The public health sector has long been geared towards managing communicable diseases – those that are spread from one person to another through various means – but comparatively little attention has been paid to the health risks that come with products any person can take home from the supermarket.

An unhealthy diet has become a significant risk factor for disease in South Africa, even as major industries and companies continue to profit from marketing and selling harmful goods, according to Karen Hofman, research professor and founding director of the SAMRC Centre for Health Economics and Decision Science (PRICELESS SA) at Wits University.

“They are marketed to our children to start with, so by the time we get to our early teens and twenties, we’re already indoctrinated,” she said.

“These are not diseases of lifestyle; these are not things that we can control. We think we have choices [but] those choices have been predetermined.”

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Hofman is co-author of a three-paper Lancet series on the commercial determinants of health, launched at Wits on Wednesday, 29 March. The series draws attention to the “substantial group of commercial actors…  escalating avoidable levels of ill health, planetary damage and inequity”.

“We define commercial determinants of health as the systems, practices and pathways through which commercial actors drive health and equity. These are not just the products – it’s a whole system behind it,” said Hofman at the launch.

The first paper in the series, “Defining and conceptualising the commercial determinants of health”, cites the 2019 Global Burden of Disease study’s estimate that just four commercial products – tobacco, alcohol, ultra-processed food and fossil fuels – account for 19 million deaths globally each year. This equates to 34% of the total deaths per year (56 million) and 41% of the non-communicable disease deaths per year (42 million).

“There are concerns over the societal acceptance of the commercial sector’s practice of… externalising the costs of the products and operations, as the norm. And these commercial sector practices violate our constitutional right to health,” said Hofman.

“The poor and the vulnerable, whose healthcare is poor quality… are suffering the most.”

The companies that profited from these harmful commercial products had a common “playbook” and deep pockets, she continued.

“They commission their own research; they challenge or cherry-pick the evidence. There’s no declaration of conflict of interest… they challenge peer-reviewed research despite South African-specific evidence in our case, and consistent, reliant evidence from academia and civil society… They use delaying tactics and they sow doubt,” she charged.

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The politics of change

The launch of the Lancet series is an exciting, but fragile moment, says Jeff Collin, professor of global health policy at the University of Edinburgh and co-author of the series.

“Paradigm shifts don’t come easily and this is a key moment if we’re going to check… whether we can really commit to the forms of political will and the difficult decisions that advocacy organisations, research organisations and policymakers are going to have to take,” he said.

Collin pointed to the success of the World Health Organization (WHO) Framework Convention on Tobacco Control – ratified by countries across the world – as an example of how harmful commercial products could be controlled, but noted there was “a notable reluctance to think about extending lessons from this model to other areas of health governance”.

“The key point in this regard is that everything in the [WHO Framework Convention on Tobacco Control] is underpinned by recognition that we’ve got to take conflict of interest seriously,” he said.

“Politically, we need to think about minimising industry engagement in policy formulation. In the scientific context… we’ve got to be very careful about the role of unhealthy commodities in funding research.

“We’ve got to prohibit governments or inter-governmental organisations from partnering with health-harming commercial sector organisations. This has really radical implications for the food systems agenda.”

The role of Coca-Cola – a major global plastic producer – as a sponsor for the most recent United Nations climate summit, COP27, was an example of a partnership marred by conflict of interest, according to Collin.

A South African lens

Speaking at the Lancet series launch, Dr Anban Pillay, deputy director-general for health regulation and compliance management in the South African Department of Health, said thorough vetting for staff in the department was instrumental in ensuring there was no undue influence of industry in policymaking.

“I think the issue is that many of these conflicts of interest are not apparent in the initial declarations because they need to go much deeper in terms of trying to understand the interests of individuals,” he said.

“These interests could not necessarily be financial… [but] could move into other areas as well, about ideology or personal values.”

Pillay spoke about his one-time involvement in the Government Employees Pension Fund (GEPF) as an employee representative. The Public Investment Corporation (PIC) is the investment arm of the GEPF.

“While we, on the health side, are busy regulating tobacco and alcohol etc, the PIC is investing in these corporations,” he explained. “So, I had a huge difficulty with that, objecting to it, but didn’t succeed because the PIC would argue, well, it’s our right to invest in whichever industry we think will provide a return.”

At times, conflict could arise between government departments, as they were fulfilling different mandates, continued Pillay. The Department of Health was responsible for the health of the population, but the Department of Trade and Industry, for example, was largely interested in ensuring industry thrived, and less interested in the type of industry.

“I think [commercial determinants of health are] being approached in a fragmented way because the understanding is still very limited,” he said.

“One of the things we have done is obviously the sugar tax… the other area that’s recently been published is the food labelling regulations, which are intended to inform consumers about exactly what is contained within food.

“This obviously is intended to drive consumer behaviour and we’re hoping this, coupled with some good marketing within communities, can help consumers make decisions about which products they should purchase.”

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The draft regulations for food labelling will introduce mandatory warning labels for pre-packaged foods high in sugar, salt and unhealthy fats – associated with increased risk of obesity, type 2 diabetes and some cancers – as well as for foods and drinks containing artificial (non-nutritive) sweeteners, which increase the risk of obesity, type 2 diabetes and cardiovascular diseases, according to a Daily Maverick report. These regulations are expected to go into effect in 2025.

In South Africa, about 31% of men and 68% of women are obese, according to the African Centre for Obesity Prevention.

The role of communities

Communities were central to addressing commercial determinants of health, said Nzama Mbalati of the Healthy Living Alliance, another speaker at the Lancet series launch. Lessons could be drawn from different struggles and contexts, he said.

“I think it’s important when we are launching this service… that we don’t forget that we are actually part of a community. How do we then integrate that community because… the community knows what their problems are, but what they need from us is capacity and resources to [take action] within their own context, to address their own issues.”

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Pillay emphasised the need for a coalition between civil society and government to monitor the social determinants of health and make communities aware of the risks associated with the products they use or consume. DM/MC