Benedict Saracen
If the Social Determinants of Health make us understand the mechanisms through which inequalities affect people’s health, the Commercial Determinants of Health show how the profit of a few threatens the health of many.
In 2016, in an article that appeared in the Lancet, Ilona Kickbush for the first time defined a different type of health determinants: “We define commercial determinants of health as those perspectives and strategies used by the private sector to promote products and choices that are harmful to health” (1). Over the years, the notion of the Commercial Determinant of Health (DCdS) has become more precise. According to the World Health Organization DCdS are all those private sector activities that have a negative or positive impact on health (2). The difference with the Social Determinants of Health (DSdS) is subtle and probably artificial, but it is useful to maintain a distinction between the two notions since DSdS are macroscopic and complex conditions attributable to a multiplicity of factors and political responsibilities (think of poverty or lack of schooling) while i DCdS are more circumscribed factors and attributable to more defined and identifiable responsibilities. In other words, if the fight against poverty is a vast program with macroscopic and complex social, economic and political implications, the fight against the harmful use of tobacco, alcohol or junk food presupposes interlocutors and counterparts that are more definable and defined in this way as well as more targeted and specific actions. Let’s say that the neoliberal policies typical of advanced capitalism are responsible for social inequalities but that it is more difficult to identify a well-defined counterpart, while in the case of food or substances harmful to human health, the counterparts have first and last names.
There is no doubt, however, that the issue is more complex than it is summarized hereas it is also true that many neoliberal policies can have defined counterparts (think of the deforestation industry in Amazonia) just as it is true that the identified multinational of alcohol or tobacco acts and thrives also thanks to a complex and less definable network of support, alliances and complicity.
In conclusion, if the Social Determinants of Health make us understand the mechanisms through which inequalities shape and build and deconstruct people’s health, the Commercial Determinants of Health make us understand how the profit of a few threatens the health of many.
Industry strategies
The private sector, and more specifically the agro-food sector, influences the social, physical and cultural environment, both through direct business actions and through indirect social interventions. The range of such strategies is wide and ranges from large product distribution chains to the design of their containers, from investments in research to systematic lobbying actions. According to Kickbush (1) the channels of action of the private sector are basically four:
- il marketing which promotes the desirability and acceptability of products harmful to health;
- lobbying actions seeking to curb or disrupt the barriers put in place by regulatory authorities;
- the implementation of corporate social responsibility policies which serve to delude the general public about an alleged social responsibility of the producers of harmful products themselves;
- the massive and progressive extension of distribution chains.
McKee and Stuckler (3) identify further channels of action, different from those set out by Kickbush. According to these authors, these channels are: i) influencing and redefine the dominant narrative; ii) set the rules that society uses to regulate trade; iii) transform the knowledge in commercial product; iv) threaten rights political, social and economic.
Let’s take a closer look at the four actions identified by McKee and Stuckler.
- The redefinition of the narrative implies strategies aimed at undermining scientific knowledge about products harmful to health and the use of the mass media to instill doubts about their actual harmfulness. Alongside this critical intervention of scientific evidence, the private sector tries to convince the authorities, doctors and the public of the fact that, in any case, the consumption of substances harmful to health is a private affair, an affair of individuals which, in full exercising their personal freedom, they choose to smoke, drink alcohol or consume unsaturated fats or sugars. However, we have extensive literature which tells us that this freedom of choice is an illusion: the most vulnerable and fragile people (above all children and adolescents) are the most exposed to the consumption of harmful substances, as well as people who for social and economies have less capacity for choice and discernment. The debate on free choice is ancient and sees the defenders of public health collide on the one hand and the defenders of the presumed free choice of citizens to consume what they want without the state (defined by them as “nanny” or nanny) establish rules in order to protect them. This claim of freedom not only hides the profit interests of the producers who want to avoid the risks of any regulation but above all it is profoundly unfounded. We have an impressive critical mass of epidemiological studies which have amply demonstrated that the freedom of the poor is a greatly weakened freedom and their consumption of harmful substances is often not a choice but rather the only option.
- Intervention on regulatory actions, on the other hand, consists in the massive use of experts, researchers and economists placed at the service of redefining new rules that mitigate the regulatory power and allow the private sector greater degrees of autonomy of action.
- The transformation of knowledge into a commodity is the strategy that we find in all attempts to promote and defend inflexible rules for the protection of drug or vaccine patents.
- Finally, the threat to rights (political, social and economic) is expressed in all those actions that seek to reduce public investment in prevention (prevention of both the consumption of harmful substances and diseases induced by those substances) and more generally to reduce the regulatory action of the public so as to leave the matter of health to a wild privatization, without rules and without regulatory authorities.
All of these strategies have a negative impact on health, clearly evidenced by the impressive increase in obesity, type 2 diabetes, cardiovascular disease, cancer, road accidents and violent behavior. We recall the dramatic growth in mortality due to non-communicable diseases which is estimated at 74% of all global mortality (6).
What to do
It would be easy to simply say that too little is being done to counter the nefarious action of the DCdS, but the real problem is that, whether little or much is done, the rapacious aggressiveness of the agri-food multinationals is conquering more ground every day and exercising an impressive control over politicians, ministers and regulatory bodies. To date, only twenty-nine countries (ie 12% of the world‘s population) have adopted effective tobacco advertising prohibition strategies; according to JAMA Network (4) during the last week of March 2020, in the midst of the COVID 19 pandemic, alcohol sales in the United States increased by 262%. Despite, or perhaps thanks to, the pandemic, the expansion of the alcohol industry has been impressive. In 2017 in the United States, multinational beer companies increased their investments in new forms of advertising through social media by 60%.
L’OMS seeks to promote the use of fiscal instruments to lessen the negative impact of substances harmful to health and seeks to engage with the private sector through a Private Sector Governance Advisory Group as well as through policy and treaty approaches, as is the case with the WHO Convention on Tobacco Control. In addition, WHO has launched a new program of action on the economic and commercial determinants of health with four objectives: to strengthen the evidence; develop tools to counter trade determinants; convene partnerships and dialogue; raise awareness and advocacy. However, one gets the clear impression that these commendable efforts remain without significant effects and this dramatic disparity between the pervasive power of “for profit against health” and the good will of public health militants, once again highlights the great moral, political and technical questions raised by the mix between business, economic logic and public health. There is a progressive pollution of Global Health discourse and action due to the growing influence of economic logic and commercial interests (5).
This state of affairs requires a serious debate on issues that are not only ethical but also political and technical, issues that require clear field choices and intense “health diplomacy” activity. Indeed, it is a question of building that dialogue between the (often inevitable) “economic agenda” and the “public health agenda”. The so-called “Health Diplomacy” consists of the concertation between economic thrusts often promoted by the poor countries themselves (think of economies based exclusively on the production of substances harmful to health: in Cuba, for example, sugar, tobacco and alcohol ) and drives towards improving public health. Close collaboration between global/political and local/technical is indispensable because today there is an urgent need “to understand and reform the pathogenic nature of the rampant capitalist market” (6).
Benedetto Saraceno, Secretary General, Lisbon Institute of Global Mental Health
Bibliography
- Kickbush I, Allen L, Franz C. (2016). The commercial determinants of health. Lancet. Volume 4, Iss. 12e895-e896, December 01. https://doi.org/10.1016/S2214-109X(16)30217-0
- World Health Organization. Commercial Determinants of Health. WHO, Geneva, 2022.
- McKee M, Stuckler D. (2018). Revisiting the Corporate and Commercial Determinants of Health. Am J Public Health. Sep;108(9):1167-1170.
- Pollard MS, Tucker JS, Harold Green D. Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US.JAMA Netw Open. 2020;3(9): e2022942. doi:10.1001/jamanetworkopen
- Saraceno B. (2022). Fairness, WHO and Bill Gates. International Health 26 maggio.
- Lee K. (2023). Advancing the commercial determinants of health agenda. 401. January 7. 16-17.