Concerns about the potentially corrupting influence of private industry on medical research, education, and practice have been growing since the 1970s, when the U.S. Congress passed the first anti-kickback law applying to medicine. Since then, Congress has banned self-referrals in medicine, enacted laws that regulate the commercialization of publicly funded biomedical research, and held hearings on conflicts of interest in biomedicine. Government agencies have issued policies concerning disclosure of financial interests in research, professional associations have published guidelines pertaining to financial relationships with industry, and scientific journals have developed conflict of interest policies.

The Institute of Medicine (IOM)’s Conflict of Interest in Medical Research, Education, and Practice makes an important contribution to the continuing debate about financial conflicts of interest in medicine. This report reviews empirical studies, analytic essays, regulations, and guidance documents concerning conflicts of interest in medical research and makes recommendations for researchers, educators, physicians, institutions, corporations, and government agencies. The report consists of nine chapters as well as appendices that examine particular topics in greater depth, such as the relevance of psychological research on subconscious biases to conflict of interest policies, and a comparative analysis of conflicts of interest in nonmedical professions.

To draft this report, the IOM assembled experts from various fields including medicine, public health, law, health policy, ethics, philosophy, and economics. The authors acknowledge that collaboration with industry is a double-edged sword: Collaboration can produce important benefits, but it can compromise the integrity of professional judgment and erode the public’s trust in medicine. In crafting their recommendations, the authors strike a balance between protecting medical research, education, and practice from the harmful effects of industry collaboration and avoiding unnecessary administrative burdens that could undermine the benefits of collaboration. They make judicious use of empirical evidence to support their conclusions and recommendations. When evidence was lacking, the authors developed arguments based on their own experience and judgment as well as different approaches found in the literature.

The IOM report makes 16 recommendations for reforming medicine, some of which would require radical changes. For example, the report recommends that all academic medical centers, teaching hospitals, and training sites prohibit faculty, students, residents, and fellows from accepting gifts from pharmaceutical, biotechnology, or medical device companies, except in some circumstances, and not allow drug and medical sales representatives to have access to faculty, except by invitation in specified situations. The IOM report also recommends that academic medical centers, hospitals, and training sites develop a new system of funding continuing medical education that is free from industry influence; that research institutions prohibit investigators from conducting research with human subjects if they have a significant financial interest related to a product that would be affected by the research, except when the investigator’s participation is essential for conducting the research; and that physicians in private practice refrain from accepting items of value from pharmaceutical, biotechnology, or medical device companies.

The report also contains a conceptual framework that provides a foundation for policy recommendations. This includes a definition of conflict of interest (“a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest”) and criteria for assessing conflict of interest policies, such as proportionality (does the policy focus on the most important conflicts and is the policy practical?), transparency (is the policy understandable to those to whom it applies?), accountability (does the policy have enforcement procedures?), and fairness (does the policy apply equally to all relevant people in similar situations?). The authors also discuss problems with interpreting and applying the notion of an apparent conflict of interest.

This comprehensive and insightful report will undoubtedly have considerable influence over research, scholarship, and policy development for years to come. It is highly recommended reading for physicians, medical researchers, and medical educators.

Conflict of Interest in Medical Research, Education, and Practice

Objectives Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. Methods We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. Results There are clear commonalities across UCIs’ strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. Conclusion UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.

https://gh.bmj.com/content/bmjgh/6/2/e003543.full.pdf

The case for developing a cohesive systems approach to research across unhealthy commodity industries

Introduction There is an urgent need for effective action to address the over 10 million annual deaths attributable to unhealthy diets. Food industry interference with policies aimed at reducing non-communicable diseases (NCDs) is widely documented at the national level but remains under-researched at the global level. Thus, this study explores how ultra-processed food industry actors have attempted to influence NCD policy at WHO. Methods A combination of inductive and deductive thematic coding of internal industry documents, academic literature and interviews with key informants from international organisations and global civil society was used to identify action-based strategies ultra-processed food industry actors employ to influence global-level policy. Results Ultra-processed food industry actors have attempted to influence WHO and its policies through three main action-based strategies: coalition management, involvement in policy formulation, and information management. Coalition management includes the creation and use of overt alliances between corporations—business associations—and more covert science-focused and policy-focused intermediaries, the hiring of former WHO staff and attempted co-option of civil society organisations. Industry involvement in policy formulation is operationalised largely through the lobbying of Member States to support industry positions, and business associations gaining access to WHO through formal consultations and hearings. Information management involves funding and disseminating research favourable to commercial interests, and challenging unfavourable evidence. Conclusion We provide novel insights into how ultra-processed food industry actors shape global-level NCD policy and identify a clear need to guard against commercial interference to advance NCD policy. In their approach, the political behaviour of multinational food corporations bears similarities to that of the tobacco industry. Increased awareness of, and safeguarding against, commercial interference at the national as well as the global level have the potential to strengthen the crucial work of WHO.

https://gh.bmj.com/content/bmjgh/6/6/e005216.full.pdf

Big food and the World Health Organization: a qualitative study of industry attempts to influence global-level non-communicable disease policy

Background For decades, the food industry has sought to deflect criticisms of its products and block public health legislation through a range of offensive and defensive strategies. More recently, food corporations have moved on to present themselves as “part of the solution” to the health problems their products cause. This strategic approach is characterised by appeasement, co-option and partnership, and involves incremental concessions and attempts to partner with health actors. This paper details how corporate practices have evolved and changed over the past two decades and gives some definition to what this new political economy signifies for the wider behaviours of corporations producing and selling harmful commodities. Methods  This paper draws on public health and political science literature to classify the food industry’s “part of the solution” strategy into three broad components: regulatory responses and capture; relationship building; and market strategies. We detail the key characteristics and consequences of each component. Results  The three components of the food industry’s “part of the solution” strategy all involve elements of appeasement and co- option. They also improve the political environment and resources of the food industry. Regulatory responses offer incremental concessions that seek to maintain corporate influence over governance processes and minimise the threat of regulations; relationship building fosters access to health and government stakeholders, and opportunities to acquire and maintain channels of direct influence; and market strategies to make products and portfolios healthier bolster the market share and revenue of food corporations while improving their public image. Conclusion  Rather being a signal of lost position and power, the food industry’s repositioning as “part of the solution” has created a highly profitable political economy of ‘healthy’ food production, alongside continued production of unhealthy commodities, a strategy in which it is also less burdensome and conflictual for corporations to exercise political power and influence.

https://www.ijhpm.com/article_4138_dbe30ab03ded5561acacfc38a5202cfd.pdf

"Part of the Solution:" Food Corporation Strategies for Regulatory Capture and Legitimacy.

Today’s food systems are contributing to multiple intersecting health and ecological crises. Many are now calling for transformative, or even radical, food systems change. Our starting assumption in this Special Issue is the broad claim that the transformative changes being called for in a global food system in crisis cannot – and ultimately will not – be achieved without intense scrutiny of and changes in the underlying political economies that drive today’s food systems. The aim is to draw from diverse disciplinary perspectives to critically evaluate the political economy of food systems, understand key challenges, and inform new thinking and action. We received 19 contributions covering a diversity of country contexts and perspectives, and revealing inter-connected challenges and opportunities for realising the transformation agenda. We find that a number of important changes in food governance and power relations have occurred in recent decades, with a displacement of power in four directions. First, upwards as globalization has given rise to more complex and globally integrated food systems governed increasingly by transnational food corporations (TFCs) and international financial actors. Second, downwards as urbanization and decentralization of authority in many countries gives cities and sub-national actors more prominence in food governance. Third, outwards with a greater role for corporate and civil society actors facilitated by an expansion of food industry power, and increasing preferences for market-orientated and multi-stakeholder forms of governance. Finally, power has also shifted inwards as markets have become increasingly concentrated through corporate strategies to gain market power within and across food supply chain segments. The transformation of food systems will ultimately require greater scrutiny of these challenges. Technical ‘problem-solving’ and overly-circumscribed policy approaches that depoliticise food systems challenges, are insufficient to generate the change we need, within the narrow time-frame we have. While there will be many paths to transformation, rights-based and commoning approaches hold great promise, based on principles of participation, accountability and non-discrimination, alongside coalition building and social mobilization, including social movements grounded in food sovereignty and agroecology.

https://www.ijhpm.com/article_4167_cbfb5becc4f149adb4fe616516182298.pdf

The Political Economy of Healthy and Sustainable Food Systems: An Introduction to a Special Issue.

Background
With multi-stakeholder approaches central to efforts to address global health challenges, debates around conflict of interest (COI) are increasingly prominent. The World Health Organization (WHO) recently developed a proposed tool to support member states in preventing and managing COI in nutrition policy. We analysed responses to an online consultation to explore how actors from across sectors understand COI and the ways in which they use this concept to frame the terms of commercial sector engagement in health governance.
 
Methods
Submissions from 44 Member States, international organisations, non-governmental organizations (NGOs), academic institutions and commercial sector actors were coded using a thematic framework informed by framing theory. Respondents’ orientation to the tool aligned with two broad frames, ie, a ‘collaboration and partnership’ frame that endorsed multi-stakeholder approaches and a ‘restricted engagement’ frame that highlighted core tensions between public health and food industry actors.
 
Results
Responses to the WHO tool reflected contrasting conceptualisations of COI and implications for health governance. While most Member States, NGOs, and academic institutions strongly supported the tool, commercial sector organisations depicted it as inappropriate, unworkable and incompatible with the Sustainable Development Goals (SGDs). Commercial sector respondents advanced a narrow, individual-level understanding of COI, seen as adequately addressed by existing mechanisms for disclosure, and viewed the WHO tool as unduly restricting scope for private sector engagement in nutrition policy. In contrast, health-focused NGOs and several Member States drew on a more expansive understanding of COI that recognised scope for wider tensions between public health goals and commercial interests and associated governance challenges. These submissions mostly welcomed the tool as an innovative approach to preventing and managing such conflicts, although some NGOs sought broader exclusion of corporate actors from policy engagement.
 
Conclusion
Submissions on the WHO tool illustrate how contrasting positions on COI are central to understanding broader debates in nutrition policy and across global health governance. Effective health governance requires greater understanding of how COI can be conceptualised and managed amid high levels of contestation on policy engagement with commercial sector actors. This requires both ongoing innovation in governance tools and more extensive conceptual and empirical research.

https://www.ijhpm.com/article_3793_99c25a697ec01c9a6080c1d4ce1fac93.pdf

Fabio da Silva Gomes

Papers

Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool