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Recognising the elephant in the room: the commercial determinants of health
  1. Cassandra de Lacy-Vawdon1,
  2. Brian Vandenberg2,
  3. Charles Henry Livingstone1
  1. 1School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  2. 2School of Social Sciences, Monash University, Clayton, Victoria, Australia
  1. Correspondence to Dr Charles Henry Livingstone; charles.livingstone{at}monash.edu

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Summary box

  • The discourse and terminology of ‘Commercial determinants of health’ should be used in preference to other similar terminology, and should be broadly applied when examining any aspect of population health where there are clear links between commercial and/or corporate forces and health.

  • Systems of power are fundamental to and reinforce the commercial determinants of health. These require recognition and consideration within the commercial determinants of health context, particularly where populations are exposed to risk factors, and other vectors of harm.

  • Commercial determinants of health should themselves be recognised as reflexive systems, and systems approaches should be prioritised in interventions seeking to improve population health.

  • Commercial determinants of health definition(s) should recognise potential for both harms and benefits, and the multidirectionality of commercial determinants of health as risk and protective factors. However, reducing and preventing harms should remain the primary focus.

Introduction

To counteract global growth in non-communicable diseases (NCDs), the health consequences of climate and environmental emergencies, and inequity in health, it is necessary to better understand fundamental influences on health, and recognise how these differ within and between populations. Social determinants of health (SDoH) studies provide understanding of how inequality shapes health. However, we understand less about how capitalism, globalised corporate and commercial systems and broader political–economic and global governance conditions facilitating these, directly and indirectly shape inequality and health. As these systems have profound influence over population health and social circumstances,1 understandings of commercial determinants of health (CDoH), and integrating these conceptually within SDoH, are crucial.2

CDoH represent a significant global health concern for a number of reasons. Due to the globalised nature of modern commerce, and the transnational presence of commercial actors, the effects of CDoH are felt the world over.3 4 These are facilitated by the weakening of global governance structures such as the World Trade Organization, the proliferation of multinational free trade policies that favour business and the increasing concentration of commercial actors into global oligopolies, among others.4–6 These systems have roots in colonialism,7 and see commercial interests originating from high-income countries extracting resources and wealth from low-income and middle-income countries (LMICs).8

While the effects of commercial and corporate influences on population health are continually being identified and recognised, these are an emerging field of public health and are yet to be comprehensively integrated within CDoH framing. As a recent review found, CDoH literature lacks precision, with CDoH definitions and/or conceptual frameworks only occasionally provided, portrayed as ‘assumed knowledge’, inconsistently applied and unrepresentative of broader literature.9 Additionally, CDoH are not well-articulated nor communicated, with analyses often narrowly formulated around specific industries,10 and yet to be included systematically within public health policy frameworks2 and interventions. Together, these represent ‘an elephant in the room’: the increasingly obvious but often ignored problem of the profound influence of commercial and corporate influences on human and planetary health.

Why commercial determinants of health matter

The notion of power is central to understanding CDoH. Power is conceptualised in a number of different ways. The definition most pertinent to CDoH is arguably Fuchs’ three forms of corporate power which defines power as the ability of business actors to successfully pursue political objectives.11 Fuchs’ three forms of power include: (i) instrumental—political and policy influences via mechanisms including lobbying or political donations; (ii) structural—agenda-setting power via institutional processes such as private investment, employment, taxation and economics; and (iii) discursive—power to pursue and shape interests by shaping societal values and norms, and ideas.11

Many describe CDoH as originating from unchecked and unseen corporate power, including setting social narratives, influencing legal and political processes, framing rights and taking ownership of knowledge and ideas.6 12–15 Contemporary systems of trade, employment, public policy, political, legal, economic, civil society, media and others create environments that encourage and support the unbridled growth and power of corporate and commercial actors, with carefully constructed discourses supporting and shaping such systems. It is imperative for population health that public health actors effectively recognise and respond to corporate power in all forms.

Recent CDoH discussions emphasise incorporating systems thinking approaches, and recognising the dynamic, reflexive nature of power, governance and other social institutions.16 Embedded in these are communication technologies and practices including media businesses, social media platforms and interactive data harvesting enabling highly targeted marketing practices. These systems coalesce to produce health-harming and/or health-promoting environments in some cases.

A systems focus recognises that solely aiming to change individual behaviours cannot mitigate harm because of the various social, relational and institutional forces shaping agency, and shaping where agency is perceived to exist (ie, individual responsibility).17 Discourses promulgated by commercial interests commonly portray public health problems as resulting from ‘flawed consumers’ lacking individual responsibility and control, rather than acknowledging consumer markets flooded with heavily marketed health harming products. Industry generated messages to ‘drink responsibly’, ‘gamble responsibly’ or ‘consume within a healthy balanced diet’ are examples of narratives that focus solely on consumer behaviours and ignore potential harms inherent to commercial products and practices.18–20 Instead, action at leverage points within, between and across systems is needed to promote health.21

Taking a systems approach to CDoH also brings issues of equity and social justice into focus. Consequences of CDoH are often gendered, social class dependent,2 increasingly influential in LMICs10 and favour corporate rights over human rights. CDoH roles in shaping global patterns of inequity,21 22 and pursuing crude models of economic growth leading to neglect of social goods,23 require a response to strengthen ethical, legal and social systems to combat these and reduce the incidence of NCDs and other harms.

Why adopt the terminology of commercial determinants of health?

CDoH are one of many frameworks describing health challenges arising from corporate and commercial interests. These include studies in political economy, the genealogy of discourse and the imaginary basis of capitalist society.24–26 However, the adoption of CDoH discourse is now imperative, for three reasons.

First, because of increasing familiarity with SDoH language within the broader public health field, CDoH can be readily conceptualised as the study of ‘systems shaping the conditions of daily life’ and health. This is congruent with understandings of health determinants, making CDoH widely accessible conceptually. This is arguably preferable to less inclusive concepts or discourses such as ‘industrial epidemics’,3 27 28 ‘unhealthy commodities’29 or the ‘corporate consumption complex’,30 notwithstanding these being clearly interlinked. Despite recent criticism of the determinism that frames SDoH, building on broad understandings of SDoH is advantageous to more readily comprehending CDoH underpinnings. However, CDoH extend these, conceptually providing a ‘more holistic, integrated and targeted approach’.1

Second, CDoH incorporate multiple important concepts which should be held in conjunction. For instance, CDoH acknowledge the prominent roles of corporate sector profit maximisation, globalisation and industrialisation in driving contemporary disease patterns. Further, CDoH acknowledge global corporate structures, activities and relations as being highly integrated and sophisticated, wielding extensive influence over global health.

Third, CDoH language has already come to the fore with institutions such as the WHO Collaborating Centre on Social, Political and Commercial Determinants of Health Equity,31 the SPECTRUM Consortium32 and the Center on Commercial Determinants of Health within the Milken Institute School of Public Health.33 These institutional cores strategically convey the import of CDoH. Uniting research and literature conceptually under CDoH discourses may assist in guiding research, policy and practice, facilitating communication between academic and non-academic stakeholders alike.2

Defining commercial determinants of health

Conceptual development of an agreed CDoH definition, and related concepts, theory and study methods, have been highlighted as CDoH research priorities.21 As a first priority, there is a need to review conceptual models shaping CDoH understandings, including its aetiology, evidence of outcomes and proposed responses.2

Box 1 shows prominent CDoH definitions. These predominantly focus on CDoH as negative health influences. Acknowledging that these activities influence both health and disease is compatible with the increasing recognition of positive and negative CDoH outcomes and compatible with recent CDoH framing.1 12 22 34

Box 1

Defining the commercial determinants of health (CDoH)

  • Kickbusch et al describe CDoH as private sector strategies and approaches for promoting products and choices detrimental to health.40

  • West and Marteau describe these as factors influencing health stemming from the ‘profit motive’.41

  • Kosinska and Ostlin highlight inherent tensions between commercial and public health objectives in consumption, accessibility and affordability of goods and services.42

  • Freudenberg describes CDoH as ‘structures, rules, norms and practices by which business activities designed to generate wealth and profits influence patterns of health and disease across populations’.43

Private enterprise makes positive social contributions through systems providing employment, wealth generation, technological innovation and the provision of products and services valued by the community and beneficial to health.35 However, notwithstanding commercial businesses’ health promoting potential, this is often offset by cascading harms attributable to corporate and commercial actors, including exploitative work conditions, environmental and climate degradation and the entrenchment of inequality and inequities. Such harms typically arise when commercial profit motives conflict with public welfare and social well-being,35 36 where social and political systems fail to protect workers and the environment, and where social revenues (eg, taxation) are not well guarded. That said, in systems where such protections are upheld, real opportunities to promote population health may be available.

Towards a systems definition of commercial determinants of health

Drawing on existing CDoH and SDoH definitions, and considering CDoH literature more broadly, we propose that CDoH definitions incorporate five elements, shown in box 2.

Box 2

Proposed elements for a commercial determinants of health definition (CDoH)

Any CDoH definition should incorporate the following elements:

  • The CDoH are a series of systems that initially materialise around systems of commercial and/or corporate power;

  • These systems are strongly oriented towards pursuit of profit;

  • In this pursuit they are greatly enabled by political, social, technical and economic systems, and frequently exercise significant influence over these;

  • All of these systems are inter-related, and form a constellation of factors with potential to profoundly influence population and planetary health and well-being; and

  • While acknowledging that CDoH systems’ influences may be positive or negative, the primary focus must be on preventing and reducing harm.

We propose positioning CDoH as similar to SDoH, where benefits and harms are nuanced, circumstantial and sometimes concurrent. Modifying systems that facilitate CDoH may modify, reduce or eliminate commercial and corporate forces’ harm-producing characteristics, and may have potential to facilitate or maximise benefits. These systems include macro-level political–economic conditions and power dynamics, and associated activities, structures and relations such as marketing and media interactivity, corporate political activity, corporate social responsibility, supply chain integration, product formulation, production processes and accessibility, industrial relations, and social, environmental, economic and financial policy, including enforcement or reasonable taxation. Further, we emphasise that CDoH are at the intersection of political, economic, social, environmental and other determinants of health.

Moving forward

In public health policymaking and practice, effective CDoH informed approaches are needed at every intervention level. This includes developing adaptive models to document and address CDoH, as pertinent to different situations and populations. In this, we join others in calling for the development of a new CDoH framework tying together core concepts and facilitating a shift toward systems that support population health and well-being more equitably,2 21 and also suggest additional priorities.

Practically, applying our CDoH definitional recommendations would involve recognising CDoH as highly nuanced and contextual, requiring careful examination in each situation. Like power, many CDoH are invisible. Therefore, shifting public health (and public) consciousness to interrogate discourses, products, industries and systems is necessary. This involves moving beyond the duality of ‘good’ or ‘bad’ products, choices, practices and so on, to recognise the effects of power in each scenario.

As CDoH are highly reflexive, change within CDoH systems, including public health interventions, could be expected to generate additional, unintentional and at times unexpected outcomes and political responses.37 Public health approaches should, accordingly, themselves be reflexive in responding to these outcomes, requiring ongoing monitoring and modification as new information and outcomes arise.

Developing effective alternative discourses should be considered alongside efforts to change the apparent structures of CDoH systems. Drawing on Fuchs’ conceptualisations of discursive power may be helpful here.11 We support a shift in public health focus from conceptualisations primarily (and often solely) emphasising structural determinism, towards better understanding of discursive articulations and practices, in order to better understand and in turn disrupt systems creating harm. Reshaping norms and narratives has been successful previously (eg, in tobacco control where smoking has been successfully denormalised, and industry reframed as ‘merchants of doubt’).38 39 Considering CDoH as systems, and acknowledging the power of discourses as core components of these systems, may assist with rationalising this.

Adopting these approaches will enable the public health community to more effectively recognise CDoH as a major, but often unacknowledged, elephant in the room.

Data availability statement

There are no data in this work.

Ethics statements

Patient consent for publication

References

Footnotes

  • Handling editor Seye Abimbola

  • Twitter @CassiJayde, @CLjeSuppose

  • Contributors All authors have contributed significantly to this manuscript. CdL-V and CHL were responsible for the initial conceptualisation of this commentary. BV provided suggestions and comments to refine and extend the content. CdL-V has led the drafting processes, with input from all authors. All authors have approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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