Why action on the commercial determinants of health is vital

The In Conversation: Boundary Spanners, Thinkers and Policy Actors Round Table Series provides a platform for researchers, policy actors and implementation experts to elevate discussion on emerging issues, present research and facilitate conversation around impacts and possible solutions.1 This editorial is based on one of the In Conversation sessions. The policies, practices and products of commercial entities shape our lives influencing living conditions, consumer behaviour and political decisions. Often the actions of these commercial organisations are harmful to health and well-being, exacerbating inequities, and prioritising private interests and profit over public interests. Commerce—the buying and selling of goods and services—is not inherently bad for health. Many goods and services are beneficial, even essential, to health, for example, healthy food, clothing, medical products and access to digital technology. Businesses can offer safe and accessible employment options and add to the economic prosperity of countries. Having a good quality, secure job is beneficial for health. Where economies are thriving, governments can redistribute income and invest in health and social services that protect and promote the health of their citizens. Commerce becomes a concern when the drive for economic outcomes and interests puts the health of individuals and populations at risk. In 2021, the World Health Organisation (WHO) acknowledged both the positive and negative impacts stating ‘Commercial determinants of health are the private sector activities that affect people's health positively or negatively’ including ‘the conditions, actions and omissions by corporate actors that affect health’4 and most recently the landmark Lancet series defines the CDoH as ‘the systems, practices, and pathways through which commercial actors drive health and equity’.5 Lacy-Nichols et al provide a useful framework designed to distinguish between diverse commercial entities through consideration of their practices, portfolios, resources, organisation and transparency. This enables, for instance, a distinction to be made between a local small business and a trans-national corporation.7 Commercial determinants have long been known to have an impact on health, but governments have had mixed success in prioritising public health. Tobacco control is the most successful example of controlling the negative impact of commercial interests—‘Big Tobacco’—dramatically reducing smoking rates and related deaths, particularly in high-income countries. This healthy public policy approach has been accelerated by the adoption and implementation of the global treaty, the WHO Framework Convention on Tobacco Control.8 Other examples where commercial interests were managed through policy and legislative responses include road safety measures (e.g., seat belts, drink driving and airbags) and occupational health and safety (e.g., asbestos and lead controls). Worryingly, action on the biggest threat to health, climate change,9 is impacted by the commercial interests of the fossil fuel sector through strategies including intensive lobbying, donations, election campaigning and employment of former politicians and advisors.10 The past 5 years has seen a burgeoning of literature pointing to the impact of the commercial determinants on health and equity with research providing real-world examples.11, 12 It is fundamental to fully understand the operation and impact of the CDoH to develop and implement interventions that protect and promote health. ‘Health is a political choice’ requiring governments to choose actions that favour population health and equity.13 Public health actors and communities also have power, including through coalitions, social mobilisation and organised campaigns. The Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and Public Health is one such example of a coalition of actors working together for broader public good.14 Lacy-Nichols and Marten note that advancing health promotion practitioners' knowledge and understanding of the myriad sources and forms of power and strategies used by commercial actors will assist in advocacy, research and partnerships.16 This must be a priority for capacity building in the health promotion sector including a focus on the sector's capacity for action on CDoH. Building partnerships with colleagues in sectors including finance, law and economics will assist in implementing policy reforms, especially when combined with a well-organised approach, a clear plan and persistence.17 Partnerships and coalitions, including with civil society, are fundamental to health promotion and the expertise and experience of Health in All Policies specialists in making political and policy sense of the complexity of determinants of health and required action should prove useful in this regard. Reworking ‘common social determinants of health (SDOH) frameworks’ to include CDoH will enhance understanding and awareness.11 The increasing attention given to the well-being economy of health could also assist with measuring the impact of commercial activities. So too will consideration of progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social and environmental goals, and strategic civil society mobilisation.18 This is a vital area in which the health promotion community must engage, with considerable potential to make a difference to health and inequity. Michele Herriot received funding as a consultant from the Centre for Health in All Policies Research Translation, SAHMRI to support the writing of this article.