Benedict Saracen
Increasing scientific evidence demonstrates the importance of commercial determinants in influencing the health of individuals and communities. Four industries (tobacco, junk food, alcohol and fossil fuels) are responsible for at least a third of global annual deaths. But this discourse, in order not to be a simple academic exercise, must urgently be translated into an assumption of responsibility by states towards industry and economic operators.
The debate already started in 2016 with the historic article by Ilona Kickbush which for the first time defined the notion of “commercial determinants” (1) has been developing above all thanks to the strong impetus given by the editor of LancetRichard Horton, who hosted a series of speeches on the topic turning it into a current public health priority. The series, published in March 2023, consists of an editorial and three articles (2, 3, 4, 5). On the one hand, the series aims to conceptualize the notion of commercial determinants in an articulated and precise way, but above all to provide useful recommendations to the authorities responsible for defending and promoting public health.
“International Health” it has already dealt with this issue (6) and believes that it is useful and necessary to continue to maintain attention and vigilance on the consequences for public health of an underestimation of the role of commercial health determinants.
The Lancet editorial reminds us that the conflict between profits and health equity is not new. It is well known that the global health community has struggled for decades to provide access to antiretrovirals for HIV/AIDS patients. The recent Lancet series on breastfeeding showed how a large network of lobbying from infant formula companies has derailed progress in breastfeeding education. It is no mystery how many actors in the commercial universe try to negatively influence national and international politics, undermine science and even directly attack people who denounce their actions. Four industries (tobacco, junk food, alcohol and fossil fuels) are responsible for at least a third of global annual deaths. However, research on commercial determinants of health still remains an endeavour, underfunded and insufficiently taken into consideration by health authorities. In many countries the industries that produce goods with a high (negative but also positive) impact on health play a fundamental role in the economy of those countries and this determines that tension between the public health agenda and the economic agenda which are often in contrast (think to conflicting interests causes tobacco tax revenues and negative health consequences of tobacco). Rob Modie, the undisputed leader of “Global Health Promotion” and inspirer of the Lancet series, underlines that it is not about being “anti-business” but rather “pro-health”.
Even if the formula is effective and reassuring, however, it leaves open the fundamental question of the political choices of each country and of the international community with respect to questions such as the issue of vaccines and drugs, patents, the regulation of the alcohol and tobacco markets and harmful food substances. In other words, being ‘pro-health‘ often involves choices that can only be ‘against the business‘. Tedros Adhanom Ghebreyesus, director general of the World Health Organization states, in a commentary on the Lancet series, that public health cannot progress without action on the commercial determinants of health: “Health does not begin in clinics or hospitals any more than it justice begins in the courts or peace on the battlefield. Rather, health begins with the conditions in which we were born and raised, in schools, streets, workplaces, homes, markets, water sources, kitchens and the very air we breathe” ( 7). These are beautiful and important words that sum up all the effort of the WHO Commission on Social Determinants chaired by Sir Michael Marmot.
However, reading those words and appreciating the intellectual and somewhat “militant” enterprise of the authors of the Lancet series, one is left with the impression that the gap between discourse and reality is still gigantic.
First, the definition of the commercial determinant of health still remains vague and probably too broad: in fact, every product and every artifact interferes with health both positively and negatively (from the computer to the car, from medicine to food). Therefore, we should define the indispensability of each product and the useful or harmful methods of use (again, think of the dependence on electronic tools of adolescents or the immoderate use of certain food substances or even drugs). In other words, not only should the definition of commercial determinant of health be better conceptualized and probably restricted but, above all, the boundary between positivity and negativity of each determinant remains ill-defined. The pharmaceutical sector alone constitutes a fundamental field of investigation in which to measure positivity and negativity or, ultimately, the relationship between benefits and risks.
Finally, two central questions remain open and unresolved, namely the relationship between Health Promotion and Health Education, on the one hand, and the Regulatory Action and Sanctioning Action of the state authorities, on the other and, above all, what should be the correct balance between the two pairs of shares. In other words, Health Promotion cannot be limited to Health Education alone but must use the multiple and often ignored tools that allow people to increase control over their health and to improve it. Promotion, in fact, goes far beyond attention to individual behavior and implies a wide range of social and environmental interventions. As a fundamental function of public health, health promotion should be a tool used by governments and communities to address health challenges. This is achieved by building pro-public health public policies. For example, through initiatives that are successful in promoting urban health, building healthy environments (schools and workplaces) and developing health literacy. Too often, on the other hand, Promotion is reduced to educational initiatives of little impact and which do not commit the health authorities and the States in general to initiatives with a systemic impact. On the other hand, if we consider the other pair of actions, i.e. the Regulatory and Sanctioning activities, we note that they are insufficient, uncoordinated and not sufficiently transnational (within the European Union itself different regulatory and sanctioning practices often coexist and with varying degrees of intensity). Often regulatory actions are too complacent with the demands of industry lobbies and ineffective or non-existent sanctioning activities.
Hence, the discussion on commercial determinants in order not to be a simple academic exercise must urgently be translated into an assumption of responsibility by states towards industry and economic operators.
If the role of research and academia is to increase knowledge on the impact of commercial determinants of health, the role of states is to take research indications seriously. The function of cultural interventions such as the one promoted by the Lancet with the series of scientific contributions on commercial determinants is to irreversibly introduce the question of the role of determinants into public health discourse and we cannot ask a scientific journal to do more but health authorities, states and multinational bodies must establish clear and shared rules both of a regulatory nature (think of strategies to reduce alcohol consumption or drug pricing policies) and, which is even more difficult, of a disciplinary nature , effective and, above all, truly independent of the pressures of the industry.
Benedict Saracen. Lisbon Institute of Global Mental Health
Bibliography
Kickbush I, Allen L, Franz C. (2016). The commercial determinants of health. The Lancet. Volume 4, Iss. 12e895-e896, December 01. https://doi.org/10.1016/S2214-109X(16)30217-0Top of formThe Lancet. (2023). Unravelling the commercial determinants of health. The Lancet. Flight. 401, No. 10383. Full-Text HTMLPDFGilmore AB, Fabbri A, Baum F, Bertscher A, Bondy K, Chang HJ, Demaio S, Erzse A, Freudenberg N, Friel S, Hofman KJ, Johns P, Abdool Karim S, Lacy-Nichols J, Maranha Paes de Carvalho C , Marten R, McKee M, Petticrew M, Robertson L, Tangcharoensathien V, Thow AM. (2023). Bas du formulaire Defining and conceptualising the commercial determinants of health. The Lancet. Flight. 401, No. 10383. Full-Text HTMLPDFLacy-Nichols J, Nandi S, Mialon M, McCambridge J, Lee K, Jones A, Gilmore AB, Galea S, de Lacy-Vawdon C, Maranha Paes de Carvalho C, Baum F, Moodie R. (2023). Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations The Lancet. Flight. 401, No. 10383. Full-Text HTMLPDFFriel S, Collin J, Daube M, Depoux A, Freudenberg N, Gilmore AB, Johns P, Laar A, Marten R, McKee M, Mialon M. (2023). Commercial determinants of health: future directions The Lancet. Flight. 401, No. 10383. Full-Text HTMLPDFSaraceno B. Commercial determinants of health. International Health January 30, 2023.Ghebreyesus Tedros A. (2023). Achieving health for all requires action on the economic and commercial determinants of health. The Lancet. Volume 401, ISSUE 10383, p.1137-1139. TWO: Alcohol, fossil fuels, WHO Commission on Social Determinants, commercial determinants, Health determinants, Health Education, Global Health Promotion, Ilona Kickbush, junk food, Lancet, Michael Marmot, Health Promotion, Richard Horton, Tobacco, Tedros Adhanom Ghebreyesus