The Invisible Hand Making You Sick
Commercial Determinants of Health sounds like academic jargon. It isn’t.
I’m writing this on the way to yet another seminar - no rest for the wicked - but there are three great things going for this trip: the attendees, the topic, and the anticipation of being somewhere with 19℃ weather.
I’m snatching free moments during travel and meetings to write this instead of the normal, leisurely full-day thing, so I’m going to keep this short. Besides, last week’s issue was a long one and you probably need a break from all these newsletters too.
Last point and for full disclosure: I used Claude to trace the term’s origin and history, then fact-checked the sources. I discovered two earlier pieces the machines missed, so I’m feeling a little smug right now.
Hope everyone is staying cool.
I don’t remember the first time I came across the term “Commercial Determinants of Health,” or its clunky acronym CDoH.
However, I do remember thinking, “What a mouthful!” And “What on earth does it mean?”
That’s why WHO Europe’s 2024 report was groundbreaking and illuminating for me. It delved into the powerful actors, including food and beverage companies, and the tactics they deploy to maximise profits and undermine public health, while framing their activities as supporting freedom and consumer choice.
It identified four corporate products - tobacco, ultra-processed foods, fossil fuels and alcohol - as responsible for the deaths of nearly 7,500 people every day or 2.7 million deaths a year in the WHO’s Europe Region.
I devoted a whole issue of Thin Ink on it.
Since then, more studies, research, and papers have been published about this term, probably to the displeasure of the corporate players who use these tactics. So I wanted to spend this week looking at it in a bit more detail.
The Origin Story
The earliest mention of the term I could find was in August 2012.
“The marketing campaigns of multinational corporations are harming our physical, mental, and collective wellbeing,” and public health should be concerned with the commercial determinants of health, wrote Gerard Hastings, Director of the Institute for Social Marketing at University of Stirling, in an analysis for the BMJ.
Four months later, Swiss-based academic Ilona Kickbusch argued that “we totally underestimated globalised corporate power combined with its global marketing onslaught and its transnational influence on political decision-making.”
She titled her editorial: “Addressing the interface of the political and commercial determinants of health”.
However, it wasn’t until March 2013 that CDoH had a proper defintion - “factors that influence health which stem from the profit motive”, according to addiction researcher Robert West and health psychologist Theresa Marteau.
A similar term emerged later that year when John Millar, a physician at the School of Population and Public Health, University of British Columbia, published a two-page commentary “The Corporate Determinants of Health”.
He wrote of companies “selling products that are damaging to health and the environment, at prices that do not account for these damaging effects and often target consumers that are ill-informed and susceptible” and identified producers of “tobacco, alcohol, drugs, junk foods and beverages, resource extraction, arms production and the electronic media” as belonging to that group.
“Governments have a responsibility to take action when the market mechanism fails in this way,” with the food and beverage sector a priority for action, he added.
But the definition that has become prevalent came in December 2016, in a Lancet commentary by Kickbusch, Luke Allen, and Christian Franz: “strategies and approaches used by the private sector to promote products and choices that are detrimental to health”.
NOTE: The term itself doesn’t assign value. A determinant can be good or bad. However, much of the research and the definitions above have focused on the bad actors because that’s where policy changes are needed most.
What does all that mean?
It means your health is shaped not only by your genes, your doctor, or your lifestyle choices, but also by commercial activities from corporations with considerably deeper pockets than many national governments and civil society groups.
What products are available and affordable to you, how they are marketed to you, and whether there are any regulations that affect their availability, affordability, and ubiquity also shape your health significantly.
According to scholars, corporations play a very important role in determining these things. Hence, “commercial determinants”.
The CDoH “playbook” includes marketing products that are detrimental to health; extensive and highly integrated supply chains that make such products easily accessible; political activities like lobbying, litigation, political donations, corporate social responsibility initiatives, and embedding themselves in public-private partnerships and government commissions.
It also includes funding industry-friendly science; actively promoting misinformation; and sowing doubt and confusion over evidence linking their products to ill health; and using international trade arrangements to resist regulations.
Academic literature has identified these sectors as having products and practices that harm our health: tobacco, alcohol, food, fossil fuel, chemicals and pesticides, firearms, mining, pharmaceuticals, and gambling.
But I’m going to focus on my passion topic and something we come into contact with every single day - food and drinks.
The globalisation of trade, the way our corporate, economic, and political systems work, and the neoliberal and capitalist ideologies have also been identified as facilitating CDoH.
The WHO has a factsheet on CDoH that’s worth pursuing, and the agency has also been preparing a Global Report on the Commercial Determinants of Health. Watch this space.
Why it matters
Well, it can determine whether we live a long, healthy life or not.
The terminology is unwieldy and it’s tempting to see as an academic term that wouldn’t catch on in real life. But I think it should become mainstream.
We are currently facing an unprecedented public health crisis:
75% of global deaths or 43 million lives lost are due to non-communicable diseases (NCDs)
Nearly 3 out of 4 of these deaths are in low- and middle-income countries
Cardiovascular diseases account for most NCD deaths, followed by cancers, chronic respiratory diseases, and diabetes.
For a long time, the industry has framed ill health as a result of “personal choice” to prevent regulatory accountability, and labelled governments that attempt regulate as “nanny state” to sow fear among policymakers.
But how much choice do we actually have if all that we can find and afford is food that could give us hypertension, diabetes, or cardiovascular disease?
For example, if you live in one of those food deserts where fresh food is a half-hour drive away and you don’t have a car, it is going to be incredibly difficult for you to eat fresh, seasonal food.
Or if you are in a food swamp, surrounded by snacks, sugary drinks, and sweets, well, it’s going to take a whole lot of willpower to go in search of healthy foods. Often, food deserts and food swamps are the same place.
How about being bombarded by advertisements of crisps, chocolates, and fast food every time you look at your instagram feed, walk to the bus stop to get to school or office, or watch your favourite show? Chances are that at least once in a while, some of us are likely to be famished when they pop up and be tempted to reach for them.
Even if you live somewhere near fresh produce and studiously avoid the marketing and promotion of junk food, what if, due to time and costs constraints, the only meals you can eat are loaded with sugar, salt, fat, and additives?
Consider this one: you’re an exhausted new mother who see aggressive marketing and advertising - including at your doctor’s clinic, on the website of your physician association, or by your own social circle - that formula milk is equivalent or even superior to breastfeeding.
The science is clear - breastfeeding protects both mothers and children, reducing the risk of infections, obesity, and certain cancers - but you’re being told your child will have a higher IQ if they take formula milk, or that it will help you get back to work quicker and contribute to the household. What would you choose?
Millions of mothers, in exactly that situation, chose formula.
Government policies can temper the situation: zoning laws to make sure there is a dearth of - or deluge of - certain types of shops, providing clear information on food packaging so you know if what you’re eating has too much sugar, salt, or fat, or restricting where and when certain products can be advertised.
It’s Not You. It’s Them.
These are just the more visible activities, the ones we encounter in our daily lives.
The food environments around us, the advertisements targeting our children, the price gap between a bag of crisps and a bag of apples? Well, these are the product of deliberate commercial decisions, not accidents of the market.
But there is also a less visible layer that is, in some ways, even more powerful: the lobbying, the political donations, the funding of industry-friendly research, and the quiet capture of the regulatory bodies meant to hold these industries to account.
This is where the real power lies, and where investigative journalism, public health research, and advocacy have the hardest and most important work to do.
Both layers can be addressed through regulation and the evidence shows that regulation works.
Chile’s warning labels reduced purchases of products carrying them by 37% for sugar, by 22% for sodium, and nearly 16% for saturated fat.
Colombia's healthy tax survived 17 legal challenges and raised the equivalent of over US$700 million in its first full year of collection.
The WHO's tobacco control framework has saved millions of lives since coming into force in 2005.
So if you’re ever tempted to beat yourself up for not having the willpower to resist a pack of crisps or a can of soda, remember this line from a report by the The European Economic and Social Committee(EESC):
“Health is a fundamental human right shaped by a complex set of social, economic, commercial, environmental and digital determinants. 70% of the state of health is influenced by these factors, compared to only 10% for individual behaviours.”)
Papers that helped me further my understanding of CDoH
Thin’s Pickings - CDoH Edition
Commercial power, conflicts of interest and health policy with Elena Whitham - Money Power Health with Nason Maani
A sharp, accessible conversation with the former Member of the Scottish Parliament and Minister for Drugs and Alcohol Policy in the Scottish Government about how industries that profit from harmful products gain influence over the policies meant to regulate them.
The Deck is Stacked Against Healthy Eating - The New York Times
A brisk opinion piece arguing that the barriers to healthy eating are structural, not personal, and that blaming individuals for poor diets while corporations engineer the food environment is both scientifically inaccurate and politically convenient.
The Supreme Court’s Decision about Glyphosate: Wrong, Infuriating, and Un-MAHA - Food Politics
I can’t summarise this bone-headed decision that handed over public health to the agrochemical industry better than the OG of nutrition science Marion Nestle - Wrong, Infuriating, and Un-MAHA.
As always, please feel free to share this post and send tips and thoughts on bluesky @thinink.bsky.social, mastodon @ThinInk@journa.host, my LinkedIn page, twitter @thinink, or via e-mail thin@thin-ink.net.
Thank you for the focused overview!
Is it possible to determine labor, technology and all inputs that go into ultra-processed foods? As the following step: Can we do a call for proposals how to re-purpose, or phase out those inputs so that negative externalities are reduced but economic output is maintained?
I think this is a good tactic: not to vindicate but achieve visibility for a major health challenge and pro-actively identify alternative food supply and food and food service jobs.