income or self esteem? A Scottish study. J Epidemiol Community Health. 1998;52(10):657-64.

15 “Urban Transport.” Encyclopedia of Public Health. Ed. Lester Breslow. Gale Cengage, 2002. eNotes.com. 2006. 23 Jun, 2009 http://www.enotes.com/public-health-encyclopedia/urban-transport

16 Broder JM. EPA clears way for greenhouse gas rules. New York Times, April 18,2009. Available at:http://www.nytimes.com/2009/04/18/science/earth/18endanger.html

17 DeCicco J, Fung F. . Global warming on the road. Environmental Defense, 2006. Available at:http://environment.about.com/gi/dynamic/offsite.htm?zi=1/XJ&sdn=environment&cdn=newsissues&tm=17&f=00&tt=2&bt=0&bts=0&st=23&zu=http%3A//www.environmentaldefense.org/documents/5301_Globalwarmingontheroad.pdf

18 Tankerley R, Simon R. US to limit greenhouse gas emissions from autos. Los Angeles Times, May 19th, 2009. Available athttp://articles.latimes.com/2009/may/19/nation/na-emissions19.

19 World Health Organization and World Bank. World Report on Road Traffic Injury and Prevention. Geneva, Switzerland, 2004.

20 Bradsher K. High and Mighty SUVs: The World’s most Dangerous Vehicles and how they Got that Way. New York, NY: Public Affairs; 2002.

21 Frank LD, Andresen MA, Schmid TL. Obesity relationships with community design, physical activity, and time spent in cars. Am J Prev Med. 2004 Aug;27(2):87-96.

22 Alliance of Automobile Manufacturers,. Automakers support President in development of national program for autos. Press Release, May 18, 2009. Available at: http://www.autoalliance.org/index.cfm?objectid=55B4BAFF-1D09-317F-BBB0DA0B7783C956

23 Romm, J. Is Detroit Worth Saving? Salon. November 12, 2008. Available at:http://www.salon.com/env/feature/2008/11/12/barack_obama_detroit/

24 Moore, M. Goodbye GM. June 1, 2009. Available at: http://michaelmoore.com/words/message/index.php

25 Westen D, Lake C. Speaking with Americans about Energy and Climate: From the Think Tank to the Kitchen Table. The Huffington Post, May 20, 2009. Avialable at : http://www.huffingtonpost.com/drew-westen/speaking-with-americans-a_b_205598.html

Photo Credits:
1. trashd
2. thomashawk
3. httpdcmaster

Is the Food Industry Playing with our Brains? New book by former FDA commissioner David Kessler examines neuroscience of overeating

Posted on July 8, 2009 by Corporations and Health Watch

In his new best-selling book titled The End of Overeating: Taking Control of the Insatiable American Appetite, David Kessler, M.D., former U.S. Food and Drug Administration Commissioner, presents research on the newest discoveries of neuroscience related to appetite and eating, as well as the insights he learned from top food industry executives that resulted in his theory on overeating.

It’s no longer news to point out that Americans are gaining weight and most public health folks have heard the alarming projection that if current trends continue, by 2015, 75% of American adults will be overweight and 41% will be obese¹ And it’s also no news that many Americans are trying to lose weight. We spend nearly $60 billion annually on weight loss products and diets ². This year Weight Watchers stands to earn a $1.58 billion in revenue (excluding sales of food products), and Jenny Craig will earn nearly $610 million ². Unfortunately, most dieters return to their initial weight within three to five years ³, suggesting that more dieting isn’t going to solve America’s obesity problem.

In his new book The End of Overeating: Taking Control of the Insatiable American Appetite David A. Kessler, M.D., a physician and lawyer who served as Commissioner of the U.S. Food and Drug Administration (FDA) from November 1990 until March 1997, brings a fresh perspective to the obesity problem. He argues that it is not faulty metabolism or lack of will power that causes people to eat too much or fail at dieting but rather complex brain functions that lead to “conditioned hypereating.” Acording to Kessler, environmental cues trigger biological drives for foods high in fat, sugar and salt and eventually overwhelm the mechanisms that controlled overeating in earlier eras when unhealthy food was less promoted and less available.

Having spent many years at the FDA synthesizing research on the addictive powers of tobacco, Kessler turned his attention to high fat, salt and sugar foods, which, after tobacco, are the second leading killer of Americans. His new book is the result of seven years of research, and last month it emerged on the top-ten bestsellers list for non-fiction in the New York Times Book Review. In his book, Dr. Kessler presents research on the newest discoveries of neuroscience related to appetite and eating, as well as the insights he learned from his interviews with food industry executives.

Hyperpalatable foods engineered by industrial chefs and conditioned overeating

In essence, Dr. Kessler maintains that foods high in fat, salt and sugar alter brain chemistry in a way that compels people to overeat. While these foods have always been “salient” to humans, the modern food industry has taken advantage of this phenomenon. Kessler describes how industrial chefs have engineered “hyperpalatable” foods that are layered in fat, sugar and salt to trigger a release of the neurotransmitter dopamine, resulting in “conditioned hypereating.” He profiles engineered foods from some of the most popular brand manufacturers, chain restaurants, and fast food restaurants, including the Cinnamon Crunch Bagel at Panera (430 calories, 8g fat, 430mg sodium), and the Sowthwestern Eggrolls (910 calories, 57g fat, 1960mg sodium) and Boneless Shanghai Wings (1260 calories, 71g fat, 3030mg sodium) from the nation’s second-largest restaurant chain Chili’s Grill and Bar. Dr. Kessler said he estimates that approximately 70 million Americans are affected by hypereating⁴, and he maintains that what “the food the industry is selling is much more powerful than we realized.” ⁵

Advertising: “The emotional gloss”

When hyperpalatable foods are combined with modern-day marketing and advertising (“the emotional gloss,” as Dr. Kessler puts it), the result is changed social norms that make it acceptable for Americans to eat foods daily that used to be considered occasional treats. According to Dr. Kessler, “We took down all these barriers; now you can eat anytime, anywhere. It’s socially acceptable. We have this constant stimulation, and we’re no longer eating for nutrition. We took fat, sugar, and salt, made it very appealing, put it on every corner, and made it socially acceptable.” ⁶ While some have argued that advertising serves an important function in informing consumers about products, Dr. Kessler’s research reveals that food advertisements in fact serve as cues to induce people to eat these engineered, unhealthy foods⁴. Constant bombarding by advertisements that link these foods to fun and good times makes it more difficult for people to address their overeating.⁵

Dr. Kessler’s inspiration for the book

In interviews, Dr. Kessler describes his inspiration for the book as well as his own struggles with overeating. Before he wrote the book, he said that he didn’t know the causes of overeating, but that he knew it “wasn’t just a matter of diet and exercise.” ⁶ Kessler says his inspiration came seven years ago when he was watching a woman on The Oprah Winfrey Show ^{5, 6} who in tears, described how she could not control her eating. He said, “I was sitting there trying to listen as a doctor, but I could also relate to what she was talking about from my own experience. I needed to understand what was driving her behavior.⁶

Solutions to the overeating epidemic

This book promises to be highly influential in changing the way that Americans view the practices of the food industry as well as the epidemic of overeating. In an interview with a Huffington Post reporter, Kessler summarized the basic premise of his theory, “Now, we know that highly palatable foods – sugar, fat, salt – are highly reinforcing and can activate the reward center of the brain. For many people that activation is sustained when they’re cued. They have such a hard time controlling their eating because they’re constantly being bombarded …For decades the food industry was able to argue, ‘We’re just giving consumers what they want.’ Now we know that giving them highly salient stimuli is activating their brains.” ⁴

Dr. Kessler says that his book is not meant to be a policy prescription. Instead, he wants to explain why people have such a difficult time with overeating. ⁶ Based on his tobacco experience at the FDA, Dr. Kessler has noted that there are many parallels between problems associated with food and tobacco industry practices. Both industries manipulate consumer behavior to sell products that are harmful to health.⁵ He maintains that while government has a role to play, many of the great public health successes have come from changes in the way people perceive the product.⁴ He states, “We did this with cigarettes. It used to be sexy and glamorous but now people look at it and say, ‘That’s not my friend, that’s not something I want.’ We need to make a cognitive shift as a country and change the way we look at food.” ⁵

References

1 Wang Y, Beydoun MA. The obesity epidemic in the United States – gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiologic Reviews. 2007;29:6-28. Available at: http://epirev.oxfordjournals.org/cgi/content/abstract/29/1/6

2 Miley M. New Year, new round of diet programs. Advertising Age. January 12, 2009.

3 Wadden TA, Phelan S. Behavioral assessment of the obese patient. In: Wadden Ta, Stunkard AJ, eds. Handbook of Obesity Treatment. New York: Guilford Press, 2002:186-226.

4 McCready L. Interview with Dr. David Kessler, author of The End of Overeating, on why we can’t stop eating. The Huffington Post. May 6, 2009. Available at: http://www.huffingtonpost.com/louise-mccready/d-kessler-author-of-emthe_b_195676.html.

5 Layton L. Crave man: David Kessler know that some foods are hard to resist; now he knows why. The Washington Post. April 27, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2009/04/26/AR2009042602711.html.

6 Hobson K. David Kessler on why we’re prone to eating too much. U.S. News & World Report. May 4, 2009. http://health.usnews.com/blogs/on-fitness/2009/05/04/david-kessler-on-why-were-prone-to-eating-too-much.html.

Photo Credits:
1. publiccitizen

Researching for Advocacy: The Industry Trade Press as a Resource for Activists

Posted on July 8, 2009 by Corporations and Health Watch

A recent report put out by the Berkeley Media Group, entitled, Navigating the Trade Press: What are the food and beverage industries discussing?, recommends public health advocates concerned with obesity regularly monitor various publications, including trade journals and magazines, to stay on top of the latest developments in the food and beverage industries. This review of the report features links to the report and key trade publications recommended for tracking.

To plan effective advocacy campaigns to change health-damaging corporate practices, activists need to understand what company managers are thinking and what business and political strategies they are planning. Unlike big corporations and trade associations, few advocacy groups or independent researchers have the resources to hire investigators to gather this intelligence. One practical and inexpensive alternative is to monitor business and trade press coverage of the industry in question.

A few years ago, the Berkely Media Stduies Group released a useful guide called Navigating the Trade Press: What are the food and beverage industries discussing? [pdf] It provides a starting point not only for activists seeking to change the food industry but also for other corporate campaigners who need an overview of the world of trade presses, business publications geared towards industry insiders. In the report, author Lori Dorfman and Elena Lingas argue that “reading these sources makes it easier to articulate the divergent goals of public health and the food, beverage, and advertising industries,” enabling advocates, who often go up against companies with many times more resources, to more effectively and efficiently contest the practices of these industries that harm heath.

A web link to a 200-item annotated bibliography of key sources for tracking activities of these industries is a main highlight of Navigating the Trade Press. Separating the sources into business and science- focused categories, and then into tiers according to their direct proximity to issues of interest to most obesity prevention advocates, the report highlights the most relevant sources (including websites) for all public health advocates whose work is affected by these industries. In addition to these sources, the report recommends that advocates choose specialty journals from the bibliography, in addition to the more general sources listed below, in order to stay on top of industry practices that affect the issues they work on. Dorfman and Lingas note that most sources offer an opportunity to sign up for periodic newsletters and news alerts via email, making it easy to monitor issues of interest.

Key sources for tracking food and beverage industry activities:

New York Times Business section (see especially the Advertising column)
Wall Street Journal Marketplace section
LA Times
Washington Post
Ad Age
Ad Week
Grocery Manufacturers of America
Food Institute
Food Chemical News
Obesity Policy Report

Some of these publications may require a subscription for viewing full contents on line. Most large public or university libraries have such electronic subscriptions, making these institutions a useful resource for activist researchers.

Future Corporations and Health Watch postings will examine how policy advocates can use the trade press of other industries (e.g., pharmaceutical, firearms, alcohol, tobacco, etc.) in their work. We invite readers to send suggestions to responses@corporationsandhealth.org

To read the full Navigating the Trade Press report and download the excel spreadsheet of food industry sources, please visit:

Mapping the Debate on Food

Marin Institute Releases New Alcohol Tax Calculator Tool

Posted on July 8, 2009 by Corporations and Health Watch

Read about and link to the new tool developed by the Marin Institute designed to assist states in raising revenue through alcohol taxation.

Online Feature Helps States Charge for Harm to Raise Revenue

Marin Institute has released the country’s first online alcohol tax and fee calculator to assist lawmakers looking for new revenue. The user-friendly tool is available at www.MarinInstitute.org.

The powerful program works for every state, as well as nationally and the District of Columbia. You just enter the amount of new tax (nickel or dime a drink, for example) for beer, wine or spirits (or any combination). Then the program instantly estimates additional annual revenues, based on a variety of factors specific to that particular jurisdiction.

Marin Institute developed the tool in response to inquiries from states looking for new revenues sources while holding Big Alcohol accountable for the enormous harm its products cause. Many states have not raised alcohol taxes or fees in decades. States with pending legislation to raise alcohol taxes or fees include: California, Illinois, Massachusetts, Minnesota, New York, Oregon, South Carolina, Tennessee, Wisconsin, Arizona, and Hawaii.

Visit the Tax / Fee Revenue Calculator on Marin Institute’s website to quickly estimate how much your state can raise in new alcohol taxes and fees.

The Impact of Corporate Practices on Health Inequities in the United States

Posted on May 1, 2009 by Corporations and Health Watch

This month, Corporations and Health Watch focuses on the role of corporate practices in producing or maintaining socioeconomic, racial/ethnic or other inequities in health. In our interview, Stephen Thomas [pdf], the director of the Center for Minority Health at the University of Pittsburgh Graduate School of Public Health and founding co-chair of the new Academy for Health Equity, describes the ways corporate decisions contribute to health disparities and assesses various strategies for putting this issue on the agenda in Black, Latino and other low income communities. In the second feature,Martha Lincoln, a PhD student in anthropology at the CUNY Graduate Center, tells the story of Bidil, a prescription drug approved by the US Food and Drug Agency in 2005 for treatment of congestive heart failure. Bidil is the first “race-specific” pharmaceutical to be awarded federal approval. Lincoln describes the ethical, health and financial issues raised by “racial targeting” of a specific population with a specific drug. The third contribution is a selected bibliography and abstracts of recent scientific publications on the role of corporate practices on health disparities. Finally, Alexandra Lewin examines the impact of rising food prices on the school lunch program, suggesting that these price hikes may further reduce access to healthy food for vulnerable populations.

In this commentary, I review some of the pathways by which corporate practices may contribute to health inequities, describe some of the strategies advocates have used to reduce harmful corporate practices or policies and suggest some directions for research and advocacy.

Pathways: How corporate practices contribute to health inequities

How do corporate practices influence the differential burden of disease on different population groups? In previous work, my colleagues and I have identified four business practices that influence health: product design, marketing, retail distribution and pricing. ^{1, 2} Let’s examine how each contributes to disparities in health.

Product design

By designing products to appeal to specific groups, producers hope to increase sales to these markets. When the product harms health or the targeted population has other vulnerabilities that can magnify its adverse impact, this practice can lead to differential disease profiles. For example, the tobacco industry added menthol to tobacco products in the belief that African-Americans preferred mentholated cigarettes.³ Some research suggests that menthol cigarettes increase the risk of dependence and tobacco-related illnesses.^{4, 5, 6} As a result, concludes one researcher, menthol “may be partly responsible for the disproportionately high tobacco-related disease and mortality among African Americans generally and African American males particularly.”³ Similarly, the production of malt liquor, characterized by high alcohol content, a sweet taste and often sold in 40 ounce containers, is designed to appeal to male African-Americans, where it has been associated with higher rates of binge drinking and alcohol-related health and safety problems.⁷ In both the case of menthol cigarettes and malt liquor the problems associated with a product designed to appeal to a specific population were aggravated by heavy marketing to that group.

Targeted marketing

Tobacco, alcohol, and food companies target advertising at Blacks, Hispanics and low-income communities, leading to greater exposure to health-damaging messages.^{8, 9, 10} In some cases, differential media exposure further exacerbates the adverse impact. Since African-Americans watch more television than whites, they are more exposed to unhealthy food or alcohol advertisements. One study found that 52% of food and beverage advertisements in magazines for Hispanic women were for unhealthy foods and drinks compared to only 29% in this category in mainstream women’s magazines aimed mostly at white women.¹¹ Other forms of marketing such as product promotions and corporate sponsorships also often target vulnerable groups,^{12, 13} contributing to the health burden these groups experience.

Retail distribution

Corporations play a role in deciding where to locate retail outlets for their products. The density of such outlets results in differential access by socioeconomic status and race/ethnicity to unhealthy products such as tobacco, alcohol, and high fat foods and less access to healthy products such as fresh fruits and vegetables.^{14, 15} For example, a study in Detroit found that the nearest supermarket was, on average, 1.1 miles further away from neighborhoods in which African Americans resided than from White neighborhoods.¹⁶ Decisions to preferentially locate retail outlets selling unhealthy products in Black, Latino or low income communities and those selling healthy products in better off areas may result solely from an assessment of where opportunities for profit are highest or also from implicit or explicit racial prejudice. The motivation, however, does not change the impact of these decisions on health.

Corporate decisions on retail distribution are also a consequence of patterns of racial segregation. Kwate argues that housing segregation drives out supermarkets, which often sell healthier foods, and attracts fast food outlets, which sell calorie dense but nutrient low foods at an affordable price.¹⁷ In this case, housing and real estate policies and corporate decisions intersect to create food environments that contribute to obesity, now increasingly concentrated in low income and Black and Latino neighborhoods.

Pricing

By developing pricing policies that make unhealthy products more accessible or healthy products less available to low income, Black, Latino or other ethnic populations, corporations contribute to health disparities. In some cases, this differential pricing is the result of impersonal market forces, e.g., super markets cannot offer volume discounts on products for which a strong demand already exists, making some healthy foods more expensive in poor neighborhood than better off ones. In other cases, big companies choose not to confront pricing practices in the informal or black market economy because they are ultimately profitable. The easy availability of unregulated inexpensive handguns (“Saturday night specials”) in poor communities served as a profit center for many gun manufacturers, even though it also contributed to higher rates of homicides and gun injuries.^{18, 19} Similarly, the ubiquity of “loosies”, single cigarettes, and untaxed black market cigarettes, helps the tobacco industry to attract and keep young and poor customers and also serves to concentrate tobacco-related diseases on the lower end of the socioeconomic spectrum.²⁰

Corporations make decisions that can contribute to maintaining or increasing disparities through these four business practices, but also through their opposition to stronger government regulation. Weak public health regulation adversely effects all populations but especially those with fewer resources to escape or protect themselves from harm. For example, the automobile industry’s success in avoiding more stringent air pollution standards may have a more detrimental effect on low income and Black and Latino populations since these communities are less able to block or move away from highways or other high traffic areas.²¹ The tobacco industry’s global success in delaying enforcement of laws against illegal sales of cigarettes contributes to the differential impact of the illicit tobacco market by income and race/ethnicity. For example, one California study found that underage Black and Latino youth were 2.5 times more likely to be sold cigarettes than their white counterparts.²² Finally, vulnerable populations may have less access to public health campaigns that provide the knowledge and skills to reduce the impact of health-damaging industry practices.²³ When corporations and their allies advocate privatization of public health services, oppose increased taxes to improve public services or sponsor media campaigns that emphasize individual responsibility for health, they may further undermine the capacity of poor Black or Latino communities to protect themselves from harmful corporate practices.

In sum, the pathways by which corporate decisions may create, maintain or widen socioeconomic or racial/ethnic inequities in health suggest that these business practices can be viewed as a significant determinant of health disparities. In the next section, I describe some of the advocacy strategies that have been used to reduce these disparities.

Strategies ²⁴

In recent years, many organizations and individuals have mobilized to change the practices of the industries that contribute to ill health.²⁵ In some cases, these campaigns have targeted industry practices that contribute directly to health inequities. For example, in Philadelphia, a coalition of African American, community, church, and health organizations led a campaign to force R.J. Reynolds Tobacco Company to drop plans for test marketing Uptown cigarettes, a brand aimed at African Americans. ²⁶

Similarly, a coalition of Chicago Black and Latino groups and the attorneys general of several states worked together to force R.J. Reynolds to modify its Kool Mixx, a tobacco promotional campaign that used hip hop music to appeal to young Blacks and Latinos.²⁷ A neighborhood coalition and a university in Chicago joined forces to advocate bans on alcohol and tobacco billboards in low-income communities of color.²⁸ Many communities have used land-zoning regulations to reduce the density of alcohol, tobacco, and fast food establishments.²⁹

In other cases, community or health advocacy organizations have launched counter-advertising campaigns using African American or Latino images and themes designed to counteract industry’s use of similar elements. In schools across the country, including many in big cities with high proportions of low-income students, parents and advocacy organizations are working to force food companies to end marketing of high-calorie low-nutrient foods within schools.³⁰

In sum, public health campaigns to modify health damaging industry practices are a promising strategy for the primary prevention of health inequity. Using social justice and health equity as themes for community mobilization and policy change may help to bring new constituencies into the effort to reduce disparities.²⁵

A Research and Policy Agenda

For researchers, considering corporate practices as a social determinant of health inequity raises many challenging questions:

What is the differential impact of business practices such as product design, marketing, retail distribution and pricing on health disparities?
How does the relative impact vary by health condition, industry and population characteristics?
What is the attributable risk for business practices in producing health disparities? How do business practices compare to (and interact with) other determinants such as poverty, social hierarchy, and social stress?
What policy and programmatic interventions are most effective in reducing the harmful impact of business practices?
How do strategies for reducing harmful business practices compare in the preferential benefits they bring to disadvantaged groups?
How do the business practices that contribute to health inequities in the United States and other developed nation compare to those operating in the global south?

By focusing attention on these and related questions, conducting systematic studies of the efficacy of various intervention strategies, and better documenting the many existing efforts to change industry practices, researchers and health professionals can bring evidence-based lessons to policymakers that would assist them in selecting policies to maximize the potential for the reduction of disparities.³¹

For policy makers and policy advocates, framing corporate practices that harm health as a cause of health inequity opens the door for new alliances among those working across industries, e.g., food, tobacco, and guns; across political levels, e.g., local, national and global; and across issues, e.g. corporate reform and responsibility, human rights, and consumer protection. Recent calls for the development of social movements to reduce disparities³² create opportunities for dialogue on these issues. To date, however, more attention ahs focused on public rather than corporate policies that contribute to disparities. By expanding our understanding of the causes and solutions to health inequities, public health advocates can help to move from description of disparities to action to end them.

Nicholas Freudenberg is fonder and Director of Corporations and Health Watch and Distinguished Professor of Public Heath at Hunter College, City University of New York.

References

1. Freudenberg N. Public health advocacy to change corporate practices: implications for health education practice and research. Health Educ Behav. 2005;32(3):298-319.
2. Freudenberg N, Galea S. The impact of corporate practices on health: implications for health policy. J Public Health Policy. 2008;29(1):86-104.
3. Gardiner PS. The African Americanization of menthol cigarette use in the United States. Nicotine Tob Res. 2004; 6 Suppl 1:S55-65.
4. Garten S, Falkner RV. Continual smoking of mentholated cigarettes may mask the early warning symptoms of respiratory disease. Prev Med. 2003;37(4):291-6.
5. Richardson TL. African-American smokers and cancers of the lung and of the upper respiratory and digestive tracts. Is menthol part of the puzzle? West J Med. 1997;166(3):189-94.
6. Wackowski O, Delnevo CD. Menthol cigarettes and indicators of tobacco dependence among adolescents. Addict Behav. 2007;32(9):1964-9.
7. Time to reclassify malt liquor and flavored malt beverages as a distilled spirit? Available athttp://www.corporationsandhealth.org/malt_liquor_product_profile.php
8. Moore DJ, Williams JD, Qualls WJ. Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethn Dis. 1996; 6(1-2):83-98.
9. Alaniz ML. Alcohol availability and targeted advertising in racial/ethnic minority communities. Alcohol Health Res World. 1998;22(4):286-9.
10. Balbach ED, Gasior RJ, Barbeau, EM. R. J. Reynolds’ targeting of African Americans: 1988-2000. Am J Public Health. 2003; 93:822-827.
11. Duerksen SC, Mikail A, Tom L, Patton A, Lopez J, Amador X, Vargas R, Victorio M, Kustin B, Sadler GR. Health disparities and advertising content of women’s magazines: a cross-sectional study. BMC Public Health. 2005;18;5:85.
12. Rosenberg NJ, Siegel M. Use of corporate sponsorship as a tobacco marketing tool: a review of tobacco industry sponsorship in the U.S.A, 1995-99. Tob Control. 2001;10(3):239-46.
13. Kuo M, Wechsler H, Greenberg P, et al. The marketing of alcohol to college students: the role of low prices and special promotions. Am J Prev Med. 2003;25(3):204-11.
14. Schneider JE, Reid RJ, Peterson NA, et al. Tobacco Outlet Density and Demographics at the Tract Level of Analysis in Iowa: Implications for Environmentally Based Prevention Initiatives. Prev Sci. 2005; 15;1-7.
15. Harwood EM, Erickson DJ, Fabian LE, et al. Effects of communities, neighborhoods and stores on retail pricing and promotion of beer. J Stud Alcohol. 2003; 64(5):720-6.
16. Zenk SN, Schulz AJ, Israel BA, et al. Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. Am J Public Health. 2005 Apr;95(4):660-7.
17. Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place. 2008;14:32-44.
18. Wintemute GJ. Ring of Fire: The Handgun Makers of Southern California, 1994. Violence Prevention Research Program. 19. Wintemute GJ. The relationship between firearm design and firearm violence. Handguns in the 1990s. JAMA. 1996 275(22):1749-53.
20. Smith KC, Stillman F, Bone L, Yancey N, Price E, Belin P, Kromm EE. Buying and selling loosies in Baltimore: the informal exchange of cigarettes in the community context. J Urban Health. 2007;84(4):494-507.
21. American Lung Association. Urban air pollution and health inequities: a workshop report. Environ Health Perspect. 2001; 109 Suppl 3:357-74.
22. Landrine H, Klonoff EA, Campbell R, et al. Sociocultural variables in youth access to tobacco: replication 5 years later.Prev Med. 2000 May;30(5):433-7.
23. LaVeist, TA. Disentangling Race and Socioeconomic Status: A Key to Understanding Health Inequalities. Journal of Urban Health. 2005;82:iii26-iii34(1).
24. An earlier version of this section appeared in: Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008;19(1):26-40.
25. Freudenberg N, Bradley SP, Serrano M. Public Health Campaigns to Change Industry Practices That Damage Health: An Analysis of 12 Case Studies. Health Educ Behav. 2007 Dec 12. [Epub ahead of print]
26. Robinson RG, Sutton C. The coalition against uptown cigarettes. In: Jernigan D, Wright PA, eds. Making news, changing policy: case studies of media advocacy on alcohol and tobacco issues Washington, DC: U.S. Department of Health and Human Services, 1994; 89-108.
27. National African American Tobacco Prevention Network (NAATPN). National African American Tobacco Network demands that Kool’s stop targeting the hip-hop generation. Press Release. Summerville, NC: NAATPN, 2004 Apr 8.
28. Hackbarth DP, Schnopp-Wyatt D, Katz D, et al. Collaborative research and action to control the geographic placement of outdoor advertising of alcohol and tobacco products in Chicago. Public Health Rep. 2001;116(6):558-67.
29. Ashe, M., Jernigan, D., Kline, R, et al.. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003; 93: 1404-1408.
30. Peterson KE, Fox MK. Addressing the epidemic of childhood obesity through school-based interventions: what has been done and where do we go from here? J Law Med Ethics. 2007;35:113-30.
31. Gibbs BK, Nsiah-Jefferson L, McHugh MD, Trivedi AN, Prothrow-Stith D. Reducing racial and ethnic health disparities: exploring an outcome-oriented agenda for research and policy. J Health Polit Policy Law. 2006; 31(1):185-218.
32. Prevention Institute. Laying the Groundwork for a Movement to Reduce Health Disparities Report II. Prevention Institute, Oakland, CA, April 2007.

Baby Carrots: Model Product for a New Economy?

Posted on April 1, 2009 by Corporations and Health Watch

Under what circumstances can the interests of companies and consumer health coincide? Can food companies make a profit promoting healthier food? To find answers to these questions, this month CHW examines a single product—baby carrots. An analysis of the industry and consumer practices contributing to the rise in popularity of baby carrots offer an opportunity to examine how healthy food can mean big profits for food companies.

Under what circumstances can the interests of companies and consumer health coincide? Can food companies make a profit promoting healthier food? To find answers to these questions, this month Corporations and Health Watch examines a single product—baby carrots. In his classic The Wealth of Nations, Adam Smith analyzed a pin factory to understand the workings of the newly emerging capitalism. He claimed that by understanding this “trifling manufacture” his readers could appreciate deeper economic dynamics. Here, our more modest goal is to gain insights into the connections between profitability and population health.

Baby carrots are in fact not babies at all. They are specially grown carrot varieties that are cut and peeled into a standard size, so they can be packed and eaten without peeling or any other preparation. Baby carrots were introduced in the late 1980s and a decade later, per capita carrot consumption had more than doubled, with nearly all the growth coming from fresh carrots. According to Ken Hodge, communications director for the International Fresh-Cut Produce Association, the rise in carrot consumption is “one of the biggest success stories in produce.”

Health benefits of carrots

Why is increased carrot consumption important? First, carrots are an important source of Vitamin A and the beta-carotene in carrots is available for synthesis into A with little waste or health risk. According to the U.S Department of Agriculture, Americans get 30% of their Vitamin A from carrots. Second, most nutritionists believe that increasing fruit and vegetable consumption brings a plethora of health benefits: reduced rates of heart disease, cancer, diabetes and other conditions and reductions in obesity, an important contributor to the socioeconomic and racial/ethnic health disparities that characterize the United States. Most Americans fail to eat the suggested 5-10 daily servings of fresh fruits and vegetables so finding products that can lead to increases in consumption is an important priority. Baby carrots are convenient and versatile. They can be part of school lunches, snacks, party food or airline fare; sold in bodegas and grocery stores as well as super markets; or served in day care and after school programs. Carrots can be stored in refrigerators for several days, making them attractive to institutional food programs, small stores and ordinary eaters. Easy to serve and store, baby carrots, sticks, and other types of peeled and cut carrots accounted for 69 percent of U.S. households’ expenditures for fresh carrots in 2003.

Baby carrots: a new profit center?

For producers, baby carrots also have attractions. Baby carrots sell for more than regular carrots and many chains now market their own brands of baby carrots. Baby carrots sell for two or more times the price of their full-sized cousins, making them a profitable value-added product. Overall, according to the United States Department of Agriculture, in 2004, the average wholesale price for fresh carrots (in 2000 dollars) was $18.76 per hundred pounds, down from the 20-year high of $21.28 in 1984. Thus, for consumers prices went down while the shift to baby carrots allowed producers to earn more. Since the late 1990s, however, per capita consumption of carrots began to decline, perhaps revealing the fickle tastes of the American consumer or the very modest investments in carrot advertising. (Have you ever seen a television ad for baby carrots?)

Designer carrots

Like so much of the produce we now eat, baby carrots are designer products, literally shaped by growers to make them more marketable. Not only did growers change the shape and texture of the carrot varieties used for baby carrots—they are longer and narrower so they can be cut into four rather than three segments and peeled more easily, resulting in less waste. Growers also selected for taste and texture. Baby carrots are sweeter than other varieties, part of their appeal for children. Some food activists prefer the taste of other carrot varieties such as the purple carrot or less sweet varieties.

Big Carrot Industry dominates baby carrot market

Baby carrots are not a Mom-and-Pop product from the local family farm. According to the USDA, carrot production is highly mechanized and highly concentrated. Carrots used for processing and fresh carrots use mechanical harvesting techniques and two major California firms account for the majority of all carrot products sold. Grimmway, the largest company, planted about 35,000 acres of carrots a few years ago and grows carrots around the year in Southern California. Grimmway markets more than 40 brands of carrots, segmenting its market into multiple slices. Bolthouse Farms, the other big carrot producer, also sells health drinks. Together these two companies produce 90% of the carrots sold in California.

Lessons for health

So what can we learn from the story of baby carrots? First, baby carrots suggest that there are products than can improve health and make money for the food industry. Selling more baby carrots is good for public health and for the bottom line of some companies. Identifying other similar products and developing strategies to promote their use is an important priority for the nutrition and public health communities. Baby carrots also show that consumers will choose healthy, convenient products when they are readily available and that consumption of healthy products can increase rapidly in certain circumstances.

However, baby carrots also illustrate the some of the dilemmas our current food system faces. Promoting baby carrots, arguably good for health, now supports big growers, encourages energy-consuming food transportation patterns, and discourages locally grown produce. Several characteristics of baby carrots make them an ideal mass market product—dependent on mechanized agriculture, convenient packaging, efficiencies of scale for processing, and highly concentrated production that allows a few growers to make money promoting and expanding baby carrot production. These characteristics give baby carrots the potential to get into enough stores, kitchens and mouths to actually change national patterns of vegetable consumption—an important health priority. Yet these same characteristics may undermine other important goals such as sustainability, wider taste variability, a less concentrated food system and more locally grown food.

In addition, although baby carrots are more profitable than uncut carrots, they still constitute a tiny portion of the food market. No one advertises baby carrots, no websites or Internet games encourage children to use them (please contradict me, readers, if you can), and the profit margins on baby carrots or similar products are unlikely to change the dynamics of California agribusiness. Only a publicly subsidized promotion campaign could change this. The experience of the federal Five a Day Fruit and Vegetable Campaign provides a sobering example of the challenges. Its total budget was one third what Lays and Doritos alone spent marketing their chips.

Finally, baby carrots present both a risk and an opportunity for reducing disparities in access to healthy food and improved health for the socioeconomic and racial/ethnic groups disproportionately burdened by our current food system and economy. On the one hand, like so many other upscale products that promote health, baby carrots could become yet another yuppie food—more available to better off communities and more educated individuals and thus exacerbating the already large differences in fruit and vegetable consumption among the poor and the better off. On the other hand, baby carrots are a product that could be part of every school lunch program, served in child care programs, senior citizens centers, jails and homeless shelters, providing healthier, fresher and tastier options to disadvantaged populations. Already many food programs have introduced baby carrots.

For such an approach to yield public health benefits, however, might require subsidies to keep the market growing and prices affordable. Activists working on the Farm Bill have proposed decreasing public subsidies for unhealthy crops like corn, soy and tobacco and increasing them for healthier foods. Baby carrots might make a good test case for the potential of this strategy to yield sustainable changes in the American diet.

In sum, baby carrots help us to understand the potential and limits of the market forces that currently shape our food system. As food and nutrition advocates chart a healthier future food system, it will help to analyze other products and to consider the micro and macro educational, political and economic strategies that can better align market forces with public health. More broadly, concrete empirical analyses of other products that influence health will help public health professionals and advocates to develop new approaches to health promotion and disease prevention. To advance this consideration,Corporation and Health Watch invites its readers to submit ideas or reports on other products in other sectors.

Nicholas Freudenberg is Distinguished Professor of Public Health at Hunter College and Founder and Director ofCorporations and Health Watch.

Sources

Bonne J. Convenient carrot charms consumers. MSNBC.com July 23,2003. Available at:http://www.msnbc.msn.com/id/3072775/

Brunke H. Commodity Profile: Carrots. Agricultural Marketing Resource Center. Updated and Revised January 2006. Available at: http://aic.ucdavis.edu/profiles/Carrots-2006.pdf

Kuchler F, Stewart H. Price Trends Are Similar for Fruits, Vegetables, and Snack Foods / ERR-55Economic Research Service/USDA, 2008. Available at: http://www.ers.usda.gov/Publications/ERR55/ERR55c.pdf

Nunez J. Off-Colored Vegetables Are Good For You – No Joke. Bakersfield.com, October 10, 2007. Available at:http://people.bakersfield.com/home/ViewPost/33464

Photo Credits:
1. unsureshot
2. amanky

The Depression Epidemic: The “Medication-alization” of Sadness

Posted on April 1, 2009 by Corporations and Health Watch

Is there really an epidemic of depression or is it, as some have suggested, forces of medicalization at work? This article looks at pharma’s direct-to-consumer advertising practices of marketing antidepressants and the health insurance industry’s influence on the perception of depression prevalence.

Surviving America’s Depression Epidemic, “Depression: Epidemic for a Postmodern Age,” “Depression: The Hidden Epidemic.” These kinds of titles lamenting or questioning the popular lay and professional conception of depression as increasingly widespread have become more and more common in recent years. It is true that depression is understood by many as a major public health problem of epidemic proportions. The United States Surgeon General’s 1999 report, “Mental Health: A Report of the Surgeon General,” stresses the widespread nature of mental illness, with one in five Americans affected by mental illness each year. The World Health Organization describes depression as an epidemic that will, within the next 20 years, be second only to cardiovascular disease in terms of disease burden worldwide.¹

But what is an epidemic? And for that matter, what exactly do we mean when we say “depression?” The U.S. Centers for Disease Control defines an epidemic as: “the occurrence of disease within a specific geographical area or population that is in excess of what is normally expected.” The term depression is used regularly in our everyday lexicon to refer to a variety of concepts relating to weather patterns to the state of our economy. We also use the word depression to describe a fleeting mood state—the disappointment after failing a test or a feeling resulting from a particularly sad or “depressing” movie. However, increasingly over the last few decades, the general public uses depression as physicians and mental health researchers do—to refer to a mental illness called “major depressive disorder (MDD),” which, as described above, seems to be affecting more and more of us each year.

If depression is an epidemic then, according to the CDC definition, depression is a disease. It also means that depression is occurring “in excess of what is normally expected.” But what is a “normal” amount of depression? Is the number of people found to be depressed in U.S. higher than what should be expected? Are those diagnosed in epidemiologic studies as depressed experiencing disease or just plain old sadness resulting from the normal ups and downs of life?

There is no doubt that depression is a serious, debilitating condition for sufferers, who can be helped immensely by professional interventions, including medication. But it remains the case that there is no definitive test—no blood test or x-ray—to confirm or deny someone has MDD. This uncertainty about cause and the widespread nature of depression “symptoms” makes depression diagnosis malleable and suggestible—offering opportunity to the pharmaceutical industry to expand sales by expanding what is considered treatable “illness.”

Medications work on our biology and therefore pharmaceutical companies depend on biological definition of depression to sell their products. Because of the difficulty in identifying clear cut biological mechanisms for the diagnosis of various mental disorders, the degree to which the mental is medical remains contested.

Medicationalization—DTCA

The medicalization of “sadness,” as it is called by critics of the depression as epidemic perspective, points to direct to consumer (DTC) advertising of antidepressants by pharmaceutical companies as a major vehicle in the expansion of depression diagnoses.^2,³ “Medication-alization” seems more like it. In 1997, The Food and Drug Administration approved the use of DTC drug advertisements in broadcast media (TV and radio); before that, advertising was relegated to publications targeted at physicians.⁴ By 2000, the pharmaceutical industry was spending more than $2 billion on DTC advertisements.

DTC ads for antidepressants typically feature the DSM defined symptoms of major depressive disorder in conjunction with explicit reference to biological etiology, defining depression as a “chemical imbalance” or lack of normal levels of the neurotransmitter serotonin in the brain. While this was once a promising theory, science has not borne out the truth of the “chemical imbalance” theory.⁵ Today’s science increasingly depicts depression as resulting from a highly complex interaction of human biology, genetics, psychology, and social and physical environments. But even though psychiatry shies away from direct claims about cause, the pharmaceutical industry is sticking with what works—and the result is continued sales. SSRIs have come to be some of the best selling drugs of all time, and the success of these drugs has lead to a proliferation of new antidepressants on the market for depression and a variety of other mental health problems.

Managed care and mental health treatment

Around the time that SSRI antidepressants came on the market in the late 1980’s to early 1990’s, managed care was expanding. Managed care prefers the quickest, least expensive treatment alternatives. In the case of depression treatment that means medication over psychotherapy. The result—patients seeking care for depressive symptoms were more than four times more likely to receive medication for depression in 1997 than in 1987.⁶

What doctors can diagnose and prescribe as treatment is subject to the approval of a patient’s health insurance companies and what it defines as acceptable diagnosis and treatment. To the degree that patients are unable or unwilling to pay for service out of pocket, they must seek the services covered by their health insurance carrier, all of whom employ at least some managed care practices these days. With recent mental health parity legislation, insurance companies being forced to provide increased psychotherapy benefits, but most still have strict limits on coverage, ironically requiring a mental health problem to be deemed “biologically-based” by the provider to get reimbursed for psychotherapy treatment services.

Protecting the healthy

The number of people experiencing the “symptoms” of Major Depressive Disorder may be plenty. No doubt, the symptoms of depression are common and widespread human experiences. We may have a lot of depression going on, but that there’s “disease” in excess of what’s normally expected in this case is less certain.

Contrary to popular sentiment, while lots of people may be experiencing symptoms of depression, it’s not clear that this is occurring at higher rates than in the past, nor is it the case that everybody who goes to their doctor is clamoring for medication. But with Pharma, physicians and health insurance industries telling us that yes, our experience is very common, but no, it is not normal, and that medication is our best option for feeling better, it’s no wonder that we’ve got a society ripe for viewing depression as an epidemic.

No question society needs to make the protection of the rights and interests of persons with mental illness a priority since they have in the past often been ignored and trampled on. But convincing people who are sad or live in difficult circumstances that the only way they can get better is to take a powerful drug carries its own dangers. Only by critically analyzing the social forces that have created the “epidemic” of depression can we chart effective policies to recues its burdens.

References

1 Summerfield D. Depression: epidemic or pseudo-epidemic? Journal of the Royal Society of Medicine. 2005: 99: 161-1.

2 Horwitz A, Wakefield J. The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; 2007.

3 Conrad P. The shifting engines of medicalization. Journal of Health and Social Behavior. 2005: 46(1): 3-14.

4 Conrad P, Leiter V. From Lydia Pinkham to Queen Levitra: DTCA and medicalization. Sociology of Health and Illness. 2008: 30: 825-838.

5 Lacasse JR, Leo J. Serotonin and depression: A disconnect between the advertisements and the scientific literature. PLoS Medicine. 2005: 2(12): 1211-1216.

6 Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA. 2002;287:203-209.

Photo Credits:
1. angelinawb

Sara Kuppin, DrPH, is a postodoctoral fellow in Urban Public Health at Hunter College.