Our Postpandemic World: What Will It Take to Build a Better Future for People and Planet?

Policy Points

• Despite the pandemic''s ongoing devastating impacts, it also offers the opportunity and lessons for building a better, fairer, and sustainable world.
• Transformational change will require new ways of working, challenging powerful individuals and industries who worsened the crisis, will act to exploit it for personal gain, and will work to ensure that the future aligns with their interests.
• A flourishing world needs strong and equitable structures and systems, including strengthened democratic, research, and educational institutions, supported by ideas and discourses that are free of opaque and conflicted influence and that challenge the status quo and inequitable distribution of power.

     

The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID‐19 Pandemic,Economic Downturn,and Racial Inequity

Policy Points

•  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.
•  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.
•  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.
•  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post‐COVID‐19 world.

The united states finds itself amid three concurrent and interrelated crises. First, at the time of writing, the United States has reported more than 27 million confirmed COVID‐19 cases and more than 500,000 Americans have lost their lives. ¹ Second, in part as a consequence of the physical distancing measures enacted to slow the spread of the pandemic, the United States has faced record unemployment, a rise in the number of Americans unable to afford medical insurance, an end to federal support measures, and an uncertain economic outlook. According to the US Department of Labor, more than 50 million Americans have filed for unemployment benefits since the COVID‐19 pandemic started; more than 10 million Americans remain on state unemployment benefits. ² Third, the country is still contending with how to respond to mass civil protests in 2020 unlike any seen in half a century, triggered by the killing of George Floyd at the hands of police in Minneapolis. This civil unrest reflects centuries of structural racism and has brought unprecedented attention to this problem. ³ , ⁴ , ⁵ In each of these three concurrent crises, the pandemic, ongoing large‐scale unemployment, and civil protests, ⁶ the US federal response has been criticized as being delayed and poorly coordinated, involving downplaying the threat posed by the pandemic and building on longer‐term failures by previous administrations to make investments in public goods that may have facilitated a more robust and effective collective response.By contrast, it would appear that some of the largest entities in corporate America have responded more rapidly to each of the ongoing crises than the federal government has. A number of large companies have engaged in activities that responded to needs emerging from the pandemic, such as producing hand sanitizer, ⁷ setting up COVID‐19 testing sites, ⁸ and partnering on contact tracing. ⁹ Most notably, the pharmaceutical sector has contributed to an unexpectedly and unquestionably successful vaccine development process for SARS‐CoV‐2, with almost 200 million shots already distributed. ¹⁰ In response to the economic downturn, many companies have been adapting their business practices to supply essential services in a time of great disruption. For example, food and other essential businesses have largely kept supply chains for essential goods open, ¹¹ through extending working hours, hiring additional staff, and implementing new means of operating. Several large employers have responded to changing circumstance, aiming to keep as many employees working as possible, often through an embrace of remote working and implementing more permanent shifts into patterns of working. ¹² In response to the global protests around structural racism that erupted in 2020, a number of large companies, including Nike, Reebok, Twitter, and Citigroup, have publicly aligned themselves with the Black Lives Matter movement, ¹³ including committing more than a billion dollars in pledged donations. ¹⁴ In a moment of great national turmoil, when government seems not up to the task, private sector actors have appeared, by contrast, to be better positioned to address the three crises of the moment. This plays neatly into a private sector–centric narrative, and there is little question that much good has come from elements of the private sector during this time.It is certainly true that these visible private sector efforts have contributed to helping populations deal with the consequences of an unprecedented global pandemic. But, given the emerging evidence about the populations at risk for COVID‐19, and why that risk exists to begin with, it is legitimate to ask: in the case of COVID‐19, what was the contribution of the private sector in creating the conditions that made us vulnerable to the pandemic and its consequences to begin with? And, by extension, how can private sector actions align with a durable set of solutions to the crises that characterize this moment?We already know that large, consolidated corporate entities, particularly those that manufacture harmful products, can have profound effects on population health. ¹⁵ , ¹⁶ , ¹⁷ The most obvious way in which this manifests is through “market activity,” that is, the direct consequences of manufacturing and marketing particular products. For example, it is easy to recognize that marketing of cigarettes harms health. However, such actors also influence population health through a range of “nonmarket” activities that shape the political, social, and cultural environments that they operate in. ¹⁸ Examples of this activity include political donations, lobbying, corporate social responsibility initiatives, and legal activity. These activities, often seen as intrinsic to corporate practice, support and protect commercial interests, yet do not necessarily promote population health or structures of governance. Bearing this in mind, it is worth understanding how such activities, both market and nonmarket, have contributed to the vulnerability of the United States to the three crises we now face.     

Dark Nudges and Sludge in Big Alcohol: Behavioral Economics,Cognitive Biases,and Alcohol Industry Corporate Social Responsibility

Policy Points

• Nudges steer people toward certain options but also allow them to go their own way. “Dark nudges” aim to change consumer behavior against their best interests. “Sludge” uses cognitive biases to make behavior change more difficult.
• We have identified dark nudges and sludge in alcohol industry corporate social responsibility (CSR) materials. These undermine the information on alcohol harms that they disseminate, and may normalize or encourage alcohol consumption.
• Policymakers and practitioners should be aware of how dark nudges and sludge are used by the alcohol industry to promote misinformation about alcohol harms to the public.

Context“Nudges” and other behavioral economic approaches exploit common cognitive biases (systematic errors in thought processes) in order to influence behavior and decision‐making. Nudges that encourage the consumption of harmful products (for example, by exploiting gamblers’ cognitive biases) have been termed “dark nudges.” The term “sludge” has also been used to describe strategies that utilize cognitive biases to make behavior change harder. This study aimed to identify whether dark nudges and sludge are used by alcohol industry (AI)–funded corporate social responsibility (CSR) organizations, and, if so, to determine how they align with existing nudge conceptual frameworks. This information would aid their identification and mitigation by policymakers, researchers, and civil society.MethodsWe systematically searched websites and materials of AI CSR organizations (e.g., IARD, Drinkaware, Drinkwise, Éduc''alcool); examples were coded by independent raters and categorized for further analysis.FindingsDark nudges appear to be used in AI communications about “responsible drinking.” The approaches include social norming (telling consumers that “most people” are drinking) and priming drinkers by offering verbal and pictorial cues to drink, while simultaneously appearing to warn about alcohol harms. Sludge, such as the use of particular fonts, colors, and design layouts, appears to use cognitive biases to make health‐related information about the harms of alcohol difficult to access, and enhances exposure to misinformation. Nudge‐type mechanisms also underlie AI mixed messages, in particular alternative causation arguments, which propose nonalcohol causes of alcohol harms.ConclusionsAlcohol industry CSR bodies use dark nudges and sludge, which utilize consumers’ cognitive biases to promote mixed messages about alcohol harms and to undermine scientific evidence. Policymakers, practitioners, and the public need to be aware of how such techniques are used to nudge consumers toward industry misinformation. The revised typology presented in this article may help with the identification and further analysis of dark nudges and sludge.     

The Evolution of Supply and Demand in Markets for Generic Drugs

Policy Points

• Much concern about generic drug markets has emerged in recent policy debates.
• Important changes in regulations, the structure of purchasing, and the length of the drug supply chain have affected generic drug markets.
• Effective price competition remains the rule in generic markets for large‐selling drugs. Smaller markets and those for injectable products often have less price competition and are more susceptible to supply disruptions.

ContextThe image of generic drugs as a commodity sold in competitive markets is an oversimplification, as evidenced by increasing accounts of price spikes, sustained high price‐cost margins, and market disruptions. The mismatch between the canonical economic model of generic drug markets and reality motivated our empirical project.MethodsTo explore recent changes in those factors impacting the supply and demand for generic drugs, we studied, from a variety of sources, the data on price, competition, supply disruptions and recalls, changes to the supply chain, and buy‐side concentration. We examined quarterly data through 2018 for a cohort of 77 molecules that lost patent protection during the so‐called patent cliff between 2010 and 2013.FindingsOn the supply side, we found that for large‐market oral solids, generic entry and price declines were consistent with past studies showing a significant number of market entrants and substantial reductions in the average price of a molecule. In smaller markets for oral solids and injectable products, we observed fewer entrants, higher rates of exit, smaller price reductions, and, in some cases, considerable price instability. The number of reported shortages increased across all generic market types over time, with the rate of shortage increases especially pronounced in markets for injectable products. The number of product recalls also rose over our study period. Although we did not estimate causal effects, we did find several changes in the market environment for generic drugs that may contribute to these phenomena. The demand side for generics has become more concentrated. Supply chains rely more on producers outside the United States (particularly from China and India). Contracting practices have undergone changes that may inhibit competition in product supply. FDA regulatory scruitiny has increased.ConclusionsCompetition in generic drug markets varies widely by market size and product form. Recent changes in demand‐side market structure imply more downward pressure on prices stemming from buy‐side concentration. The FDA''s greater regulatory oversight puts upward pressure on costs, and the lengthening of the supply chain increases production uncertainty for producers. Demand and supply‐side changes point to further market instabilities across all generic markets due to producers’ changing economic position.