Commerce, trade, and public health: Unmasking the commercial determinants of health

India today stands at a crossroad. On one hand, the country is growing forward with rapid economic development and high aspirations to be a developed nation by the year 2027. On the other hand, it is facing an unyielding and costly health crisis: a huge burden of noncommunicable diseases and environmental hazards that disproportionately affect the bottom of the pyramid. For too long a time, public health activities have mainly focused on individual biological risks and behavioral risks.[1] However, this approach loses the forest for the trees. These devastating consequences underscore the urgent need to recognize and address a deeper, systemic driver – the commercial determinants of health (CDoH). The CDoH are rooted within the systems. The actions of powerful corporate actors whose profit motives usually collide with the importance of well-being. In this dynamic context, commercial influence gets a unique, fertile ground, which is helping to grow it further, causing devastating health consequences. A huge aspirational young population, a largely unregulated digital marketplace, fragmented and nonstandardized regulatory systems, and increasing disposable incomes create a perfect environment for the action of corporates. Sectors from processed foods, alcohol, tobacco, pharmaceuticals, fossil fuels, and big tech are giving increasingly harmful influence.[2] Their strategies are not only shaping what people consume but also, in reality, altering how they think, what they think, how they behave, and seek health care, making sure that India’s disease burden continues to rise despite policy progress and advancement in health care. India’s markets for unhealthy commodities have expanded drastically over the past decade. Ultraprocessed foods and sugary drinks, even artificial sweeteners, have become ubiquitous. They are marketed aggressively through celebrity endorsements, sports sponsorships, and digital influencers. Children, adolescents, and young adults are routinely exposed to unhealthy food and alcohol branding through sports live telecast, online gaming, OTT platforms for watching series, episodes of various shows or movies, and social media, including X, Facebook, Instagram, and other areas where regulatory oversight is weak or nonexistent.[3] The normalization of these products is neither accidental nor passive; it is the result of tactically designed corporate strategies for market profit that display several harmful commodities as symbols of aspiration, attractiveness, convenience, and modernity. Indian industries rely hugely on strategies such as denial, distortion, and delay to protect their commercial interests. Whether it is the long-standing controversies around the popular noodle brand “Maggi,” the debates surrounding artificial sweeteners, or the framing of alcohol as a matter of “personal responsibility,” corporations are skilled at manufacturing confusion. These tactics often shift attention away from evidence and weaken policy momentum. The tobacco industry has skillfully mastered this playbook, influencing research projects, clinical trials, sponsoring events, and lobbying against effective regulations. Similar patterns are emerging across modern sectors, including e-cigarettes, energy drinks, and digital entertainment platforms. The pharmaceutical sector provides another significant area of commercial influence. The dynamics between pharma companies and healthcare professionals in India are highly interconnected, with industry sponsorship also getting reflected in attending conferences, seminars, continuing medical education, samples and investigations, and promotional materials. As a result, branded medicines are overshadowing generic medicines even when generics are equally effective. Patients perceive free or low-cost government medicines as inferior, not because evidence suggests so but because corporate marketing and social norms help to reinforce such beliefs. The result is a cycle where patients, especially from low-income backgrounds, are pushed toward higher out-of-pocket spending, deepening financial vulnerability. A similar pattern is also being seen in diagnostics. Reports of public sector laboratories are usually delayed, frequent malfunctioning of laboratory equipment, or long waiting times create opportunities for private labs that promote themselves as faster and more reliable in spite of being too costly. Sometimes, patients perceive direct or indirect benefits from healthcare providers toward private testing centers, aggravating mistrust in public systems. Such experiences reflect how commercial incentives can purposefully redirect patient care pathways, even in settings where public services exist.[4] Underlying these issues is India’s regulatory framework, which remains fragmented, under-resourced, and vulnerable to industry influence. Food labeling standards, digital advertising rules, alcohol-related regulations, clinical establishment norms, and occupational safety laws are spread across multiple ministries and agencies, often with overlapping or unclear mandates and regulations. Corporate lobbying utilizes the existing gaps. Evidence from global tobacco interference indices suggests that several Indian states still continue to experience significant industry influence, undermining public health policies and regulations. When regulatory laws are weak and transparency is limited, commercial actors gain disproportionate power to shape both markets, policies, and result in adverse health outcomes. The consequence of these altered market dynamics is a deepening of health inequities. For wealthier subgroup, harmful products are lifestyle choices that can be modified or substituted. However, for the people at the bottom of the pyramid, they become the default products. Energy-dense foods are cheaper than healthier alternatives; safe public spaces for physical activity are inadequate; high occupational and environmental exposure to pollution; healthcare choices are increasingly shaped by affordability and convenience rather than need.[5] In essence, the CDoH creates an environment where illness becomes more likely for those with the least resources to cope with. Addressing these challenges requires shifting health priority from being a sectoral priority to whole-of-society approach where governments (all sectors), private sector, civil society, communities, and individuals stand together to recognize and address the CDoH through strong and effective public policies. Stronger conflict-of-interest declarations, transparent policies on influencer advertising, clear pharma company–physician relationships, robust food-labeling laws, and accountability mechanisms for corporate political activity are essential steps. Public literacy on commercial influence must also grow alongside, empowering communities to recognize and challenge harmful corporate practices. India’s health future healthcare delivery system depends not only on strengthening its public health system but also on reshaping the environments in which people live and the commercial drivers that influence their preferences in day-to-day life. Addressing the CDoH is more than an academic pursuit; it is essential to achieve “Vikashit Bharat” by 2047.