Nicholas Freudenberg

Every day, owners and managers of hundreds of thousands of retail establishments across the United States make decisions that influence the health of the American people. They decide what to sell, which products to promote, where to display goods and how much to charge for them, and where to locate new outlets.  Their decisions shape the choices consumers face in the market and make it easier or harder for people to buy tobacco, alcohol, food and beverages, medicines, firearms, automobiles or many other products associated with current patterns of health and disease.  In this review, Corporations and Health Watch provides an overview of the impact of retail practices on health and suggests some directions for future research that can guide policies to encourage health-promoting and discourage health-harming retail practices.

Retail practices are the decisions that owners and managers of retail establishments make about how, where and when to sell what to whom.  These practices, listed below, are shaped by corporate policies, the state of the economy, government regulations, customer behavior and many other factors. Other business practices such as product design, pricing and advertising influence and are influenced by decisions about retailing, making it difficult to isolate the unique impact of decisions about retail operations.

While public health officials and advocates have sometimes looked at specific retail practices such as the sales of tobacco products to minors or food safety procedures in restaurants, few public health agencies or researchers have systematically considered retail practices as an important influence on health or considered alternative approaches to encouraging healthier retail business practices.

 

Selected Retail Practices Point of purchase advertising Local advertising  Internet merchandising Location and density of stores Product placement within stores and on shelves Shelf space dedicated to various products Sales and pricing Labeling and warning signs Verification of customer eligibility (e.g. tobacco, alcohol and guns)

 

As we shall see, growing evidence makes a compelling case for studying the health impact of retail practices more carefully and of developing new approaches to preventing their adverse consequences.  First, retail outlets are everywhere, as shown below.  No community and few neighborhoods are without several convenience stores, fast food establishments, tobacco and alcohol outlets and drug stores.  Most Americans can buy a gun or an automobile within a few miles of their home. On any given day, up to 100 million Americans visit a convenience store.¹ Thus retail outlets are a ubiquitous part of our social environment that play a major role in determining  patterns of the sale and consumption of healthy and less healthy products.

 

Prevalence of Selected Retail Outlets in US 19,700 new car and truck dealers 2 30,000 beer, wine and liquor stores 3 35,394  supermarkets with $2 million or more in annual sales4 54,000 federally licensed gun dealers5 56,000 retail pharmacies6 80,000 casual-dining restaurants7 144,875 convenience stores8 195,000 fast-food establishment7

 

Second, data suggest that number of retail outlets or their size is growing, at least in some categories. Between 1970 and 2001, for example, the number of fast food restaurants in the United States increased more than seven-fold, from 30,000 to 222,000.⁹ While the overall number of super markets appears to have declined, the number of very large stores has increased significantly. Wal-Mart, for example, the world’s largest public corporation, operated 125 stores in the United States in 1975 and 3,800 by 2005.¹⁰ The vastly expanded shelf space available in Wal-Mart superstores puts many more products, some healthy and many unhealthy, at the fingertips of consumers across the United States, profoundly influencing the diet of millions of Americans. Similarly, the growth of pharmacy retail chains puts many drug, food and other products within easy reach.

Third, a growing body of research evidence shows that the characteristics of retail establishments influence health and health behavior. For example, local gun retail availability is significantly associated with increased risk of firearm injury and homicide,¹¹ and alcohol outlet density is associated with self-reported driving after drinking and drinking frequency.¹²Patients living in areas with fewer pharmacies are less likely to fill prescriptions for medications.¹³ Exposure to point-of-purchase tobacco advertising is associated with higher tobacco use.¹⁴ These and dozens of other studies show that retail practices influence health, making a summary and synthesis of these diverse studies an important priority. For a selected bibliography on the health impact of retail practices in the alcohol, automobile, firearm, food and beverage, pharmaceutical and tobacco industries, click here.

In addition, differences in retail practices in different types of communities may contribute to socioeconomic and racial disparities in health. For example, the differing retail face of the alcohol, tobacco and food industries in better off and poor neighborhoods and in Black, Latino and white areas may explain some of the differences in cancer prevalence among these communities. ¹⁵ In some studies, differences in the density of supermarkets and fast food outlets in neighborhoods with different socioeconomic and racial/ethnic characteristics have been associated with differences in rates of obesity.^16 17

Convenience stores illustrate well how retail outlets can become amplifiers of ill health. Often sited at gasoline stations, convenience stores sell candy, ice-cream, soft drinks, and processed food as well as other products and perhaps some groceries. They are often located along busy highways, in densely-populated urban neighborhoods, or near transportation hubs. Some are open 24 hours a day. In 1994, there were 98,200 convenience stores in the US, today the count is 144,875, an increase of almost 50%.⁸ In 2008, as shown below, convenience stores sales of cigarettes and other tobacco products accounted for 36.6 % of in-store sales; packaged beverages, mostly sweetened sodas, accounted for 14.1 %; food service, often high fat, sugar and salt cooked products, accounted for 13.9% and beer for 10.2 %.¹⁸ This product mix makes these outlets convenient places to purchase the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.

 

Percentage of Products Sold at Convenience Stores, 2008

Convenience stores sell the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.

 

Changing Retail Practices to Improve Health

Fortunately, there are several domains of experience in modifying the health impact of retail practices that provide evidence that can guide policy and practice. As shown below, local, state and federal governments, consumers, corporations and retail owners themselves can each take action to change harmful practices. To date, most of these approaches have been tried somewhere but few studies provide evidence about which strategies or mix of strategies are most effective in promoting health and under what circumstances.

 

Strategies for Changing Retail Practices to Promote Health and Prevent Disease Changes initiated by government Regulation of products (what is sold, price (via taxes or subsidies), quality; customers (age, sobriety, mental status, criminal record); store environment (safety, hygiene, etc.) Requirements for posting of labels or warning signs Requirements on density of outlets, distance from schools or churches Regulations on hours of operations Changes initiated by consumers Community organizing to encourage police or regulatory action Boycotts of stores or products Changes initiated by corporations Slotting fees to support healthier products Development and promotion to retailers of healthier products Changes initialed by retailers Voluntary posting of health information Strict enforcement of rules on sales to minors Discounts on healthier products

To illustrate with tobacco, perhaps the industry with the best studied retail practices, change can come about through:

• Restrictions on sales to minors
• Requirements for warning labels in stores
• Zoning laws limiting density of tobacco outlets
• Requirements for placement of displays of tobacco products
• Consumer boycotts of merchants who continue to sell to minors
• Ending tobacco industry payments and incentives to merchants who sell their  products
• Voluntary retailer agreement to stop selling or displaying tobacco products

A review of the evidence on retail practices provides some grounds for optimism that changes in these practices can contribute to healthier environments, behaviors and health outcomes. For example, the decision by a single gun store owner in Milwaukee to stop selling cheap Saturday night special hand guns was associated with a 96% decrease in recently sold, small, inexpensive handguns use in crime in Milwaukee, a 73% decrease in crime guns recently sold by this dealer, and a 44% decrease in the flow of all new, trafficked guns to criminals in Milwaukee.¹⁹ In 2007, New York City required restaurant chains to post prominently the caloric content of the food they sold, a policy subsequently adopted by many other municipalities and states. Preliminary evidence suggests that calorie posting may be associated with changes in consumer behavior and in the products that restaurants offer but more research is needed.^{20 21 22 23} Synthesizing findings such as these from policy, programmatic, voluntary and mandatory efforts to change retail practices across industries and jurisdictions may contribute to new approaches to primary prevention.

Research Questions on Retail Practices and Health

Available evidence suggests that retail practices influence health, that intentional changes in these practices can promote health, and that some jurisdictions have successfully implemented such changes. Thus, the development of a systematic body of knowledge to guide elected and public health officials and advocates may help to accelerate these changes, thus reducing the prevalence and inequities in chronic diseases, accidents and injuries and other health problems. What are some research priorities for a better understanding of the impact of retail practices on health?

1. How do retail practices change over time and place?

In the last few decades, the density and size of many retail outlets has increased significantly. Some sectors have become increasingly vertically integrated—think Wal-Mart –giving them far greater influence in the economy and in communities. How do macro-economic forces change retail practices? The current recession seems to be favoring retailers who offer bargains and hurting more high-end outlets. What are the health consequences of these changes? Does the recession present any opportunities for more effective oversight of harmful retail practices? What are the best metrics for studying changes in retail practices? For example, a recent study found that that the cumulative shelf-space allocated to energy-dense snack foods was positively but modestly associated with BMI²⁴, suggesting that the imaginative selection of indicators such as shelf-space may help to assess the impact of changes in retail practices.

1. What’s the role of retailers in the supply chain and what decisions do they make?

From the time a product is manufactured until it reaches the consumer’s hands, it passes through many other hands, including growers, factory workers, packagers, wholesalers, distributors, and truckers. What is the influence of each of these stages on the health impact of retail practices? What are the opportunities for intervention at each stage? In addition, retailers vary in the degree of vertical integration and autonomy granted to local managers.²⁵ How do the health-related retail practices of a vertically integrated company like Wal-Mart,¹⁰ which provides detailed real-time data on purchases to store managers, differ from those of chains that give franchisees more autonomy, such as the Subway fast food chain or independent retailers?

To change retail practices will require identifying who makes what decisions. At McDonald’s, for example, managers have little control over what products to offer, suggesting that campaigns to modify product mix will need to target the national corporate level. Bodegas and grocery stores, on the other hand, could decide to display alcohol and tobacco products less prominently, perhaps in exchange for support from health officials for displaying healthier products. Some chain stores set retail prices nationally, while others give local managers discretion. Mapping decision-making across industries and levels (e.g., global and national corporate, regional and local) might help health officials decide on appropriate levels for intervention to achieve a specified change in practice.

 

1. What’s the impact of retail practices on disparities in health?

As noted previously, differences in retail practices in communities with different socioeconomic and racial/ethnic characteristics appear to contribute to health inequities.¹⁵ What is the fraction of inequities in obesity, diabetes or heart disease that can be attributed to such differences? What are the windows of opportunity for changing disparity-enhancing retail practices such as higher density of alcohol outlets in poor communities or more lax enforcement of tobacco regulations? Does the human rights perspective or civil rights law offer a way of re-framing these issues? For example, some community groups have charged that higher densities of fast food outlets in Black or Latino neighborhoods constitutes a form of racial profiling that widen disparities in health.

On another front, health advocates need to ensure that health-promoting changes in retail practices do not end up exacerbating health inequities. For example, if a supermarket offers healthier food at a higher price, only better off customers may benefit, widening existing socioeconomic disparities in obesity or other food-related health conditions.

1. What incentives can health officials use to encourage health-promoting changes in retail practices?

For retailers to change practices voluntarily, the costs of change and the adverse impact on their bottom lines need to be low and the promise of a better reputation and increased sales volume and profits needs to be high. A pharmacist may be willing to offer discounts on some prescription medicine to attract customers or a fast food outlet may add salads or fruits to their menus to entice health-conscious mothers and their children. When do these changes lead to real improvement in health and when are they merely public relations window dressing? Health officials and advocates with a firm grasp of how retailers make decisions might be better able to negotiate meaningful changes than those who have to rely on retailers’ good will. For example, a study of how fast food owners made decisions about their menus found that obstacles to healthier menus included the belief that the demand for healthier foods is low and that healthier menu items have a short shelf life and take more time and money to prepare.²⁶ Finding ways to help managers overcome these obstacles may lead to change.

1. What advocacy strategies are most effective in changing retail practices?

Only a few studies have compared advocacy strategies across industries^27 28, and none appear to have focused specifically on campaigns to change retail practices. Developing evidence-based guidelines for selecting the most effective activities to change practices such as location of retail outlets, point-of-purchase marketing or store-based labeling can help health officials and advocates to make more informed strategic decisions.

From a community organizing perspective, one asset for mobilizing for changes in retail practices is that retail outlets have a visible presence in most communities, making them an attractive target. On another level, small business owners often identify with their communities, making them perhaps more open to moral appeals for changing harmful practices and also less likely to leave for other jurisdictions in response to demands for change.

For retail outlets that are closely controlled by a single corporation – McDonalds, Wal-Mart, Walgreens or CVS Pharmacies — shareholder actions by national consumer groups or corporate campaigns using internet or other new communications media might be an option. For global companies whose brand names and logos are their most valuable asset, the threat of a campaign that could engage customers in boycotts or brand shifting at local outlets around the country or world remains a powerful fear.²⁹

Aggregating and analyzing advocacy and health department experiences from diverse efforts to change retail practices can help to develop a framework for selecting effective and efficient strategies.

 

1. How can advocates integrate local and global efforts to reduce the harm of retail practices?

Activists seeking to change corporate practices that harm health have learned that successes in one place can lead to defeats in others. In tobacco control, for example, success in changing the practices of the tobacco industry in the United States and other developed nations has led to more aggressive marketing and public relations campaigns in Africa, Asia and Latin America.  Forcing harmful practices to migrate to another region or country can unintentionally maintain or exacerbate developed and developing nation disparities.  How can public health officials and advocates avoid this outcome as they seek to change retail practices?  One strategy that some corporate reform groups have used is to establish global websites and networks, providing a forum for activists working across issues, industries and continents to share information and debate strategy. Some of these focus more on labor and environmental issues than on the retail consumer practices described here.  The box below shows some sources on monitoring retail practices.

 

Selected resources and organizations on monitoring of retail practices Corporate Accountability International Value the Meal Cruz TB. Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations for research and evaluation. Prev Med. 2009;48(1 Suppl):S24-34. McSpotlight Slater S, Giovino G, Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products. Nicotine Tob Res. 2008;10(1):187-93. Sprawl-Busters Wagner MM, Robinson JM, Tsui FC, Espino JU, Hogan WR. Design of a national retail data monitor for public health surveillance. J Am Med Inform Assoc. 2003;10(5):409-18. Wagner MM, Tsui FC, Espino J, et al.  National Retail Data Monitor for public health surveillance. MMWR Morb Mortal Wkly Rep. 2004 Sep 24;53 Suppl:40-2 Wal-Mart Watch

 

Towards a public health agenda on retail practices 
In sum, retail outlets constitute a critical intermediary between the producers and consumers of products that influence health. A better understanding of the forces that shape retail environments and practices may help to inform new approaches to primary prevention of our most serious health problems in these settings. By defining research, advocacy and policy agendas to enhance health- promoting and discourage health-damaging or disparity-widening retail practices, health professionals can contribute to improved population health.

 

By Nicholas Freudenberg, Distinguished Professor of Public Health at Hunter College, City University of New York and the founder and director of Corporations and Health Watch.

 

References

 

Photo Credits:
1. roadsidepictures
2. k-ideas
3. glasgows
4. loneprimate
5. walmartmovie

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What to teach about corporations and health?

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

Box 1 Ten Key Concepts about Corporations and Health 1. Corporations and their practices can be considered as vectors of  disease. (e.g., the tobacco, alcohol, and food industries  distribute and promote pathogenic products) and as  social determinants of health. 2. Decisions made in corporate boardrooms and executive offices  have a profound influence on health. 3. Corporate practices account for a significant proportion of the  attributable risk for many major causes  of mortality and morbidity. 4. Differential exposure to unhealthy corporate practices  contributes to socioeconomic, racial/ethnic  and other health inequities. 5. Corporate marketing is a major determinant of  lifestyle and thus health. 6. In order to increase profits, corporations often promote disease. 7. Public health researchers have a responsibility  to study major determinants of health and to  report findings to public, even if such findings challenge the status  quo. 8. Reducing harmful corporate practices and  encouraging health-promoting ones is an  appropriate task for public health professionals and  has led to prior public health successes. 9. Strategies to reduce harmful corporate practices  must consider local, national and global responses,  otherwise the burden is merely shifted to another population. 10. Changing corporate practices will require changing  the relationship between government and business.

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

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

Box 2 Integrating Concepts on Corporations and Health into the Core Public Health Curriculum
Core Course	Selected Concepts
Biostatistics	Methods to assess roles of industry in causation; history of industry efforts to challenge statistical methods and assumptions
Epidemiology	Attributable risk, corporate practices as social determinants, industry challenges to various epidemiological methods, contested science, multilevel methods to assess impact of corporate practices on behaviors
Health Policy and Management	Roles of insurance and pharmaceutical industries in health and health policy, prevention vs. treatment, roles of special interests in shaping policy, advocacy strategies to change policies
Environmental Health Sciences	Roles of industry in setting standards and regulatory practices, pathways by which products influence health and environment, sustainability, links between occupational and consumer exposures to dangerous products
Health and social behavior	Corporate disease promotion vs health promotion, corporate influences on lifestyle and health behavior, strategies to modify corporate practices, community organizing and coalitions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

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

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

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

Box 3 Getting Started Organize a faculty seminar on corporations and health and invite interested researchers from throughout your university Create a websites or list serve on corporations and health for your school or university Share course syllabi and discuss how to integrate the topic into core and other courses Organize sessions on corporations and health at professional meetings Encourage the Council on Education for Public Health, the American Public Health Association, those planning the public health certifying exam and other organizations to consider this topic Create model academic and research programs where critical mass of faculty and resources exist.

 

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

 

References

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

Photo Credit:

1. Mountainbread