The public health playbook: ideas for challenging the corporate playbook

Summary

Many commercial actors use a range of coordinated and sophisticated strategies to protect business interests—their corporate playbook—but many of these strategies come at the expense of public health. To counter this corporate playbook and advance health and wellbeing, public health actors need to develop, refine, and modernise their own set of strategies, to create a public health playbook. In this Viewpoint, we seek to consolidate thinking around how public health can counter and proactively minimise powerful commercial influences. We propose an initial eight strategies for this public health playbook: expand public health training and coalitions, increase public sector resources, link with and learn from social movements to foster collective solidarity, protect public health advocates from industry threats, develop and implement rigorous conflict of interest safeguards, monitor and expose corporate activities, debunk corporate arguments, and leverage diverse commercial interests. This set of strategies seeks to amplify inherent assets of the public health community and create opportunities to explicitly counter the corporate playbook. These strategies are not exhaustive, and our aim is to provoke further discussion on and exploration of this topic.

Translation

For the Spanish translation of this paper see Supplementary Materials section.

Introduction

To protect their interests, many commercial actors use a range of integrated and sophisticated strategies that we consider to be a corporate playbook.^{1, 2, 3, 4} This playbook is designed to protect and promote commercial interests, often at the expense of public health,⁵ the environment,⁴ and democracy.⁶ The corporate playbook spans numerous health-harming and planet-harming industries, such as tobacco, alcohol, gambling, pharmaceuticals, ultraprocessed foods and beverages, firearms and weapons, automobiles, social media and technology, oil and gas, and chemicals. The corporate playbook also spans the actors enlisted to support these industries, such as lobbyists, lawyers, tax advisers, consultants, front groups, financial services, media, marketing, and public relations.^{5, 7} Beyond the harmful industries, the privatisation of public goods and services (including health care, education, utilities, incarceration, defence, aged care, and mass transit) is a crucial and often overlooked commercial determinant of health,⁸ as commercial actors in this space also apply the corporate playbook.

There is no formal corporate playbook circulated at annual meetings or as part of the onboarding process for staff. Neither is it solely applicable to corporations. Trade associations, non-profit organisations (often funded by corporations), and other commercial and quasi-commercial actors also deploy corporate playbook strategies. We recognise that the commercial sector is diverse. Beyond organisational differences (eg, corporations vs cooperatives), commercial actors have different portfolios, market shares, geographical footprints, revenues, profit margins, and other tangible and intangible assets. Their actions, interests, incentives, and disincentives differ across contexts.

Naming and conceptualising these efforts as the corporate playbook makes explicit the idea that, despite diversity, many commercial actors consistently draw on similar strategies (table). For example, the alcohol industry misrepresents evidence about the adverse health effects of alcohol, and has long sought to develop public–private partnerships to portray the industry as a benevolent partner alongside constructing arguments that irresponsible individuals are to blame, instead of the supply of alcohol.¹⁰ Unfortunately, the alcohol industry is not alone in applying these strategies.

Table.

Methods employed by the corporate playbook

	Definition	Example
Intimidate and vilify critics	Use smear tactics, intimidation, and lawsuits (or threats of) against industry critics, such as scientists, academics, health practitioners, advocates, and civil society groups	In Colombia and Mexico, proponents of a tax on sugary drinks received threatening phone calls and had their computers hacked
Attack and undermine legitimate science	Fund counter-studies, sponsor conferences, recruit corporate scientists, skew data, distort evidence, claim manipulation, exaggerate uncertainty, plant doubt, minimise the severity of the issue, insist the problem is very complex, and demand balance for both sides	Chemical company Monsanto deliberately blocked research that could show the toxicity of its product Roundup, and company employees were ghostwriters on supposedly independent research
Frame and reframe discussion and debate	Promote narratives of personal or individual responsibility, moderation, consumer freedoms, free markets, the nanny state, government intrusion, and businesses as part of the solution	The plastics industry coined the term litterbug and created a campaign focused on personal responsibility for waste to distract from proposed regulations of their production practices
Camouflage actions	Leverage front groups and pseudo civil-society groups to act as a mouthpiece for the industry, create the appearance of independence, and avoid bad publicity	Big Oil promotes itself as supportive of climate change policies yet spends millions on trade associations such as the American Petroleum Institute, which vigorously oppose regulation of fossil fuels
Influence the political process	Lobby, make political donations, recruit former politicians, and participate in policy development to influence, block, weaken, and delay policy and regulatory outcomes	Google has more than 258 instances of former government employees starting work in the private sector (and vice versa) in the USA, including individuals from the White House, the Department of Justice, and the Federal Trade Commission—the same agencies tasked with investigating antitrust
Develop corporate alternatives to policies	Create voluntary self-regulation, codes, and commitments to delay or pre-empt public health interventions	In response to concerns about Meta's promotion of hate speech and inciting violence, the company has developed an internal oversight board, which is criticised for its lack of independence and mandate
Deploy corporate social responsibility and partnerships	Donate to community groups, sports, entertainment, and non-governmental organisations, and develop public–private partnerships with governments and credible organisations to foster corporate goodwill and distract and deflect from harmful products or behaviour	Consultancy firms such as KPMG portray themselves as giving back to society—meanwhile the company has helped tobacco companies to develop their own, misleading corporate social responsibility campaigns
Regulation and policy avoidance and evasion	Impede the implementation of policies through legal challenges in national and international courts, alongside use of legal loopholes, tax avoidance, corporate restructuring, and violation of laws, treaties, and codes	Philip Morris International unsuccessfully sued the Australian and Uruguayan Governments to block implementation of their laws requiring plain packaging and warning labels on tobacco products

Synthesised from the following sources: Wiist,¹ Brownell and Warner,² Freudenberg,³ Oreskes and Conway,⁴ and Moodie.⁹

Some of the corporate playbook's strategies, such as intimidation or undermining science, are overtly hostile to public health interests. Other strategies are designed to appease or neutralise critics, such as the development of self-regulation, or the creation of healthier or harm-reduction products.¹¹ The corporate playbook is not a static phenomenon. Commercial actors are agile and dynamic, adapting strategies and evolving in response to shifting market and political pressures.^{12, 13} The corporate playbook is global, but in practice it is calibrated to local contexts and regulatory systems. To counter the corporate playbook and advance a public health vision of creating health and wellbeing, public health actors—together with other groups such as social justice, environmental, human rights, and Indigenous rights groups—need to develop, refine, and modernise their own public health playbook (panel).

Panel. Recommendations for the public health playbook.

Expand public health training and coalitions

Expand training provided to public health practitioners and actively recruit non-traditional public health personnel into the service of public health

Increase public sector resources

Promote policies and initiatives to ensure that governments have the financial and human resources to guarantee their citizens the right to fundamental goods and services

Link with and learn from social movements to foster collective solidarity

Learn from the countertactics and political knowledge of other activist organisations and foster collective solidarity through shared goals and coalition building

Protect public health advocates from industry threats

Develop a set of resources to inform and support health practitioners, researchers, and other public health actors

Develop and implement rigorous conflict of interest safeguards

Protect public health organisations and policies from inappropriate commercial influence

Monitor and expose corporate activities

Systematically gather intelligence on the market activities and political activities of corporations and share this information widely

Debunk corporate arguments

Provide a counter to corporate arguments that highlights the social and commercial determinants of health

Leverage diverse commercial interests

Identify divergent interests or tensions between commercial actors and strategically leverage these to weaken industry coalitions or individual companies

There have been many previous attempts to develop approaches to counter commercial influence, not only for public health, but also for sustainability, human rights, and democracy. These issues face a shared threat from commercial interference and opposition. In this Viewpoint, we seek to consolidate previous thinking to counter powerful commercial influence and highlight potential actions for public health actors. We set out eight potential strategies and briefly elaborate on how they can proactively anticipate, pre-empt, and counter corporate strategies, as well as amplify existing public health strengths. These strategies will enable public health actors to build the capacity of the public health community and related groups to challenge and counter the corporate playbook. This set of strategies is not definitive, and we hope that it provokes the development of many additional strategies and ideas.

Expand public health training and coalitions

This strategy consists of two parts. The first is training the next generation of public health practitioners to understand and challenge powerful commercial forces. The current focus on technical aspects of epidemiology, biostatistics, evaluation, and health economics is insufficient. Public health students should be offered training in political science, law, economics, advocacy, and communications (including digital strategy, community mobilisation, public policy, and business). A pragmatic first step would be for graduate schools of public health to offer classes on commercial determinants of health to sensitise the future public health workforce.¹³ Commercial determinants of health should also be added to the medical curriculum. Public health advocates can also work more closely with medical, nursing, and allied health practitioners to participate in the media, testify, lobby policy makers, and foster greater health awareness among the public (eg, orthopaedic surgeons leading advocacy campaigns for prevention of road trauma or oncologists supporting tobacco control efforts).¹⁴

The second element of the strategy is the need to collaborate with a broader confederation of actors. This collaboration could include current and former politicians and bureaucrats, journalists, lawyers, business experts, and community champions (appendix 2 pp 1–2). The list of potential allies for public health advocates is, in theory, limitless, and will depend on the context and issue. A first step is to acknowledge the need for diverse perspectives, skills, and partners, and to foster connections. Subsequent work will be needed to identify processes that facilitate meaningful and effective engagement.

Increase public sector resources

To develop and enforce strong public health regulations and provide an alternative to corporate-led initiatives, the public sector must be adequately resourced. It can be challenging for states to hold actors accountable, especially when transnational corporations provide foreign direct investment. Moreover, COVID-19 has revealed the risks of privatising sectors of the economy (ie, health care and aged care), so calls to build back better must ensure that this approach is not exclusively business-led.^{15, 16} Some governments are using remunicipalisation to reclaim state ownership of privatised services such as water, energy, and telecommunications. This process has led to reduced costs and improved service quality, working conditions, and accountability.¹⁷ The use of innovative health taxes such as those levied on tobacco, alcohol, and sugary drinks, as well as other products such as fossil fuels, can also bolster public resources if funds are earmarked for spending commitments towards advancing public health.¹⁸ An additional avenue is to enact wealth or solidarity taxes to ensure that corporations and billionaire elites pay their fair share. The 2021 G20¹⁹ initiative has taken some steps towards a fairer tax regime, but still falls far short of what is necessary and risks widening existing gaps between low-income and high-income countries. Debt forgiveness from financial institutions such as the World Bank and the International Monetary Fund offer a further step to address the neocolonial wealth disparities between low-income and high-income regions, and foster greater capacity for low-income and middle-income countries to invest in public health.

Link with and learn from social movements to foster collective solidarity

Some practitioners would proudly claim the title of activist, but public health more broadly tends to focus on less political, more biomedical approaches. However, to challenge the political and market power of transnational corporations requires nothing short of radical, revolutionary change. Ultimately, the most powerful companies blocking public health efforts are transnational, so transnational networks and coalitions are necessary to counter their influence. In the wake of COVID-19, there are clear opportunities to link with other prosocial movements that share similar goals of a more equitable society, such as those combating climate change, political corruption, human rights violations, or corporate control. There are risks that collective agendas can be too broad, even without expanding the remit of particular movements, but there are clear opportunities for public health advocates working across a range of issues and contexts to learn from the experience of other organisations fighting powerful commercial interests, such as Avaaz, Move On, 38 degrees, Get Up, and La Via Campesina. One emerging example is shareholder activism, where charities and other organisations purchase shares in powerful companies, giving them voting rights. Through this process, the charities and other organisations seek to influence the actions of the company from the inside—eg, the proposal from Oxfam²⁰ for Amazon to put an hourly worker on its board of directors. This strategy is not without its limitations, as seen in the strategy from Philip Morris International²¹ to pre-empt shareholder activism and turn it into a public relations exercise.

Protect public health advocates from industry threats

Public health advocates, policy makers, researchers, and other practitioners face personal threats and intimidation from corporate actors, including defamation, litigation, hacking, surveillance, and threats to their safety and the safety of their family.²² Unfortunately, this unequal power dynamic between public health actors and corporations is unlikely to change, but there are steps that can be taken to prepare for these tactics and to put support in place when possible. One approach is to develop relationships with lawyers and more broadly engage them in public health efforts. This strategy could include the development of a guide on strategic responses to threats of litigation and defamation tailored to different national and legal contexts. The McCabe Centre for Law and Cancer in Australia provides legal training to help others develop, implement, and defend laws addressing non-communicable diseases, and similar models could be developed to provide information and training for public health activists. Public health institutions, such as universities, research institutes, or non-governmental organisations can also provide protection, either through the provision of legal and financial resources, or through broader support such as secure employment contracts and taking a public stance to defend threatened public health practitioners. In low-income and middle-income countries, where funding for public health is a real concern, international organisations, public health philanthropy donors, and domestic resources raised through taxes could also be used to develop these resources to protect against industry threats, provide support to advocates under threat, and generally promote health and wellbeing—as the Bloomberg and Open Society Foundations²³ have done in the past.

Develop and implement rigorous conflict of interest safeguards

Powerful commercial actors influence local, national, and international decision-making fora—a status quo that frequently undermines efforts to promote and protect public health. This influence goes beyond overt lobbying and political donations to include more intractable and less visible forms of power and influence—for instance, the reluctance of some governments to enact strict standards on transnational corporations if they are dependent on foreign investment. Realistically, efforts to minimise commercial influence in politics are a long game requiring a fundamental shift in global power structures and substantial capacity building. However, there are steps that can be taken by public health institutions and actors to support these efforts to minimise commercial influence. Proactively developing and enforcing rigorous conflict of interest safeguards is a crucial element towards limiting inappropriate commercial influence on policy making.²⁴ Public health organisations and non-governmental organisations can lead by example, establishing strict standards for health systems and health policies, as well as their funders, partners, and conference sponsors to safeguard their mission and activities from commercial interference. This behaviour can help to normalise the practice of conducting due diligence. Public health actors and institutions can also advocate to apply these strict standards to minimise commercial influence elsewhere (eg, to sporting associations such as the International Federation of Association Football). Government health departments and agencies can also enforce conflict of interest standards for their contracts and tenders. Conflict of interest policies are relevant and necessary for all policy making, and health departments can lead their implementation—eg, by applying the draft approach from WHO²⁵ for preventing and managing conflicts of interest in nutrition programmes.

These safeguarding efforts could limit uncontrolled multistakeholderism, a form of governance that invites non-government actors into multilateral decision-making fora. Although proponents laud multistakeholderism as a more inclusive and participatory form of governance, in reality, these efforts often risk undermining less resourced actors at the expense of well resourced private interests.²⁶ In the short term, rigorous conflict of interest standards can add a layer of scrutiny to existing multistakeholder arrangements.

Monitor and expose corporate activities

Efforts to respond to and counter corporate tactics will be complemented by the capacity to proactively anticipate, predict, and prevent corporate playbook strategies before they occur. A growing number of organisations have developed corporate watch programmes to monitor harmful practices. Some organisations have developed databases of information including Tobacco Tactics, Stopping Tobacco Organizations and Products, Open Secrets, Transparency International, US Right to Know, Project Toxic Docs, and Preemption Watch, as well as the industry documents library hosted by the University of California, San Francisco. These organisations have different aims and missions, but they are all concerned with the influence of corporations. Alongside these efforts, the nascent commercial determinants of health literature has accelerated since 2016, seeking to shed light on commercial practices. Through often novel data collection approaches, the research into corporate activities provides an inside look at commercial actors as a vector of disease and ill health by studying their internal operations, plans, reports, memoranda, and emails.^{27, 28} Fortunately, there are steps that can be taken to develop a commercial actor monitoring database (appendix 2 pp 1–2).

Debunk corporate arguments

The corporate playbook includes a wealth of arguments and rhetorical devices—such as the nanny state, personal or individual responsibility, partnership, and freedom—that are used as arguments to protect commercial interests and harm public health interests.^{2, 29} These arguments, supportive of unrestrained capitalism and neoliberalism, generally present corporations as benevolent actors, the government as intrusive, and individuals as irresponsible. Indeed, the push for multistakeholderism (especially in the development of the Sustainable Development Goals) is but the most recent manifestation of the pervasiveness of neoliberal paradigms in global governance.⁶ Challenging these arguments and ideologies requires far more than academic evidence. These values are so deeply embedded in the fabric of society they might be seen not just as values, but rather truths. Thus, a public health counter-strategy begins with putting forward an alternative set of values centred on equity. This approach includes continual re-emphasis that the ultimate causes of poor health and health inequity are structural—the social, political, and economic determinants of health.³⁰ In addition, it emphasises that government regulations, including progressive taxation, are the most important evidence-based mechanisms to protect public health.³¹ There are multiple strategies that can amplify public health messages (appendix 2 pp 1–2).

Leverage diverse commercial interests

The commercial sector is far from homogeneous, and the diverse interests of commercial actors can be used to leverage power against power.¹¹ The divestment agenda is an excellent example of using one element of the commercial world against another. This strategy has focused thus far on a narrow set of commodities (tobacco, fossil fuels, and controversial weapons in particular), but there are calls for more health-focused investment and divestment activities.³² The ongoing negotiations over the UN Binding Treaty on Business and Human Rights could provide further opportunities to promote a pro-equity agenda.

Public health actors can also seek to fragment powerful industry associations. For example, the issue of genetically modified organisms and added sugar labelling in the USA has led several major food companies to renounce membership of the Grocery Manufacturers Association, and the American Legislative Exchange Council has lost numerous members because of its opposition to climate change policies.^{11, 33} A similar pattern has occurred with companies revoking sponsorship of controversial organisations, such as the National Rifle Association. Weakening the powerful lobby groups that industries use is one avenue to rectify the gross power imbalance between public health and corporate actors.

Strengthening the capacity of public health to take on corporate interests

The public health playbook set out in this Viewpoint offers an initial step towards consolidating relevant ideas, practices, and approaches from within and beyond public health to develop a counter-strategy. It seeks to amplify inherent assets within the public health community and create opportunities to counter the corporate playbook. Its study and application could become an important part of training in public health and of the work to regulate products, practices, and policies of health-harming and planet-harming industries and their supporting actors. The public health playbook could also be used to assess the current resources of a public health team and to establish which areas of this team need strengthening. It could include the development of specific objectives, goal setting, and establishing measures of progress.

We acknowledge that the strategies we present here are far from exhaustive. Moving forward, there is a need for further work to develop a rigorously researched and tested public health playbook. Although both the corporate playbook and the public health playbook present generalised strategies, future iterations of the public health playbook could be adapted to focus on specific contexts or issues. These adaptations of the playbook could include a regional or national focus, a focus on a particular industry or commercial organisation, or on countering a particular commercial practice. They could also be tailored to specific public health domains, recognising that the public health workforce itself is diverse and operates with differing opportunities and constraints. Systematically identifying examples of best practices around the world could complement ongoing work to understand and develop mechanisms to challenge the dominance of commercial actors.^{34, 35, 36} These next steps all highlight different but complementary roles for the many stakeholders who have an interest in promoting and protecting public interests.

Declaration of interests

We declare no competing interests.