Rem­co van de Pas, Katha­ri­na Wab­nitz

The Com­mer­cial Deter­mi­nants of Health (CDoH) have been defi­ned as “the sys­tems, prac­ti­ces, and pathways through which com­mer­cial actors dri­ve health and equi­ty, both in a posi­ti­ve and nega­ti­ve way”.¹ The CDoH have impact on health in diver­se ways, as the exam­p­le of nut­ri­ti­on poli­cy below indi­ca­tes.

The dou­ble bur­den of mal­nu­tri­ti­on

As ear­ly as 2013, the WHO had reco­g­nis­ed the harmful side-effects on health of all the unre­gu­la­ted prac­ti­ces of indus­tries invol­ved in ‘Big Food’, ‘Big Soda’ and ‘Big Alco­hol’. Sin­ce mar­ket power rea­di­ly trans­la­tes into poli­ti­cal power, few govern­ments have sin­ce prio­ri­ti­zed health over big busi­ness.⁴ In 2023, the­se phe­no­me­na are known as the CDoH.¹ It has beco­me a glo­bal patho­lo­gy dri­ving dise­a­se and death as the avai­la­bi­li­ty of UPF has now deep­ly pene­tra­ted even the midd­le and lower-inco­me stra­ta across the glo­be. Ama­zin­gly, only four com­mer­cial pro­ducts (tob­ac­co, alco­hol, UPF and fos­sil fuels) account for one-third of annu­al deaths world­wi­de.¹ Glo­bal obe­si­ty has almost tri­pled sin­ce 1975; 39% (1.9 bil­li­on) of adults aged 18 years and older were over­weight and 13% obe­se in 2016.⁵ 39 mil­li­on child­ren below the age of 5  are over­weight, as are 340 mil­li­on child­ren and ado­le­s­cents bet­ween the ages of 5 and 19.6 At the same time, more than 900,000 peo­p­le world­wi­de live in fami­ne-like con­di­ti­ons. ⁶ This dou­ble bur­den of mal­nu­tri­ti­on is a form of inju­s­ti­ce that, like the eco­lo­gi­cal cri­ses, is unfol­ding across the glo­be like a slow-moti­on dis­as­ter.

The Com­mer­cial Deter­mi­nants of Health

Com­mer­cial enter­pri­ses are diver­se and do not ope­ra­te in iso­la­ti­on. They are an actor along­side other actors, inclu­ding govern­ments, who would have the poten­ti­al to shape the regu­la­to­ry sys­tems that curr­ent­ly enable com­mer­ci­al­ly dri­ven health harms so that this is no lon­ger pos­si­ble. Howe­ver, ins­tead of using regu­la­to­ry mecha­nisms, regu­la­ti­on and taxa­ti­on is too often limi­t­ed by govern­ments, which helps to fur­ther expand neo­li­be­ral glo­ba­li­sa­ti­on, a form of mar­ket fun­da­men­ta­lism or free mar­ket ideo­lo­gy.¹ Major cor­po­ra­ti­ons achie­ve this, among­st other stra­te­gies, by crea­ting inter­na­tio­nal public pri­va­te poli­cy initia­ti­ves and mul­ti-stake­hol­der approa­ches, which gene­ral­ly accom­mo­da­te cor­po­ra­te busi­ness inte­rests. An exam­p­le of this is the ‘Sca­ling Up Nut­ri­ti­on’ (SUN) move­ment, which includes the food indus­try, ther­eby legi­ti­mi­sing a vol­un­t­a­ry part­ner­ship model and poten­ti­al con­flicts of inte­rest over more strin­gent govern­ment regu­la­ti­ons.⁷ Cor­po­ra­te inter­fe­rence in poli­cy­ma­king fur­ther includes legal thre­ats, media cam­paigns, poli­cy cap­tu­re and delay­ing, under­mi­ning and cir­cum­ven­ti­on tech­ni­ques.⁸ 

The CDoH lens is a direct respon­se of inter­na­tio­nal Public Health sci­ence, prac­ti­ce and acti­vists to the framing by com­mer­cial com­pa­nies that food con­sump­ti­on and healt­hy food beha­viour are indi­vi­du­al choices.⁹ This framing shifts respon­si­bi­li­ty from tho­se pro­du­cing unhe­alt­hy pro­ducts and more important­ly, from tho­se set­ting the regu­la­to­ry frame­work con­di­ti­ons for busi­nesses. A major ques­ti­on is then what kind of col­la­bo­ra­ti­ve ide­as and alli­ances could chall­enge this con­glo­me­ra­te of powerful com­mer­cial enti­ties that have cap­tu­red (inter-)national poli­tics that ought to pro­tect Public Health? Can we ima­gi­ne an alter­na­ti­ve set of stra­te­gies to coun­ter this deve­lo­p­ment and to fur­ther a pro-‘Public Health Play­book’ for busi­nesses?¹⁰

Coun­ter­ac­ting the nega­ti­ve impacts of the CDoH

To this end, we could learn from long­stan­ding, some­what negle­c­ted efforts by acti­vists, femi­nists and cri­ti­cal scho­lars sin­ce the late 1970s to coun­ter the influence of com­pa­nies like Nest­lé. Among other cri­ti­cal prac­ti­ces, Nest­lé has mar­ke­ted (and still does) breast milk sub­sti­tu­tes, such as infant for­mu­la as an alter­na­ti­ve to regu­lar breast­fee­ding. The Inter­na­tio­nal Baby Food Action Net­work (IBFAN), an inter­na­tio­nal coali­ti­on of advo­ca­cy groups, has been cam­paig­ning for over 40 years for the right of mothers to breast­feed their babies, free from mis­lea­ding com­mer­cial pres­su­re and decep­ti­ve claims by the baby food indus­try. ¹¹ IBFAN urges count­ries to imple­ment the WHO Inter­na­tio­nal Code of Mar­ke­ting of Breast-milk Sub­sti­tu­tes, adopted in 1981. ¹² They have used methods such as tar­ge­ted popu­lar cam­paig­ning and advo­ca­cy efforts with govern­ment diplo­mats in the UN for stric­ter regu­la­ti­ons. They also sought to link their cau­se to a broa­der social and health move­ment by harnes­sing the power of legal advice and stra­te­gic liti­ga­ti­on, health edu­ca­ti­on and the pro­mo­ti­on of grass­roots owner­ship.¹¹ IBFAN’s suc­ces­ses indi­ca­te that it takes a dedi­ca­ted inde­pen­dent coali­ti­on with a long-term stra­tegy and stami­na, as well as solid fun­ding that is free from con­flict of inte­rest, to con­front cor­po­ra­te inter­fe­rence in poli­tics.

Recent rese­arch has shown how Ultra-Pro­ces­sed Food Indus­try (UPFI) actors actively use various methods to shape WHO’s NCD poli­cy­ma­king in accordance with their inte­rests.¹³ The­se include inten­si­ve lob­by­ing by UPFI actors in WHO Mem­ber Sta­tes, co-opting civil socie­ty, hiring for­mer WHO employees, and actively chal­len­ging or under­mi­ning unfa­voura­ble sci­en­ti­fic infor­ma­ti­on.¹³ Simi­lar­ly, indus­try actors have been found to under­mi­ne poli­ti­cal efforts to rest­rict UPF adver­ti­sing on Trans­port of Lon­don faci­li­ties e.g. by exag­ge­ra­ting poten­ti­al cos­ts and under­play­ing poten­ti­al bene­fits of the poli­cy.¹⁴

Over the last deca­de, the glo­bal public health com­mu­ni­ty has faced, and is facing, seve­ral cri­ses inclu­ding the lack of pre­ven­ti­on, pre­pared­ness and respon­se to pan­de­mic risks and the impacts of the cli­ma­te emer­gen­cy, bio­di­ver­si­ty loss and eco­lo­gi­cal degra­da­ti­on. The­se cri­ses, inclu­ding its cor­po­ra­te cap­tu­re in the form of glo­bal public pri­va­te initia­ti­ves as pos­si­ble solu­ti­ons, has delay­ed and dis­trac­ted govern­ments from taking actions on the CDoH. Cyni­cal­ly, one could say that com­mer­cial enti­ties in the Food, Alco­hol and Fos­sil indus­try bene­fit, at least on the short term, from govern­ments having to focus on other, see­mingly more urgent issues. Nevert­hel­ess, the dou­ble bur­den of mal­nu­tri­ti­on is not­hing but ano­ther sym­ptom of an eco­no­mic sys­tem that is not deli­ve­ring on its inten­ded pur­po­se, as it has enab­led unsus­tainable eco­no­mic growth that does not account for envi­ron­men­tal or health harms. ¹⁵ Actions on the CDoH should hence be con­side­red part of a broa­der rethin­king of (glo­bal) poli­ti­cal gover­nan­ce of the eco­no­mic sys­tem, with the aim of pushing back on pro­fit ori­en­ta­ti­on and cent­ring health and equi­ty as the system’s pri­ma­ry pur­po­se. ¹⁶ Post- or degrowth eco­no­mic models which are based on rege­ne­ra­ti­ve and dis­tri­bu­ti­ve prin­ci­ples to meet the needs of all peo­p­le within the means of the living pla­net, will be cru­cial to achie­ving the­se goals. Such a well­be­ing-ori­en­ted approach is now also being pro­mo­ted by WHO.¹⁷

The devil is in the details

It depends howe­ver on the design of poli­ci­es inten­ded to pro­mo­te a well­be­ing approach as fur­the­red by govern­ments and inter­na­tio­nal insti­tu­ti­ons. In essence, con­sidera­ble shifts in trade rules and inter­na­tio­nal taxa­ti­on agree­ments are requi­red. At the moment, the­se bene­fit the inte­rests of inves­tors and glo­bal com­pa­nies over public inte­rests. It would also be neces­sa­ry to estab­lish more strin­gent inter­na­tio­nal regu­la­to­ry frame­works, for ins­tance a UN con­ven­ti­on on mini­mi­sing the harmful impacts of com­mer­cial food and drink pro­ducts, simi­lar to the Frame­work Con­ven­ti­on on Tob­ac­co Con­trol. ¹⁸ More con­cre­te­ly, govern­ments, citi­zens group and busi­ness would have to enga­ge in alter­na­ti­ve forms of busi­ness models, such as local coope­ra­ti­ve food sys­tems models.

 Moreo­ver, a public invest­ment model for food and water com­pa­nies, sub­si­di­sed by govern­ments, wher­eby eco­lo­gi­cal and social aims are reward­ed, and pro­fit mar­gins by share­hol­ders are mini­mi­sed, but fair, is pos­si­ble. In Aus­tra­lia, India and Bra­zil the­re have been decent expe­ri­en­ces with such ‘public-public’ initia­ti­ves as they are known.¹⁶ It requi­res a united health, social, eco­lo­gi­cal and labour move­ment that demands, via a poli­ti­cal and citi­zen mobi­li­sa­ti­on pro­cess, govern­ments and com­pa­nies to pro­found­ly chan­ge their prac­ti­ces. Histo­ry tea­ches us that such mobi­li­sa­ti­on is requi­red to enforce trans­for­ma­ti­ve chan­ge given the poli­ti­cal and finan­cial power of com­mer­cial actors.¹⁶ It requi­res public health actors to form coali­ti­ons, in order to be pro­tec­ted against indus­try thre­ats while moni­to­ring and expo­sing cor­po­ra­te acti­vi­ties, debun­king its argu­ments.⁹ The deca­de long cam­paign by Food­watch around the Nut­ri-Score, a con­su­mer-fri­end­ly nut­ri­tio­nal label lob­bied against by UPFI for 18 years, shows what kind of dedi­ca­ted and per­sis­tent effort has been requi­red to attain a man­da­to­ry Euro­pean nut­ri­ti­on label.¹⁹

Limits to the con­sump­ti­on and pro­duc­tion of harmful pro­ducts

At the core of mat­ters, it is nee­ded to limit the con­sump­ti­on and pro­duc­tion of unhe­alt­hy food­s­tuff and other harmful CoDH, such as sweeten­ed and alco­ho­lic drinks. This neces­si­ta­tes at the more struc­tu­ral level, at least in high inco­me count­ries, limi­ting cur­rent direc­tions of eco­no­mic growth and enga­ging with post-growth poli­cy pro­po­sals in the indus­tria­li­sed health, food and agri­cul­tu­ral domain.¹⁶ This con­firms the need for mas­si­ve invest­ments across the glo­be in diver­si­fied, small-sca­le, non-com­mer­cial, eco-fri­end­ly far­ming. Peasants must be repre­sen­ted in decis­i­on-making and glo­bal health actors can enga­ge in inter­na­tio­nal soli­da­ri­ty on buil­ding food sove­reig­n­ty.²⁰ At the basis of this dri­ve for increased food and health sove­reig­n­ty is an ethics of suf­fi­ci­en­cy and ‘limita­ria­nism’. This pro­mo­tes the idea that in the world as it is, as well as in the near­by future, no-one should have (or con­su­me), more than what is nee­ded to lead a healt­hy, ful­fil­led life.²¹ In the medi­cal and public health field this trans­la­tes to ‘First, Do No Harm’ as a prin­ci­pal value in inter­vening in socie­ties or pati­ents. ¹² The CDoH are a key glo­bal public health chall­enge, and pos­si­bi­li­ty for con­cre­te action, in the coming deca­de to enga­ge with. We need to limit the harms inflic­ted on peo­p­le and pla­net by the CDoH in a glo­ba­li­sed mar­ket eco­no­my by regu­la­ting the food envi­ron­ment and crea­ting the con­di­ti­ons for a healt­hy nut­ri­tio­nal die­ta­ry land­scape.

This text was published first by the Rosa-Luxem­burg-Stif­tung Gen­e­va on 17 July 2023. You will find the ori­gi­nal text here, a French ver­si­on here and a Ger­man ver­si­on here.

¹ Gilm­o­re, A. B., Fabbri, A., Baum, F., Bert­scher, A., Bon­dy, K., Chang, H. J., … & Thow, A. M. (2023). Defi­ning and con­cep­tua­li­sing the com­mer­cial deter­mi­nants of health. The Lan­cet, 401(10383), 1194–1213.

² Mon­tei­ro, C. (2013) Spe­ci­fic poli­ci­es to tack­le diet-rela­ted NCDs in Euro­pe. Euro­pean Minis­te­ri­al Con­fe­rence on Nut­ri­ti­on and Non­com­mu­ni­ca­ble Dise­a­ses in the con­text of Health 2020 https://www.slideshare.net/who_europe/specific-policies-to-tackle-dietrelated-ncd-in-europe (abge­ru­fen am 26.07.2023)

³ Mus­gra­ve, P. (2019) Mikhail Gorbachev’s Piz­za Hut Thanks­gi­ving Mira­cle. FP https://foreignpolicy.com/2019/11/28/mikhail-gorbachev-pizza-hut-ad-thanksgiving-miracle/ (abge­ru­fen am 26.07.2023)

⁴ World Health Orga­niza­ti­on (2013) WHO Direc­tor-Gene­ral addres­ses health pro­mo­ti­on con­fe­rence. World Health Orga­niza­ti­on https://www.who.int/director-general/speeches/detail/who-director-general-addresses-health-promotion-conference (abge­ru­fen am 26.07.2023)

⁵ World Health Orga­niza­ti­on (2021) Obe­si­ty and over­weight. World Health Orga­niza­ti­on https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (abge­ru­fen am 26.07.2023)

⁶ World Food Pro­gram­me (2023) A glo­bal food cri­sis. World Food Pro­gram­me https://www.wfp.org/global-hunger-crisis (abge­ru­fen am 26.07.2023)

⁷ Lie, A. L. (2021). ‘We are not a partnership’–constructing and con­test­ing legi­ti­ma­cy of glo­bal public–private part­ner­ships: the Sca­ling Up Nut­ri­ti­on (SUN) Move­ment. Glo­ba­liza­ti­ons, 18(2), 237–255.

⁸ Lacy-Nichols, J. et al. (2023). Con­cep­tua­li­sing com­mer­cial enti­ties in public health: bey­ond unhe­alt­hy com­mo­di­ties and trans­na­tio­nal cor­po­ra­ti­ons. The Lan­cet, 401(10383), 1214–1228.

⁹ Glo­bal Health Watch 6: in the shadow of the pan­de­mic. (2022) Con­fron­ting the com­mer­cial deter­mi­nants of health. Bloomsbu­ry Publi­shing. https://phmovement.org/wp-content/uploads/2023/03/GHW6-chapter-C3.pdf (abge­ru­fen am 26.07.2023)

¹⁰ Lacy-Nichols, J. et al. The public health play­book: ide­as for chal­len­ging the cor­po­ra­te play­book. The Lan­cet Glo­bal Health 10.7 (2022): e1067-e1072.

¹¹ Ster­ken, E. (2021). IBFAN News Brief: Breast­fee­ding Pro­tec­tion and Tack­ling Mal­nu­tri­ti­on in the Time of COVID. https://journals.sagepub.com/doi/pdf/10.1177/08903344211017024 (abge­ru­fen am 26.07.2023)

¹² World Health Orga­niza­ti­on (1981) Inter­na­tio­nal Code of Mar­ke­ting of Breast-Milk Sub­sti­tu­tes. World Health Orga­niza­ti­on. https://www.who.int/publications/i/item/9241541601 (abge­ru­fen am 26.07.2023)

¹³ Lau­ber, K., Rut­ter, H., & Gilm­o­re, A. (2021). Big Food and the World Health Orga­niza­ti­on: A qua­li­ta­ti­ve stu­dy of cor­po­ra­te poli­ti­cal acti­vi­ty in glo­bal-level non-com­mu­ni­ca­ble dise­a­se poli­cy. BMJ Glo­bal Health, 6(6), [e005216].

¹⁴ Lau­ber, K., Hunt, D., Gilm­o­re, A.B., Rut­ter, H., 2021. Cor­po­ra­te poli­ti­cal acti­vi­ty in the con­text of unhe­alt­hy food adver­ti­sing rest­ric­tions across Trans­port for Lon­don: A qua­li­ta­ti­ve case stu­dy. PLOS Medi­ci­ne 18, e1003695.

¹⁵ Hens­her, Mar­tin, et al. Health care, over­con­sump­ti­on and une­co­no­mic growth: A con­cep­tu­al frame­work. Social Sci­ence & Medi­ci­ne 266 (2020): 113420.

¹⁶ Fri­el, S., Col­lin, J., Dau­be, M., Depoux, A., Freu­den­berg, N., Gilm­o­re, A. B., … & Mial­on, M. (2023). Com­mer­cial deter­mi­nants of health: future direc­tions. The Lan­cet, 401(10383), 1229–1240.

¹⁷ World Health Orga­niza­ti­on (2022) Achie­ving well-being — A draft glo­bal frame­work for inte­gra­ting well-being into public health uti­li­zing a health pro­mo­ti­on approach. World Health Orga­niza­ti­on. https://www.who.int/publications/m/item/achieving-well-being (abge­ru­fen am 26.07.2023)

¹⁸ WHO Frame­work Con­ven­ti­on on Tob­ac­co Con­trol (2023) WHO Frame­work Con­ven­ti­on on Tob­ac­co Con­trol. https://fctc.who.int/who-fctc/overview (abge­ru­fen am 26.07.2023)

¹⁹ Food­watch (2022) Nut­ri-Score in the EU: 18 years of food lob­by­ing https://www.foodwatch.org/en/news/2022/nutri-score-in-the-eu-18-years-of-food-lobbying/ (abge­ru­fen am 26.07.2023)

²⁰ Via Cam­pe­si­na (2023) What is La Via Cam­pe­si­na? https://viacampesina.org/en/who-are-we/what-is-la-via-campesina/ (abge­ru­fen am 26.07.2023)

²¹ Robeyns, I. (2022). Why limita­ria­nism?. Jour­nal of Poli­ti­cal Phi­lo­so­phy, 30(2), 249–270.

²² Sokol D K. “First do no harm” revi­si­ted. BMJ 2013; 347:f6426