Addressing power and politics through action on the commercial determinants of health

This national health promotion symposium has an underlying theme about the social determinants of health. A noble idea, but let me tell you that in Canberra it is not a concept that resonates. Mostly it is a giant turn off. While social determinism is an important framing for public policy development and discussion it lacks something when it comes to power and politics.1 Perhaps a better framing in the debate about remedying social and economic inequality is to think about commercial determinants of health, and their partners in crime—addictive or unhealthy commodity industries.2 “Commercial” because it speaks to power. It speaks to the power of the corporation, political influence, money, wheeling and dealing, and often corruption. “Social” does not, it generally speaks to weakness and disadvantage. And while public health too frequently comes off second best in the brutal execution of corporate power, ironically, given the present state of public trust in corporations and the political system, it may be that this distrust can be exploited to give public health the “upper hand” in some of these clashes. Understanding that corporations wield enormous power is not news. Similarly, recognising that this power is wielded to benefit the corporation and its agents is not news either. If you want to get a feel for the relative size of corporations have a look at the 100 biggest economies and see how the world's biggest corporations ranked against nation states in 2016. The US is the world's biggest economy at $3251 billion. Australia is ranked 12th at $426 billion. Among the corporations, Walmart comes in 10th ($482 billion), Shell 18th ($272 billion) and Apple 25th ($234 billion). Of the world's top 100 economies, 69 are corporations.3 But are corporate interests too powerful? Are these interests beyond democratic control? Are our political institutions concerned about this and further motivated to act in the public interest? It is hard to say given the evidence of the abuse of corporate power and the mighty reluctance by governments to act. Witness the painful way the Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry came into being. It took threats by Government members to cross the floor of the Australian Parliament and join the Opposition to establish the Royal Commission before the Turnbull Government finally relented and announced the inquiry.4 These powerful, and not so powerful corporations have become a feature of our economic world and our daily lives. Some are regarded as benign, while others like Apple are regarded more fondly. We have little affection for banks and mixed feelings for the likes of Google and Facebook. When I first became intrigued by the power of business corporations, and particularly by their ability to wrest concessions from national governments, it seemed perfectly possible to bring these concentrations of economic power under democratic control. Now I'm not so sure. It seems to me that many of the democratic gains fought for so heroically over the last 150 years have simultaneously created a set of nominally economic forces which have emptied many of those gains of real meaning. The truly worrying prospect is that those forces… have created new autocrats, immune from effective popular control.5 Wilks says that the conventional pluralist view, that business corporations are subordinate to the political process and an elected government, is a conceit.5 He argues, that instead the state and corporations co-exist in a system that bias's politics towards business interests. And this bias runs deep. He says corporations have more influence within democratic process than do voters.5 Neo-liberal, market-oriented economies have tended to acquiesce to corporate power.5 Competition policy, deregulation, privatisation and outsourcing have strengthened the hand of corporations and increased the risks of perceived and real undue influence on the political class.5 The implications for democracies and the public interest are serious. Historically governments have placed checks on corporate power, but over the years, these constraints have waxed and waned, been whittled away or just plain circumvented. A recent edition of the ABC television program Four Corners focused on Australia's growing obesity problem and its dramatic impact on Australia's health.6 The reporter, Michael Brissenden, told the story of the rapidly increasing number of Australians who are overweight and obese and the diseases that accrue. He reported on the opportunities to prevent this growing catastrophe and inevitably was led to ask questions about the powerful interests completely opposed to proven scientific recourses, such as a health levy on sugary drinks and advertising restrictions. In a follow-up story in The New Daily online newspaper Brissenden focused on the behaviour of powerful corporate interests like Coca-Cola, Pepsico, Unilever, Nestle and Kelloggs, who have worked assiduously to block the adoption of these policies.7 Other unhealthy commodity industries—alcohol and gambling—behave similarly. The alcohol industry fought for nearly 20 years to prevent the mandating of pregnancy warning labels on alcohol products until Australian and New Zealand Governments in October 2018 finally decided enough was enough.8 The gambling industry has successfully stalled all attempts by public interest activists to introduce pre-commitment regimes on poker machines. There are innumerable examples. Brissenden's Four Corners program revealed the tobacco industry-like tactics the food and sugar industries use to stave off government intervention in the public interest to arrest Australia's chronic obesity problems. They also merchandise doubt about the public health prescription for action, creating doubt about the science (and increasingly the economics), casting aspersions about scientists and of course influencing the political agenda. The contempt these corporations have for civil society can be breathtaking. But it's not all one way. Australia's corporate tax dodgers are being exposed by the work undertaken by the likes of the Tax Justice Network Australia and independent journalist Michael West.9, 10 West has been particularly active in focusing attention on the tax practices of Google, Facebook and Apple who, despite massive revenues, arrange their affairs in a way that minimises their tax liabilities in Australia. To this end, the Australian Tax Office reported in October 2018 the “more detailed scrutiny of the tax affairs of multinationals, large corporations and wealthy individuals… has collected $5.6 billion in extra tax in just 2 years.”11 The previously mentioned Banking Royal Commission has uncovered and reported on illegal behaviour and questionable practices that have confirmed what many already suspected about the banks (see Commission's Interim Report).12 It shows the value of major commissions of inquiry, which combine clever people with tough investigative powers, to expose abusive and harmful behaviours. The prolific lobbying by unhealthy commodity industries is well known. At the recent Public Health Association of Australia (PHAA) Health Prevention Conference in Sydney (2-4 May 2018) Curtin University's Professor Mike Daube AO, reported the tobacco industry employs 20 direct and 14 indirect lobbyists, alcohol 43 and 23, junk food, 33 and 13, and gambling 31 and 16.13 Redressing the imbalance requires mechanisms to increase transparency, regulatory officials who will not be intimidated, and legislation to stiffen penalties to discourage poor behaviour and punish offenders more heavily. Greatly enhanced lobbyist registers are required. Registers that provide real-time information about who these vested interests seek to influence. And while we are at it, introduce sanctions against the public service which repeatedly undermines the country's freedom of information laws. Commissions of inquiry, used judiciously, are powerful vehicles for targeting corporate malpractice. With strong investigative powers, they can go places others cannot and frequently will not. A federal corruption commission is sorely needed. Proposals are on the table, and one cannot be too far away now that Labor is supporting The Greens in its establishment. Banning corporate political donations (both direct and indirect) is much needed. When it comes to donations, there is always a price to be paid. We saw this with the former Senator Sam Dastyari, who allowed Chinese backers to make payments of a few thousand dollars on his behalf for travel and legal bills, and who then spoke in defence of the Chinese Government's activities in the South China Sea.14 It seems it does not cost much! In the case of health promotion, adherence to the World Health Organization's policy that corporate interests should not be involved in the formation of public health policy, would be a good place to begin. Stephen Wilks has a long prescription for reform. He accepts that “the exercise of corporate power is an everyday feature of life in advanced industrial societies,” but argues for broad change ranging from the incremental, through revolutionary to institutional change. However, his prescription relies on political elites becoming less enamoured of corporate privilege and to make large corporations “more accountable, less destructive and better able to contribute towards human fulfilment.” Public scepticism about these corporate interests is significant. The Foundation for Alcohol Research and Education's Annual Poll shows this. And herein lies corporate power's vulnerability. Corporations are very susceptible to criticism that they are only motivated by profit and what is good for their highly paid executives and their shareholders. This allows for public health advocates to mount emotive public interest arguments. Do not make the mistake of seeing industry as a unified force. They are not. Certainly not in the case of the alcohol industry. For example, the brewers and distillers, along with public health organisations, have lobbied hard against the preferential tax treatment of wine. Hotel proprietors complain about the growth of Coles and Woolworths’ ever-expanding network of bottle shops capturing a larger and larger share of packaged alcohol sales. These divisions can be capitalised upon in advocating for public policy change to address the commercial determinants of health. Finally, there is no secret to achieving policy change. Rather, it is just damn hard work with a bit of luck. Yet, much has been written about policy change. There are many theories, including Kingdon's “windows of opportunity,” but there are others that have equal validity.15 For all of these though, you need to be organised, you need to have a plan with clear policy objectives and be prepared to do the work. Collaborating with others and forming alliances has long been a public health tradition. Do that too—it works. Get involved and support those who are taking the lead and honour the three “Ps” of public health—persistence, persistence and persistence. The author declares that there are no conflicts of interest in connection with this article.