This article is from the third chapter of Silent Killers, our editorial series on chronic disease.
Michael Bloomberg is spending more than anyone on the planet to save people from themselves. The question is whether he’s getting his money’s worth.
The American media mogul’s philanthropy is the top giver to preventing the ailments that are often fueled by lifestyle choices, such as cancer, heart disease and obesity. The fact that these noncommunicable diseases are responsible for 70 percent of deaths worldwide has made them an appealing target for Bloomberg, who is looking to spend down his fortune — now estimated at $70 billion. Compared with infectious diseases — the darlings of the philanthropic world even before COVID — NCDs are an underfunded area in global health, receiving only 1 percent of international health assistance.
The man who got the financial world hooked on his Bloomberg Terminals for market-moving information knows that helping people break their addiction is no simple matter. He’s promoting innovative policies from his three terms as mayor of New York City — like creating smoke-free areas and banning trans fats — to help people around the world make healthier choices, with a nudge or a shove. He’s wielding his credibility to spread the message at the local level through his network of mayors, and using his cash to drive global policy through the World Health Organization, where he serves as global ambassador for noncommunicable diseases and injuries.
“You can’t manage what you can’t measure,” Bloomberg wrote in 2020, announcing a new initiative for health data. Yet it’s not always possible to say whether his policy prescriptions work: With viruses, clinical trials can prove whether a vaccine prevents disease. With a condition like obesity — fueled by a complex brew of social, economic and biological factors, not to mention canny marketing and aggressive lobbying by Big Food — the cause-effect calculus of something like a tax on sugary drinks isn’t clear.
The stakes aren’t just about effective public health interventions. Some longtime anti-smoking experts worry that in his latest crusade against Big Tobacco — to protect American kids from getting hooked on e-cigarettes — Bloomberg is getting ahead of the science and shutting off a path to healthier lives for the millions of adults around the world who smoke tobacco and would be better off with the less-than-ideal vapes.
A Bloomberg Philanthropies spokesperson was quick to send studies backing up the organization’s policies, but did not provide requested figures about the charity’s financial commitments.
Public data from the past few years reflects the scope: $23.1 million in 2020-21 to the WHO. More than $100 million to three NGOs working on tobacco control, obesity prevention and opioid addiction in 2020, according to Forbes. Tax filings from 2019 show tens of millions going to universities churning out research on fighting NCDs in Australia, Mexico and the U.S. — especially Johns Hopkins University’s Bloomberg School of Public Health.
Regressive and effective
“We’re not afraid to take on things that seem intractable,” said Kelly Henning, the longtime leader of Bloomberg Philanthropies’ public health program, in an interview. “And we were looking for population-wide impact, like how can we improve health on the largest number of people?”
The Bloomberg News founder doesn’t discount the systemic, macro-level problems making us sick — he also serves as the U.N’s Special Envoy for Climate Ambition and Solutions. However, the politically awkward reality is that individual choices do matter — an estimated 40 percent of cancers are preventable, for example. His embrace of some heavy-handed techniques like taxes on tobacco and junk food have been characterized by one libertarian writer as “nanny-state illiberalism.”
Bloomberg’s conviction that he knows best has driven some illiberal moves: “Hizzoner” (as New York’s mayors are colloquially known) pushed through an exception to the city’s terms limits in order to run for a third stint in City Hall. He’s more pragmatic than ideological: When he decided to make the leap from stocks and software to politics, Bloomberg ran as a Republican for his first term in 2001 — he knew that he couldn’t win a Democratic primary. For his reelection in 2007, he changed his registration to independent. In 2020, he relearned his first lesson the hard way, spending $1 billion on an unsuccessful bid to win the Democratic presidential nomination. His pollsters did get one major thing right: They warned in advance of the “red mirage” phenomenon that would show U.S. President Donald Trump ahead on election night, even as a full count would reveal Joe Biden as the victor. That race also highlights Bloomberg’s willingness to plow his own fortune into pursuing results.
The former mayor’s focus on results over political sensibilities explains why the public health approach championed by Bloomberg, who is now 80, can make those on both the left and right uneasy. He has shrugged off the regressive nature of his proposed taxes by saying that’s exactly why they work. Hiking the price of a Coke by 10 cents is going to likely have a bigger impact on a poor person’s choices than a rich one’s — but the poor are more affected by noncommunicable diseases.
Taxes on sugary drinks aren’t the only element of Bloomberg’s policy prescription for preventing the estimated 11 million deaths attributable to diet each year. There’s also limits on junk food advertising, labels to make the dangers of calorific ingredients clear, and subsidies for fruits and vegetables. This type of intervention has become a signature policy recommendation that Bloomberg and the WHO say is both budget-friendly and effective — despite its potential to cause a political headache.
Mexico is the poster child for the idea. Since the government imposed a one-peso-per-liter tax on sweetened beverages in 2013 — promising to use the extra cash to install more water fountains in schools — studies show a persistent drop in sales. Many countries — including the U.K., Ireland, Belgium, France, Latvia, Portugal and Hungary — have adopted similar policies.
But do fewer Fanta purchases actually reduce obesity? We don’t know yet, Henning acknowledged.
“Probably the earliest place you would see some change would be in early childhood obesity,” she said. That will take “a number of years” to observe. But even then, Henning added, it will likely require a comprehensive policy package to achieve widespread weight reductions, making it hard to define the impact of any one element.
A study in Philadelphia, an American city of about 1.6 million, highlights the nuanced potential of a tax on sugary drinks. The tax appeared to reduce sweetened soda consumption in both kids in and adults, but not enough to really move the needle. There were some exceptions, however: Among African-American children, drops in consumption amounted to about 32 calories a day — a real difference — while African-American adults cut down by about a soda a day. Given that these groups face higher risks of both obesity and poverty, it’s a sign the tax could be most effective where the stakes are highest.
And even if the tax doesn’t cut consumption, well, the resulting government revenue might help the health system bear the costs better.
“Of course, we do all of this for public health, but it’s also a matter of health budgets for countries, especially when we want all of this to be part of the universal health coverage,” said Bente Mikkelsen, the WHO’s NCDs chief.
To be sure, some of Bloomberg’s policies have proved clearly effective. He wasn’t the first to ban smoking in restaurants, bars and clubs. But his move, in New York in 2003, to make lighting up more inconvenient while protecting everyone else from second-hand smoke, helped the policy go mainstream, proving unfounded the yowls from the sector that it would kill hospitality and tourism. He also hiked both prices and the minimum purchase age. By the time he stepped down a decade later, 15 percent of New Yorkers said they smoked regularly, compared with 22 percent when he took office, according to the New York Times.
Launched in 2006, the Bloomberg Initiative to Reduce Tobacco Use — which includes the WHO, the Campaign for Tobacco-Free Kids and The Union, a lung research organization — also doles out cash to promote WHO-backed policies like graphic pack warnings and taxes in heavily affected countries, including India, Ukraine, China and the Philippines. For the first time, global sales started dropping in 2012, and their decline continues, according to data from Euromonitor and Bloomberg Terminal.
“In many ways his record is terrific, said Steven A. Schroeder, a professor emeritus of medicine at the University of California, San Francisco. Schroeder knows what he’s talking about: as CEO of the Robert Wood Johnson Foundation in 1995, Schroeder help found the group that eventually became the Campaign for Tobacco-Free Kids.
“That’s why it’s a little bit sad,” Schroeder said, “to see that he’s gone beyond the data in his latest campaign.”
With some 8 million still dying from smoking-related causes each year, campaigners are increasingly divided over the question of e-cigarettes. Vapes deliver nicotine, a highly addictive substance, without tobacco and tar.
Vapes aren’t safe — and researchers are still building the evidence base of their risks — and signs that they help people quit completely aren’t exactly encouraging. But most agree that they are almost certainly less dangerous than smoking cigarettes, given the choice between the two. So, for one school of tobacco fighters, we should make it easy for smokers to make the switch to e-cigs.
But the same things that could make vapes appealing to adult smokers — appetizing flavors and a lower price tag — could also make them more enticing to kids.
Bloomberg Philanthropies has focused on the latter possibility, pouring $160 million in 2019 into a campaign to ban flavors and restrict e-cig advertising, a move backed by 76 public health, medical, education and parenting organizations.
While that effort is aimed at the U.S., the approach is going global. The WHO recommended banning flavors in a 2021 report, and the European Commission last year flagged restrictions on them as a needed update to the bloc’s tobacco rules. Finland and Hungary have already banned flavors. (At least 32 countries have banned vapes outright, including India and Brazil, and Bloomberg partner The Union endorsed outlawing their sale in poorer countries in May 2020.)
Not everybody agrees this approach is a good idea, however. In September, a group of 23 predominantly American tobacco control experts said Bloomberg’s tack could do “more harm than good,” in a letter to Henning, the foundation’s health chief.
The letter, first reported by the journalist Marc Gunther, cited efforts to “shut down and even censor debate” about evolving science. While there are signs that rates of kids vaping are increasing — and that kids who vape have a higher chance of becoming smokers — it doesn’t yet appear that there’s a corresponding increase in smoking uptake.
In an interview, Henning acknowledged that, as research accrues, e-cigs as harm reduction for adult smokers “could turn out to be an important area.”
Her bottom line, however, is that “the evidence is quite strong that kids have taken these products up in large numbers,” she said. “And that’s really quite alarming to us and really where our focus is.”
While Bloomberg’s policies can often appear to be a leading indicator of WHO recommendations, officials at the U.N. health body are adamant that they take the lead on technical policy matters. Bloomberg’s money and influence helps, they say, when it comes to actually implementing their recommendations.
Bloomberg has also been key to recruiting other funders, said the WHO’s Mikkelsen. Bloomberg Philanthropies helped the WHO put together its first two investment cases for NCDs, inspiring “many other donors.” These include Norway, which in 2019 became the first government to make a line item for preventing noninfectious diseases in its foreign aid funding.
For all his riches, Bloomberg will need extra help if he wants to catch up to spending by the big businesses that profit from our indulgences and addictions. In the U.S. alone, the tobacco industry spent $9.5 billion on advertising in 2016, according to the University of Bath’s (Bloomberg backed) Tobacco Tactics program, and the fast food restaurants (just a small part of the junk food industry) spent $5 billion in 2019.
“Our biggest challenges remain interference by the tobacco and food industries, who use any measure or erroneous argument to put profits over public health, and the woeful underfunding of NCD prevention,” said a Bloomberg Philanthropies spokesperson.
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