Making China safe for Coke: how Coca-Cola shaped obesity science and policy in ChinaBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5050 (Published 09 January 2019) Cite this as: BMJ 2019;364:k5050
All rapid responses
On February 11, the industry-funded nonprofit, the International Life Sciences Institute (ILSI), posted on its website a lengthy rebuttal1 of my January 9 feature article, Making China Safe for Coke: How Coca-Cola Shapes Obesity Science and Policy in China,2 and companion piece in the Journal of Public Health Policy.3
ILSI’s rebuttal contained two serious distortions of my arguments, one misleading statement, and two dubious claims. There was also one critically important point of agreement.
On February 15, I asked ILSI to correct the two distortions, and it did so the same day. The other issues remain unaddressed, however. ILSI has declined invitations to submit a rapid response to The BMJ. In the absence of such a statement, I address those problems here, relying primarily on direct quotations to reveal the misrepresentations.
Distortion (Now Corrected): Author Claims That China Focuses Almost Exclusively on Physical Activity
ILSI: “The articles published by the BMJ and the Journal of Public Health Policy state that ‘public health advocates in China have always almost entirely focused on physical activity’ is unequivocally not true.”
SG: That is a blatant misrepresentation of my work. I say repeatedly that in its response to obesity, China has advocated both diet and exercise improvements. Yet between 1999 and 2015 – and this is my main point -- the emphasis on physical activity increased. Here is what I write:
“Before 2004... some prevention activities focused on nutrition, but none centered on physical activity.... In the coming years... ILSI-China’s focus on physical activity began to overshadow nutrition. Between 2004 and 2009, a third of ILSI-China sponsored or co-sponsored obesity activities focused on physical activity. Between 2010 and 2015, the proportion rose to almost two thirds while obesity activities focused on nutrition sank to around one in five.” (BMJ)
China’s chronic disease policies have the same focus. I write: “[China has] a host of national plans and programs stipulating improved diets and exercise, yet these emphasize physical fitness. In health targets and indicators, for example, nutritional targets are generally limited to restricting salt intake. Concrete policies are few and weakly enforced, with emphasis on healthy-lifestyle education rather than industry regulation.” (JPHP)
Distortion (Now Corrected): Author Suggests that ILSI Promotes Soda Consumption
ILSI: “No program has ever been a platform to promote the consumption of soft drinks.”
SG: This implies I say that, but of course I do not. To the contrary, I write that: “Support for limiting sugary-beverage consumption in China’s 2016 dietary guidelines is encouraging.” (JPHP)
My point is that China’s policies fail to tax soda consumption: “Hard hitting dietary policies recommended by the World Health Organisation – taxing sugary drinks and restricting food advertising to children – were missing.” (BMJ)
Misleading Statement: Coke “Dictates” Policy to China
ILSI: “Coke has not dictated ILSI Focal Point in China’s agenda nor the Chinese Health Ministry policies.”
SG: This implies I say that, but I do not. Coke is far more cunning than that. In China, I found: “Through a complex web of institutional, financial, and personal links, Coke has been able to influence China’s health policies. The company has cleverly manoeuvered itself into a position of behind-the-scenes power that ensures that government policy to fight the growing obesity epidemic does not undermine its interests. It has done this by leveraging the Chinese branch of ... ILSI.” (BMJ)
Dubious Claim: All Projects are Funded by at Least Three Companies
ILSI: “ILSI Focal Point in China complies with ILSI’s Mandatory Policies, which require a minimum of three companies to fund all projects, to ensure that no one company dominates the research agenda.”
SG: This may be the policy, but it was not always the practice during 1999-2015. Coke was the sole corporate funder of the ILSI China-Coca-Cola fellowship program in exercise science.4 Coke is the only (known) corporate supporter of the school exercise program Happy 10 Minutes, which was funded through the ILSI Center for Health Promotion led by Alex Malaspina, senior vice president at Coke. Happy 10 received financial support from Coke-China and was proudly featured in Coca-Cola’s corporate responsibility reports.5 Finally, Coke was the founding corporate partner of Exercise in Medicine (EIM), which has become a major enterprise in China.6
Dubious Claim: ILSI Merely Advises the Government on Health Policy
ILSI: “ILSI Focal Point in China and the relevant expert institutions... have worked together, under the leadership and coordination of government related departments, to provide technical support and recommendations for the formulation of ‘Guidelines on the Prevention and Control on Overweight and Obesity for Chinese Adults.’”
SG: In fact, according to Chen Chunming, ILSI-China’s long-time director and senior advisor, ILSI took the initiative in drafting those guidelines and proposing them to the Ministry of Health. Chen was proud of ILSI’s tight connections to the ministry, and used the promise that ILSI translates science into policy to encourage corporations to become supporting companies. In a 2013 interview, she told me: “The Chinese branch emphasizes that we do not just hold scientific meetings. Instead, we focus on major public health issues in China, and we put the scientific evidence into policy.” (JPHP, online appendix 2, Excerpts from Interviews)
In the same interview, Chen described how ILSI-China crafted the guidelines, asked the ministry to request that ILSI draft them, then worked with ministry officials to revise them. “Between 1999 and 2003, ILSI-China... created guidelines for the prevention and management of obesity and overweight in adults. Those guidelines were issued in the name of the Ministry of Health. ILSI-China’s involvement was not mentioned, even though it had prepared the guidelines.” (BMJ)
Point of Agreement: ILSI Plays a Critical Role in Obesity Work in China
ILSI: “ILSI Focal Point in China was the first to organize and lead a series of scientific discussions on the prevention and control of obesity in China... ILSI Focal Point has proactively led the dialogue for obesity prevention in China.”
SG: On this we are in full accord: ILSI-China’s “substantive role in tackling obesity was arguably greater than that of the government.” (BMJ)
And that is why scrutiny of ILSI’s work is so vitally important to the global health community – and to China itself.
My hope is that this conversation about ILSI’s work might prompt China to take a fresh look at its policies on chronic disease prevention and control, and to consider the possibility that a friendly American company that has generously funded health work might be supporting policies that are not in the best interest of the health of China’s people.
4. ILSI FP-China-Coca-Cola Food Safety and Physical Activity Scholarship Winner Meeting. ILSI Focal Point in China Newsletter 2013;38(1): 14-15.
5. “Happy 10" Project Are (sic) Expanding in China. ILSI Focal Point in China Newsletter 2006;24(1): 9-10.
Competing interests: No competing interests
Calling People Out or Deepening our Understanding of How Industry Penetrates Science? Response to Russell S. Greene
I welcome a broadening of the conversation about Chinese obesity science and policymaking. Analysis of Chinese health affairs, however, must be grounded in an understanding of the distinctive bureaucratic, legal, political, and cultural context of contemporary China. Assumptions of equivalence between Euro-American institutions and those of China almost always lead us astray.
Mr. Greene makes three claims. None holds up to scrutiny when we take Chinese realities into account.
(1) Bureaucratese matters: China CDC and other public health experts are not civil servants or government officials
Mr. Greene’s first claim is that I miss ILSI-China’s leaders’ affiliations with the China CDC, and so fail to see that “ILSI-China’s leadership simultaneously worked for the Chinese government as public health officials... [T]hey are government officials.”
Misreading my text, Mr. Greene alleges that I say Chen Chunming left the Chinese Academy of Preventive Medicine (and its successor, the China CDC) when she created ILSI-China. What I wrote is that she left her position as the Academy’s president. Though the spare prose could have been read as suggesting that she left the Academy, such a reading would be inconsistent with everything else in the article, which stresses ILSI-China’s close operational ties to the CDC. ILSI-China was physically located in the CDC building, availed itself of CDC staff and experts, and extensively collaborated with the CDC. In China, informal power is often greater than formal, position-based power, and it is Chen’s informal ties to the CDC and her informal power – her genius in parlaying her status as a former high official and her reputation as a scientist into hidden policymaking clout – that I stress in my work.
Mr. Greene makes a different and much blunter claim. Based on the professional location listed on a few publications, he maintains that Chen was a “government official” in the CDC, thus conflicted. The evidence for her holding a formal CDC position is weak, however. The articles give Chen’s professional location as the Chinese Academy of Preventive Medicine (CAPM). Such a listing does not prove Chen was an employee. She had to list some institutional base, and the CAPM made the most sense because her ILSI-China office was located in the CAPM building. I suspect Chen wanted to list as her professional home an academic institution, not ILSI-China, and her status as former Academy president would have allowed her to do that. Greene also assumes that Chen’s title of Senior Advisor on Science to the CDC is a government job, but that too is problematic. Senior Advisor most certainly was a courtesy title, not a formal, paid position. Things are more complex than Mr. Greene thinks.
Mr. Greene also claims that Chen Junshi’s position as chair or vice chair of two governmental advisory committees makes him a “government official.” (Chen Junshi was Chen Chunming’s deputy and close collaborator.) That is not the case, however. In China, as in most countries, scientists serve on such committees in their capacities as expert advisors.
But even if they had been employees of the CDC, the two Chens would not have “government positions” or be “government officials.” China’s administrative system formally distinguishes between government (and party) organizations, known as dangzheng jiguan, in charge of policy, and nongovernmental public or technical units, known as shiye danwei, which provide services to the people and government. The Ministry of Health (MOH, now National Commission on Health) is the jiguan in charge of health; only the ministry can issue policy directives. The CDC is a shiye danwei overseen by the MOH. It cannot issue policy documents and has little formal power. The CDC gets much of its funding and workplan from the MOH. It could be considered quasi-governmental, but its staff are technical employees, not civil servants or public officials. Again, I’m describing the formal setup; actors in any position can accrue informal power. But Mr. Greene is talking about formal governmental position, and on that he is misguided.
(2) What’s our goal? Understanding the world or calling people out?
Mr. Greene considers it “strange” that I discuss only Chen Chunming, neglecting two others who later led ILSI-China. That emphasis was deliberate and in part mandated by the journals’ word limits. More importantly, my account centered on Chen Chunming because she was the central figure in the story of Coke’s success in re-directing China’s approach to obesity. Chen Junshi was in charge of food-safety and Zhao Wenhua joined ILSI-China later, initially serving under the direction of the two Chens.
Mr. Greene and I are pursuing very different goals. His agenda seems to be calling people out – naming everyone with any soda-industry connection or governmental affiliation that he can find on the internet, on the assumption that such ties invariably mean the individual is corrupted. The trouble is one often doesn’t know what information taken from the internet means: local social, cultural, and legal realities remain hidden from sight. That may be especially true for information concerning the global south. This is one of the dangers of today’s internet-based gotcha culture – people may be judged and found guilty before a full understanding of their commitments is achieved.
I seek to understand the complex dynamics of the Chinese case, laying bare how Coke, working through ILSI, gained so much influence without anyone so much as noticing. I aim for a responsible form of scholarship, in which I work to contextualize and understand people’s views and actions in their own terms before drawing conclusions about them.
(3) More, not less attention to local factors
Mr. Greene frequently misreads me and puts words into my mouth. I do not “ascribe ILSI’s role in China to China-specific factors such as the country’s low funding of public health.” Instead, my argument is that such factors shape the reception and impact of ILSI initiatives in China.
Mr. Greene dismisses the importance of country-specific factors, insisting that “ILSI and its ilk” work the same everywhere. “ILSI’s extensive overlap with public health officials... is not unique to China,” he writes. Of course it’s not unique to China; I neither said nor implied that it was. Quite the contrary, I concluded the companion article in the Journal of Public Health Policy by maintaining that similar dynamics are unfolding around the world and urging researchers to study them in other settings.
Greene’s view that local factors are unimportant should be resisted. Of course, Coke and ILSI-Global have game plans that give their operations some congruence wherever they work. But, as I show for China, country-specific factors affect how ILSI operates in different corners of the world. A better understanding of China’s political culture – which sees nothing wrong with industry support of research and lacks a conflict-of-interest concept -- would have helped Mr. Greene grasp why ILSI-China’s leaders declared no conflicts of interest in their publications. As researchers, it is incumbent on us to try to understand other people’s culturally conditioned points of view before judging them as conflicted and unethical.
Greene, R. S. Reply. Re: Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China. BMJ 2019; 364 doi: https://www.bmj.com/content/364/bmj.k5050/rapid-responses. Publ online 16 January 2019.
Greenhalgh, S. Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China.
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5050. Publ online 9 January 2019.
Greenhalgh, S. Soda industry influence on obesity science and policy in China. J Public Health Pol 2019. https://doi.org/10.1057/s41271-018-00158-x. Publ online 9 January 2019.
Competing interests: No competing interests
I'd like to thank Dr. Susan Greenhalgh for her work in exposing the role of Coca-Cola in China's public health efforts. I hope that other researchers will follow suit elsewhere.
Coca-Cola's influence, however, appears to exceed even what Dr. Greenhalgh has demonstrated here. This article claims that Chen Chunming “became the founding president of the Chinese Academy of Preventive Medicine, a division of the Ministry of Health that was the forerunner of the CDC, and in 1993 left to head up ILSI’s new ‘Focal Point in China’ (ILSI-China), which she headed until 2004.” While it is reasonable to expect that a public health official would leave her government position prior to—or at the very least after—founding an ILSI entity, that is not what happened. Rather, Chunming’s research published after 1993 confirms that she retained her position at the Academy of Preventive Medicine. As a sample, please see the following articles:
“Nutrition status of the Chinese people” (https://www.ncbi.nlm.nih.gov/pubmed/8886318)
“Eating Patterns: A Prognosis for China”
“Research Proposal: The Interaction of Health, Education and Employment in Western China” (https://drive.google.com/file/d/0B8wI0BJ2R7tMY1VzQkw0SURRZG5uQ1BNQ1l6QlF...)
“Awareness, treatment and control of hypertension in patients attending hospital clinics in China”
The latter article was published in 2003 and confirms that Chunming continued in her Chinese government position for a full decade after becoming the founding director of ILSI-China. In fact, when she received the Asia Pacific Clinical Nutrition Society Award shortly before her death in 2018, the citation still referred to her as “Senior Advisor on Science for the Chinese Center for Disease Control and Prevention” (http://apjcn.nhri.org.tw/server/APCNS/2018.pdf).
Moreover, Dr. Greenhalgh’s article somewhat misleadingly states, “The staff of the industry funded ILSI-China have unparalleled access to government officials, and the organisation established itself as a premiere scientific body capable of providing access to the best that Western science has to offer.” Yet, in at least two cases other than Chunming’s, ILSI-China's leadership simultaneously worked for the Chinese government as public health officials. ILSI-China's leadership does not require “access to government officials”; they are government officials. In the United States, pundits often complain of the “revolving door” between political and industry posts, and the conflicts of interest and regulatory capture this situation facilitates. Yet, to my knowledge, we do not have a term for the pattern of simultaneous industry and government employment that so often afflicts the field of public health. Perhaps we might refer to it as the double duty problem.
For example, a 2018 ILSI bio of ILSI-China director Junshi Chen states that he is "Chair of the Chinese National Expert Committee for Food Safety Risk Assessment and the Vice-Chair of the National Food Safety Standard Reviewing Committee." According to ILSI, Chen "has engaged in nutrition and food safety research for more than 50 years at" the Chinese CDC and its forerunner. The bio also states, “He has been Senior Research Professor at the China National Center for Food Safety Risk Assessment since 2011" (http://ilsisea-region.org/wp-content/uploads/sites/21/2018/04/Junshi-Che...).
Strangely, Dr. Greenhalgh's BMJ article does not mention Chen. Nor does it mention Wenhua Zhao, the deputy director of ILSI-China and Associate Director of China's National Institute for Nutrition and Health at the Chinese CDC (http://www.exerciseismedicine.org/assets/documents/pdf_files/EIM%20China...).
Zhao served as a vice president of Coca-Cola's now-defunct front group, the Global Energy Balance Network, and appeared, under her ILSI email address, in the Coca-Cola correspondence released by the University of Colorado (https://drive.google.com/file/d/1BNd35gLo8GsByhWxNxFjCc03E5erMbdv/view (p 345)). Both Chen and Zhao serve on the advisory board of Exercise is Medicine in China as well. Dr. Greenhalgh's related Journal of Public Health Policy article similarly omitted both Chen and Zhao, though her supplementary materials indicate that she was at least aware of Chen's dual role (https://www.foodpolitics.com/wp-content/uploads/Online-Supple-Material-C...).
My colleague Derek Fields and I first covered Chen and Zhao's overlapping ILSI-China and CDC roles in our January 2018 article "How America’s Soda Industry Conquered China’s Public Health Agency" (https://keepfitnesslegal.crossfit.com/2018/01/11/how-americas-soda-indus...). There, we observed,
“Despite all this advocacy for industry, Chen’s published papers in the Lancet declare ‘no competing interests ... Zhao’s published work declares ‘no conflicts of interest relevant to this article,’ despite her conflicted positions with EIM and ILSI ... In fact, in several instances Zhao listed her ILSI email as her official email address and still declared no conflicts of interest.”
And note that the articles where Chen and Zhao failed to acknowledge their ILSI conflicts of interest were published in outlets belonging to the United States CDC, as well as in the Lancet and JAMA, some of the most prestigious journals.
ILSI's extensive overlap with public health officials in South Africa, Malaysia, and the U.S. confirms that this phenomenon is not unique to China. Therefore, it is not appropriate to ascribe ILSI's role in China to China-specific factors such as the country's low funding of public health. Countries that generously fund health science and public health policies, such as the U.S., have tolerated similar inappropriate levels of industry capture. It would thus be naive to expect that an increase in the Chinese government’s public health funding alone would sufficiently address the ILSI problem. Instead, government policymakers and academic institutions must recognize the obvious truth about ILSI and its ilk. As we wrote in 2018, “If a corporation presents a conflict of interest, then a nonprofit it founded and/or funds presents a conflict as well." No one would accept a public health official simultaneously heading up a Coca-Cola branch. On what basis, then, is it acceptable for the same official to lead an ILSI outlet?
I salute Dr. Greenhalgh and the BMJ for helping to bring light to this issue and hope that JAMA, the Lancet, the U.S. CDC, and the Chinese CDC adjust their conflict-of-interest policies in accordance with the reality of industry-managed nonprofits.
Competing interests: The author is a full-time employee of the fitness company CrossFit Inc., whose founder and chairman Greg Glassman has made it his company's goal "to drive Big Soda out of fitness and by extension, the health sciences."