Susan Greenhal描述了可口可乐公司如何在中国主导肥胖政策: 对科学诚信的威胁, conflict of interest
Mao Zedong famously said that “political power grows out of the barrel of a gun.”1 As he was someone who looked to the Russian Revolution for inspiration while engaged in a war to liberate his country from Japanese occupation, his view was understandable. Yet power can be exerted in different ways and can be most effective when it is hidden, with decisions made behind closed doors, or even invisible, so that the decisions one person makes are influenced by another without them realising it.2
The growing literature on what are termed “the commercial determinants of health” pays particular attention to the hidden and invisible forms of power, whereby large corporations use various methods to shape thinking about what are appropriate responses to the health consequences of their products.3 In the accompanying article, Susan Greenhalgh describes how the Coca-Cola Company came to dominate obesity policy in China even though its influence was obscured behind the public face of intermediaries (doi:10.1136/bmj.k5050).4
In the late 1970s, Coca-Cola took advantage of the opening of Chinese society to the international community, exploiting the then extremely limited opportunities for Chinese researchers to access funds to undertake studies or to develop links with Western counterparts. It was not, however, Coca-Cola that made the approaches to Chinese researchers. Instead it was an organisation called the International Life Sciences Institute—a name that combined ideas of health, academia, and international links while also forming a memorable acronym, ILSI. Yet ILSI was established by a Coca-Cola executive with substantial funding from the company.
As Greenhalgh describes, the ILSI “Focal Point in China” (ILSI-China) has been able to exert remarkable influence on development of obesity policy by promoting a narrative that all foods and drinks, including those produced by Coca-Cola, could be part of a healthy diet. What matters, it claims, is that individuals expend the calories they ingest by taking sufficient exercise. This was also the core message of the Global Energy Balance Network, also set up by Coca-Cola and with members well represented at the Chinese conferences supported by ILSI. Coca-Cola had viewed the network as a “weapon” to “change the conversation” about obesity to one that diverted attention from their products in what it portrayed as a “war between the public health community and private industry.”5
We now know that corporations make extensive use of third parties such as ILSI to create a dominant narrative that frames how issues are viewed and sets the boundaries within which responses are seen as “reasonable,” while excluding the most effective measures—especially those that harm the interests of the corporations—from the agenda. Some have specific goals, such as the Center for Indoor Air Research, which sought to undermine the evidence on the dangers of secondhand smoke.6 Others use a broad based approach that includes promotion of individual choice over collective action, supporting often ineffective educational campaigns rather than the legal or regulatory measures that tackle price, availability, and marketing of their products.7 This is exemplified in the use of the term “nanny state” to attack many of the most effective public health measures.8 Their approach also emphasises the “complexity” of public health problems, implying that little can be done to tackle them, applying the same language to issues as diverse as junk food, gambling, and asbestos.9
This approach also downplays potential conflicts of interest. Industry funded reports contend that everyone is in some way conflicted—for example, in holding certain political views—and that as long as funding is declared any conflicts are easily managed. If everyone is conflicted, there is no cause for concern.10 Yet a wealth of evidence shows that industry funded studies tend to reach conclusions favourable to their sponsors11 and that disclosure of funding alone is inadequate, as researchers may exaggerate their findings and reviewers discount the potential for bias.12
ILSI’s activities in China are similar to those it pursues elsewhere, which have long raised concerns. In 2001 a World Health Organization report condemned its links to the tobacco industry.13 A 2002 paper described ILSI’s involvement in research partnerships as a “threat to scientific integrity.”14 Yet, despite this information being freely available, ILSI’s 18 constituent bodies continue to be influential around the world.
There are, however, signs that attitudes are changing. Recently, the food company Mars pulled out of ILSI, noting concern about its “advocacy led studies” that “mostly for the right reasons, have been criticized.”15 The new Philip Morris funded Foundation for a Smoke Free World has attracted much adverse comment,16 and many universities and public health associations have stated that they will not accept funding from it. The US National Institutes of Health has withdrawn from an alcohol industry funded project on moderate drinking and issued new guidelines for such partnerships.17 The UK Charity Commission is questioning the status of some of the think tanks that have been most active in supporting the narrative of corporations18 but refuse to publish details of their funders.19 Yet, as the recent heavily criticised decision by Public Health England to partner with the alcohol industry funded charity Drinkaware shows, this message has not got through to everyone.20