Gangster capitalism and our health: In the US and in the World

There has been a lot written about capitalism. Karl Marx, for example, wrote a multi-volume study of it just about 150 years ago, and since then a lot of the writing has been about what he wrote, supportive and critical. There is no question that it has remained the dominant economic system in the world; it is the linchpin not only of Western “democracies” and totalitarian fascist states but also ostensibly Marxist governments like China. While capitalism has both its defenders and detractors, it is interesting to me that the defenders spend little time defending the amazingly deleterious effects that it has on the quality of life (and even existence of life!) of people, the environment, war, and (to the point of this blog) health.

The problem is that, in pursuit of profit, industries will do and have done almost anything, with no moral compass or conscience, and, worse, with no concern for future generations or the planet. Some of the most obvious and egregious examples in the US at this time include their (largely successful) lobbying of the current administration to roll back on rules to ensure clean air and water and the overall environment so that they (in this case, extraction industries like oil and mining) can further increase their unconscionable profits without worrying about the damage it does. So we have mining and extraction in and near our national parks (“near” is important; air and water do not respect boundaries!), scaling back of national monuments so extraction can take place, poisoning of the water through leaks in oil pipelines (such as Keystone), and poisoning of the air we breathe when fossil fuels are burned. Oh yeah, and the increase in global warming which has already permanently altered the climate and will eventually wipe out life on earth (starting with the lowest lying areas) if nuclear war doesn’t first.

Our health and safety is also constantly at risk from aggressive efforts by corporations to increase their profits. This can take the form of producing unsafe products either because it saves money (e.g., dangerous child toys) or costs a lot to not do (e.g., not having lead in our water or asbestos in talcum powder), or by making important and beneficial (and hopefully safe) medications unavailable to many people because of incredible price increases (for the tip of the iceberg, see “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016). We of course know about the ongoing – and largely successful efforts – of the tobacco industry to increase their profits by promoting a product that kills 400,000 people a year in just the US (mainly from cancer and heart disease), including through promoting it to children (e.g., the cartoon character “Joe Camel” – see Fischer et al, “Brand Logo Recognition by Children Aged 3 to 6 Years: Mickey Mouse and Old Joe the Camel”, JAMA 1991;266(22):3145-3148, December 11, 1991).

One of the most vicious and insidious efforts to compromise our health in the interest of profit has been carried on for more than a half-century by the sugar industry. For decades, under the table, sugar producers funded scientific research into the negative effects of a high-fat diet while ignoring the almost-certainly more detrimental effects of a high-carbohydrate, especially simple carbohydrate – sugar – based diet. Soda pop became the national beverage with incredible impact on the rate of obesity, in the US and internationally. A 12-oz can of Coca-Cola® has 140 calories, so what about that 40oz fountain drink at the convenience store? A 2-liter bottle has 812 calories. That’s a lot. So most health professionals, like doctors, tell people to not drink it, or not very much of it. This is, however, competing against the messaging of the industry, which pushes it a lot, and gets the cooperation of many nutritionists through the use of – wait for it – money! I have written about the corruption (or conflict of interest, to put it nicely) of health organizations like the American Academy of Dietetics and Nutrition (AADN) and the American Academy of Family Physicians being funded by Coca-Cola® and other sugar purveyors and having their ads on their websites (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). The ads are no longer there, but you can read about the AADN at the fooducate blog, and if you search sugar on the current AADN website, you will find some pieces on limiting sugar, but as many on the potential risks of artificial sweeteners (which, whatever your beliefs,  the FDA rules as safe) and fats.

Of course, as with the case of tobacco, efforts to limit the sugar market in the US (such as Mayor Michael Bloomberg’s failed attempt to limit the size of sugary sodas in NYC), have led the industry to branch out and increase its efforts to profit in the rest of the world, particularly the developing world. While many countries can be targeted, the biggest markets, China, India, and Mexico, have received special attention. The NY Times has an important exposé  on January 9, 2019, ‘Research details how junk food companies influence China’s nutrition policy”, citing work published in BMJ (“Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China”) and the Journal of Public Health Policy (“Soda industry influence on obesity science and policy in China”) on the role of the International Life Sciences Institute (ILSI):

…a worldwide organization with a Washington headquarters, funded by many of the biggest names in snack foods, including Nestlé, McDonald’s, Pepsi Co. and Yum! Brands as well as Coca-Cola. It has 17 branches, most of them in emerging economies like Mexico, India, South Africa and Brazil, and promotes itself as a bridge between scientists, government officials and multinational food companies.

But in China ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

Thus China’s health policy, which almost entirely focuses on exercise like “Happy 10 minutes” (good for you!) and ignores the dangers of high-calorie sugar-laden foods for obesity (and there is excellent evidence that diet is probably about 80% of the issue, with exercise critical for the other 20%).

There are those who will argue that it is not capitalism itself, but “unfettered capitalism” that is the problem. There is a lot of truth to that. The blind pursuit of maximal profit with no attention at all to the negative impacts on the world around them is not a necessary part of any profit making endeavor. Indeed, the “Wealth of Nations” by Adam Smith cautions strongly against this sort of excess, and “the only responsibility of business is to make profit for its stockholders” guru Milton Friedman sort of assumed that they wouldn’t do it.

But they do, and “unfettered” – or corporate gangster capitalism – is what is running the world. And it is not good for our health.

The AAFP, Coca-Cola, and Ethics: Serving the public interest?

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Last fall, the American Academy of Family Physicians (AAFP) (full disclosure: the organization of family physicians, to which I belong) entered into a partnership agreement with the Coca-Cola Company for support of its patient information website, FamilyDoctor.org. The amount of the funding is uncertain, but it is reputed to be in the “mid-six-figures”. The arrangement came in for a great deal of criticism, both within and outside of the family medicine community, and several members of the organization resigned in protest. I addressed this as a small part of a larger blog, Harvard Medical School limits outside income: a good start, on January 21, 2010.

The debate has not gone away, and has been highlighted by two articles in the recent (July-August 2010) issue of Annals of Family Medicine, the research journal sponsored by all the family medicine organizations in the US and Canada. The first is by Howard Brody, the family physician and medical ethicist from the University of Texas Medical Branch at Galveston, “Professional Medical Organizations and Commercial Conflicts of Interest: Ethical Issues”, and the second is response by Lori Heim, President of the AAFP, “Identifying and Addressing Potential Conflict of Interest: A Professional Medical Organization’s Code of Ethics.” Brody’s essay is a clearly written review of the ethics of conflict of interest, addressing both whether the relationship between AAFP and Coke is a conflict of interest (COI) and whether it is ethically worrisome, and an analysis of the reasons and defenses put up by AAFP and Coke. In the first, he notes that a conflict of interest can, and often does, exist even when no “bad” outcome can be identified; it is simply a conflict between the primary set of responsibilities (in this case, of physicians and their organizations’ social responsibility for looking out for the best interests of their patients’ health; in other settings it might be awarding of government contracts or foundation grants) and a second, usually financially motivated set of interest.

Brody distinguishes between two strategies for addressing COI, a Management Strategy in which COIs are divulged so that others (presumably in this case, patients and the public) can take them into account, and the Divestment Strategy, in which organizations rid themselves of COI relationships. He dispenses with the conflation of COI with intellectual conflicts (that an investigator might want to show that his/her “pet hypothesis” is correct and put it in the best light) because readers will always be aware of the latter, but will not know of commercial relationships unless they are divulged. He notes that the Divestment Strategy is favored in most recent ethical literature (and in increasing numbers of medical schools, as per my January 21 blog), although not by the AAFP.

He then addresses the counterarguments and justifications that the AAFP has put forward in this case. These include:

· “Premature Accusation”, in which the AAFP says “you can’t know that we have a conflict until you see the content. He notes the conflict exists regardless, and offers this “crude” analogy: “imagine that a judge who is sitting on a case involving a contract dispute between two companies is discovered to own $100,000 worth of stock in one of the companies. The judge cannot divert criticism of this conflict of interest by saying, ‘But you haven’t waited until I delivered my verdict—how do you know that I won’t rule against the company in which I own stock?’ In the AAFP case, if the final educational material includes a strong statement against sugary soft drinks, we will never know whether, absent the Coca-Cola funding, the statement would have been even stronger. That such questions will inevitably be raised shows the conflict of interest is both present and serious, quite apart from the eventual contents of the educational materials."

· “Other Party not Evil”, in this case Coca-Cola. The issue, of course, is not whether they are evil, but whether their interests may lie in opposition to the interests of the health of doctors’ patients; “The physician has a duty to prescribe medications or make dietary recommendations based on scientific evidence. The companies have an interest in selling more beverages, or more drugs, regardless of the evidence.”

· “Wrong not to Engage” with organizations such as Coca-Cola. “Schafer[1] noted the propensity for engagement with industry, in such discussions, magically to convert itself into accepting large sums of money from industry.…No one is suggesting that the AAFP not engage Coca-Cola if the engagement avoids conflicts of interest and the result of the engagement would be improved public health.” [my bold]

Brody also addresses the similarities and difference between this and the 1997 relationship in which the American Medical Association (AMA) actually endorsed products made by Sunbeam. He notes that the relationship is called a “Consumer Alliance”, when it is more properly a corporate alliance. (I had missed this Newspeak usage in my January 21 blog, where I mistakenly called it a “corporate partnership”!)

Heim’s response states that Brody misses the point, and goes on to make the same arguments that AAFP has made before, that Brody has addressed and debunked, offering nothing new to the discussion. It refers to the AAFP Code of Ethics, and creates the disturbing sense that “we want the money, we don’t think we are doing anything unethical with the money, and so stop criticizing us.” In other words, it purposely and deliberately misses the point.

Does the AAFP’s relationship with Coke go beyond a conflict of interest (which it clearly is) to actually providing unhealthful material? Some authors believe so; public health attorney Michelle Simon, in her blog Appetite for Profit, addresses the issue on July 22, 2010. She notes that FamilyDoctor.org contains the disclaimer “This content was developed with general underwriting support from The Coca-Cola Company,” and comments “That makes it sound as if the Coca-Cola is just paying someone else to do the writing. But it appears the company is directing the substance of the content as well, since the verbiage is pretty similar to that found on Coca-Cola's own website on these very topics. (See for example, the company's page on sweetener ‘facts and myths’.)”

Simon quotes Dr. Heim’s article, “To gauge an individual or organization’s ethics, one must view its behavior over time, define the goal of that behavior and compare the outcome with the mission and values. Within this context, one can determine whether the assumption or appearance of conflict of interest or ethical lapse was, in fact, correct.” And comments: “What? She lost me somewhere between outcome and values. Taking money from Coca-Cola is not a science experiment that you watch over time, gather data, and then publish the analyzed results. But if one were to approach the issue that way, there's no shortage of evidence of Coca-Cola's 'ethical lapses.' Whether your concern is marketing to children, labor abuses, or contaminating water supplies in developing nations, Coca-Cola would be the one company you'd not choose as a partner. Journalist Michael Blanding has written an entire book called The Coke Machine: The Dirty Truth Behind the World's Favorite Soft Drink, due out in September, which chronicles these misdeeds and more.”

Certainly, the AAFP is not the only organization that has potentially undermined its public trust. For another big one, the American Dietetic Association (ADA) has a partnership (I don’t know if they’ve dared to call it a “consumer alliance”) with – Hershey! (see ADA’s press release at its own website; also see the Fooducate blog).

Maybe the ADA’s partnership is more outrageous, but as a family doctor and educator, I take the AAFP’s relationship with Coke more personally because it undermines me. At the time of this deal, several of the other family medicine organizations, including the Association of Departments of Family Medicine (ADFM, academic department chairs, to which I also belong) expressed serious concerns about this relationship to the AAFP leadership. These concerns related particularly to the fact that, to the public, family medicine is family medicine, and when the largest family medicine organization, AAFP, does something the entire discipline is affected; for example, medical students, or faculty in other departments, who may be distressed by the relationship express that concern to the faculty of family medicine. AAFP, the big dog on the block, listened. It didn’t change its policy, though. Money talks, of course, but if AAFP’s 55,000 active members (not including students, residents, and retirees) each sent in $10, it would be about the same amount as they received from Coke. Are we that cheap? As far as the content on FamilyDoctor.org is concerned, check it out for yourself. You can start by clicking on the benign (but somehow familiar) logo at the top of its web page.

Brody concludes his essay with: “Family physicians are widely trusted by their patients and communities. Merely by having chosen our specialty, family physicians have demonstrated a commendable commitment to putting the health needs of their patients ahead of personal financial gain. They deserve to be represented nationally by an organization that fully reflects those high ethical commitments and standards.” I couldn’t agree more.

[1] Schafer A. Biomedical conflicts of interest: a defence of the sequestration thesis—learning from the cases of Nancy Olivieri and David Healy. J Med Ethics. 2004; 30(1):8–24

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