Gilmore Lancet Series 2023 Conceptualising the CDH copy

Commercial Determinants of Health (CDOH)

Overview

The concept of Commercial Determinants of Health (CDOH) refers to the products and practices of commercial entities that influence health outcomes and exacerbate social inequities. Many industries, particularly those categorized as unhealthy commodity industries (such as tobacco, ultra-processed food, fossil fuels, and alcohol), significantly impact preventable diseases and deaths globally. For example, according to the World Health Organization (WHO) in 2021, tobacco use is attributed to over 8 million deaths each year globally, highlighting the detrimental health impacts of this industry. The rise of market fundamentalism has fostered an environment that allows these commercial actors to augment their wealth and power while contributing to societal and health inequities.

Definitions

  • Commercial Entities: Organizations involved in commercial activities primarily for profit, ranging from small businesses to multinational corporations.

  • Unhealthy Commodity Industries: Industries whose primary products are recognized as harmful to health, including tobacco and alcohol. For instance, the alcoholic beverage industry generated an estimated $1.485 trillion in revenue in 2020, as cited by Statista, while contributing to global health issues such as liver disease and alcohol dependence.

  • Externalities: Costs or benefits experienced by third parties as a result of commercial activities, which can lead to market failures.

Commercial Practices and Health Harms

  • Political Practices: Commercial entities often exert influence on legislation through lobbying and political funding. For example, in the 1990s, the tobacco industry spent over $45 million in lobbying against smoking regulations in the United States, as reported by the Campaign for Tobacco-Free Kids.

  • Scientific Practices: Some commercial entities manipulate scientific research to endorse their products, jeopardizing public health through misrepresentation. For example, the pharmaceutical company Purdue Pharma misrepresented the safety of OxyContin after its launch in 1996, contributing to the opioid epidemic that has claimed hundreds of thousands of lives in the U.S.

  • Marketing Practices: Aggressive marketing strategies adopted by these industries boost the demand for unhealthy products. An example is the marketing of fast-food products, which often target children and contribute to rising obesity rates. The U.S. Centers for Disease Control and Prevention (CDC) reported in 2019 that approximately 14.4 million children and adolescents were classified as obese.

  • Supply Chain and Waste Practices: Strategies that prioritize profit over environmental health can lead to pollution, further impacting health, particularly in economically disadvantaged areas. For instance, in 2014, the Fukuchiyama City Yamaguchi Plant in Japan was found responsible for chemical wastewater discharge that contaminated nearby water sources, impacting local residents' health.

  • Labour and Employment Practices: Exploitative labor tactics that jeopardize worker health, especially in industries with insecure employment conditions, are also evident. For example, the garment industry has faced scrutiny for poor working conditions in factories, such as the Rana Plaza collapse in Bangladesh in 2013, which killed over 1,100 workers.

  • Financial Practices: Tactics such as tax evasion and aggressive financial maneuvers weaken state finances and exacerbate health inequities. A 2020 report by Oxfam revealed that companies like Google and Apple collectively avoided billions in taxes by utilizing offshore tax havens.

  • Reputational Management Practices: Corporate social responsibility (CSR) programs often do not result in genuine positive social efforts but are instead public relations strategies. For instance, in 2017, fossil fuel companies like BP launched campaigns promoting their environmental commitments, despite continuing to invest heavily in oil extraction.

Pathological System and Consequences

The convergence of these commercial practices establishes a pathological system characterized by:

  • Escalating health harms due to the absence of effective regulations, as seen in the case of sugar-sweetened beverages that have contributed to rising diabetes rates. According to the CDC, 34.2 million Americans had diabetes in 2020.

  • Widening inequities as marginalized communities suffer the consequences of commercial exploitation; a report by the U.S. Surgeon General in 2020 indicated that Black Americans were disproportionately affected by COVID-19, partly due to underlying health inequalities exacerbated by commercial influences.

  • Diminished agency and wealth in governments and communities.

As a result, a power imbalance emerges, allowing transnational corporations to wield significant influence while public entities struggle to exert control and governance.

Proposed Solutions

To combat the negative impacts of CDOH, a structured approach is necessary:

  • Consensus Definition: Broad recognition that all commercial entities contribute to both positive and negative health outcomes should be established.

  • Conceptual Model: Develop a clear model to visualize the operations of CDOH across various systems, emphasizing its effects on societal norms, policies, and individual health decisions.

  • Policy Recommendations: Governments should prioritize public health policies designed to favor human health and environmental sustainability over corporate interests, including:

    • Regulating harmful commercial practices, such as enacting taxes on sugary drinks, as implemented in Mexico in 2014, which led to a 12% reduction in sugary drink consumption.

    • Ensuring that commercial entities bear the costs linked to their products, similar to the tobacco taxation models applied in many countries since the 2000s.

    • Promoting social norms that foster equitable health outcomes, for example, through public health campaigns aimed at reducing smoking rates, which saw a decline from 20.9% in 2005 to 14.0% in 2019 in the U.S.

Importance of a Systems-Level Approach

Addressing CDOH necessitates an understanding of the systemic issues that allow commercial influences to undermine public health. Key considerations include:

  • The media's role in advancing corporate interests, such as advertising for junk food during children's programming, which has been shown to influence dietary choices.

  • The obligation of governments to prioritize public health over economic interests.

Thus, a comprehensive strategy that tackles both specific commercial practices and the broader systemic issues is essential for achieving improvements in health equity and overall health outcomes.