16. Responsible Consumption and Production

Sustainable Development Goal: 12 Responsible Consumption and Production focuses on ensuring sustainable consumption and production patterns.

Quinn Grundy is a registered nurse and an Assistant Professor with the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto and a Faculty Associate with the Center for Bioethics and Humanities at the University of Colorado, Anschutz Medical Campus. She is a fellow with the WHO’s Collaborating Centre for Governance, Accountability, and Transparency in the Pharmaceutical Sector and the Centre for Sustainable Health Systems at the University of Toronto. Dr. Grundy's research explores the interactions between medically-related industry and the health system, health professionals, and the production of health-related research and the implications for equitable, sustainable public health care. She is the author of Infiltrating healthcare: How marketing works underground to influence nurses (Johns Hopkins University Press, 2018).

Daniel Eisenkraft Klein is a PhD Candidate at the University of Toronto's Dalla Lana School of Public Health. His SSHRC-funded doctoral research centres on how the pharmaceutical industry frames its involvement in the policymaking sphere. Daniel is presently also a Research Consultant for the Opioid Industry Documents Archive at John's Hopkins University, and has previously taught on the Commercial Determinants of Health at Simon Fraser University's Faculty of Health Sciences.

CREDITS: This podcast is co-hosted by Dr. Erica Di Ruggiero, Director of the Centre for Global Health, and Ophelia Michaelides, Manager of the Centre for Global Health, at the DLSPH, U of T, and produced by Elizabeth Loftus. Audio editing is by Sylvia Lorico. Music is produced by Julien Fortier and Patrick May. It is made with the support of the School of Cities at U of T. 

Transcript

Erica Di Ruggiero [00:00:07] I'm Erica Di Ruggiero and this is Healthy Cities in the SDG era, a podcast about the Sustainable Development Goals and how research conducted by faculty and students at the University of Toronto is helping to achieve them. We're recording from Toronto or Tkaronto, which for thousands of years has been the traditional land of the Huron-Wendat, the Seneca and the Mississaugas of the credit. Today, this meeting place is still home to many indigenous people from across Turtle Island and we are grateful to have the opportunity to work on this land. In this episode we'll look into SDG 12, which focuses on ensuring sustainable consumption and production patterns. SDG 12 is made up of 11 targets which span a multitude of areas, including resource use, sustainable business, environmentally sound technologies and policies. Today's episode will focus largely on Target 6 of this goal, which aims to encourage companies, especially large and transnational corporations, to adopt sustainable practices. The commercial determinants of health refer to the actions and activities of the private sector, including these large and transnational corporations which affect people's health. The impact of these commercial determinants on public health outcomes has become increasingly recognized as power and influence of corporations continue to rise to unprecedented levels. In the context of sustainability specifically, there is much to be considered between a corporation's goal of maximizing profit and how this relates to fiscal and environmental consumption. In this episode, we'll speak with Quinn Grundy about the interaction between corporations, specifically the medically related industry and the public health system. Then we'll speak with Daniel Eisenkraft Klein about how the balance between sustainability and pressures from corporations are, or rather should be realized in policymaking. 

Erica Di Ruggiero [00:02:20] Quinn Grundy is a registered nurse and an assistant professor with the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto and a faculty associate with the Center for Bioethics and Humanities at the University of Colorado and Schulz Medical Campus. She's a fellow with the W.H.O. Collaborating Center for Governance, Accountability and Transparency in the Pharmaceutical Sector and the Center for Sustainable Health Systems at the University of Toronto. Dr. Grundy's research explores the interactions between medically related industry and the health system, health professionals and the production of health related research and the implications for equitable, sustainable public health care. She's the author of Infiltrating Health Care How Marketing Works Underground to Influence Nurses. 

Erica Di Ruggiero [00:03:10] Hello, everyone. I'm delighted to be joined by Quinn Grundy, one of our colleagues here at the University of Toronto. Quinn, thanks for joining us. Really look forward to this discussion. Thought I'd start off with, you know, a big, big question. So tell us a little bit about yourself and and about your research. 

Quinn Grundy [00:03:32] Yeah, thanks for having me. And I would characterize my program of research really as interested in the activities of corporations. And Public Health Nursing. I'm a registered nurse by background. We've really come to appreciate the importance of the social determinants of health as key drivers of health and well-being. I think we need now more attention to what we call the commercial determinants of health. Corporations are the most powerful entities globally and I think have unprecedented ability to influence our choices as consumers and our lifestyles. Public policy and policy processes scientific evidence. And if we look systematically across sectors, regardless of what products a corporation sells, we can see that they have activities, strategies, practices in common. And so my research really seeks to understand and anticipate these activities to detect patterns across sectors and to understand ultimately how we might craft effective regulation to ensure that those activities and strategies achieve public health. And specifically, I'm really interested in the way that medically related industry. So pharmaceutical, medical device, health, information technology, infant formula for the companies, how they interact with our public health systems, including interactions in the day to day with health professionals, influence over and sponsorship of our health related research and the evidence that we use to make clinical decisions. And then, of course, health policy process. 

Erica Di Ruggiero [00:05:13] It sounds like a very rich insights of interrogation and also, you know, very refreshing because in public health, I know we tend to also put a lot of focus on the role of nation states and governance and governments. And so this is a really a powerful actor to interrogate. So thanks for for that introduction. So I want to shift, since we're talking about SDG 12, which is really around responsible consumption. So when we talk about consumption in health care, so one of the many sectors where this applies. How sustainable is it, in your opinion? 

Quinn Grundy [00:05:51] I think would be when we look at corporations and understand how they behave. One thing that they have in common and again, regardless of the product that they sell, is the need to maximize profit, but even more so to demonstrate growth and to deliver a return to investors. And that's regardless of, I think, some very important sustainability considerations, which could be fiscal in terms of the fact that worldwide a lot of health care is publicly funded or funded out of pocket by patients, but also environmentally. And I think to achieve that kind of growth or that profit, corporations are looking for strategies or are engaged in activities to ensure that they can increase the volume of products sold which they achieve through marketing and promotion, but also expanding indications for use, ensuring a favorable regulatory climate. And I think what that translates into is that when a new health technology comes to market, we see that companies have these very multifaceted promotional strategies that often involve education of health professionals, policymakers, patients, research. So creating an evidence base, peer to peer influence. And that's in addition to advertising that happens through sales reps, visiting physicians or, you know, direct to consumer advertising. And what we've seen in the body of literature is that these activities actually are not very sustainable in many senses of the world. So, first of all, in that in a health sense and the W.H.O. in I think the 1980s even released guidance around the ethical promotion of pharmaceuticals, because what typically results is that we see overtreatment. So for example, I think we saw this with the opioid crisis where products like opioids were promoted aggressively and were used for people that didn't, you know, for dental extractions or things that didn't require those powerful drugs. We also see mistreatment. So, you know, an example might be promoting drugs for conditions that are really mild that won't see benefit from that. And then paradoxically, we also see undertreatment. So we're putting a lot of resources into the development of health technologies that may be the latest and greatest, but either provide only incremental benefit or are really not addressing our unmet public health needs. And we can see that with diseases like malaria or antibiotics, where we have a kind of a crucial, you know, drying up of that pipeline. And so I think when we think about sustainable consumption and health care, we have some real problems. So first of all, we have an unsustainable health impact and also not a pipeline for research and development that's addressing unmet need. We are seeing governments and public payers around the world really struggling to keep up with the increasing costs of health technologies. With with the advances in science, we often see more and more products for smaller and smaller groups of people coming with exorbitant price tags. But also so we're seeing problems with sustainability in the environmental sense. We see products with incremental benefit. We see these meta drugs. We see planned obsolescence. And of course, there is no incentive within the system when we rely on for profit industry to create the products we use in health care, to decrease the volume of use or to use less. And I think movements like less is more, which has come out of medicine, are really getting consumers and physicians to think about, you know, what is going to be the most cost effective, useful way of allocating health resources. 

Erica Di Ruggiero [00:09:47] Mm hmm. Yeah. So I think from the many examples you provided, we're seeing, you know, a misalignment in terms of meeting a need and also whose needs, which I think raises questions about equity and whose problems might matter more based on ability to pay, whether that's individuals or also even countries where in many parts of the world are being left behind. So, uh-

Quinn Grundy [00:10:12] And I think in the sustainability sense, we're seeing that in higher income countries, the health sector are now among the most polluting sectors. And yet when we look at the burdens of climate crisis, the health effects, the social effects, those are disproportionately carried by people living in regions of the world that are not benefiting from those high tech and high carbon intensive health services. 

Erica Di Ruggiero [00:10:38] Hmm. Yeah. Well said. So, I mean, given the many problems that you've identified and some of the disconnects, what do you think needs to be changed to ensure sustainable consumption in health care and including medically related industries? What's your research telling us? We're really good at documenting problems sometimes in research, but what are some of those evidence based solutions or even promising solutions that research is telling us we should be investing in? 

Quinn Grundy [00:11:09] I think one of the biggest challenges is that medically related industry is exceptionally profitable, and so it's going to require a great deal of political will to to create shifts in this space. And I think one of the things that props this up is that we have a very strong belief in our society that innovation can only happen in industry. And when it comes to our health, we really, really want the best for our family. We want the greatest technology. We want these life saving interventions. But what I think is coming out and we've seen this during COVID, is that the public sector actually invests very heavily in research and development and is responsible for seeding many of these breakthroughs. And yet at the end of the day, the public is not getting the credit or sharing in the risks or rewards in the benefits of the innovation. And I think we've seen this with many of the testing, the vaccines, the treatments for COVID 19 that were funded and seeded within universities with public dollars. And yet the intellectual property, the patents and the profits are kept within private industry and are not allocated equitably. So I think the first thing is when we think about developing new health technologies, we need to give the public sector the credit it is due and to think about kind of a more fair share for taxpayers and the public who have shouldered the costs of research and development to make sure that it is equitably allocated and that we have the access at sustainable prices. I think, too, we need to really think about this value of independence. And just as we have seen in the health sector in terms of health related research, there has been kind of a drawing back of of resources and public funding for research. Many researchers are are faced with having to turn to industry for research. Most of the clinical trials in the world are industry sponsored. And this system of knowledge production is is not generating kind of the sustainable outcomes and addressing those unmet needs, which would make sure that when we are consuming health products, it is really in the interests of public health. And so I think we need to think about how do we bring more transparency? How do we bring more accountability? How do we ensure that the health evidence that we base our decisions on the guidelines we produce is really independent and rigorous and is kind of the influences on the research agenda that might drive it toward more profitable solutions or overtreatment or higher consumption and putting some checks on that. I think the last piece would be in terms of how health professionals receive information about new technologies. A great deal of education is provided through the companies that have a commercial interest in that education. And so when a hospital purchases a new product, it's often the sales representative from that company that is delivering that education about how to use it. When clinicians find out about new products in their area, it is often through industry at a conference or at a sponsored dinner or for samples dropped off. We know that physicians, when they choose the tools with which they work there, often have strong preferences. And those preferences are determined about often by what they trained on. And so they often industry is looking to form relationships with clinicians very early in their career. And so while I think industry has a very important role and expertize, certainly both in research and in education, we need to find ways that clinicians can learn about, can test, can evaluate, can contribute, can change, can tweak and work with products independently of those commercial interests. 

Erica Di Ruggiero [00:15:13] Yeah, no, I think that's well-said because, I mean, we know health professionals are key gatekeepers and very much in contact with people and patients and influencing their decisions. So very well said. Thanks so much, Quinn, for sharing your perspectives on some pretty big questions that still need further investigation and action. And we really appreciate you sharing your perspective with us today. 

Quinn Grundy [00:15:37] Well, thank you so much for having me. 

Erica Di Ruggiero [00:15:46] Daniel Eisenkrraft Klein is a Ph.D. candidate at the University of Toronto's Dalla Lana School of Public Health. His Social Science and Humanities Research Council of Canada funded doctoral research centers on how the pharmaceutical industry frames its involvement in the policymaking sphere. Daniel is presently also a research consultant for the Opioid Industry Documents Archive at Johns Hopkins University and has previously taught on the commercial determinants of health at Simon Fraser University's Faculty of Health Sciences. Hello, everyone. I'm delighted to have Daniel Eisenkraft Klein join us today. Welcome to the program, Daniel. 

Daniel Eisenkraft Klein [00:16:27] Thank you. 

Erica Di Ruggiero [00:16:29] Yeah. So let's just start off with a question about yourself. So can you tell us a little bit about yourself and and about your research for sure? 

Daniel Eisenkraft Klein [00:16:40] I'm a third year PhD candidate at the School of Public Health at the University of Toronto. In addition to my doctoral research at the university, I'm quite extensively involved in a project at Johns Hopkins University that also examines the pharmaceutical opioid documents that came out of recent litigation. So broadly speaking, I'm interested in corporate power and public health. But more specifically, I research how policy stakeholders make their regulatory decisions around tobacco and pharmaceutical opioids. So I'm especially interested in how policymakers balance the importance of public health and sustainability with that pressure to allow markets and businesses to thrive. 

Erica Di Ruggiero [00:17:26] Well, it sounds like and an area that we heard from another speaker on which is really around the commercial determinants of health are corporate determinants of health. Yeah. So just building on that, you know, as you know, according to a 2006 Ethical Corporation's State of Responsible Business study, fewer than half of the respondents plan to engage with the Sustainable Development Goals. So, you know, based on that finding, how do corporations interfere with the implementation of certain policies that could hurt their profit margins, for example, in the field of health and in relation to sustainable consumption? 

Daniel Eisenkraft Klein [00:18:08] Sure. So this is actually what my field often called the corporate determinants of health are. The commercial determinants of health, as you said, has really done terrifically well. I think it's kind of exposed the various strategies that cut across health harming industries. And there are a lot, you know, including lobbying, stalling regulators that have previously worked with corporations into governance bodies, creating corporate social responsibility projects that distract from its harmful practices. But I'll give two examples that maybe are less known outside of the field. The first is this kind of constant manufacturing of doubt. So the tobacco industry early on realized that they couldn't really refute the evidence of the harms of smoking. So instead, they sought to simply keep the controversy alive by spreading doubt and confusion. There is actually something in writing, I think, from one of the tobacco companies that said, doubt is our product. And they they did this through a number of means, through funding scientists, researchers, think tanks, what have you. All those groups that were willing to challenge the scientific consensus. And so that's kind of given us a framework for understanding this manufacturing of doubt. But it hasn't just been tobacco. We saw it with, you know, acid rain with DDT and now increasingly with the climate crisis. And actually we've even seen it with the meat industry. And I think media are often pulled into this in their sincere efforts to tell both sides, despite often one side representing really a minuscule percentage of scientists. Now, that said, much of this can be countered, making the funding of projects more transparent, ensuring conflicts of interests are declared and checked. There are plenty of strategies to fight the manufacturing of doubt. A second strategy is through individualistic framing. So let me explain what I mean by that. If we think about the sustainable development goal of ensuring sustainable consumption and product production patterns, I would almost guarantee you that health harming industries will say they're all on board for sustainable consumption. So if you think of programs that encourage us to recycle, to eat healthier, and I think that's because we've seen that corporations generally wish to maintain a focus on personal responsibility and on individual decision making. So you'll see that big food corporations often encourage us to think of the obesity crisis as simply poor eating decisions. They would even maybe support a campaign that aims to educate individuals about healthy eating choices. And though those are good, that is a very intentional strategy. What it does is it takes away the focus from the, you know, for example, the mass marketing of ultra processed foods. The food guidelines that industry often tries to sponsor. The constant efforts to penetrate food markets in low and middle income countries that have, let's say, less regulatory ability to fight those big industries. So anytime we have this crisis of sustainability, I think it's important to to pay attention to the strategies that receive the most attention. And if they are overwhelmingly focused on individual decisions rather than shifts in policy or shifts in governance, it's good to look at take a close look at really why those are the policies that make it to the table. And I guess that that's part of a broader theme of. Industry is good not only on influencing policy, but influencing which policy decisions are considered viable. So if we're always sort of stuck debating the minutia of a particular policy sphere, then we've almost gotten lost in what might be possible. Otherwise, if we're debating, you know, exactly what time marketing should end or shouldn't begin, whether it's 8 p.m. or 9 p.m., because we're trying to ensure that there's less marketing of food to children. We're missing a bigger picture of sort of a what has become quite acceptable in terms of mass marketing, extremely unhealthy food to pretty much the general population. So that can that can be tricky to actually see because it's kind of an absence as opposed to what is actually right in front of you. But it's important to take a look at. 

Erica Di Ruggiero [00:22:56] Yeah. No, I think you highlight some really important tactics. I mean, this idea of manufacturing doubt, just to go back to that, you know, sort of plays right into what policymakers are actually trying to do, which is to reduce uncertainty. Yet by continuing to put that element of doubt in their minds, that it sort of plays with that uncertainty that they're trying to at least mitigate. 

Daniel Eisenkraft Klein [00:23:21] Yeah, and I think it's good to be sympathetic to policymakers who many of whom are quite well-intentioned. But, you know, it's not often the expertize of the policymaker to look at a conflict of interest disclosure, to understand exactly how funding policies work, especially when often funding can come from a third party body where you'd have to actually do quite a deep dove to find out. So, you know, it's it's somewhat on us as researchers and others to to make sure that's out there for policymakers to see. 

Erica Di Ruggiero [00:23:55] Yeah, no, absolutely. And I think your second point around, the individualistic frame feels like, you know, since the beginning of time, the public health that we're trying to not always make it about the individual, but, you know, the conditions under which people live, work and play. And yet we continue to see these strategies that are making everything about individual responsibility, which we know don't work. 

Daniel Eisenkraft Klein [00:24:18] But yeah, and I think most people, they understand it when it comes to tobacco. You know, I don't think we understand people smoking when they were being told that smoking wasn't that bad for them when they were being marketed. It makes sense that it's not just on the smoker and hopefully we can get those understandings to other industries as well. 

Erica Di Ruggiero [00:24:39] Yeah, I know. Absolutely. So I just want to close maybe with a sort of more, you know, forward thinking kind of question. So in your opinion, what do you think could be changed in this field to ensure that sustainable and beneficial health policies are implemented? So, you know, if you had that sort of crystal ball, like where should we be headed. 

Daniel Eisenkraft Klein [00:24:58] That would be nice. Well, I think that people are starting to recognize that these changes just won't happen naturally. It will take quite a bit of effort, but I think people are also starting to see that change really is possible. So it's always useful to go to tobacco as a place to begin that. Generally speaking, we've seen in high income countries at least, we've banned marketing, we've exposed lobbying, we've shown that industry friendly researching and the results are pretty clear. You know, we've had massive decreases in smoking rates, in secondhand smoke exposure, etc. But if we had simply just asked the tobacco industry to just start acting nicely, I don't think anyone truly believes we would have made the progress that we have. So I think it's important to be kind of realistic here about multinational corporations. I think you should put yourself in the shoes of an executive at a fast food or at a tobacco company, kind of like what we're saying with a with a policymaker. Or if you were at the head of a corporation that's creating one of these health harming products, why would you worry about a sustainable goal unless you do have a financial incentive? I think it kind of doesn't make sense for us to be surprised when a corporation simply does its job, which is to maximize profit. So I guess that's the first point. We would... I would love for us to stop expecting multinational corporations to do anything that goes against their bottom line. And that's not a good thing or a bad thing, per se. It's just the structure of what a multinational corporation is. I make just one other point here. I'm teaching a course this semester on the commercial terms of health to undergraduates, and the reception has really been good. And I think there is a real appetite and a desire for more focus on corporate interests, impacts on health and on policy. So my hope would be that just like we now often have a required social determinants of health course in many public health schools, maybe a commercial determinants course would also be required, or something that really makes sure that health professionals understand the role that corporate interests have in their field. And that would be that could be for public health, but that would also be for people studying nutrition, for medical doctors. You know, if you're interested in reducing alcohol consumption, I'm doing some work around indigenous inequities and how those intersect with corporate effort. I think this intersects with a lot of other important areas and a lot of other social determinants of health that we could really contribute to. So making sure those sustainable policies are implemented that you mentioned might really start with training health professionals. The ones that are coming up into the field to start looking for them. Mm hmm. 

Erica Di Ruggiero [00:28:06] Yeah, but as you say, I mean, this is an area that's so pervasive and it cuts across so many sectors and issues and society. And really, we do need to do a better job to, you know, help expose people to the role of the commercial determinants of health in shaping not just policies, but how health is, you know, produced or undermined depending on the topic. So thanks for leading the charge, right? I think, yeah, it's already well underway, as you say. Absolutely. Well, thank you for leading the charge and actually taking a step forward and helping to train the next generation. And thanks for joining us today, Daniel. 

Daniel Eisenkraft Klein [00:28:44] My pleasure. Thank you so much. 

Erica Di Ruggiero [00:28:54] From individual lifestyle choices to policy to the scientific evidence base on which we make clinical and public health decisions. The conversations with our guests today have shed light on the influence of corporations at both the individual and systemic level. As our speakers have described. These commercial determinants must be recognized and examined critically for their influence on population, health, health equity and sustainability. As highlighted by Quinn, changes promoting sustainable consumption in the space, especially in the health care sector, requires the political will to prioritize sustainability over profitability. Additionally, we must recognize the importance of the public sector in innovation to champion for a more sustainable and equitable knowledge production process. Additionally, as highlighted by Daniel, we must reconcile with the idea that sustainability will not necessarily be a priority for these large corporations. As such, we must not rely on them to make changes themselves, but rather take action, including through policy, to ensure these changes are made. 

[00:30:02] Healthy Cities in the SDG Era is made with the support of the School of Cities at the University of Toronto, whose mission is to bring urban focused researchers, educators, students, practitioners and the public together to explore and address complex urban challenges. We'd love to hear your thoughts on healthy cities in the city era. If you enjoyed this episode, please rate, subscribe and share. To help others find the series, you can find healthy cities in the city era on Spotify, Apple Podcasts and the Dalla Lana School of Public Health's YouTube page, as well as our Center for Global Health website. Join us for our next episode where we'll look at SDG 17 Partnerships for the Goals. Thank you for tuning in and we look forward to speaking soon. Take care.