The devastating and wide-ranging ways that webs of powerful commercial interests are undermining health and equity are outlined in a landmark new series of articles calling for transformation in the relationships between commercial actors and wider society.
The series, published by The Lancet, argues that diverse groups – including governments, international organisations, businesses, civil society groups and researchers – must work for transformational change of political, economic, and social structures and systems in order to tackle the commercial determinants of health (CDOH).
The CDOH are defined “as the systems, practices, and pathways through which commercial actors drive health and equity”.
The COVID-19 pandemic, the climate emergency, the rising burden of non-communicable diseases (NCDs), and growing health inequities within and between countries make a business-as-usual approach to public and planetary health increasingly untenable, says one of the articles, led by Professor Sharon Friel of the ANU.
“In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort,” these researchers write.
The series, led by Professor Rob Moodie of the University of Melbourne, supported by VicHealth, and involving several leading Australian researchers, broadens longstanding concerns about the impact of transnational companies that produce unhealthy commodities, such as tobacco, alcohol, ultra-processed foods, gambling, coal and weapons.
It looks at how diverse commercial interests influence policymaking, regulation, norm setting and the exercise of power, and also considers business-friendly think tanks, lobbyists, law firms, public relations and advertising agencies, tax accountants and other professional services as part of the CDOH. It also considers a variety of ways that CDOH affect health and equity, including through labour and employment practices, supply chain and waste practices, and financial practices.
Notably, the series examines “often-overlooked issues” such as how the media, ownership of which has become concentrated among a wealthy elite, has been shown to increasingly serve that elite, including global corporate interests.
It also outlines the role of Big Tech and media in contributing to pervasive misinformation and disinformation environments, with one of the papers stating that “an entire ecology of misinformation has developed, creating what has been described as post-truth or agnogenesis – the deliberate creation of ignorance”.
The series does not explore in any detail the intersections with another “CDOH”, the cultural determinants of health, which are so important for the health and wellbeing of Indigenous Peoples. It does, however, give Rio Tinto’s destruction of Juukan Gorge as an example of how extractive companies despoil the environment and affect the health and wellbeing of Indigenous communities.
One of the articles explores how the shift towards market fundamentalism and increasingly powerful transnational corporations has created “a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so”.
“Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests,” say the authors.
“This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented.”
The Director-General of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, also contributed to the series, writing that much of our international system, in trade, finance and even development, supports the drive for ever-increasing profits and economic growth over the social, environmental, and health impacts of commercial products or practices.
“When profits are threatened, some companies and other actors with vested commercial interests deliberately undermine public health policies, including WHO guidance, through lobbying, legal threats, ineffective self-regulation, distorting evidence, concealing their practices, and other actions,” he wrote.
Next year, the WHO will publish the first WHO Global Report on the Commercial Determinants of Health, to be accompanied by a WHO Global Conference on the Commercial Determinants of Health.
Dr Tedros also cited evidence on the connection between commercial determinants of health and racial disparities; for example, the global tobacco industry’s historical links with colonialism and slavery and the power asymmetries in food systems within and between countries.
He said WHO is committed to supporting national governments in developing, implementing, and enforcing policies that tackle the commercial determinants of health.
The authors put forward a range of suggested solutions, including progressive economic models such as the degrowth, circular economy, wellbeing economy, and doughnut economy approaches, equitable taxation measures, international frameworks, government regulation, compliance mechanisms for commercial entities, and regenerative business types and models that incorporate health, social and environmental goals.
Friel and colleagues also stress the potential power of strategic civil society mobilisation, through strategies such as electoral campaigning, litigation, public education, lobbying and other forms of advocacy.
Other suggested strategies include:
- Public procurement or the purchase by governments of goods, services, and works, as a mechanism to control the CDOH across key settings
- Minimise industry engagement in policy formulation
- Create enforceable conflict of interest, lobbying, and transparency policies (including funding for think thanks, lobby groups, civil society organisations, and lawyer firms)
- Implement enforceable bribery and corruption legislation
- Protect whistleblowers
- Ensure transparency in policy consultations (eg, public disclosure and details of funding)
- Strengthen conflict of interest and transparency governance in research organisations and scientific journals
- Promote scholar activism
- Enforce comprehensive controls on the marketing of products damaging to health (including via social media, labelling, and predatory marketing methods—eg, automated marketing and robot calls)
- Institute rules on pay gaps within organisations (including caps on CEO salaries and bonuses)
- Hold commercial organisations responsible for supply chain labour conditions
- Implement anti-monopoly competition policies
- Prohibit government or intergovernmental partnerships with health-harming commercial sector organisations.
The authors call on the global health community to “move beyond observation to action”, and say this requires “breaking from the hegemony of a biomedical model of health”.
Specifically, health actors must understand the language of, and engage with, influential government and business actors such as finance and trade ministers and financial investors.
In an accompanying editorial, The Lancet said that given their huge unresolved impacts, the commercial determinants of health must be recognised – and funded – as a crucial field of research.
Croakey asked some of the Australian co-authors for further reflections on the series and its impact.
Q: What is one action you would like to see governments (or Prime Ministers/Premiers/Ministers) take in response to the series?
Professor Rob Moodie: To sit down and listen to these arguments and to work with civil society, academic and the business leaders who really understand which “rules of the game” need to be changed for a much healthier Australia.
Dr Alexandra Jones: I’d like to see governments develop robust conflict of interest policies and rules for engagement with a range of different commercial organisations. Our Paper sets out a framework for making more meaningful distinctions between a wide range of commercial players to help policymakers know who they should engage with (and who they should not) if they’re serious about promoting health, equity and wellbeing over profits.
In Australia we have robust rules for engaging with tobacco companies, but we lack a coherent approach to engaging with industry in other areas such as gambling and food policy – and our policy outcomes are weaker as a result.
The series also highlights the potential of policy innovations such as wellbeing economic approaches to put long term wellbeing over short term profits. It’s encouraging to see Federal Treasurer Jim Chalmers signalling the government’s interest in these approaches, and there is much we can learn from countries such as Wales and New Zealand in moving in this direction.
Dr Sandro Demaio: With the publication of the series, governments now have this important resource and roadmap to address the commercial determinants of health.
Chronic disease is Australia’s biggest killer and is responsible for 9 in 10 deaths nationally. This robust and independent piece of world-class research provides new insights and contributions to our thinking on chronic disease.
Investing in prevention, improving access to affordable, fresh food, supporting people to quit smoking and vaping, and promoting physical activity are all essential for improving health outcomes and reducing the burden of chronic diseases on our people and health
Dr Jennifer Lacy-Nichols: Develop a strategy to identify and manage conflicts of interest around government engagement with commercial actors (oversight could be embedded in the National Anti-Corruption Commission, NACC) – e.g. increased transparency of lobbying activities, public tenders, grants, use of consultants; more comprehensive ‘cooling off’ periods for public servants (see Canada for a good precedent).
Q: Have you had any response/comment/feedback from any governments or policy makers to the series?
Professor Rob Moodie: WHO are very keen – but not yet from others – too early.
Dr Sandro Demaio: The series will continue the conversation about the ways in which certain industries may contribute to negative health outcomes, even if they are operating within the bounds of the law.
We support the experts in this series, in their calls for a comprehensive approach to addressing these issues, and that might involve policy solutions. Ultimately, we believe that improving public health is a shared responsibility, and we are committed to working to achieve this goal with policy makers.
Q: How would you like the health sector, especially the public health community, to respond to the series?
Professor Rob Moodie: We need to ensure the health sector really understand how commerce determines health and equity outcomes – and we need to start partnering much more strongly with groups who speak the language of commerce, with other social movements, with investment advisors.
Dr Alexandra Jones: It’s time to mobilise action. It’s one thing to broaden our research, but to make change we need to build coalitions with a wide range of partners, develop consensus evidence-based positions, and use focused, timely and persistent advocacy. We basically need to market our message as effectively as commercial actors often do, admittedly with a much smaller budget, but at least the evidence on our side.
Dr Sandro Demaio: Together we can create systems and policies that prioritise health, wellbeing and equity, and as a public health community we can make progress through persistent advocacy and a combination of actions.
Groups such as health organisations, grassroots groups, journalists and academics, have an important role in taking action against commercial factors that affect health. They also contribute to building knowledge and practices that can help develop effective strategies to counteract these commercial forces.
Dr Jennifer Lacy-Nichols: I think some healthy and frank reflection on our own industry is productive (whether that is higher education, or healthcare, or other) – all of us will be connected in some way or another to commercial actors/CDOH. This could be through funding, our institutions, academic publishers, partners, healthcare providers, our banks, and many others. We so often focus on really obvious harmful sectors with fairly obvious messages (Tobacco! Gambling!) that the many shades of grey for the rest commercial world are ignored. Yes there are some really problematic activities that need to be addressed. But it is worthwhile to think in a more nuanced way about the extent to which commercial actors influence health in other ways, and how we might try to minimise harms and amplify health when the industry or issue is less black and white.
Q: Are you aware of any actions taken by any of the industries/companies mentioned in response to the series?
Professor Rob Moodie: Too early to say – but the recent proposal of the Transition Accelerator has a lot of promise – see https://www.afr.com/policy/energy-and-climate/rich-lister-s-100m-investment-in-huge-commercial-opportunity-20230321-p5ctzn – “I’m asking business to do more, to get political, stand up and ask for even more regulatory and policy change, to speak up, because business normally feels that politics is not our role, but I’m saying this time it is.”Trawalla already helps to fund ClimateWorks, Beyond Zero Emissions and Grata, among other NGOs.
Dr Sandro Demaio: Not yet, but intention of this series is to promote good health, not to be against businesses and we encourage the commercial sector to pursue new business models that prioritise health, equity, and sustainability and support government policies that promote health.
While it is important to acknowledge that many businesses are crucial to society, we also need to acknowledge that some of their practices and products are harmful to both people and the environment.
For instance, industries that produce tobacco, alcohol, highly processed foods, and fossil fuels responsible for over a third of preventable global deaths each year.
Q: Any other comments you’d like to make?
Professor Rob Moodie: There are some really important initiatives around – such as B Labs and Share Action in the UK – that can really help to raise the standards for business – in the interest of long term investors and sustainable business
Dr Sandro Demaio: As an organisation, VicHealth has long supported independent and world-class research to guide evidence-based responses to health challenges, such as vaping and unhealthy food. Investment in prevention is essential to address the growing and significant burden of chronic disease among Australians. Actions like improving access to affordable, fresh food and doubling our supports for those quitting smoking can return around $14.30 to the Australian economy for every dollar we invest.
Read the series
- Unravelling the commercial determinants of health
- Defining and conceptualising the commercial determinants of health
- Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations
- Commercial determinants of health: future directions
- Achieving health for all requires action on the economic and commercial determinants of health
Read Croakey’s archive of articles on the commercial determinants of health
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