In her opening remarks to the 8th Global Conference on Health Promotion, Margaret Chan, Director General of the World Health Organization (WHO) warned:
[e]fforts to prevent non-communicable diseases go against the business interests of powerful economic operators. In my view, this is one of the biggest challenges facing health promotion . . . [i]t is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.
The health impact is clear – worldwide, the greatest risk factors for negative health outcomes are now high blood pressure, smoking, and drinking alcohol. Of particular concern is that the most vulnerable are at the greatest risk. To combat undue influence from the industry, WHO and others stress that public health must be more vigilant, seek greater public regulation, and exclude the industry from meaningful dialogue.
Putting value judgments aside – we may not want to talk to the industry, but we do have a good deal to learn from them. In their unabashed pursuit of a single goal – profit – successful corporations understand how to survive and thrive in a competitive environment. While public health may not be a for-profit enterprise, we are fiercely competitive – we also seek consumers, market share, resources, and political capital in a crowded field, contesting not only with the industry, but more often, with one another.
Public Health v. Big Tobacco
Both a success story and a cautionary tale, the history of public health and Big Tobacco is illustrative. There is no product that embodies a more perfect adversary to public health than tobacco – given that it has no nutritional or medicinal value and is specifically engineered to kill you, eradicating tobacco should have been relatively simple.
When public health mobilized a response to combat tobacco use, they arguably did everything “right” – legislation, litigation, taxation, behavioral/educational campaigns – an entire global treaty is devoted solely to appropriate norms for tobacco regulation. Despite this concerted, multi-sectorial, and often impassioned action, WHO estimates that tobacco still kills nearly 6 million people per year, and Big Tobacco lives on . . . profitably. They just got smarter.
Cutting their losses in increasingly hostile markets in high-income countries, they moved to friendlier ones in lower and middle-income countries, which welcomed increased investment, production, and consumption as harbingers of prosperity.
Their message is continuously refined, adapted, and tailored – men, women, and young people – but the underlying allure of smoking as “cool” endures. The Marlboro Man remains rugged, free – iconic – whereas Michael Bloomberg, mayor of New York City and public health champion, is a nanny – excessively paternalistic. And they are opportunistic – electronic cigarettes, now fashionable, but suspect health-wise, present a significant new market. The major tobacco companies – RJ Reynolds, Altria, and British American Tobacco – are all poised to compete in this space.
Furthermore, when public health should have been studying them, they learned from us, and evolved. Freedom of speech, individual privacy, human rights – the rhetoric of the harmed – is now part of the standard lexicon of the tobacco industry.
‘What Will the Donors Say?’
Before launching a new product and certainly before entering a new market, the industry knows that it needs a comprehensive understanding of the local environment – consumers, government, and competitors, etc. The unfortunate conflation, “glocalization,” explains how companies adapt their products and services to a specific environment. The industry is only able to be effective by being “evidence-based” – to understand the market, they need accurate, real-time, and voluminous data on behavior.
Greater nuance in understanding equals competitive advantage in design, market selection, and messaging. The ability to achieve sophistication in data collection demands innovation, adaptation, and agility – retailers like Wal-Mart pioneered information technology platforms to rapidly read and store information. More importantly, they then used that data to extrapolate and predict consumer-spending habits.
In this regard, public health uses a similar approach – we necessarily begin with evidence. But, we still struggle with what comes next. My colleague, Tanya Baytor, recently wrote, “there have been a number of studies showing that the Latino population in the United States is disproportionately affected by obesity.” This is not a particularly new finding, yet we are only beginning to consider that existing outreach and messaging is insufficient to connect with this audience.
Additionally, while lack of resources is a very real and urgent issue, even when there is funding, public health can be ineffective. A recent campaign in Swaziland to expand voluntary medical male circumcision (VMMC) to prevent HIV faltered. Evidence-based and well funded, it should have been a success, but failed. Why? The program implementers did not understand their market well enough. In fairness, implementers did conduct an initial survey about potential barriers to VMMC – concerns about pain, lack of awareness – but unanticipated was the very real concern about witchcraft. By local accounts:
The circumcision initiative failed because of this arrogance on the part of its promoters. It would have been easy to be honest and explain to the Swazi men that their foreskins would be incinerated like all surgical refuse. But the promoters said, ‘Oh, no, we can’t talk about witchcraft. What will the donors say?’
While we would hope that the Swaziland example is an isolated incident, it tends to be the rule, not the exception in global health. In Rwanda, they refer to “The Battle of the Stickers” or donors’ preoccupation with self-promotion and the desire to take credit for initiation of local health programs. This raises a troubling question about our own motives – the industry is there to make money, what are we there for?
None of the foregoing should be taken to discredit the enormous progress that has been made, and continues to be made, in health. Many working at the front lines of health innovate, adapt, and refine with regularity, or at least are learning. The motto for this year’s American Public Health Association’s annual meeting is “Think Local, Act Global.” Internationally, worn down by decades of failure and the economic downturn, donors now acknowledge for success to be even feasible, countries must be engaged and empowered as partners in the local allocation of development dollars.
Nor is it meant to minimize the very real danger that limited resources, lack of collective will, and industry interference pose to our most challenging health concerns. We should absolutely remain vigilant and continue to seek public regulation of the industry. However, we also have to get smarter.
It should come as no surprise that the story of Big Food, Big Soda, and Big Alcohol parallels that of Big Tobacco. When public health went after the latter, the operative question was when, not if, the former would be next. However, they pose much more formidable foes – greater resources coupled with greater preparation – and unlike tobacco, they make imperfect adversaries and are occasional allies.
Simply, good ideas come from everywhere, even from the people we don’t like – sometimes especially from them.
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.