- The Commercial Determinants of Health
- Oxford University Press (2023)
We’ve long known about the social determinants of health. Those are factors like education, income, working conditions and social inclusion or exclusion that can protect us from diseases or make us perilously vulnerable to them. The ongoing COVID-19 pandemic continues to afflict the poor and marginalized more than the prosperous and secure.
Less understood are the commercial determinants of health, which underlie the social determinants. As the World Health Organization defines them, they are “the private sector activities impacting public health, either positively or negatively, and the enabling political economic systems and norms.”
Several recent publications show us that CDOH are gaining increasing attention as a critical factor in the health of nations and as a major cause of disease and death around the world.
The Commercial Determinants of Health is a book that should transform how public health is defined, taught and delivered. Its contributors, 54 academics from Canada to New Zealand to Ethiopia to the U.K., explain how corporations and governments promote prosperity even at the cost of their customers’ and citizens’ lives.
The scholars are too polite, though, to claim what seems self-evident: that our present political and economic systems, worldwide, are a kind of economic cannibalism.
In the course of making a living, we sicken and kill one another — and even ourselves and our children.
Commercial actors can shape the world
It’s important to remember that these commercial determinants aren’t all bad and they’re not all driven by big business. “Commerce” refers mostly to large national and transnational corporations, but it includes businesses all the way down to individual stalls in village markets. And such commerce, at all levels, may be positive as well as negative. One of the authors points out that Nestlé has been criticized for promoting its baby formula over breast milk; it also produces and sells many safe, healthy products including clean water.
As the editors of The Commercial Determinants of Health say in their introduction, “Commercial actors, particularly large, multinational commercial actors, have the social, economic and political gravity to shape the world in ways health departments and even entire national governments cannot. Certainly, commercial actors can shape our health as individuals and as populations, but beyond that, they can shape how we define ourselves, live our lives, interact with others, and how we perceive problems and solutions.”
The authors present case studies of five notable “unhealthy commodity industries”: alcohol, tobacco, fossil fuels, gambling and sugar-sweetened beverages. These industries are notable for the sophistication of their response to criticism, and many other industries have followed their strategies.
These strategies include lobbying political decision-makers as well as co-operating with them to “solve” the health problems created by their products. This co-operation often leads to outright capture of regulatory agencies and a revolving door that welcomes co-operative politicians to well-paid positions on corporate boards. Former B.C. premier John Horgan's agreement to join the board of Elk Valley Resources, a proposed coal-mining corporation that Teck Resources this week decided not to spin off from its operations, is a case in point.
How unhealthy behaviour becomes the norm
Another strategy is normalization — making the product or service just another part of life. We have normalized the presence of lottery tickets at every supermarket cash register, and the news stories about the lucky winners. We hear much less often about gambling addiction.
Older Canadians well remember when smoking was normal; it took decades of research and legislation to de-normalize it. Now vaping is normal, at least among young people, and so is marijuana consumption — after almost a century of prohibition.
Denialism is a key strategy: smoking doesn’t cause cancer, neither does alcohol, Oxycontin isn’t addictive and global warming is a hoax.
“Explicit denial is not the only form of denialism adopted by industry,” one article says. “Denialism encompasses a wide range of tactics, including undermining and misrepresenting existing evidence, selectively presenting and amplifying misinformation through different channels, funding competing messages and/or research, and promoting uncertainty more generally.”
Having worked so well for decades, such tactics have been widely adopted to spread misinformation about the pandemic — to populations already well-confused since childhood by corporate fake news.
It’s all your own fault
Another strategy is the offloading of responsibility for ill health on the individual — the person who drinks or smokes too much, or lives on a diet of ultra-processed food, or becomes addicted to gambling. The unhealthy commodity industries urge us to use their products “in moderation,” while heavily advertising the pleasure, fun or other rewards of engaging in a self-damaging activity. You didn’t know your limit and play within it? That’s your own damn fault.
Too often, public-health workers fall for this tactic. As one chapter says: “Responsibility messaging often seems logical to public-health practitioners — it ‘must makes sense.’ However, it is important to remember that these are not health messages: ‘Responsibility’ is not a health outcome. It is a public relations outcome, which simply signifies the successful deflection of responsibility from the industry to the person. Of course, it also shifts it to the taxpayer, families, their communities and the health services or other public services that often bear the costs of this harm.”
Another example of public relations success is the recently reported gift of $19 million by the Sackler family, owners and promoters of Oxycontin, to the U.S. National Academies of Sciences, Engineering and Medicine.
The National Academies advise the American government on opioid policy, among other issues. The Sackler family “gift” was a bargain that helped promote opioid sales. It also increased American and Canadian overdose deaths, and reports of the gift further damage public trust in government.
Always a new market
The corporations are also skilled at outsourcing, finding new customers in neglected markets like teenagers, or foreign markets where a western lifestyle symbolizes prosperity and social mobility.
One chapter notes that “the displacement of traditional food systems in Latin America, Asia and Africa by ultra-processed and low-nutrient products, marketed by TNCs [transnational corporations] and operating mainly from the United States and Europe, has been rapidly increasing since the 1980s.”
As the authors of a case study on the alcohol industry argue, “Free market economics will not work to minimize health risks in a situation where adverse consequences often occur many years after consumption of a product, and especially when harms are only partly attributable to this consumption and not usually identified as such in hospital records or on death certificates.”
Such industries and their investors seem unmoved by the consequences they inflict on their customers. The authors of the case study on tobacco are blunt:
“Tobacco may be uniquely deadly: It is the only legal product that kills between one-half and two-thirds of its long-term users when used precisely as its manufacturers intend — but its manufacturers otherwise have much in common with the commercial disease vectors featured in other chapters of this volume.”
Notably, this book doesn’t deal with industries that operate outside the law, like illegal opioids. But the principle is just the same for fentanyl merchants as for cigarette makers: if a demand exists, it will be met — without regard for the consequences for the individual user.
Nor does the book deal with occupational hazards like workplace safety or corporate environmental performance, which may affect the health of the industry’s workers and neighbours. The impact of over 200 petrochemical plants and refineries along the Mississippi River in Louisiana has given the region the well-deserved name of Cancer Alley.
These absences are understandable. At $168 for a hardback copy, the book is clearly intended as a textbook for a captive market of public-health students, not the general reader.
Presumably other courses (with equally expensive textbooks) will cover other issues in public health.
Four products, 20 million yearly deaths
Meanwhile, The Lancet, a prestigious British medical journal, recently published a series of articles on the commercial determinants of health that is reaching a broad global readership of health practitioners, researchers and journalists.
The first article bluntly estimates the death toll attributable to commercial determinants of health:
“The 2019 Global Burden of Disease study estimates that just four commercial products (tobacco, alcohol, ultra-processed food and fossil fuels) account for 19 million global deaths annually (34 per cent of the 56 million total deaths or 41 per cent of the 42 million [non-communicable disease] deaths). They also provide a very conservative estimate that commercial practices cause over 1.2 million deaths globally, bringing the total annual deaths to 20.3 million (36 per cent of total or 45 per cent of deaths from non-communicable diseases).
“These numbers are likely to be significant underestimates as they take no account of numerous other products (e.g., lead or prescribed opioids) or practices (e.g., dumping of toxic substances in water courses). Moreover, other data, including specific GBD studies, suggest a higher toll from some products. For example, deaths from unhealthy diets as a whole (rather than just ultra-processed foods) reach an estimated 11 million deaths, air pollution from fossil fuels over 10 million, and alcohol 3 million. If we add these to the GBD estimate of 9 million deaths from tobacco, the total reaches 33 million annual deaths (58 per cent of all deaths and 78 per cent of deaths from non-communicable disease globally).”
To this the article adds the consequences of other kinds of commerce. “The financial sector's role in the so-called deaths of despair; social media's malign effect on mental health; and the pharmaceutical industry's use of intellectual property protections to secure high prices, restricting access to essential drugs, including COVID-19 vaccines, despite massive public investment in their development.”
Living and dying in a pathological system
If commerce drives so much misery and death, why haven’t we recognized it until now? The article suggests that the corporate world has shaped our vision of it (normalization, denial and so on), so we have a problem even thinking about commerce itself as the problem. The article offers a definition and a model of a “pathological system” that keeps growing more powerful while its opposition grows weaker.
The second article in the series tries to examine the commercial determinants with some nuance, looking beyond the traditional bad guys (alcohol, tobacco, ultra-processed food and fossil fuels) to see where other commercial entities are also doing harm — or good. It looks at state-owned corporations like Sinopec, sovereign wealth funds like the Norwegian Government Pension Fund, and organizations we might not even think of as “commercial.” For example, “The National Collegiate Athletic Association is a multibillion not-for-profit organization that relies on the unpaid labour of student athletes.”
Given the complexities and variations of such organizations, we can’t simply elect the right government to pass laws to make them all behave better. (And even if we tried to, the organizations’ own employees and customers would likely vote against us.)
The third article in the series tries to suggest more effective approaches:
“Imagine progressive business models that embed health, equity and environmental goals, for which businesses are held accountable: macroeconomic policies designed to ensure a fair social foundation and economic environments operating within the ecological ceiling. Imagine public policies free from commercial interference; employment, education, transport, housing and health-care policies and systems that support people to live with dignity, in good health, and with a full sense of well-being; and a governance model that privileges the public over private interests.”
That’s a tall order, as the authors realize. They write: “Given what is known about the CDOH, this will require government actors to harness their structural power, as some have done during the COVID-19 pandemic, through norm setting and regulation of markets, to mitigate harms from economic activity and promote human and planetary well-being. Central to reimagining social progress will be the embrace of new economic ideas such as the degrowth, circular economy, well-being economy and doughnut economy approaches.”
Mitigation, not elimination
The allusion to the COVID-19 pandemic may be unfortunate, since most governments have rapidly yielded their structural powers right back to the free market, allowing the pandemic to continue unabated but unreported.
And the best the authors can promise is “mitigation,” not outright elimination of mortality from commercial activity.
The authors’ proposals seem more like a wish list than a practical agenda:
- Commercial actors to end opposition to health regulatory policies, respect regulations to reduce harmful practices and products, and implement regenerative business models
- Civil society groups to raise their collective voices, articulate alternative visions, and hold commercial actors and governments accountable
- Academia and researchers, in collaboration with policy actors, to provide evidence that is fit for purpose and presented in the right way, at the right time, to the right audiences
- Health actors to break with the hegemony of a biomedical model of health and engage more broadly, for example, with influential trade, finance and business actors.
However, I may have been exposed to too much corporate propaganda in my life to think that commercial actors would obey health regulations, or that civil society would acquire the clout to hold corporations and governments accountable.
Nor would I expect researchers to reject corporate funding, or the health-care industry to sit down with business and show them the error of their ways. After all, business provides health care with most of its patients.
Still, the articles sets out so many ways to approach the commercial determinants of health that some of them could well be achievable for a particular industry.
For example, a government might create a national centre for vaccine research and production, delivering reliable products at affordable prices. That might encourage other countries to do the same, or to offer pharmaceutical corporations a choice: reduce prices or be nationalized.
A few such successes could inspire more efforts in other areas.
Would you vote yourself out of a job?
It would still be a long, hard slog. Governments owe too much to their donors to betray them. The donors’ wealth comes from enterprises that often sicken and kill their customers (though not too quickly). The customers themselves often work for such enterprises, usually in low-paid and precarious jobs; a smoke or a six-pack or a big bag of junk food offers some immediate pleasure whatever the long-term consequences.
Most of the workers in such industries might fight to improve workplace safety, but they wouldn’t be eager to vote themselves out of their jobs for the sake of preserving the lives of unknown people using what the workers have produced. At best, the people who make cigarettes or ammunition for AR-15 assault rifles might say it was the customer’s choice to risk cancer, or to shoot up a school. Nothing to do with the industry itself.
But the managers and shareholders know very well that they are killing many of their workers and customers. And their children. They have spent many decades and billions of dollars to create a society in which the victims are always to blame.
As the 17th-century French writer La Rochefoucauld famously observed, “Somehow we always find the strength to bear the misfortunes of others.”
Until we collectively overturn our cannibal economy, it will continue to feast on us.