In a highly competitive global health funding environment, funds from corporations and foundations linked with specific corporations ("corporate funds") are increasingly considered as a core source of support. (1-3) Corporate sectors such as pharmaceutical, agri-food, resource extraction, and information technology have contributed to urgently-needed research, capacity-building and interventions, although their contributions earn them significant tax breaks and are therefore partially subsidized through foregone public revenue. (1,3,4) Reasons for this prominence of corporate funding are complex, but include reduced public investments in research, reduced public revenues through tax reductions and avoidance, and increasing faith in private-sector solutions for health problems. (2-4) In this funding climate, researchers and organizations contemplating corporate funding sources to support their work encounter unique challenges, particularly in confronting the potential for competing interests. As a group of global health researchers, from emerging to seasoned, we convened a workshop at the 2015 Canadian Conference on Global Health to explore such risks and benefits. We extend this exploration here by articulating a set of questions to support critical reflection on corporate financing for global health research, using selected examples from multiple corporate sectors. Our objective is to promote a cautionary and intentional approach to considering relationships with corporate funders.

Guidance for navigating interactions with corporations

Many universities and medical organizations have developed policies regarding the acceptance of tobacco or pharmaceutical industry funds. Five tests have recently been proposed for governments and international agencies to apply when considering partnerships with large corporations, asking whether a proposed corporate partner: markets health-damaging products or services;promotes health in its own workplaces; submits its corporate social responsibility (CSR) activities to independent audit;contributes to "the commons" by, for example, sharing data with researchers; or exerts inappropriate influence on public policy-making. (5) Existing guidelines, while valuable, tend to deal with overt conflicts of interest, obviously health-damaging products (e.g., tobacco), or clear interference with research or policy design. In addition to obvious conflicts of interest, our questions address more subtle or indirect potential impacts of corporate partnerships, to promote equity-focused navigation of new and potentially controversial issues.

Question 1: Does this funding allow me/us to retain control over research design, methodology and dissemination processes?

The direct effects of corporate funding on public health science are illustrated by empirical findings such as the significantly higher likelihood that industry-funded studies of drugs and medical devices will return results favourable to the commercial interests of the corporations funding them. (6) Such "industry bias" may occur through influences on research question framing, the design or conduct of the study, data analysis, selectively reporting favourable results, and spin in interpretation of results in discussion/ conclusion sections. (6) Such biases may result from understandable phenomena such as self-censorship and feelings of collegiality with corporate funders, even when no overt pressure is placed on researchers. In response to such possible biases, many journals and conferences require the disclosure of conflicts of interest, and trial registries have been instituted to minimize publication bias, although inventive strategies are nevertheless employed by many corporations to generate scientific knowledge supportive of their interests. (3,4)

Question 2: Does accessing this funding source involve altering my/our research agenda (i.e., what is the impact of this funding source on research priorities)?

Experienced and careful researchers may be able to carry out rigorous research with corporate funding. A more subtle risk is posed by the influence of corporations on overall choice of study topics. While the issue of inappropriately-targeted research arguably extends to funding priorities of governments, corporate priorities are established through publicly-unaccountable mechanisms that support their commercial interests. (7) Recently, research on physical activity's relationship to obesity has been promoted by the Coca-Cola Company as a way of diverting attention away from sugar consumption. (8) Less obviously, the Rockefeller Foundation in the early 20th century promoted a model of international health based on technical interventions (e.g., hookworm eradication) that would demonstrate quick results, rather than tackling diseases such as tuberculosis, with its greater burden of disease but more complex and politically-controversial interventions (e.g., reducing poverty). Important similarities exist between this technical approach to international health and the seemingly apolitical, technology-focused global health funding of the Bill & Melinda Gates Foundation. (9) Researchers have finite amounts of time and energy, and devoting these precious commodities to technology-based funding streams means they are not available to advance effective upstream interventions. Importantly, the effects of the Rockefeller and Gates Foundations on priority-setting do not directly relate to harmful substances produced by their associated corporations (Standard Oil and Microsoft respectively).

Question 3: What are the potential "unintended consequences" of accepting corporate funding, in terms of legitimizing corporations or models of development that are at the root of many global health problems?

An example from the mining sector further illustrates the need to go beyond direct conflict of interest in assessing the global health implications of corporate funding. Over the past two decades, groups such as marginalized Indigenous communities living in mineral-rich areas around the world have increasingly come into conflict with mining companies over the effects of large-scale mining on local environments, or violence by mine security personnel against local communities. (10,11) Another root of conflict has been the lack of local economic development created by technologically-intensive large-scale mining, which generates relatively few jobs and requires highly-qualified personnel not often available in local communities. Resulting conflicts pose an image problem for the global mining sector, which has responded to protect its highly-profitable access to mineral resources through CSR activities such as promoting local employment or conducting environmental monitoring. (10,11)

While the health implications and community benefits of specific mining projects and community-level CSR initiatives must be evaluated on a case-by-case basis, the funding of universities by mining companies is part of a broader strategy. Against the backdrop of declining public investments in universities, mining companies donated at least $459.6 million a conservative estimate based on review of university and mining company websites--to Canada's 21 largest universities between 1995 and 2011. (12) Donations to respected sectors such as health and research are effective ways for corporations to portray themselves as positive contributors to society, and thereby promote voluntary forms of governance. (11,12) This overall strategy has allowed the industry to avoid legislation such as Bill C-300, which would have held Canadian mining companies to basic human rights and environmental standards when operating abroad, but was narrowly defeated in 2010 after a massive industry lobbying effort. (10,12) The mining industry has instead been vigorously promoted abroad by the Canadian government through mechanisms such as bilateral trade agreements. (10) Foreshadowing such bilateral agreements, promotion of unrestricted access to mineral resources by multinational corporations has been central to "structural adjustment programs" imposed by international financial institutions with the nominal goal of promoting economic growth in indebted countries of the global South. (10,11) Health consequences of the structural adjustment--or more recent "austerity"--model occur through pathways that include reduced health system capacity, increased income inequality, and decreased protections for workers and the environment. (13) This example suggests that accepting corporate funding for global health activities may inadvertently legitimize corporations and economic models with negative consequences that outweigh any short-term health gains produced by a particular research project or program. We recognize that the arguments involved in building such a hypothesis are not uncontested. Blindly accepting the converse position, however that funding of academic research has no impact on the societal image of the mining sector and of macroeconomic policies related to it--would amount to a leap of faith, based on no credible evidence that we have been able to uncover. Research on the possible relationship between academic funding decisions and both small- and large-scale determinants of health is clearly needed. In the meantime, researchers concerned with broader economic and political dimensions of global health governance and research funding may find public health-relevant resources on economic theory helpful. (14)

CONCLUSION

Application of the above questions may be helpful when considering funding options for global health research, and public health initiatives more generally. Our presentation of the questions employed illustrative examples from selected sectors. Applying the questions to specific funding decisions will require exploring the kinds of issues we have raised in novel settings, recognizing that the effects of corporations on health and health research differ by sector. (15) In addition, while corporations by definition share certain legal structures and profit-making incentives, they are complex and diverse organizations, complicating one-size-fits-all approaches to analysis and engagement. (11) We offer our questions not as a standard recipe for arriving at decisions, but rather as a helpful heuristic to guide reflection. Engaging in such a process will involve additional time commitments for already-busy people, but avoiding such reflection is not an "objective" option. To assume that it is unproblematic to accept corporate funding is often to effectively intervene on behalf of some of the most powerful actors shaping the inequitable global economic status quo. While some may still decide that accepting corporate funds is justified in particular situations, we hope that this commentary will promote more thoughtful deliberation when researchers, funding agencies, institutions and research stakeholders are making such decisions. Concurrently, our brief analysis and the examples presented here suggest a need for collective action to promote public research funding, and the tax systems required to underwrite it. (2,3)

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Received: April 22, 2016

Accepted: September 9, 2016

Ben W. Brisbois, MES, PhD, [1] Donald C. Cole, MD, MSc, [2] Colleen M. Davison, MPH, PhD, [3] Erica Di Ruggiero, PhD, RD, [4] Lori Hanson, PhD, [5] Craig R. Janes, PhD, [6] Charles P. Larson, MD, MSc, [7] Stephanie Nixon, MSc, PhD, [8] Katrina Plamondon, RN, MSc, [9] Bjorn Stime, MPH [10]

Author Affiliations

[1.] Postdoctoral Fellow, Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON

[2.] Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[3.] Assistant Professor, Department of Public Health Sciences and Department of Emergency Medicine, Queen's University, Kingston, ON

[4.] Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[5.] Associate Professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK

[6.] Professor and Director, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON

[7.] Clinical Professor, Department of Pediatrics, University of British Columbia, Vancouver, BC

[8.] Associate Professor, Department of Physical Therapy, Dalla Lana School of Public Health, International Centre for Disability and Rehabilitation, University of Toronto, Toronto, ON

[9.] Regional Practice Leader, Research and Knowledge Translation, Research Department, Interior Health; PhD Candidate, Interdisciplinary Graduate Studies, University of British Columbia; Adjunct Professor, School of Nursing, University of British Columbia, Kelowna, BC

[10.] PhD Candidate, School of Population and Public Health, University of British Columbia, Vancouver, BC

Correspondence: Ben W. Brisbois, PhD, Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Tel: 416-606-1738, E-mail: [email protected]

Acknowledgements: This article was informed by discussions at a conference workshop organized by the Canadian Coalition for Global Health Research. Brisbois was supported during development of this article by postdoctoral fellowship funding from the Dalla Lana School of Public Health, University of Toronto. Plamondon was funded through a Banting & Best Canada Graduate Scholarship from the Canadian Institutes of Health Research.

Conflict of Interest: Cole was co-investigator on the Mama SASHA project, funded by the Bill & Melinda Gates Foundation (Grant OPP53344, 2009-2015). Larson worked as consultant to Teck Resources Ltd. in support of funding for scaling up zinc treatment of childhood diarrhea in sub-Saharan Africa and South Asia. Nixon works as a policy consultant for the International AIDS Vaccine Initiative.