Time to interrogate corporate interests in public health?

A healthy population is a public good, and in most countries, there is a consensus that it is in everybody’s interests that services such as vaccinations, environmental health inspectors, sexual health provision, health promotion, or emergency planning are funded through taxation. There is, broadly, a trust in public bodies to act in ways that protect the health of the public. However, this is potentially undermined by the increasingly ‘mixed economy’ of public health provision (Garnett, Baeza, Trenholm, Gulliford, & Green, 2018). Public health has increasingly become the business of big (and small) business.

Corporate interests in public health are diverse. Some are straightforwardly utilitarian. A healthy workforce is an efficient workforce, and it is no surprise to find growing investments in corporate well-being programmes, or in workplace health insurance linked to healthy lifestyles. Other industries create positive public health effects as a by-product of unrelated profit-maximisation strategies. Car insurers, for instance, increasingly use telematic technologies (‘black boxes’) so they can open up markets for young drivers. These maximise efficient management of insurance risks, and potentially generate data that can be profitably sold on, but also potentially create a public health pay-off, if telematics prove to be a more effective method of reducing road injuries than traditional public health approaches.

Corporations of course also aim to shape public health policy (Williams & Nestle., 2015). In the UK, Public Health England recently came under fire from public health practitioners for planning an alcohol reduction campaign with Drinkaware, a charity whose aim is to ‘make better choices about drinking’. Drinkaware is funded by the alcohol industry. Like other so-called ‘harmful commodity’ industries – tobacco and fast food corporations – the alcohol industry makes profits from goods which damage health. Rising concern about the role of these commodities in causing non-communicable diseases (NCDs) led the Lancet NCD Action Group (Moodie et al., 2013) to state that collaboration with industry was both unethical and ineffective, given there were no incentives to reduce profits through self-regulation. Public Health England’s decision, then, raised both ethical issues and concern about damage to credibility, as well as questions about likely effectiveness. Others, however, have taken a more pragmatic approach to industry collaboration. For instance, recent contributors to debates in the journal Addiction (Hughes et al., 2019) defended the usefulness of working with tobacco companies on less-risky alternatives to smoking, given that harm reduction is in line with public health goals.

As Herrick (2016) has argued, focusing on such ‘ideological schisms’ hampers our ability to develop a detailed, empirical understanding of exactly what effects corporate behaviour does have on health. A focus on ethical debates about funding from specific industries hides a rather larger issue: the rise in corporate funding of public health in general, from sources such as corporate philanthropy. The scope and impact of this have been under-researched to date, at least in countries such as the UK, yet its reach is far greater than industry-funded charities for those harmed by gambling or alcohol. To take one example, The Daily Mile is a popular scheme in the UK to get primary school children running for 15 minutes each day in school time (Fairhurst & Hotham, 2017). It was started by a head teacher in Scotland and supported by a charity which promotes the scheme: a charity now entirely funded by INEOS, a large oil, gas, and petrochemicals company.

Given public funding is under stress, does it matter whose money is spent on schemes to encourage physical activity, reduce alcohol risks, or improve road safety? Non-state funders have some advantages: they have the capacity for rapid response; they often bear the risks of innovation; and market incentives (such as reduced insurance premiums) can be powerful drivers of changing practices.

There are, however, good reasons for disquiet about where the money for public health comes from, and these go well beyond the potential moral taint of colluding with ‘harmful commodity’ industries.

Indeed, squeamishness and distaste about particular products may be altogether inadequate guides to what is ethical. First, most commodities, or industries, are not straightforwardly ‘harmful’. Soft drinks, alcohol, and even tobacco are not simply ‘health risks’ but are also small pleasures, embedded in social practices. Oil, gas, or mining companies undeniably damage public health through environmental degradation and associated climate change, but their products are also essential to a contemporary ‘good’ life. More importantly, the larger issues at stake from corporate interests in public health relate to the potential erosion of an ethos of public health as a public good.

However flawed the decisions of central or local governments, at least they are nominally in the public domain: responsive to public and professional accountability, with decisions scrutinised and (ultimately) democratically accountable at the ballot box. Relying on business, whether corporate philanthropy or small social enterprise, to decide what will be provided and funded, how, and for whom, has no such backstop. Some campaigns and projects will inevitably be more appealing for public relations than others, and some populations (such as workers) inevitably more attractive as subjects of action. In this issue, Grunseit et al. (2019) demonstrate that the Australian public have thoughtful and contingent views on the proper role of the state in leading on public health campaigns, but that, in general, a concern about the ‘nanny state’ is not a major issue. This trust in public bodies to act in ways that protect the health of the public is potentially undermined by collaboration with those whose primary orientation is to profits. It is difficult to see how profit-motivations will not shape the choices made. An oil multinational is more likely to fund behaviour change interventions than (more effective) upstream interventions to reduce car use.

Lack of democratic control also raises pressing questions about data, and who owns, controls and has access to them. In rolling out telematic technologies, insurance companies are gathering large amounts of data on young divers’ driving styles, experiences, and geographies: data that can be exploited for profit, but which are unlikely to be openly accessible for planning, research, or evaluation. Even where philanthropic capital achieves short-term health gains, the risk of reputational damage may be too great to allow any truly neutral evaluation of its broader effects. With the increasing potential for harnessing data analytics for health gain, we need far more scrutiny of who is collating, exploiting, or controlling data generated by the public.

So the urgent questions for public health are not about taking money from ‘harmful commodities’ industries per se, but about the growing, and under-researched, role of the private sector in general. We need to know far more about what is being provided, by whom, and with what effects.

Acknowledgements

An earlier version of this editorial appeared on the Cost of Living blog site, 14 November 2018, as ‘Does it matter who funds public health’ https://www.cost-ofliving.net/does-it-matter-who-funds-public-health/