“By the 1990s, worsening patterns of population health began to raise concerns about their association with these changes in the global political economy. The sharp rise in non-communicable diseases, now accounting for 74% of deaths worldwide, were difficult to explain solely as related to individual behavioural choices. The links between population health outcomes, the strategies and products of corporations, and the political contexts that facilitate such practices began to receive closer scrutiny. Over the next two decades, detailed analyses of an increasingly globalised tobacco industry, enabled by a flood of internal documents into the public domain, were followed by similar studies of the alcohol, food, and other industries that produce health-harming products. The realisation of common themes, similar playbooks, and shared global networks spanning public relations firms, lawyers, consultants, think tanks, and scientists led to the coining of the term the commercial determinants of health (CDOH).
This needed transition, from risky lifestyle choices to unhealthy social conditions, and from an individual to cross-industry perspective, is hinted at in Simon Chapman’s book, Quit Smoking: Weapons of Mass Distraction. His book strongly criticises mainstream smoking cessation programmes focused on modifying behaviour. Despite their high cost, limited accessibility, and poor success rates, interventions using nicotine replacement therapy, counselling, and even financial incentives have not achieved substantial population-level change. Chapman highlights the “excessive medicalisation and commodification of smoking cessation” and concludes that such programmes have failed smokers while serving the interests of the pharmaceutical industry and, ultimately, when such efforts have limited success, tobacco companies. [..]
Many of the leading researchers applying this lens are brought together in the edited volume by Nason Maani, Mark Petticrew, and Sandro Galea, The Commercial Determinants of Health. The book’s chapters span the myriad of ways that profit-seeking actors and activities “influence health at every level of society, directly and indirectly”. The aim of the authors is to take stock of this “rapidly growing field” and grow this community of scholars, policy makers, and advocates. This community, including the contributors to this book, have successfully exposed the wide-ranging health-harming activities of certain industries dominated by transnational corporations. The accumulating evidence so far on corporations behaving badly is substantial; marketing to children, bribing or unduly influencing public officials, covert funding of junk science and media, tax evasion, and illicit smuggling are some of the activities meticulously documented by public health researchers. The juridical bestowing of corporations with legal personhood has further justified efforts to hold such commercial actors to legal and ethical account for population health harms. [..]
Case studies of corporate misbehaviour can generate necessary public outrage towards individual companies but are insufficient for prompting larger-scale reform of the economic systems that enable their health-harming activities. This is because how commerce is conducted depends on how markets are allowed to operate. For instance, the scope for the alcohol industry to engage with government officials is regulated by a country’s rules on, for example, lobbying, campaign donations, and conflicts of interest. The degree to which ultra-processed food products can be marketed directly or indirectly to children and young people is governed by the stringency of a country’s legislation and enforcement. The public resources available to regulate health-harming industries, more broadly, are influenced by corporate tax rates and the degree of tax evasion. The most informative CDOH research thus brings together descriptions of commercial activities (as symptoms) with causal explanations of how underlying socioeconomic conditions shape how profit-seeking is allowed to be conducted, what types of goods are produced, and at whose benefit and cost. [..]
Historically, much can be learned from how early corporations were tightly regulated by different governments to ensure they serve public interests. Today, the appropriateness of measures, such as taxation of sugary drinks and monitoring of industry influence, requires detailed understanding of varied contexts. Moreover, the health impacts of economic globalisation are not limited to end consumers but inequitably distributed along global supply chains. Many of the most affected, such as small-scale farmers and migrant workers, span multiple jurisdictions. Finally, there is much to be learned from comparative analyses of how markets might operate to be more health enhancing.
Advancing CDOH scholarship also requires deeper engagement across disciplines. Public health perspectives remain dominant in this field and there is insufficient interdisciplinary research. As a result, too much of the CDOH literature is self-referential. A fuller embrace of social sciences with long-standing expertise in comparative analyses of states and markets, different forms of power, and the inner workings of commercial actors is much needed. There remain too few examples of deep interdisciplinary engagement in both this book and the field more widely.
The diversification of the CDOH community will in turn help its struggle for greater conceptual coherence. A multitude of CDOH definitions abound, focused on transnational corporations or other commercial actors, health-harming industries, or the private sector as a whole. The source of health harms are often the products or the strategies that drive the production and consumption of these products. A definition of the CDOH might, of course, encompass all of the above. But this leaves somewhat unclear what theory of change is supported—what needs to change and how will it be achieved. At the product level, beyond cigarettes and other tobacco products, setting clear thresholds for health harms remains challenging. At the producer level, although the worst offending actors are identifiable, commercial actors range from local small businesses to transnational corporations. Global supply chains and capital markets now link businesses of varying size and purpose together in a complex web of interests. Understanding the balance between health harms and benefits accrued from this array of for-profit actors poses methodological challenges. Moreover, alongside the potential for commercial actors to create health benefits, public sector actors can contribute to health harms. Finally, in terms of strategy, what activities need to be curbed? If not all profit-seeking per se, but profit-seeking actions that contribute to health harms, how can these be clearly delineated? Overt conflicts of interest between the tobacco industry and health policy making, for example, are set out under Article 5.3 of the Framework Convention on Tobacco Control. The line in the sand for other industries is less clear, especially when industry lobbying is deemed acceptable, and even encouraged, in western liberal democracies. What are deemed health-appropriate business practices, even by health-harming industries, require clearer conceptualisation to effectively inform change.”
Full article, K Lee 2023.1.7