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J Urban Health. Jul 2008; 85(4): 462–471.
Published online Apr 25, 2008. doi:  10.1007/s11524-008-9278-7
PMCID: PMC2443242

Cities of Consumption: The Impact of Corporate Practices on the Health of Urban Populations

Abstract

The increasing concentration of the world’s population in cities and the growing accumulation of political and economic power by corporations create new threats to health and opportunities for improving global health. By considering the intersection of these two fundamental social determinants of well-being, we elucidate some of the mechanisms by which they influence the health of urban populations. After reviewing the changing historical impact of corporations on cities, we focus on the growth of consumption as a leading cause of mortality and morbidity and describe how the food, tobacco, automobile, and other industries promote unhealthy behaviors and lifestyles in urban settings. Cities are also sites for developing alternatives to unhealthy corporate practices, and we assess strategies used to modify practices that harm health.

Keywords: Urban health, Corporate practices, Urban populations, Cities, Corporations.

Introduction

In the twentieth century, two trends changed the world: the increasing concentration of population in cities and the growing accumulation of political and economic power by corporations. In this paper and in this special section of the Journal of Urban Health, we consider the intersection of these global trends and their impact on population health. This year marked the first time in history that more than half the world’s population lived in cities. By 2030, three-quarters of the world’s population is expected to be urban, creating both new threats to health and opportunities for improving global health.1,2

At the start of the twenty-first century, 51 of the 100 largest economies in the world were corporations, and the combined sales of the world’s top 200 corporations were larger than the combined economies of all countries excluding the biggest 10.3 Today, corporations influence every aspect of human experience, from diet, air pollution, work, and health care to personal identity, life style, sexuality, and governance. In many ways, the decisions that the managers of large multinational corporations make about production, marketing, and investment may now have greater influence on patterns of health and disease than the decisions of public health officials.

Yet despite this growing importance of corporations, public health researchers have rarely studied corporations or the free markets in which they are embedded as direct social determinants of health. In addition, few investigators have systematically studied the joint influence of the growth of cities and of corporations on the health of populations. In this special section of the Journal of Urban Health on corporations and urban health, we explore some of the ways that these two dominant social processes have influenced population health in recent decades. Our goals are to elucidate some of the mechanisms by which these interrelated trends influence health, to open new avenues for research, and to guide the development of interventions that can improve health.

In previous work, we have proposed frameworks for studying how city living affects health4 and, separately, how corporate practices influence health.5 In this paper, we seek to integrate these perspectives. By making the invisible hand of the market more visible, we hope to illuminate new approaches to promoting urban health.

Historical Perspective on Cities and Corporations

Cities and corporations have an intimate historical relationship; both are products of the evolution of markets and both were transformed by industrialization. Cities first emerged as agriculture produced surpluses that enabled population concentrations not directly dependent on farming. As populations grew, labor became more differentiated creating ever more specialized markets. Technological developments enabled fewer people to produce sufficient food to sustain humanity, pushing populations out of the countryside and into cities where the availability of cheap labor attracted employers, further concentrating populations. As cities became centers of production and selling, they also became nodes of trade and commerce, further amplifying their economic and political position. From their earliest days, cities were also generators of inequality, enabling some to accumulate wealth and power whereas large portions of the urban population lived in squalor.

Corporations first emerged in the cities of Europe in the sixteenth and seventeenth centuries as a way of pooling capital to invest in commercial opportunities that no single investor could realize on his own. Their distinct feature was the separation of ownership from management, creating more distant relationships among owners, managers, workers, and consumers, thus reinforcing the more anomic culture of cities compared to towns and villages.

In the nineteenth century, corporations helped to amass the capital necessary for building the railways, canals, and other infrastructure needed to sustain the industrial revolution. By the end of that century, both England and United States had passed laws limiting the personal liability of investors for the harm caused by their business activity and loosening controls on mergers and acquisitions,68 thus setting the framework for the modern corporation. By the twentieth century, corporations had become the dominant economic and political organization in the US and other developed nations.

Cities, Corporations, and Health throughout History

As cities grew and corporations evolved, their contribution to the health of populations changed. In earlier periods, corporations affected cities primarily as centers of production. The income they provided enabled some workers to have a higher standard of living than rural residents although many urban working class people lived in grim poverty.9 Occupational hazards were also common and the close proximity of commercial and residential neighborhoods aggravated exposure to harmful conditions. Cities were also centers of trade and commerce and the first multinational corporations emerged to handle the flow of goods, services, and people between developed world cities and colonial empires in Latin America, Asia, and Africa. These interchanges facilitated the spread of epidemic diseases and business leaders often resisted public health measures to control communicable diseases, fearing that the acknowledgement of epidemics would hurt their businesses.10

But cities changed, and so did their workforces and the hazards they faced. In the twentieth century, as manufacturing jobs moved out of urban areas, at least in the developed world, a new urban work force emerged that included service workers and a growing informal economy,11 which has a more indirect relationship with corporations. As manufacturers moved out of developed world cities to find places in both developed and developing countries where wages, taxes, regulation, and land prices were lower, new industries emerged in cities, including service and information-based industries like finance, insurance, health care, and social services. These changes transformed both the occupational and environmental health threats posed by urban settings and also contributed to increases in sedentary life styles associated with many chronic diseases.12 In addition, the corporate abandonment of some cities led to the growth of an informal economy and illegal businesses, which moved to fill voids in goods and services and employment opportunities.13 In some cities in both the developed and developing world, the illicit drug economy, for example, became a major employer of young people and a major contributor to the spread of infectious diseases, violence, and substance abuse.

Modern public health was founded in part as an effort to document and reduce the harmful impact of industrialization on the health of urban populations, and in many ways, public health theory and practice has tried to keep up with changing cities and their relation to the health of urban and nonurban populations. Chadwick in England, Villerme in France, and Virchow in Germany all advocated for the modification of the most health-damaging aspects of industrialization and urbanization, e.g., provision of clean water, development of public sanitation, improved housing, safer working conditions, and safe food,10 contributing to substantial improvements in health. Beginning in the eighteenth century, health researchers focused on the occupational health consequences of various industry practices—from working in the textile factories that defined England’s industrialization to installing asbestos insulation in the post-World War II construction boom.14,15

More recently, beginning in the 1980s, some researchers have studied the impact of deindustrialization, the withdrawal of capital, employment, and other resources from cities.16 In places like Detroit, Pittsburgh, Glasgow, British Columbia, and others,1719 corporate decisions to shut facilities or move them to lower wage regions led to population loss. At the municipal level, investment in some neighborhoods and disinvestment in others led to cycles of decline and gentrification and contributed to growing intraurban disparities in health. In some cases, decisions by banking, insurance, and housing businesses initiated these changes; in others, the municipal government itself was the lead actor. Changes in the housing market, for example, played a role in the emergence of homelessness as an urban health and social problem.20,21 Bank decisions to “redline” certain urban districts by refusing to offer mortgages led to housing segregation,22 further isolating low income communities and concentrating their adverse health effects.

Public health researchers concerned with environmental justice also emerged in the past quarter century as leading thinkers about the environmental consequences of modern corporate practices and urban and periurban life. As companies left cities, they often left a toxic residue behind. In the United States, the Love Canal crisis of 1978 focused public and media attention on the residue of toxic pollution in many US towns and cities, often in areas abandoned by manufacturers. Other cities plagued by the residues of industrial pollution include Woburn, Massachusetts, Newark, New Jersey, and Cleveland, Ohio.23 More recent research has documented the substantial mortality and morbidity attributed to air pollution from automobiles, power plants, and other sources.24 Whereas these pollutants can be found in both urban and nonurban settings, high population density and human-built and natural barriers to dispersion in urban settings magnify the adverse health effects in cities.25 In these cases, the decisions by the transportation industry to emphasize producing and marketing personal vehicles rather than subways or buses and by power plants to oppose the installation of pollution control technology contributed to the urban pollution penalty.2628

As consumption became more central to the global economy, public health researchers also shifted their attention from the (urban) living conditions associated with the expanding market economy to individual behavior. By the middle of the twentieth century, public health focused on modifying life styles associated with ill health, e.g., smoking, diet, and physical inactivity, and providing individuals with affordable health care. These changes reflected the successes of public health in containing infectious disease epidemics, the emergence of more complex chronic diseases as major causes of ill health, and the ideological emphasis on individualism and personal responsibility. To deter government regulation, corporations have played a major role in promoting that individualist perspective.29

Urban Consumption, Corporate Practices, and Health Today

In the late twentieth and early twenty-first centuries, cities have become centers of consumption, which has become as important a driver of the global economy as production and commerce were in earlier periods.30,31 This transformation is both a consequence of the growth of cities and corporations and a cause of their changing impact on health. Consumption cities have become the ideological command and control centers of the global economy, influencing aspirations, life styles, and behaviors in both developed and developing world. Just as Constantinople and Rome spread values and beliefs in earlier times, New York, Rio de Janiero, London, and Paris now set the standard for the world, influencing what people eat, drink, drive, and wear, as well as how they define their identity. On a more operational level, cities are home for the advertising, public relations, lobbying, accounting, and law firms that spearhead expanding corporate influence. These corporate agents now play a central role in shaping patterns of consumption and values related to health.32 In this issue, Jahiel presents a conceptual framework for the study of corporate-induced diseases and discusses its relevance to urban health.33

To illustrate some of the ways that the decisions of corporate managers influence population health, we describe briefly the history of three products that have had a major impact on the health of cities: cigarettes, sports utility vehicles, and fast food. Whereas each of these also influences the health of society as a whole, an examination of the unique roles of these products in urban areas may provide insights that can guide prevention policy.

Cigarettes

In the twentieth century, about 100 million people died from tobacco-related diseases; and in the twenty-first century, one billion such deaths are predicted.34 As Brandt has shown in his recent social history of cigarettes,35 tobacco became a major cause of ill health when the technology was invented for mass production and corporations were created to produce, market, and promote tobacco. By the early twentieth century, the tobacco industry was promoting cigarettes as a quintessentially urban product showing sophistication and modernity.

Tobacco advertising worked hard to make smoking acceptable in public places, helping to change earlier norms that had discouraged such use. Unlike alcohol, tobacco helped people cope with everyday stress without interfering with work and family relations, at least in the short run. As with other products, urban dwellers were often the early initiators of cigarette use and also the trend setters for other sectors of the population. Tobacco executives understood that the United States was urbanizing and that cities presented dense, dependable, and growing markets. As we see in the Williams et al. report in this issue,36 tobacco marketers are now applying these same lessons in South Africa and elsewhere in the developing world.

Throughout the twentieth century, urban populations continued to attract cigarette marketers. Whereas tobacco advertising used the rural image of the Marlboro Man in the 1950s and 1960s designed to appeal to urbanites wishing to escape, by the 1980s, Joe Camel strolled onto the scene, a sophisticated clearly urban character, wearing sunglasses and enjoying jazz clubs. Joe Camel’s mission was to convince young people, especially those attracted to urban life styles, to take up smoking.

Cities also presented unique marketing opportunities. In many developed and developing world cities, low income and adolescent smokers can only afford black market or single cigarettes (“loosies”), so an illicit tobacco economy emerged.37,38 Tobacco manufacturers consistently opposed plans to regulate or enforce existing laws, allowing this market of vulnerable consumers to flourish. At the World Health Organization’s meetings to develop an international treaty on tobacco control, the tobacco industry successfully opposed provisions for global efforts to reduce illicit sales of tobacco.39 Thus, from the municipal to the global level, the tobacco industry has successfully thwarted public health measures to reduce exposure to tobacco.

Sports utility vehicles (SUVs)

SUVs are vehicles with a pick-up truck underbody, high ground clearance, enclosed rear cargo area, and availability of four-wheel drive.40 From the early 1990s to 2005, SUVs were the best-selling and most profitable vehicles made by the US auto industry. By 2000, SUVs and pick-up trucks accounted for 40% of US motor vehicles, which doubled the 1980 rate.41

SUVs pose several health and environmental problems. Compared to sedans, they are more likely to roll over, to kill the occupants of cars and pedestrians they hit, to give their drivers a false sense of security that leads to riskier driving, and to emit more pollutants.4244 Based on a review of scientific and government reports, Bradsher estimated that SUVs account for roughly 3,000 excess deaths each year.40

What do SUVs, a vehicle originally designed for farm and military use, have to do with cities? According to auto industry reports, in the 1990s, the fastest-growing markets for SUVs were in the nation’s wealthiest cities—Houston, West Palm Beach, and the prosperous suburbs of Los Angeles.40 Despite being ill-suited for urban use—they are hard to see around and park, make traffic congestion and air pollution worse, endanger pedestrians, and attract thieves—the auto industry marketed SUVs to well-off urban males, portraying them as a vehicle to escape urban stress, protect against crime, and safeguard drivers. Between 1990 and 2001, the auto industry, the nation’s largest advertiser, spent more than $9 billion on SUV ads. As SUVs bring the auto industry profit margins 10–12 times higher than sedans, targeting a market with deep pockets made financial sense but at the expense of urban health.40

Fast food

Since its inception in the 1950s, McDonalds has become the leading global foodservice retailer with more than 30,000 local restaurants in more than 100 countries.45 As more people eat more outside of their homes, more women work, and more people live alone, fast food establishments provide a growing share of food consumption. Fast food companies prefer urban locations for new facilities, and when they allocate new franchises, urban locations are selected because of their higher profitability.46,47 In addition, as retailers of more wholesome foods often avoid low-income neighborhoods, fast food establishments often become the only readily available food source in low-income neighborhood, perhaps contributing to growing income disparities in obesity in cities in the US and elsewhere.48

All three of these product stories show how corporate decisions affect health by encouraging or discouraging health-related behaviors and by shaping the urban environment. For products like cigarettes, SUVs, or fast food, the decisions by corporate managers to make some products and market to some populations but not others has had a decisive influence on urban population health, influencing the incidence, prevalence, distribution, and disparities in health and disease. On one hand, these businesses were simply responding to impersonal market forces, looking for ways to fulfill their legal mandate to maximize profits for their shareholders. On the other hand, their decisions contributed to millions of preventable deaths, providing a moral, legal, and political rationale for submitting them to closer scrutiny. In our view, the transformation of cities into sites for marketing and consumption will have a decisive impact on the health and sustainability of cities in the twenty-first century.

How Consumption Cities Threaten Health

As market economies became more proficient in producing and distributing goods, consumer needs were no longer sufficient for generating the demand needed to sustain profitability. As Greider has observed, modern capitalism makes too many products and not enough consumers.49 To create new needs and markets, businesses rely increasingly on advertising. In 2006, global advertisers spent $424 billion to promote their products,50 about $64 for every person on the planet and far more than the total global spending on public health campaigns. As illustrated by the tobacco, alcohol, firearms, and food industries, convincing more consumers to smoke, drink, eat, or fire a gun more generates profits, epidemics of chronic diseases and injury, and premature mortality. But the direct effects of promoting unhealthy behaviors and life styles are only part of the health consequences of consumption cities. More broadly, we suggest that making consumption a central dynamic of our urban economy and culture threatens health in several other ways.

First, overconsumption threatens the sustainability of cities. By their efficiencies in energy use, housing, and transportation, cities have the potential to reduce global warming, pollution, and other environmental problems.51 But this potential is undermined if corporations promote unsustainable life styles in the urban markets most able to afford their luxury products (e.g., SUVs). In many cases, more sustainable choices threaten profitability of a single industry—and in the current political system, such special interests can block remedial action.

Second, privatization of public space and services to create more opportunities for marketing and selling has led to a decline in civic space in cities.52 Such spaces have long nurtured democracy and provided a meeting ground for social movements. There is growing evidence about the salutary effect of public spaces on health,53 and loss of such space stands as a threat to the well-being of urban residents.

Third, as corporations spend ever-increasing amounts on promoting consumption, they have become the world’s de facto “health” educators—with the rise of corporate influence, cutbacks in public oversight, and general underfunding of municipal services, people get far more information about health from corporations than from public health agencies.

Fourth, the promotion of individualism and choice can lead to the breakdown of social cohesion and protective social norms. Each person who owns an SUV may be safer than those without but the overall consequence is worsening health for all. However, as companies benefit when people buy their products, corporations promote an ideology that endangers health. Individual choice unconstrained by collective will may well be antithetical to livable cities.

Cities as a Place to Reduce or Resist Corporate Harm

In the nineteenth and earlier twentieth centuries, physicians, scientists, reformers, and a variety of social movements forged a public health practice that worked to improve living conditions and mitigate the harm from industrialization and urbanization.54 At least in part, these efforts were directed at corporations and other business interests that profited at the expense of public health. Among the achievements of that era were the development of housing codes that required developers to meet certain health standards, the creation of the Food and Drug Administration in response to exposes of the food industry by Upton Sinclair and others, and the establishment of occupational safety and environmental pollution standards. As consumption has replaced production as the dominant health influence of the current free market system and as the decisions of corporate managers on the production, marketing, and distribution of their products have become significant determinants of health, what role has the public health community played in protecting population health?

Throughout history, cities have been birthplaces of social movements. Their dense social networks facilitate mobilization, their traditions of liberty and democracy provide an ideological foundation for protest and resistance, their concentrations of poverty and wealth make inequality visible, and their heterogeneous populations provide opportunities for diverse struggles to come together in new ways. Therefore, the confluence of the influence of urban living and corporate practices on health makes cities a natural crucible for social movements that are concerned with the health and social consequences of corporate practices. In recent years, urban movements for food justice, clean air, and gun control illustrate the continuing potential for popular mobilization against corporate practices. To date, however, the broader resistance against consumption cities has been modest.

A few examples illustrate both the potential and the difficulties of such efforts. Stop Uptown Cigarettes led a successful effort in Philadelphia, Pennsylvania to end the development of Uptown cigarettes, an RJ Reynolds Company brand targeted for Black smokers. With the help of local clergy, community leaders, and some national groups, Stop Uptown Cigarettes was able to halt the pilot before any cigarettes hit the shelves.55 Recently, many urban school districts have banned fast food outlets and processed foods from the school, spurred in part by parental and community pressure to protect children against obesity.56 In this issue, Simon describes a successful campaign to reduce youth exposure to alcohol advertising by banning alcohol ads in the San Francisco Bay Area public transportation system.57

In some places, state or municipal health departments have taken on corporate interests. In New York City, for example, the health department banned trans fats from the city’s restaurant, overcoming opposition from the food and food services industries.58 In this issue, Kaplan and Graff describe how municipal health departments have restricted the rights of infant formula companies to promote their products to the detriment of breast feeding.59 In Baltimore, the City Health Commissioner initiated a petition to the Food and Drug Administration to ban heavily advertised over-the-counter sales of cold remedies for children under six based on evidence that they were ineffective and occasionally harmful.60 New York and San Francisco have been leaders in adopting forceful measures against the tobacco industry including banning smoking in public places, raising the taxes on tobacco, and launching aggressive antismoking campaigns. The Mayors of Boston, New York, and dozens of other cities proposed new controls on how the gun industry provided oversight of the retail distribution of its products.61 These and other examples illustrate the potential for the city government to initiate action to modify corporate practices that harm health.

To be more effective, however, these varying strands of urban resistance to corporate promotion of disease will need to develop a more unified and coherent political agenda, learn how to frame issues so as to generate broad coalitions, better synthesize existing evidence on both the causes and consequences of unhealthy corporate practices, and evaluate the relative efficacy of various strategies to modify corporate practices. In fact, these tasks constitute the starting points for a scientific and political agenda for public health professionals who seek to improve the health of urban populations. The following articles, we hope, will contribute to the development of an alternative agenda for healthier cities.

Footnotes

Freudenberg is with the Program in Urban Public Health, Hunter College, City University of New York, New York, NY, USA; Galea is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.

Contributor Information

Nicholas Freudenberg, ude.ynuc.retnuh@neduerfn.

Sandro Galea, Phone: +1-734-6479741, Fax: +1-734-7635706, ude.hcimu@aelags.

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