Public health researchers and practitioners are divided on the ethics of taking money from ‘harmful commodity’ industries. Ethical debates about collusion with specific industries are important, but they risk ignoring the wider consequences of the increasing privatisation of public health.
Public Health England’s recent decision to work with Drinkaware on an alcohol reduction campaign reignited debates about the ethics of public health funding. Drinkaware is a charity funded by the alcohol industry. Critics flagged concerns about the damage to credibility from working with those profiting from alcohol sales, particularly in the context of radical cuts to statutory alcohol services. Sir Duncan Selbie, Chief Executive of Public Health England, defended the decision, pointing to the behaviour change gains that can be made working with industry.
Does it matter who funds public health interventions? The so-called ‘harmful commodity’ industries – tobacco, alcohol, and fast food corporations – make profits from goods which damage health. Public health commentators argue that collaboration with these industries is neither ethical nor effective, as they have no incentives to reduce their profits through self-regulation. Others have taken a more pragmatic approach. For instance, recent contributors to debates in the journal Addiction 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.
Ethical debates about funding from specific industries hide a much larger issue: the rise in corporate funding of public health. The traditional functions of public health – promoting health, preventing disease, protecting populations from risk – have long been seen as legitimate tasks for the state. A healthy population is a public good, and there is a broad 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. But 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 wellbeing programmes or workplace health insurance linked to healthy lifestyles. Other industries create public health effects almost accidentally, from unrelated profitable 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 there is also a potentially important public health payoff: telematics might be a far more effective method of reducing road injuries in high-risk drivers and their passengers than traditional public health approaches.
Another growing source of funding is corporate philanthropy. The scope and impact of this has been under-researched to date, at least in 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 to get primary school children running for 15 minutes each day in school time. It was started by a head teacher in Stirling, Scotland, and supported by a charity which promotes the scheme: a charity now entirely funded by INEOS, a large oil, gas and petrochemicals company.
These for-profit interests in public health are in the context of a wider dissolution of the borders between the state, private and third sectors in the UK’s ‘mixed’ economy of health care. Our recent study of public health provision in south London for instance, documented the growing role of social enterprises (including large and ‘micro’ businesses) that were providing services that ranged from sexual health advice to physical activity promotion.
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; often bear the risks of innovation; 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 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. Private health care providers do not (at least by design) produce ‘harmful‘ commodities, but experience in the US suggests that their corporate behaviour is rarely in the interests of public health. Decisions about whether to accept money cannot easily be made through appeals to the morality, or otherwise, of specific products.
More importantly, the larger issues at stake from corporate interests in public health relate to the potential lack of democratic accountability and the risks of losing 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) democratic accountability at the ballot box. Relying on business (or even social enterprise) to decide what will be funded, how, and for whom, for 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. It is difficult to see how profit-motivations will not shape the choices made. Oil multi-nationals, for instance, are likely to be far more willing to fund behaviour change interventions than (more effective) upstream campaigns to reduce car use.
Lack of democratic control also raises pressing questions about data, and who owns, controls and has access to them. Insurance companies are gathering huge amounts of data on young divers’ driving styles, experiences and geographies: data that can be exploited for profit, but 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 ‘big data’ 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.