Ilakkuvan V. Examining public health partnership with the private sector through the lens of power and commercial determinants of health. HPHR. 2021;35.
As public health/private sector partnerships have proliferated, discussions around their advantages and disadvantages have suffered from a lack of nuance. Some embrace these partnerships as “win-win” opportunities while others focus exclusively on the perils of such partnerships.
Applying the lens of power and commercial determinants of health, this commentary explores the complexities of public health/private sector partnerships, examining the role of both corporate and community power, as well as the full spectrum of for-profit interests, from small, local businesses to large, multinational corporations and industry associations.
This commentary suggests there may be value in defaulting to arm’s length relationships with large corporations and industry associations and more proactively partnering with locally rooted small and midsize businesses, while still carefully considering the potential perils and benefits of each.
More comprehensive norms and guidelines to assess potential conflicts of interest and govern public health/private sector interactions broadly are necessary, such that the ability of for-profit interests to harm public health – and their ability to manipulate science, policy, and public conversation – is curtailed. These concerns are especially salient with respect to large corporations and industry associations, particularly those whose products, services, treatment of workers, and environmental impact are detrimental to public health.
By shifting the focus of public health/private sector partnerships upstream to address underlying social, commercial, and political determinants of health and partnering more effectively with local businesses, public health professionals can leverage partnerships with the private sector in ways that strengthen community power and benefit the public’s health and well-being.
Public health is chronically underfunded (McKillop & Ilakkuvan, 2019) and much of the reason for this underfunding is due to the very nature of public health – including benefits that lie in the future, benefits that accrue to a broad range of entities, not the single one that would be funding a particular public health initiative (i.e., “the wrong pocket problem”), beneficiaries that are unknown (since the goal is to prevent disease before it occurs), and solutions that are invisible by virtue of their success at preventing bad things from happening (Erickson, Galloway, & Cytron, 2012; Hemenway, 2010).
It is no surprise then, that public health has often turned to those who do have financial resources – the private sector – to fund its efforts. As public health/private sector partnerships have proliferated, discussions around their advantages and perils have suffered from a lack of nuance.
On the one hand, many in the public health field have embraced these partnerships, arguing that such partnerships are “win-win”, that “good health is good business”, that we can “do well by doing good”, and so forth. These arguments rarely include caveats or address the full range of potential perils posed by such partnerships. Even when some caveats and perils are acknowledged, such as in the recent Surgeon General’s report on Community Health and Economic Prosperity, the ultimate framing is one of “demonstrat[ing] to business leaders the opportunity investing in community health can bring to the business bottom line and the health of the economy” (“Surgeon General Releases First Report Focused on Community Health and Economic Prosperity,” 2021).
As Marks notes, “public officials and administrators frequently emphasize a convergence of interests with industry, and downplay or ignore the divergence, in order to foster collaboration and ‘get things done’. This approach comes at a price. Not least, it provides industry actors with additional opportunities to influence public health policy and research in ways that are most consonant with their commercial interests” (Marks, 2019). In addition, the emphasis on “win-win” solutions that bolster the business bottom line can put regulation, taxes, antitrust action, higher wages, union protections, and other key tools that would advance public health off the table. Particularly with respect to large corporations – with their outsize profits (“Fortune Global 500 2020 Rankings,” n.d.), the skyrocketing of the ratio of CEO-to-typical-worker pay (from 21-to-1 in 1965 to 320-to-1 in 2019 at top US companies) (Mishel & Kandra, 2020), tax avoidance (Fair Tax Mark, 2019; Gardner & Wamhoff, 2021), and contribution to climate change (Climate Accountability Institute, 2019; A. Young, 2019)– public health actors must consider whether reducing the bottom line for such companies might in fact be best for public health.
On the other hand, critics of public health/private sector partnerships have focused exclusively on the perils of such partnerships – which, as discussed earlier, are considerable, but often more applicable to large corporations and associated industry associations than to small, local businesses. These critiques also often exclude the possibility that partnerships could be designed to focus on upstream, structural changes, within a company or community.
This commentary aims to take a more nuanced approach to how public health actors might think about public health/private sector partnerships and key considerations that should inform their decisions about who to partner with in what contexts, considering both corporate and community power as well as the full spectrum of for-profit interests.
The public health field has increasingly focused on the social determinants of health, the conditions in the places people live, learn, work, and play. Attention to these determinants, which shape the vast majority of health outcomes and health inequities, is critical. However, discussion in this arena often leaves out vital considerations that lie even further upstream, creating and maintaining the social drivers of health: political determinants of health (i.e., policies and politics) (Dawes, 2020) and commercial determinants of health (CDoH) (Maani et al., 2020).
CDoH have been defined in a multitude of ways – including as “factors that influence health which stem from the profit motive” (West & Marteau, 2013) and “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (Kickbusch, Allen, & Franz, 2016). These determinants include both market and non-market activity (Eastmure, Cummins, & Sparks, 2020), and key pathways by which these determinants influence public health include marketing, lobbying, Corporate Social Responsibility strategies, and supply chains (Paichadze, Werbick, Ndebele, Bari, & Hyder, 2020).
Through pathways such as these, industry interests and large corporations, driven by their profit motives, are a driving force – often unseen – in shaping our policies, systems, environments, norms, and cultural discourse, and thus our health. Indeed, recent perspectives from CDoH researchers have detailed the myriad of ways in which corporations contributed to or exacerbated current crises facing the U.S. (the pandemic, economic downturn, and racial inequity) (Maani, Van Schalkwyk, Petticrew, & Galea, 2021) and how these same corporations seek to capitalize upon pandemic response and recovery, often at the expense of public health (Van Schalkwyk, Maani, Cohen, McKee, & Petticrew, 2021). Corporate forces must be considered and addressed by the public health field, and the CDoH framework can be a useful tool in helping us do so.
However, as Lee and Freudenberg argue, existing definitions of CDoH do not capture the complexities and nuances of these CDoH – in terms of how they vary across time and space, the complex pathways through which they affect health, and the potential for them to have positive and/or negative impact on particular populations (Lee & Freudenberg, 2020). Lacy-Nichols and Marten underscore another key gap in current conceptualizations of CDoH, namely that the issue of power in CDoH has often been overlooked. They make the case that unpacking the various “sources and forms of corporate power” is essential to “bolster the political and strategic savvy of public health advocates and their allies” (Lacy-Nichols & Marten, 2021).
The few examples in the literature where CDoH researchers have unpacked the concept of corporate power offer valuable insights. McKee and Stuckler, focusing on the imbalance of power between global corporations and governments, identify four key manifestations of corporate power that influence health, often in hidden or invisible ways (McKee & Stuckler, 2018):
Lima and Galea apply Steven Lukes’ three-dimensional view of power (power over decision making and control over the political agenda more broadly, power to define what constitutes an issue or potential issue, power to avert observable conflict and keep conflict between the powerful and those over whom power is exerted dormant) to corporate influence on population health (Lukes, 2004; Madureira Lima & Galea, 2018). Through this application, they develop a framework of how corporate power is exerted through five vehicles:
Notably, the limited existing literature on CDoH and power focuses almost exclusively on corporate power. This approach fails to consider how community power can be strengthened to counter commercial interests and reduce corporate power (as well as to push corporations to use their power to advance health and health equity). As Givens and colleagues have noted, power may be “the most fundamental cause of health inequity”, and advancing equity requires attention to power as a determinant and empowerment as a process, particularly as it applies to “strengthening the civic muscle power for marginalized communities” (Givens, Kindig, Inzeo, & Faust, 2018).
This approach also fails to consider how corporate power differs across the full spectrum of for-profit interests (from powerful industry associations and monopolies to multinational and large corporations to midsize companies to small businesses). Current conceptualizations of CDoH largely apply to powerful industry associations, monopolies, and multinational and large corporations, but the extent to which these conceptualizations apply to midsize and small businesses, particularly those that are locally owned, has not been explored in the literature. Terms and classifications related to business size vary across industries and countries, and can be dependent on various factors, including number of employees and average annual receipts. The remainder of this paper refers to large, midsize, and small businesses – these are not intended to be precise classifications but rather provide a general sense of the size and scope of a company.
The subsequent section examines implications of power and CDoH for public health partnerships with the private sector, taking into account these additional considerations of community power and the full spectrum of for-profit interests.
Applying the lens of power and the commercial determinants of health, it is abundantly clear that public health must carefully consider the potential perils of partnering with private sector businesses. As Jonathan Marks describes in compelling detail in his book, The Perils of Partnership: Industry influence, institutional integrity, and public health, these partnerships “create webs of influence that undermine the integrity of public health agencies; distort public health research and policy; and reinforce the framing of public health problems and their solutions in ways that are least threatening to the commercial interests of corporate ‘partners’” (Marks, 2019). As Marks acknowledges, there are considerable economic pressures motivating public health entities to partner with private sector businesses. However, the perils posed by these partnerships can threaten public health’s very purpose and mission; thus, a more careful weighing of costs and benefits of partnership with the private sector is warranted.
This weighing of costs and benefits must take a wide-lens view of the implications of partnering with private sector actors, including influence that is direct and indirect, visible and invisible. For example, Patricia Strach, in her book Hiding Politics in Plain Sight, explores the full range of implications of corporate actions such as sponsored walks and cause marketing (Strach, 2016). She illustrates how mechanisms like these “give industry a key role in selecting and framing issues and activists with ties to business a monopoly over its definition, shifting power in American society in largely uncharted ways”. Strach suggests that industry’s direct effect on policy through lobbying and other activities may in fact pale in comparison to its indirect effect on how problems – and especially solutions – to public problems are framed and defined.
Based on the insights of Marks, Strach, and CDoH and public health researchers whose work was outlined previously, key perils to consider with respect to public health/private sector partnerships – along with examples – are outlined in the table below. This list of perils is not comprehensive or exhaustive, but rather intended to prompt deeper consideration of a variety of potential ethical concerns for public health. Notably, these perils are especially salient with respect to partnership with large corporations and associated industry associations because of the power they possess, financial, political, and otherwise. Many of these perils do not apply – or at least are not as severe – with respect to small businesses.
Table 1. Key Perils of Public Health/Private Sector Partnerships
Cause Marketing: Private sector partners are engaging in “cause marketing” – bolstering their sales and reputations while donating pennies, and shaping public understanding of public health problems and solutions, often in ways that advantage corporate interests and draw attention away from systems and policy level solutions.
Corporate “pinkwashing” of products to show support for breast cancer awareness puts the focus on individual awareness (which is unlikely to have a meaningful impact on breast cancer rates) and routine screening (which research suggests may pose more harm than benefit (Gøtzsche & Jørgensen, 2013)) and “ignores and distracts from the structural health and environmental inequalities behind the illness, like toxic chemicals, a lack of chemical regulation policies, and exposure to carcinogens” (van Hagen, 2020) – things that many of the very corporations that are selling pinkwashed products are contributing to, including via some of the pinkwashed products themselves. In addition, many companies that place pink ribbons on their products have a small, fixed donation amount or a donation cap, meaning the vast majority of products purchased do not result in funds donated. Even with funds that are donated, it is often unclear where the money goes or what it is used for (“4 Questions Before You Buy Pink,” n.d.), and it is rarely (if ever) aimed at primary prevention.
Contributing to the Problem: Private sector partners are actively contributing to the very problems the partnership is trying to address.
Oil and gas companies, the makers of plastic, have spent millions of dollars supporting and promoting recycling over the past several decades because “selling recycling [sells] plastic” (Sullivan, 2020b) – all the while well aware that recycling plastic is not viable (with less than 10% of plastic recycled in the past 40 years (Sullivan, 2020a)).
Lobbying against Solutions: Private sector partners are actively lobbying against – or secretly paying for “grassroots” opposition to – policies that would help solve the problem at hand, even as they publicly claim they are interested in solving the problem.
Top technology companies – including Facebook and Google – fund a range of nonprofit organizations and research to demonstrate their supposed commitment to curtailing online misinformation and improving user privacy (Facebook Research, 2020a, 2020b; Mantzarlis, 2020). These companies have also disingenuously advocated for voluntary regulations and weak federal regulation in an effort to preempt and undercut stronger proposals at the state and national level (Kang, 2018). Notably, these companies spent more than $65 million lobbying the US government in 2020 (Romm, 2021), a substantial portion of which was likely focused on protecting their advertising and other revenue by weakening regulation that would help curtail online misinformation and improve user privacy (though the lobbying register does not require companies to reveal the specifics of their meetings or whether they are for or against a particular bill, making it difficult to determine what exactly these companies are seeking (Swindells & Corbineau, 2021)).
Profiting off Supposed Solutions: Private sector partners stand to make considerable profits from the solutions the partnership is advocating for.
83% of patient advocacy groups, which lobby policymakers to increase support for certain drugs, devices, and diagnostic procedures (including via expanded insurance coverage, more medical research, and streamlined approval), are funded by drug, device, and biotechnology companies (McCoy et al., 2017).
“Reputational Laundering”: Private sector partners are using these partnerships as a form of “reputational laundering” (Giridharadas, 2020)– something positive they have done (or sometimes, just paid lip service to, with no substantive action attached) that they can use to draw attention away from their core business activities that are ultimately harmful to the public’s health.
Dave Zirin offers a compelling critique of “the Super Bowl’s woke capitalism” and the NFL’s focus on showcasing Black talent “in an effort to get us to ignore its treatment of Black people” – which includes assessing Black players differently than white players when it comes to the damage caused by concussions (thus making it harder for black athletes to receive compensation from class action settlements) and limited Black representation in the ranks of leadership (with only three Black coaches, a handful of Black executives, and no Black franchise owners) (Zirin, 2021). This is reflective of the broader phenomenon of corporations stating “Black lives matter” without changing wages, benefits, or discriminatory hiring and marketing practices (Ilakkuvan, 2020).
Framing Conversation in their Favor: Private sector partners are using these partnerships to frame and distort the broader conversation and agenda in ways that favor their own interests, including by manipulating public health research and framing public health problems as individual choices instead of structural issues that require policy and systems level solutions.
Coca-Cola has long funded research and advocacy efforts to frame the obesity epidemic as primarily about exercise instead of the foods or beverages one consumes. In one particularly egregious example, the company provided financial and logistical support to launch a nonprofit called the Global Energy Balance Network, which one public health researcher characterized as “nothing but a front group for Coca-Cola…[to] get these researchers to confuse the science and deflect attention from dietary intake” (O’Connor, 2015a). Pressure from the public health community and others led to the group’s disbanding within months (O’Connor, 2015b), but in subsequent years, the company lobbied the CDC in ways that shifted attention and blame away from sugar-sweetened beverages (Maani Hessari, Ruskin, McKee, & Stuckler, 2019) and still continues to provide active and healthy living grants domestically and globally while spending far more to fight public health bills intended to reduce soda consumption or improve nutrition – including via lobbying and campaign contributions (Aaron & Siegel, 2017; Inside Philanthropy, 2021; S. Young, 2019).
Harming Public Health Broadly: Private sector partners – through their environmental impact, treatment of workers, or other aspects of their business – are harming the public’s health in significant ways, even if not directly related to the partnership at hand.
As Dana Thomas details in the book Fashionopolis: The Prices of Fast Fashion and the Future of Clothes, the clothing industry – which produces 80 billion garments a year and employs one out of six people in the world – has long exploited labor and the environment, abuses which have only grown exponentially in an age of fast fashion and globalization (Thomas, 2019). From sub-poverty wages and deadly labor conditions to rivers polluted by wastewater from clothing factories and microfibers in the water supply and food chain, these companies pose significant harm to public health, all the while partnering with nongovernmental organizations on various initiatives (Liu, Napier, Runfola, & Cavusgil, 2020; Thomas, 2019).
In addition to these specific perils, it is important to consider, as Marks notes, that partnership with the private sector “necessarily puts off the table certain measures that would promote public health”, including those that would undermine a company’s commercial interests.
For example, income inequality has been causally linked to population health and wellbeing (Pickett & Wilkinson, 2015), and efforts to reverse its key drivers – especially the decline in the real value of the minimum wage, deunionization, and economic regulation (Fortin & Lemieux, 1997) – are often seen as antithetical to commercial interests. Working in partnership with – and at times being funded by – the private sector can inhibit the desire and ability of public health entities to exert sufficient pressure on the private sector and generate public and policymaker support for such efforts.
Community power – in terms of their own wealth, health, and well-being, as well as their power to influence policy and counter commercial interests – is vital to advancing public health. It is important to consider if and how community power can be strengthened via public health partnership with the private sector.
This is where consideration of the full spectrum of for-profit interests and distinguishing businesses that are large and politically powerful from those that are midsize or small and rooted locally in communities becomes vital. Many of the aforementioned perils are less salient – and in some cases, do not apply at all – with respect to midsize and especially small businesses. Moreover, small, locally-owned businesses and public health have a shared interest in employing and supporting the health and well-being of community members, including via bolstering the local economy and building community wealth. Locally-owned businesses doing well helps build community wealth and the community doing well is of personal interest to the business owners. A few illustrative examples of locally rooted small and midsize businesses advancing public health are noted in the table below, along with discussion of why and how their size and place in the community contribute to their involvement in and effectiveness of these partnerships.
Notably, small, locally-owned businesses often have strong relationships with community members, and their size can make them more nimble, both of which can make them valuable partners in advancing public health initiatives and education. While small, local businesses can be excellent partners in terms of providing in-kind support and opportunities for social cohesion, their ability to contribute financially to public health initiatives can be limited. Midsize companies with a strong, local presence may be able to provide more substantial financial resources without posing the same degree of peril that large corporations and industry associations do. These midsize companies often have a vested interest in the community, particularly when located in smaller towns, because the members of the community constitute their labor pool and workforce.
Table 2. Examples of Locally Rooted Small and Midsize Businesses Advancing Public Health
Strengths and Motivations
COVID-19 Vaccine Rollout with Small Pharmacies in West Virginia: West Virginia outpaced the rest of the country in delivering vaccines to its long-term care facilities (Stoller, 2021). Whereas all 49 other states participated in a federal program in partnership with CVS and Walgreens to vaccinate long-term care and assisted living facilities, the lack of CVS and Walgreens stores in West Virginia led to the state taking charge of delivering its vaccine supply to 250 pharmacies, mostly small, independent stores (Noguchi, 2021).
These pharmacies already had data on – and relationships with – many patients and long-term care sites, making it easier to schedule appointments, secure consent forms, and match doses. Many of these steps were completed by the time vaccines arrived in West Virginia, enabling a speedy rollout, compared to some other states which struggled with delays in advance paperwork, the logistics of vaccine distribution, and navigating “the bureaucracy of huge national chains” (Noguchi, 2021). Ultimately, with independent pharmacies, “we get the benefits of community leaders owning the infrastructure needed by the community” (Stoller, 2021).
Public Health Partnerships with Local Corner Stores and Barbershops/Hair Salons: There are many examples of public health partnering with small, local corner stores (to improve the availability and marketing of healthy offerings like fruits and vegetables while reducing prominent placement and marketing of unhealthy offerings such as junk food and tobacco) (Public Health Law & Policy, 2009) and with small, local barbershops and hair salons (to deliver health education interventions) (Palmer et al., 2020). These quintessential examples of public health/small business partnership can advance health promotion and sustain health outcomes while also strengthening the community’s economic vitality (Hood, Hall, Dixon, Jolly, & Linnan, 2018).
Explorations of corner store owners’ and barbershop owners’ motivations to enter into such partnerships with public health have found a range of motivating factors, including: shared ethno-cultural identities and residential areas with consumers, trustworthy relationships with consumers, perceived consumer benefits, valuing and prioritizing community health (often over profits), perceptions that the partnership had potential to make a positive impact on their business while also improving population health and reducing health disparities in their community, and commitment to their community broadly (Dombrowski & Kelley, 2019; Hood et al., 2018).
A Midsize Company’s Drug Rehabilitation Program: Belden, a midcap company with a cable manufacturing plant in Richmond, Indiana (a town of 36,000) faced a high pre-employment drug screen failure rate of 10%. Recognizing their ability to hire qualified, substance-free workers was threatened, Belden developed and launched a program that offers an 18-month personalized drug rehabilitation program to those failing the drug screen. Potential employees join the company on a contract basis, are referred to a treatment provider, and enter an individualized and evidence-based treatment program. When the provider determines the participant is safe to return to work, they take a “safety sensitive role” such as cleaning or organization for a period of time before graduating to a machine operating role at the plant (Belden, n.d.).
Belden CEO John Stroup’s explanation of why the company launched this program illustrates the value locally-rooted companies stand to gain from such public health initiatives: “According to the National Safety Council, an employee with a substance abuse problem costs an Indiana employer like Belden $20,000 a year. For some applicants, the rehab program costs less than that – and we likely have cultivated a loyal employee for life. And even for those applicants where rehab costs more than $20,000, we make up the economic costs in their second year working for us while reaping societal and community costs almost immediately” (Belden, n.d.).
Public health entities should consider the strengths and motivations of potential private sector partners in pursuing partnerships (and how these strengths and motivations may differ across large, midsize, and small companies as well as those that are locally rooted versus not), and gauge whether these strengths and motivations are likely to align with avoiding the aforementioned perils of partnership, increasing community power and wealth, and improving population health outcomes.
Maximizing positive impact on public health will require some key shifts in the public health/private sector partnerships paradigm, along with more robust evaluation and research, including:
At a systems level, it becomes inescapably clear that numerous factors, sectors, and health issues intersect with each other and thus, the practice of effective public health requires multisector partnerships. However, within the public health field, there is little practical guidance and research translation informing the selection of partners and the formation of partnerships, particularly with private sector entities.
As a “practitioner doctorate” that prepares individuals for public health leadership and practice, the DrPH degree provided me a practice-oriented lens and associated skills and experiences needed to take academic theories, frameworks, and discussions around power and the commercial determinants of health and apply them to the on-the-ground practice of public health/private sector partnerships. Specifically, I sought to address what, as public health practitioners, we must consider in seeking and forming partnerships with private sector entities, including providing illustrative real-world examples and recommendations around additional guidelines, evaluation, and research that could help inform our decisions moving forward.
Vinu Ilakkuvan, DrPH, MSPH is passionate about supporting and strengthening multi-sector community efforts to address the upstream, root drivers of health – including structural, commercial, social, and political determinants of health. She is Founder and Principal Consultant of PoP Health, providing a range of consulting services (including in the areas of community collaboration, research, and communication) in this space. Her work is informed by over a decade of experience at the intersection of public health policy, communications, and research across academia, nonprofit organizations, and state government. Vinu is also a Professorial Lecturer at the George Washington University Milken Institute School of Public Health, where she teaches Public Health Communication and Marketing, advises thesis students, and collaborates with the Center on Commercial Determinants of Health and the Center for Health and Healthcare in Schools. She holds a DrPH in Health Behavior from George Washington University, a Master’s degree in Health Communications from the Harvard School of Public Health, and Bachelor’s degrees in Biomedical Engineering and Economics from the University of Virginia.