Cashing in on health: the Commercial Determinants of Health explained
The social determinants of health is a concept that is widely understood in public health circles – access to education, housing, healthcare and income can have a profound impact on the health of individual and societies. But what are commercial determinants of health? In today’s piece, VicHealth (@VicHealth) Research Fellows Alexandra Chung (@Chung_Alexandra) of Monash University, Florentine Martino (@fp_martino) of Deakin University, and Jennifer Lacy-Nichols (@JLacyNichols) of the University of Melbourne explain how commercial actors influence health and argue for prioritisation of health over profits.
What are the commercial determinants of health?
If people give any thought to the commercial determinants of health (CDoH), they are likely to think of unhealthy products that cause individuals and societies harm, in particular tobacco, alcohol, and ultra-processed foods. Indeed, these industries, along with fossil fuels, are responsible for at least a third of global preventable deaths per year.
Targeted advertisements for unhealthy products start with children and can be difficult to trace - just one example of how a profit motive trumps health concerns. Photo by Harrison Haines
Yet CDoH encompass far more than these industries. A new Lancet Series defines the commercial determinants of health as the “systems, practices, and pathways through which commercial actors drive health and equity”. This definition provides a framework for understanding the ways in which commercial determinants influence health and health equity that allows for consideration of not only products but also practices, as well as the systems that enable corporate practices.
A broad definition of the commercial determinants of health widens our gaze from the classic ‘unhealthy trinity’ of tobacco, alcohol, and ultra-processed foods. This allows for a focus, and therefore responsibility for action, that extends to sectors beyond health. This is critical, because it acknowledges that many of the factors that influence health sit beyond the health system.
It also recognises that commercial entities play an important role in society and can exert not only negative, but also positive influences on health. The commercial world is diverse. It includes harmful industries – like gambling and weapons manufacturers – as well as industries that are necessary for health and wellbeing – like education, healthcare and housing. Commercial actors in these sectors influence health, but often in very different ways.
Why we need to act on the commercial determinants of health
Harms to health occur when commercial actors engage in practices that serve their own interests ahead of protecting and promoting health. The examples are endless. Mining companies pollute community land and water. Multinational corporations avoid paying a fair tax rate. Pharmaceutical companies oppose access to generic drugs. Pesticide companies undermine scientific evidence. Employers in the gig economy undermine worker rights and job security. Companies the world over lobby governments to oppose regulations threatening profits.
These practices often harm human and planetary health and perpetuate health inequities.
Businesses do not act in a vacuum. System dynamics and norms incentivise and enable harmful practices – like the financialization of food and healthcare, or the ideologies of neoliberalism and capitalism. Challenging these entrenched dynamics is crucial to addressing commercial harms.
A key role for researchers is generating evidence and supporting knowledge exchange, which can inform targeted action and policies. Our research focuses on monitoring commercial practices to generate a better understanding of who is acting, how, and with what consequences. Below, we provide examples from our programs of work, and highlight some of the challenges and opportunities we face moving forward.
Unhealthy food marketing
Food marketing is a commercial determinant of unhealthy diets and a practice to which we, and our children, are exposed every single day. Food marketing is highly prevalent and predominantly promotes food and beverages that contribute to unhealthy diets. Food marketing influences preferences for, choice and consumption of unhealthy products.
Of significant concern, children and their caregivers are deliberately targeted. Colourful images, cartoons and health claims are placed on the front of food packages. Advertising messages are plastered across public transport infrastructure and around sports stadiums. Digital media delivers food marketing messages right into our pockets.
In Australia, rules around food marketing are guided by industry-led codes. These codes fail to adequately protect children from the harmful impacts of food marketing. Stronger regulation by governments is needed to ensure higher standards that protect children’s health. The World Health Organization outlines comprehensive policy approaches to reduces the power of, and children’s exposure to unhealthy food marketing.
Monitoring marketing practices
A problem regulators face when considering restricting marketing practices by harmful industries is their capacity to monitor these practices. Resources are often scarce and monitoring every single ad is costly and time-consuming. Marketing practices have diversified. They are often covert or the commercial intent is unclear - just think of brand endorsements by influencers. On top of that, a large proportion of marketing budgets are now spent on online ads which are hard to monitor because these are uniquely targeted towards (and designed for) the individual.
Automated monitoring using artificial intelligence (AI) can be a very helpful and cost-effective tool for regulators to keep marketing companies and their clients accountable, for example when marketing targets underage youth or minority populations. Our interdisciplinary team (public health and machine learning) at Deakin University are now working to create such a system to be able to monitor unhealthy food, alcohol and gambling brand marketing in a diverse range of settings, including outdoors, on TV (including sports sponsorship), and online.
Corporations, politics and health
We have sufficient evidence about what policies are needed to address commercial harms and improve public health. What we lack is implementation. This is a political problem.
One important barrier to implementing public health policies is vested commercial interests in political spheres. Investigative journalists have documented the influence of commercial actors in policy making – such as arms manufacturers or short term rental operators –, yet this is only a snapshot of the true breadth and extent of commercial activity.
Before public health and other stakeholders can challenge commercial influence in politics a much deeper understanding of corporate political activities is required. Who are the main actors? Who do they target? Who takes a leading role, and who acts behind the scenes? What strategies do they use? Has this changed over time? What resources do they draw on?
Answering these questions is immensely challenging, in part because there is so little data in the public domain. What data does exist is disorganised, incomplete and sometimes inconsistent. For instance, one of my studies seeks to map out commercial lobbying activities. Yet Australian lobbyist registers only capture third party lobbyists (employed by professional lobby firms), not in-house lobbyists (directly employed by companies). This excludes most lobbyists.
A first step towards supporting systematic monitoring of corporate political activity is better transparency regulations. This is on the agenda of several NGOs and politicians in Australia. The OECD is in the process of updating their recommendations on transparency and lobbying. Implementing these recommendations offers an opportunity for Australia to be a leader, not a laggard, in this space.
What needs to happen?
There is an urgent need for action. The Lancet series sets out a vision of a world where people come before profits. To achieve this vision requires a fundamental rebalancing of power dynamics. Many actions from diverse stakeholders, including commercial actors, are required as outlined in Paper 3 of the Lancet series. At the heart of this is the need to make public interest the first priority.
A collective effort is required across governments, commercial actors, and civil society to prioritise action that improves health, wellbeing and equity for the benefit of whole of society. Possible actions include:
Set higher standards to protect children and their caregivers from all forms of unhealthy food marketing
Develop robust conflict of interest policies
Improve transparency of lobbying and political donations
Support an international convention on CDoH
Ensure trade and investment policies promote health and wellbeing
Implement wellbeing economy principles
Alexandra Chung, Florentine Martino and Jennifer Lacy-Nichols currently hold VicHealth Postdoctoral Research Fellowships. Their research is integral to understanding and tracking the impacts of the Commercial Determinants of Health. Their views may not reflect the position of VicHealth.
Posted by Susan Maury (@SusanMaury)