For much of history, the word 'epidemic' applied to infectious diseases. Large numbers of cases of disease caused by organisms such as bacteria and viruses that spread through water, air, or other means, sometimes transmitted from person to person, or back and forth between people and animals. Then came epidemics of chronic diseases such as obesity, diabetes, heart disease - diseases occurring in very large numbers and created not by infectious agents, but by drivers in our day to day lives, such as a bad food environment. A new paper was just published in the PLOS global health literature that I found fascinating. It focuses on another use of the concept of epidemics: market driven epidemics. Let's find out what these are and find out a little bit more about their implications for our health and wellbeing. Our guests today are two of the authors of that paper. Dr. Jonathan Quick is a physician and expert on global health and epidemics. He is an adjunct professor at Duke University's Global Health Institute. Eszter Rimanyi joins us as well. She works on chronic disease and addiction epidemiology at Duke university.

Interview Summary

Access the PLOS article “Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption.”

So, Jono, let's start with you. Tell us what you mean by market driven epidemics.

The pattern is familiar to people. There is a product that that humans like and the business community says we can make a lot of money on this unmet need. And so they do that and they start selling a lot of it. And then people start noticing that this thing that the humans like is killing some of them. And so, the scientists do the public health. And then the business community says these scientists are going to kill the golden goose. They buy up other scientists and try to defend themselves. And then it goes on and on before we really bend the epidemic curves. This pattern of consumer products that have harmful effects, those products are major contributors to the root causes of at least a million deaths a year in the US, and over 20 million deaths worldwide.

So, to try to look at this from an epidemic point of view, we first established a case definition. Our definition of market driven epidemic is a significant increase in death, disability and other harmful effects on humans and human health and wellbeing. It's arising from a consumer product whose use has been accelerated by aggressive marketing. Whose harmful effects have been denied or otherwise minimized by producers. And for which effective mitigation is possible but actively opposed by producers.

So, we looked at the natural history of this, and we found five phases through which these epidemics pass. There's market development, either inventing a new product, developing a product like prescription opioids, or transforming an existing product like tobacco. Phase two is evidence of harm. First, there's suspicion, astute clinicians, whistleblowers, and then eventually proof of harm. Phase three is corporate resistance. Companies deny harm, seek to discredit accusers, commission counter science, manufacture doubt, mount legal challenges. All the while deaths and social upheaval and economic costs are mounting. And finally, our next phase four is mitigation. We get some regulatory efforts going, and there's a tipping point for the consumption and resulting deaths. And then finally, phase five of this is market adaptation. In a response to decreasing or threatened consumption, companies and consumers typically seek alternatives. Adaptations can be positive or negative. Some are healthier, some are equally or more harmful.

Thanks very much for that description. It really helps explain what the concept is all about. You chose three areas of focus. You could have chosen others, but you chose cigarettes, sugar, and prescription opioid use. Why those in particular?

We wanted to identify differences in these market driven epidemics in a few product categories. We wanted to look at distinctly different consumer experiences so we could see what worked and what didn't in terms of bending the epidemic curve. We picked nicotine delivery, food, and prescription medicine. And to choose within those categories we established five inclusion criteria. So, number one, the product had to have proven adverse health effects. Number two, there needed to be well documented histories of product development, marketing, mitigation efforts, and so forth. Number three, the product needed to meet the overall case definition. That is, companies knew they were doing harm, continued to do harm, and fought that harm. Number four, there needed to be long term data available for product consumption and associated impact. And number five, most important, we chose products for which mitigation efforts had already resulted in significant sustained reduction in product consumption. Based on these three criteria, cigarettes, sugar, and prescription opioids came out as the ones that we studied.

Thanks. I really appreciate that description. And when we get to the punchline in a minute, it's going to be interesting to see whether the behavior of the industry in this natural history that you talked about is similar, given that the substances are so different. We'll get to that in a minute. So Eszter, I'd like to turn to you. What kind of information did you pull together to write this paper?

I think I looked at over a thousand different documents. But there were two clear types that I interrogated to pull together all of our background data. The first category was publicly available data, so that could have been a clinical study, epidemiological study, advertisement by the company, CDC or other government reports, mortality data, etc. But then there was also a distinct different type of data that we really looked at and that was really useful for putting together these pictures of the natural history, which was internal documents. In some cases, these could have been leaked by an internal employee, which was the case with the so called 'brown documents' with tobacco. But it also came from sometimes court hearings or as a result of lawsuits that the companies had to release internal data. It was really interesting to compile together the different sides, of the outside look from CDC reports, and then the insider scoop from Purdue Pharma. So, it's a very well rounded, interesting way to find all this data.

I admire your effort. It's a big job to do a normal scientific review where you might have 50 papers and you were looking at things that were much harder to obtain and a vast number of things that are really quite different in character. Boy, congratulations for just reading all those things. Tell us what you found.

Gosh, so even though there's so many distinct differences between a lot of these epidemics, what we actually found was that there was a lot of narrative similarities. And because of that, we could really create this holistic, but also really well-fitting idea of market driven epidemics. A lot of the corporate strategies were either mirrored, imitated, or in some cases quite literally lifted over because of overlapping ownership between the companies.

One of the things that we really wanted to hammer into our article was that producers not only created their product, but they also manufactured doubt. Which means that they created, on purpose, public hesitancy around their product even when they internally knew that it was harmful to health. They wanted the public to be on the fence about what the health impact of their product was. There was a lot of different ways that they achieved that goal. Sometimes it was through showing propaganda films in high schools. Which I still can't believe that happened and then that was legal. But also in different ways, like co-opting science, paying scientists to publish articles in their favor. I know a really famous example of this that has now been public is that two Harvard researchers in cardiovascular disease published saying that sugar was not harmful to health. So, there's a lot of different ways that they achieved it, but the goals overall were very similar by all the companies.