1. What’s the Big Deal? The Ethics of Public-Private Partnerships related to Food and Health Jonathan H. Marks Director, Bioethics Program, Penn State; Non-Residential Fellow, Edmond J. Safra Center for Ethics, Harvard Ohio State University Lecture October 16, 2013

2. Acknowledgments – Edmond J. Safra Center for Ethics, Harvard – Rock Ethics Institute, Penn State Thanks to: – Don Thompson – Chris Mayes – Susannah Rose

3. The Advocate "[b]y partnering with USDA, corporations win, USDA wins, and the American consumer wins. That's a win-win-win situation!" – US Secretary of Agriculture Tom Vilsack U.S. Department of Agriculture, “National Strategic Partner List,“ (2013) http://www.choosemyplate.gov/partneringprogram/national- partners/partner-list.html http://www.choosemyplate.gov/partneringprogram/national- partners/partner-list.html

4. The Cynic “Next time you hear of a big food or beverage company sponsoring an after-school physical activity program in your community, you can be sure they’ll say it’s to show ‘our company’s concern for our kids’ health.’ But the real intent is to look angelic while making consumers feel good about the brand and drawing attention away from the unhealthful nature of the company’s products. ‘Posing for holy cards,’ as one of my colleagues used to put it.” —Michael Mudd, former Executive Vice President of Global Corporate Affairs for Kraft Foods “How to Force Ethics on the Food Industry,” New York Times, March 16, 2013, http://www.nytimes.com/2013/03/17/opinion/sunday/how-to-force-ethics-on- the-foodindustry.html?pagewanted=all&_r=2& http://www.nytimes.com/2013/03/17/opinion/sunday/how-to-force-ethics-on- the-foodindustry.html?pagewanted=all&_r=2&

5. The Concerned subordination of institutional values, mission reorientation, weakened capacity to promote regulations and monitor compliance, displaced organizational priorities, and self- censorship. Buse & Waxman, WHO Bulletin, (2001)

6. Research-Related Concerns quality of research, research outcomes, dissemination of research; public trust – in science and – in research institutions. Walt, Brugha, and Haines, BMJ (2002)

7. Public Private Partnerships “cover a wide variety of ventures involving a diversity of arrangements, varying with regard to participants, legal status, governance, management, policy-setting prerogatives, contributions and operational roles” World Health Organization, “Public-Private Partnerships for Health,” http://www.who.int/trade/glossary/story077/en http://www.who.int/trade/glossary/story077/en

8. Taxonomies of Partnership (1) direct funding, (2) contributions in kind (goods and/or services), (3) dialogue (including information exchange), (4) joint delivery. United Nations Standing Committee on Nutrition, “SCN Private Sector Engagement Policy, Rule 20” March, 2006, revised June 19, 2006, available at “SCN Interaction with Private Sector,” www.unsystem.org/scn/Publications/html/private_sector.htmwww.unsystem.org/scn/Publications/html/private_sector.htm

9. Taxonomy of Engagement (1) philanthropic—described as ”peripheral” BUT…; (2) transactional—”mutual benefit”; (3) integrative—“mission mesh.” Phases: (1)  (2)  (3) James E. Austin, “Strategic Collaboration Between Nonprofits and Business,” Nonprofit and Voluntary Sector Quarterly 29.suppl.1 (2000): 69-97 Vivica I. Kraak, Paige B. Harrigan, Mark Lawrence, et al., “Balancing the Benefits and Risks of Public-Private Partnerships to Address the Global Double Burden of Malnutrition,” Public Health Nutrition 15.3 (2012): 503-17.

10. Philly / ABA / CHOP http://www.philly.com/philly/blogs/heardinthehall/118077483.html

11. For example…

12. ICS Framework widespread or systemic practices (often legal, and perceived as ethical) that undermine the integrity or trustworthiness of an institution and/or trust and confidence in that institution

13. What kinds of “institution”? (1) academic research institutions (2) professional associations (3) scholarly and professional journals (4) patient advocacy organizations (5) government funding agencies and regulators and…(6) body of research as abstract institution.

14. Institutions: Attributes and Attitudes TrustworthinessIntegrityTrustConfidence Attributes : Attitudes:

15. an important distinction If an institution is not trustworthy and/or lacks integrity, it would be problematic to take steps solely to restore trust and confidence

16. Integrity relationship between (a) the mission or purpose of an institution and (b) its practices an institution might be said to lack integrity if its practices predictably undermine the pursuit of the very goals in terms of which it justifies its existence – c.f. Allen Buchanan and Robert Keohane (2006)

17. Integrity and Public Health Health Halo Hazard (and/or) Logo effects (may lead to) Erosion of mission and integrity of public actor

19. Healthy Fast Food? The Subway “health halo” – Leads to belief that 1000 kcal Subway meal contains 21.3% less calories than same-calorie McDonald’s meal (585 v. 744 kcal) – Calorie underestimates of familiar items such as sandwiches and burgers by as much as 35% – Biasing effects of health claims on calorie estimation are as strong for consumers “highly involved” in nutrition – Health claims lead consumers to choose side dishes containing more calories, enhancing chances of overeating – When main course positioned as “healthy,” customers choose beverages, side dishes and desserts containing upto 131% more calories than when main course is not so positioned Chandon & Wansink, J. Consumer Res., 2007

20. Image: AAMC, The Scientific Basis of Influence and Reciprocity (June 2007); See also: Dana and Loewenstein, JAMA, 2003, esp. on denial of influence

21. Integrity (cont.) Integrity—harder cases: – Institution with inherently conflicting mission(s) – Institution in transition

22. Conflicting Mission of the USDA? Strategic plan includes: “expanding markets for agricultural products” AND “improving nutrition and health by providing … nutrition education and promotion” “Mission Statement,” United States Department of Agriculture, http://www.usda.gov/wps/portal/usda/usdahome?navid=MISSION_STATEMENT http://www.usda.gov/wps/portal/usda/usdahome?navid=MISSION_STATEMENT

23. Trust and Confidence Issues

24. Public Trust

25. Industry & Professional Organizations: Professional Education (ADA-FNCE 2010)

26. ADA FNCE 2010 (cont.)

27. Industry and Professional Organizations http://www.hersheys.com/moderationnation/

28. Industry & Professional Organizations http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20091006cons-alli-coke.html

29. Global Health Philanthropy “the Bill and Melinda Gates Foundation … will soon be the largest stockholder of CocaCola and Kraft in the world” David Stuckler et al., Global Health Philanthropy and Institutional Relationships: How Should Conflicts of Interest Be Addressed? PLoS Medicine (2011)

30. Systemic Effects--Research Framing effect Technological bias Research design Interpretation Dissemination J.H.Marks, “Limits of Money Blinds,” Edmond J. Safra Center for Ethics, Money Blinds Conference, Paper Presentation, Nov. 2013

31. Systemic Effects--Policymaking preclusion of policy options (e.g. regulation) marginalization of stakeholders discounting of evidence distorted development and implementation trust and confidence issues Mayes, Thompson, Marks (2013) (manuscript on file with authors)

32. SCN Principles (2006-7) Eight Principles: Relevance of partnership to SCN vision and mandate Effectiveness and efficiency as relates to SCN’s goals Management of CoI (including exclusion in some cases) Independence from vested interests (for credibility) Transparency Diversity (no preferential treatment to private sector org.) Safeguards to insulate policymaking from corporate influence Promotion of and respect for human rights And this Rule: No financial or in-kind contributions from food-related PSO

33. Critical Assessment of 12 Principles in Rowe et al./ILSI (Nutr. Rev. 2013) 1. Clearly defined and achievable public health goal 2. Clear statement of rules, roles, responsibilities, accountability 3. Objectives tied to partner needs, with clear baseline 4. All members possess “appropriate levels of bargaining power” 5. Minimize CoI by recruiting sufficient partners to mitigate influence and broaden private-sector perspectives 6. Engage partners who agree on specific research questions

34. Critical Assessment of 12 Principles in Rowe et al./ILSI (Nutr. Rev. 2013) 7. Engage partners committed to long-term goals and data sharing 8. Engage academics and members of civil society 9. Select objective scientific measurements capable of providing common ground 10. Adopt research questions and methodologies established by partners with no vested financial interest in them 11. Flexibility and Transparency 12.Third party convener NOTE: ILSI as PPP, and industry authors of paper.

35. Ethical Analysis Substantive Criteria Procedure Monitoring and Reassessment J.H. Marks, “What’s the Big Deal? The Ethics of PPPs…,” Edmond J. Safra Center Working Paper, No. 11 (May 2013), available at www.ssrn.comwww.ssrn.com

36. Ethical Analysis Problems with “risk-benefit analysis” Problems with “model PPP” approach Alternatives: Shift presumption (e.g. against) Systemic effects (antitrust analogy) Counterbalancing (with uplift) Speak Up and Collective Action

37. marks@psu.edu

39. Images: Donald B. Thompson

40. Activia (FTC): http://ftc.gov/os/caselist/0823158/videos/exhibitF.swf http://ftc.gov/os/caselist/0823158/videos/exhibitF.swf Activia (SNL): http://www.youtube.com/watch?v=dfK3o_OclgU http://www.youtube.com/watch?v=dfK3o_OclgU Image credit: adweek.com

41. Nutrition marketing of unhealthy foods Recent study of six supermarkets in ND: – 48% of products with “nutrition marketing” were high in saturated fat / sodium / sugar content – 59% of products aim at kids and with “nutrition marketing” were high in sat.fat/sodium/sugar Colby et al., J. Nutr. Ed. & Behav., 2010

42. Impact of Nutrition Marketing Mixed evidence of public understanding of health benefits claimed in relation to food: – Consumers don’t distinguish health claims approved by FDA (after review of evidence) from other claims – Some evidence of “halo effect” (e.g. low cholesterol means low fat, Andrews et al. 1998) – Some evidence that consumers may believe claim reflects government endorsement But evidence of impact on consumer behavior is more challenging – Leathwood et al., Brit. J. Nutr. 2007

43. Fast Food Industry Spent > $ 4.2 billion in advertising in 2009 – TV ads, age 2-5: 2.8 per day (up 21% since 2003) – TV ads, age 6-11: 3.5 per day (up 34%) – TV ads, age 12-17: 4.7 per day (up 39%) Ads also target ethnic and minority youth, often with less healthy items Rudd Center, Fast Food Facts Report (2010)

44. Fast Food Industry (cont.) 84% parents report taking child at least once in past week 15% of preschoolers ask to go every day Rudd Center, FFF (2010)

45. Fast Food Industry (cont.) Of 3,039 kids meal combos: – only 12 met nutrition criteria for preschoolers – only 5 met nutrition criteria for older children Ave. restaurant: 15 signs promoting specific menu items; just 4% promoted healthy items Default = french fries or unhealthy side 84% of the time Rudd Center, FFF (2010)

47. Healthy Fast Food? The Subway “health halo” – Leads to belief that 1000 kcal Subway meal contains 21.3% less calories than same-calorie McDonald’s meal (585 v. 744 kcal) – Calorie underestimates of familiar items such as sandwiches and burgers by as much as 35% – Biasing effects of health claims on calorie estimation are as strong for consumers “highly involved” in nutrition – Health claims lead consumers to choose side dishes containing more calories, enhancing chances of overeating – When main course positioned as “healthy,” customers choose beverages, side dishes and desserts containing upto 131% more calories than when main course is not so positioned Chandon & Wansink, J. Consumer Res., 2007

48. Problems with Healthy Items Consumers erroneously believe that eating healthy foods in addition to unhealthy foods can decrease a meal’s calorie count – BUT not think healthy items have negative calories Effect stronger among individuals most concerned with managing their weight (the “dieter’s paradox”): – Burger = 711 kcal, but with salad = 615 kcal! Chernev, J. Consumer. Psych. (2010)

49. Problems with Healthy Options Presence of healthy food option: – (1) vicariously fulfils health-related eating goals; – (2) drives attention to the least healthy option; – (3) provides license to indulge. “Ironic effect of self-control”: these effects are accentuated for individuals with (relatively) higher levels of self-control C.f. Polivy & Herman’s “what the hell effect”! Wilcox et al., J. Consumer Research, 2009

50. Institutional Corruption "Institutional corruption" is the consequence of an influence within an economy of influence that illegitimately weakens the effectiveness of an institution especially by weakening the public trust of the institution. (Lawrence Lessig, IC Wiki) http://wiki.lessig.org/Institutional_Corruption

51. Institutional Corruption: A Framework "Institutional corruption" is the consequence of an influence within an economy of influence that illegitimately weakens the effectiveness of an institution especially by weakening the public trust of the institution. (Lawrence Lessig, IC Wiki) http://wiki.lessig.org/Institutional_Corruption

52. Institutional Corruption "Institutional corruption" is the consequence of an influence within an economy of influence that illegitimately weakens the effectiveness of an institution especially by weakening the public trust of the institution. (Lawrence Lessig, IC Wiki) http://wiki.lessig.org/Institutional_Corruption

53. Dependence Corruption a subset of institutional corruption (as well as individual corruption) e.g. the improper dependence of Congress on campaign contributors - L. Lessig, Institutional Corruptions, EJS Working Paper No. 1 (2013)

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