Can we leave industry to lead efforts to improve population health? NoBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2426 (Published 17 April 2013) Cite this as: BMJ 2013;346:f2426
- Klim McPherson, visiting professor of public health epidemiology
We live in a world where consumers are meant to operate free markets according to their own preferences, and that process keeps our world going—and supposedly efficient. It keeps us all happy because customers are always right. But all large public companies have a dominant responsibility to their shareholders. The economist J K Galbraith argued many years ago that commercial investment in product formulation and development must therefore deliver an adequate return and that this can often mean that it becomes essential to manipulate markets, even in the face of informed consumer preferences. Other economists, however, who like to believe that rational and exogenous consumer behaviour dominates markets, largely tended to ignore this argument, which is still regarded as marginal. It is not: the methods that industry uses to manipulate markets have become increasingly refined and development continues apace.
Galbraithian arguments have huge implications now for better health in the longer term.1 Modern industry has become increasingly technical and sophisticated, which vastly increases productive potential. As technology advances, increasingly large amounts of time, money, and specialised staff are required, increasing the complexity of planning. As a consequence, planning must be projected further into the future to protect companies against uncertainty. Manipulating taste, availability, price, packaging, positioning, and so on, are central to optimising purchasing, which is assiduously studied to maximise profit.2
Galbraith rightly pointed out in 1973, “Virtually all of the increase in modern health hazards is the result of increased consumption . . . Cirrhosis and accidents are the result of increased alcohol consumption; lung cancer, heart disease, emphysema and numerous other disabilities are the result of increased tobacco consumption.”3 Our understanding is more sophisticated now; half of premature deaths from coronary heart disease can be attributed to poor diet, for example.4 What is far less sophisticated is our understanding of how markets might work to really benefit people’s health. We are at a turning point where markets, and their exploitation, are the dominant cause of most long term health problems, such as obesity. It is time to develop a better understanding of how markets could benefit health because believing that commercial organisations can somehow naturally respond to the long term health needs of populations on their own is increasingly naive and complacent. Deliberately losing money by selling health products in competitive markets, operating largely for short term gain, is illegal.
The need to protect the investment of capital and time creates a strong incentive to ensure what is produced gets sold, and this is especially true of processed food. If large capital outlays on technology are to be recouped, then consumer response must often be managed, whether healthily or not. For Galbraith this explained the huge growth in advertising and investment in “brand management” by modern companies. Accordingly, consumer demand should not be thought of as exogenous but instead shaped by institutional processes and particular influences such as advertising and product manipulation. It has become increasingly endogenous.
The food industry, for example, spent over €1bn on a successful campaign to dissuade the European parliament from legislating proper labelling of food.5 Clearly, fully informed consumers are not what sections of the food industry needs for them to profit. We know that consumers’ preferences are often ignored when making clinical decisions.6 Why should commercial enterprise pay them any more respect.7
Governments must drive responsibility
Possibly the first part of this process is to recognise explicitly the responsibility for, and the costs of all the “externalities” of this commercial production. Tobacco is obvious; around 90% of lung cancer can be attributed to smoking. Why should manufacturers be allowed to produce and market (at all) a product with such predictable consequences and wash their hands of any responsibility? Similarly for food production and fast food outlets8; obviously the attribution is more complicated, but a tax to represent some component of the unambiguous long term health costs is not beyond the whit of imaginative governments. A tax would attract popular support if properly formulated and intelligently managed. Nowadays many of the causative loops between food and health are well enough understood to the point of being both beyond reasonable doubt and supported on the balance of probability.
We need a proper legislative framework on a level playing field for the sale of products that are potentially unhealthy. This would protect shareholders from losing money in any speculative attempt to maximise health rather than profit. Unless things change we will see rates of coronary heart disease start rising again and type 2 diabetes become more common than not, among some crucial groups of our society.9 At the very least governments have a responsibility to understand more about the causes of ill health and of inequalities in health. It is incumbent on them therefore to show that the food industry plays its proper role in preventing ill health, presumably in a less free market place. That requires governments to fund proper and rigorous research. They cannot rely on the good will of industry, however much is currently believed about that. Industry has to do what it does for its shareholders. My Medical Research Council pension is quite heavily invested in tobacco, precisely because big tobacco continues to do just that. Not a comfortable position, since the Medical Research Council’s primary objective is to understand the causes of ill health—not to subsidise them.
Cite this as: BMJ 2013;346:f2426
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Read Derek Yach’s side of the debate at doi:10.1136/bmj.f2279
Provenance and peer review: Commissioned; not externally peer reviewed.