Opinion
Sustainability, Business, and Health
VIEWPOINT
George Serafeim, DBA The coronavirus disease 2019 (COVID-19) pandemic
Harvard Business has demonstrated that response demands involve-
School, Boston, ment from every sector of society. As a major example,
Massachusetts.
some businesses have stepped up in ways previously un-
imaginable. Garment companies have repurposed pro-
Amanda M.
Rischbieth, PhD duction to face masks and other protective equipment.
Harvard T. H. Chan Alcohol distilleries and perfumeries have shifted pro-
School of Public Health, duction to hand sanitizers. Automobile companies, both
Boston, Massachusetts.
voluntarily and as compelled by the Defense Produc-
tion Act, have worked with the ventilator industry to in-
Howard K. Koh,
MD, MPH crease production. More broadly, an early analysis esti-
Harvard T. H. Chan mates that 64% of the US’s 100 largest publicly traded
School of Public Health, companies have made customer accommodations to
Boston, Massachusetts;
and Harvard Kennedy
COVID-19, including deferred bill payments; 43% have
School, Cambridge, expanded paid sick leave, including, in some cases, for
Massachusetts. part-time and hourly employees.1 Such positive changes,
however, are in contrast to a host of other public con-
cerns, including that future vaccines and therapeutics
may not be affordable for much of the world. In the next
Author Audio
phase of the crisis, the safe reopening of society will re-
Interview
quire intense interactions between the health and busi-
ness sectors to address these and other issues.
These developments reflect an even broader connec-
tion between private enterprise and public health that has
evolved over recent decades. The United Nations (UN)
World Commission on Environment and Development’s
1987 vision of “sustainable global development” defined
it as meeting present needs without compromising the
ability of future generations to meet their own needs.2
Contending that economic development at the cost of so-
cial equity and the environment undermines long-lasting
prosperity, this vision served as the foundation for the
2000UNMillenniumDevelopmentGoalsandthe2015UN
Agenda for Sustainable Development; the latter pro-
posed 17 interrelated sustainable development goals
(SDGs) and 169 targets as a shared global blueprint for
2030. The SDGs are achievable only through commit-
ments of all sectors, including private enterprise, and ad-
dress a vast range of public health issues: communicable
(including some epidemic) diseases, noncommunicable
diseases, and broader areas critical to human well-being
including climate, poverty, working conditions, and cities
and communities.
The Sustainability Imperative
Given its long-standing reputation for focusing exclu-
sively on maximizing profit, the private sector may seem
an unlikely partner to advance the SDGs. Record profits,
Corresponding increasing stock prices, and governmental support dur-
Author: Howard K.
Koh, MD, MPH, Harvard
ing economic crises, accompanied by the growing global
T. H. Chan School of burden of carbon emissions, declining biodiversity, pre-
Public Health, ventable noncommunicable diseases, and rampant so-
677 Huntington Ave,
cial and health inequities, have long fueled widespread
Kresge 401, Boston,
MA 02115 (hkoh@ public distrust of some highly profitable corporations and
hsph.harvard.edu). some highly compensated chief executive officers (CEOs).
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Nevertheless, in addition to the current COVID-19 pan-
demic, other social changes and market forces have also
been pushing companies to consider business strategies
that further the long-term well-being of employees, con-
sumers, communities, and the environment.2
Recognizingthestrategicvalueofsupportingemploy-
ees, for example, a growing number of companies
publicly support raising the federal minimum wage
beyond $7.25 per hour, with some major companies
(eg, Costco and Target) already paying $15 per hour3; more
companies could do so. About 40% of businesses pro-
vide paid parental leave benefits for both spouses.4
A changing consumer market in the midst of a global obe-
sity crisis has similarly pushed the food and beverage in-
dustry to explore a new generation of healthier products,
such as no-sugar seltzer rather than sugary sodas. In ad-
dition, since 2010, Unilever (with hand soap included
among its products) has leveraged private-public partner-
ships to scale handwashing efforts to low-income
households globally.
Recognizing also that the climate crisis threatens
businessviability,majorautomakers,includingFord,BMW,
and Honda, have also moved steadily toward hybrid and
electric vehicles, even siding with the California Air Re-
sources Board to build more fuel-efficient cars despite
federal efforts to roll back emissions standards.5 Sustain-
ability strategies within the technology industry have al-
lowed Intel to obtain 71% of its global energy from renew-
ablesources(100%intheUSandEuropeanUnion)andIBM
to recycle 89.5% of its nonhazardous waste.6 Meanwhile,
some large businesses, viewing long-term success as
linked to the well-being of their communities, are making
investments in them. For example, in 2018, United Parcel
Service Inc (UPS) spent $2.6 billion for goods and services
with small and diverse suppliers as part of their supplier
diversity program.7
Extendingwellbeyondtraditionalphilanthropyorcor-
porate social responsibility, an emerging number of busi-
ness strategies are explicitly designed to create “shared
value”2 for both the company and larger society by inte-
grating profit generation with social good. In 2019, the
Business Roundtable (comprising 181 of the most promi-
nent CEOs of US companies) upended their 40-year-old
governance model of shareholder primacy by broaden-
ing their definition of corporate purpose to include a wider
array of stakeholders, including employees, suppliers, and
communities.8 However, the announcement has trig-
gered mixed reactions—skeptics view it as “health-
washing” (ie, talk without action), while proponents main-
tain that focusing goals on selected social and
environmental issues “material” (ie, fundamental) to core
mission and operations can create a competitive
advantage.9 Resolving this debate will require close track-
ing of how business strategies can affect progress to-
ward health equity and other SDGs.
(Reprinted) JAMA Published online June 17, 2020 E1
 Opinion Viewpoint

Aligning Reporting, Metrics, and Investment
Innovativeapproachestomeasuringandaligningmetricsrelatedtosus-
tainabilityandbusinessperformance,suchasthosethatextendbeyond
the limited standard profit-and-loss statements required by regulators
for nearly a century,9 could spur future investment. A major break-
through occurred after public right-to-know demands prompted more
transparent reporting of nonfinancial environment, social, and gover-
nance(ESG)metrics,nowpubliclyaccessiblethroughprominentframe-
worksincludingtheGlobalReportingInitiative(comprisingnearly80%
of the world’s largest 250 companies); the UN Sustainable Stock Ex-
changesinitiative(comprising85stockexchangesincludingNASDAQ)9;
andtheUS-basedSustainabilityAccountingStandardsBoard.9 Environ-
ment, social, and governance reporting has facilitated global sustain-
able investments, including the UN’s first-ever exchange-traded fund
to encourage socially conscious investors to support the SDGs.
Conversely, neglecting ESG-relevant matters has triggered declin-
ing company reputations, massive corporate fines, and CEO firings and
resignations. The 2010 BP Deepwater Horizon oil spill prompted CEO
Tony Hayward to resign after reputedly minimizing the crisis. Travis
Kalanick stepped down as CEO of Uber after employees and custom-
erscitedsafety,rights,andwell-beingconcerns.JUUL’sCEOKevinBurns
resignedoverreportedcontroversyaboutthecompany’scontributions
to youth vaping, prompting lawsuits and plummeting market capital-
ization. As a message to business leaders, the UN Global Compact, the
world’s largest business sustainability effort with nearly 9500 compa-
nies(focusingonthemesincludinghumanrights,environment,andanti-
corruption), recommends aligning their ESG reporting with the SDGs.2
Evolvingeffortsforintegratedreporting,eg,consolidatingbothso-
cial and financial performance into a single annual report, could further
align business and health. Accounting procedures succinctly capturing
inherently heterogeneous ESG metrics through a common language
couldfacilitate“apples-to-apples”comparisons.9 Such“impact-weighted
accounts,” analogous to health impactassessments long used by the
World Health Organization and the Centers for Disease Control and
Prevention, are already under way for water consumption and particu-
late emissions and could deter health-washing by measuring and mon-
etizinghealthbenefits—eg,adjustingprofit-generatingabilitybyhealth
outcomesusingvaluationcoefficientsasmultipliers(oroffsets).Forex-
ample, treating resources for employee well-being (eg, healthy food,
stress management services) as assets, not costs, could also more ac-
curately reflect the financial benefits of long-term sustainability.
The Global Steering Group for Impact Investment, an indepen-
dent group of 32 countries and the European Union, is one of several
groups exploring how impact-weighted accounts might guide com-
panies interested in generating social benefits, environmental ben-
efits, or both while delivering financial return. Such work advances the
2006 UN Principles for Responsible Investment, which, with about
2700 signatories, aligns investors with SDGs and recommends ac-
tions for incorporating ESG issues into investment analyses.9
Conclusions
COVID-19 has made clear the global interdependence of health and
business. Improving public health must involve more than govern-
ments and nonprofit organizations alone. The SDGs and related sus-
tainability strategies, by focusing on material ESG issues and inte-
grated reporting strategies, can serve to align business interests with
health as part of pandemic recovery and beyond. The public will con-
tinue to have a critical role in judging specific business actions and
using its purchasing power to influence company decisions. Mean-
while, how much the business community will contribute to realiz-
ing global health goals remains a matter of great debate. Ultimately
it will depend on how well public health and private enterprise can
together overcome long-standing barriers to advance the future of
the planet and its people.

ARTICLE INFORMATION
Published Online: June 17, 2020.
doi:10.1001/jama.2020.8714
Conflict of Interest Disclosures: Dr Serafeim
reported being the faculty lead of the
Impact-Weighted Accounts Project at Harvard
Business School, of which GSG Impact Investment
is a collaborator; its chair is also the chair of the
Impact-Weighted Accounts Project. Dr Serafeim’s
additional relationships are described online. No
other disclosures were reported.
Funding/Support: Dr Serafeim receives financial
support from the Division of Faculty Research and
Development of Harvard Business School. Faculty
grant support for Dr Koh is provided in part by the
Templeton Foundation (award 61075); the Robert
Wood Johnson Foundation (award 74275); the
Harvard Catalyst Community Engagement
Program, Harvard Clinical and Translation Science
Center (award UL1TR002541); and the JPB
Foundation (award 1085).
Role of the Funder/Sponsor: The funders had no
role in the preparation, review, or approval of the
manuscript or the decision to submit the
manuscript for publication.
Disclaimer: The opinions expressed in this article
represent the personal views of the authors and not
those of their employers or those of any faculty
grant funder. Any reference to a business, product,
or service does not represent endorsement.
Additional Contributions: We are grateful to
Chelsea Heberlein, BS, Kirk Vanda, MBA, Leila
Roumani, DMD, MPH, Jack Spengler, PhD, Wendy
Purcell, PhD, and Eileen McNeely, PhD, NP, of the
Harvard T. H. Chan School of Public Health, and to
T. Robert Zochowski III, MBA, of the Harvard
Business School, for their comments on the
manuscript. No compensation was received.
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