The series proposes a global, coordinated response to what it calls a “pathological system”, by developing a “unified agenda to protect health”, and a commitment to addressing the challenges posed by the “commercial determinants of health” in a holistic way.

A series of three articles in The Lancet, by scientists from 15 countries across six continents, has turned the spotlight on multinational industries’ role in driving global epidemics of avoidable diseases, the climate emergency, and social and health inequalities which continue to worsen and further undermine countries’ ability to cope with these crises.

The series, called “Commercial Determinants of Health” and due to be published in The Lancet on 24 March, defines a “pathological system” in which globally dominant, transnational corporations cause harm to human and planetary health, while widening the power imbalances between companies and governments.

This happens not just through consumption of their products, but also because of the ways in which these corporations do business – practices until now mostly considered part of “normal” business operations in the relentless pursuit of economic growth.

The corporations are able to externalise their costs; for example, pharmaceutical and mining companies polluting groundwater with toxic waste, or agri-chemical giants exporting carcinogenic herbicides – banned in Europe – to developing countries whose weaker regulations allow it. The result is that local communities pay with their health – sometimes even their lives and livelihoods – for the collateral damage from powerful companies pursuing “business as usual”.

Getting rid of toxic waste by discharging it into the sea or other waterways is one example of a common business practice, known as a ‘commercial determinant of health’, that harms human health and the planet, when corporations ‘externalise the costs’ of their operations by making the public and nature pay. (Photo: iStock)

A critical element of the series, however, is to point out that generic terms such as “private sector”, “corporations” or “industry”… “lump together diverse entities whose only shared characteristic is their engagement in commerce”.

One of the three papers calls for looking beyond “a narrow focus on specific industries” and “should look instead at how a broad range of commercial or quasi-commercial entities influence health outcomes”.

The article also offers advanced frameworks and tools for governments and companies to understand more about how, or to what extent, commercial entities harm – or benefit – health.

This is intended to support a new generation of efforts – beyond the “environmental, social and governance” emphasis, which relies on companies’ ineffective self-regulation – to establish better ways of governing commercial entities while prioritising public health.

The ways that the commercial sector’s activities influence and even drive health problems, deaths and climate change are referred to in the policy world as “commercial determinants of health”.

To illustrate their huge scale and economic cost: Just four commercial products – tobacco, alcohol, ultra-processed foods and fossil fuels – account for 19 million deaths around the world every year; just over one-third (34%) of the 56 million total deaths recorded in the latest Global Burden of Disease study (2019).

The 19-million number does not include deaths caused by commercial practices (as opposed to products – 1.2 million), unhealthy diets overall (11 million), air pollution from fossil fuels (10 million) and alcohol (three million).

The series sets out three main discussions:

• A “consensus definition” of what commercial determinants of health are, including how they can be mutually supportive;
• A “framing”, including tools for business and policymakers, to better understand their impacts on health;
• Options for “future directions” as to how to achieve the systemic, transformative change necessary: To “[rethink] the way capitalism is organised, including looking beyond GDP to other ways of measuring progress”.

Wealth and power imbalances

The term, “commercial determinants of health”, was introduced in 2013 and the concept has been discussed extensively before, but The Lancet’s new, broader definition recognises the diversity of commercial actors, their positive as well as negative impacts, and – something previous discussions have not broached – the “extraordinary concentrations of wealth and power” that result from it.

The series goes further still, examining how the massive wealth and power imbalances that arise, especially in low- and middle-income countries, enable major corporations to shape environments that increasingly privilege their profits, while increasingly undermining the ability of weak or under-resourced governments to enact or enforce regulations on commercial activities, and, equally tragically, the ability of their health systems to cope with the illnesses those activities cause.

According to the series, tax evasion by transnational corporations, combined with wealthy individuals’ use of tax havens, means that countries lose, on average, the equivalent of 9.2% of their health budget every year. Low-income countries are disproportionately affected, losing an equivalent of more than half (52.4%) of their health budgets – and high-income countries are responsible for 97% of those tax losses.

In highlighting the complexity of forces that prioritise economic growth at the expense of society’s wellbeing, The Lancet series also tries to explain why it is so difficult to counteract these ever-escalating health harms, including what it identifies as “the ubiquity of corporate norm shaping, enabled by a media that increasingly represents corporate interests”.

It is not just the most obvious industries and products – tobacco, alcohol, ultra-processed foods and fossil fuel businesses – that are driving the damage attributed to commercial determinants of health (though they do play a major role), but also the practices of those – and many other – companies.

These practices are categorised as political, financial, scientific, reputation management, marketing, labour and employment, and supply chain and waste. Most of these seven practices are familiar to many people, but have not been considered to be obviously damaging to public health.

Profits before health

Take just one example within financial practices – cited in The Lancet editorial accompanying the series – that directly impacted South Africa and scores of other developing countries: During the Covid-19 pandemic, multinational pharmaceutical companies sold publicly funded vaccines, treatments and tests to the highest bidders, “putting a desire to make extraordinary profits before the needs of humanity”.

This cost the world more than a million lives, The Lancet says, while private companies made billions of dollars.

Another example, this time of a political practice: When the South African government in 2016 proposed a 20% tax on sugary drinks to help reduce consumption of a harmful product and reduce South Africans’ disease burden because of it, the sugar industry successfully lobbied to have the tax reduced to 10%.

A case study included in The Lancet series, co-authored by Wits School of Public Health’s Prof Karen Hofman and researchers Agnes Erzse and Safura Abdool Karim, illustrates the “pathological system” – how a global company wields its power to exploit markets and deepen inequalities, especially in low-and middle-income countries.

South Africa is one of the top 10 global consumers of Coca-Cola products, with school-age children drinking on average 2.3 servings of sugary drinks every day and with the population as a whole bearing the brunt of alarming rates of obesity: almost 40% of women, 15% of men and 17% of children are obese (a lot more are “just” overweight).

In South Africa, Coca-Cola’s marketing targets mainly poor South Africans, making their sugary drinks available literally on every street corner and at every point on the way to the most remote rural areas.

The environment is what The Lancet calls “consumptogenic” – it encourages consumption, aggravated by pervasive branding and advertising, including in schools, on TV and in social media, playing on aspirational values. At the same time, the absence of public messaging about the dangers of drinking sugary drinks (eg developing potentially fatal type 2 diabetes) or regulations to ban its sales in areas adjacent to schools, for example, enables this practice not just to continue, but to grow.

Where to from here?

This is the first time such a high-level collection of scientists from around the world have come together to push for coordinated, concerted global action in shifting power away from multinational corporations, whose routine operations are now being viewed at a global level as damaging and manipulative – much in the same way that the tobacco industry finally came to be considered a deadly influence on society, and whose activities needed to be curtailed and regulated.

In 2005, the World Health Organization launched its ground-breaking Framework Convention on Tobacco Control (FCTC), which had been adopted by all member states in 2003. It was the first international, evidence-based treaty to control the sales, marketing and consumption of an unhealthy product around the world, based on the right of all people to the highest standard of health. (The FCTC has since become “one of the most rapidly and widely embraced treaties in United Nations history”, the WHO says.)

WHO Director-General Tedros Adhanom Ghebreyesus said the organisation is rethinking “how value in health and wellbeing is measured, produced, and distributed across the economy”.

“We need to move away from crude measurements, such as gross domestic product, and towards measuring what matters, such as through approaches for a wellbeing economy.”

Greg S Garrett, Executive Director of the Netherlands-based Access to Nutrition Initiative (ATNI), which assesses the nutrition commitments of the world’s largest food companies to help build private sector accountability for sustainable nutrition, told Maverick Citizen that The Lancet series on commercial determinants of health “provides evidence that government regulatory actions, progressive business models and accountability mechanisms, together help mitigate harm from commercial entities”.

​​Garrett said ATNI welcomed the series’ new proposed framework, which looks across the private sector at different types of commercial entities (eg transnational corporations, joint ventures, cooperatives) “helping us better understand their characteristics and how they influence health”, he said.

The Lancet series makes it clear that the authors’ call to action is “pro-health”, not “anti-business”:

“The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships,” the editors said, suggesting that the findings of this series should “embolden young researchers, communities, and new government and business leaders to imagine, co-design, and – importantly – invest in a world where human and planetary health is always prioritised over profit.” DM/MC/OBP